Every finding on record at The Village of East Harbor

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include:On 06/09/2026 between 9:05 AM-9:35 AM, during an initial observation of the kitchen with Dietary Manager (DM) F, the following items were observed: There was a personal cell phone and a portable speaker on the food preparation counter, directly next to a pan of uncovered pastries. When queried about the cell phone, DM F immediately removed the phone and speaker from the food preparation table but provided no further explanation. In the walk-in cooler, there was a container of spinach dated 5/21-5/25, an opened container of raspberry vinaigrette salad dressing with a use-by date of 4/23, an opened container of Caesar dressing with a use-by date of 4/16, an opened container of salsa with a use-by date of 5/21, and an opened, undated bottle of ranch dressing. When queried about the undated/expired food items, DM F stated I usually check for that on Mondays, but I was off yesterday. In the Victory reach-in cooler, there was a container of peeled hard-boiled eggs with a use-by date of 5/27. In addition, the speed rack located inside the Victory reach-in cooler was soiled with a buildup of crumbs and food debris. The thickener bin, flour bin and oats bin were all soiled on the lid and top exterior surface with crumbs and dried on food debris. On the bottom shelf of the food preparation table located across from the walk-in coolers, there were 2 uncovered plastic bins with clean bowls stored inside. The bins were observed with debris on the inside, leaving the clean dishes uncovered and not protected from contamination. The stainless-steel baffles of the ventilation hood filters were coated with a thick layer of grease. When queried, DM F stated an outside company takes care of cleaning the ventilation hood and pointed to a sticker on the hood that noted the date of the next service would be September 2026. There was a large, wall mounted industrial fan blowing air at the clean side of the dish machine. The fan was soiled with a buildup of dust. There were gnats observed in the dish machine room. The flooring underneath the dish machine was soiled with a buildup of a black substance on the surface of the tiles, and the flooring was wet. On 06/09/2026 at 9:35 AM, Dietary Staff G was observed using the dish machine. Dietary Staff G was observed wearing disposable gloves, rinsing soiled dishware, placing the items in a rack, and sending the racks through the dish machine. Dietary Staff G was then observed going to the clean side of the dish machine and handling clean dishware without first performing hand washing. Dietary Staff G was queried about how the dish machine is checked to ensure that it is sanitizing the dishware, and Dietary Staff G stated, I don't know how to do that. Review of the dish machine log at that time, revealed the log had not been filled out for breakfast on 6/9, before staff began using the dish machine. On 06/09/2026 at 9:45 AM, the dish machine was checked for sanitization with DM F. A plate simulating dishwasher tester was sent through the dish machine twice and registered a maximum temperature of 153 degrees Fahrenheit and 154 degrees Fahrenheit (maximum temperature required for sanitization is 160 degrees Fahrenheit). 2 Thermolabels (paper thermometer for measuring the surface temperature of dishware to ensure sanitization) were sent through the machine, and neither one turned black to denote that the surface temperature of the dishware had reached 160 degrees Fahrenheit. DM F stated Maybe you have to run it a few times. I know that water is hot, it's smoking (meaning steam). On 06/09/2026 at 9:40 AM in the [NAME] kitchenette, inside the Continental refrigerator, there was an undated container of fried chicken, and an undated container of cut fruit. In addition, the interior surfaces of the microwave were heavily soiled with food splatter and dried on food debris. On 06/09/2026 at 11:45 AM, there were 2 rolling trash bins located near the kitchen entrance, that were soiled on the inside with spilled liquids and food debris, and gnats were observed flying about the bins. According to the 2022 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 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-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. According to the 2022 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces, NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. According to the 2022 FDA Food Code section 4-701.10 Food-Contact Surfaces and Utensils, Equipment food-contact surfaces and utensils shall be sanitized. According to the 2022 FDA Food Code section 4-703.11 Hot Water and Chemical, After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71oC (160oF) as measured by an irreversible registering temperature indicator; P According to the 2022 FDA Food Code section 2-301.14 When to Wash, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 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 ARTICLESP and: .(E) After handling soiled EQUIPMENT or UTENSILS; P .(I) After engaging in other activities that contaminate the hands. P According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination According to the 2022 FDA Food Code section 6-202.12 Heating, Ventilating, Air Conditioning System Vents, Heating, ventilating, and air conditioning systems shall be designed and installed so that make-up air intake and exhaust vents do not cause contamination of FOOD, FOOD-CONTACT SURFACES, EQUIPMENT, or UTENSILS. According to the 2022 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (D) Eliminating harborage conditions.

Based on interview and record review, the facility failed to address recommendations from a Medication Regimen Review (MRR) for one resident (R13) out of one reviewed for unnecessary medications. Findings include:A review of the medical record revealed R13 admitted into the facility on [DATE] with the following medical diagnoses, Schizoaffective Disorder, Bipolar type and borderline personality disorder. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7/15, indicating an impaired cognition. Further review of MRRs dated 1/2026 and 4/2026 have the following recommendation and follow up from the physician, This patient has an order for Voltaren (for pain relief) 1% Gel which does not specify the quantity to be used for each dose. The recommended dosing is as follows: Lower extremity joints: 4 gm (grams) QID (Four times a day) .Upper extremity joints: Apply 2 gm QID.Please provide the appropriate order clarification at this time .Physician/Prescriber Response.Agree, 4 gm QID.Further review of R13's physicians orders noted the following, Order: Voltaren Arthritis Pain External Gel 1% .Directions: Apply to ankles topically every 12 hours as needed for pain.Status: Active.On 6/11/2026 at 1:58 PM, an interview was conducted with the Director of Nursing (DON) and they stated when there are MRRs recommendations the physician receives them and either enters the order themselves, or will the unit manager know so they can update the orders. The DON confirmed they spoke with the physician, and they stated they did not tell the staff about the order.A review of a facility policy titled, Medication Regimen Review noted the following, .Recommendations are acted upon and documented by the facility staff and/or the prescriber.

Based on observation, interview, and record review, the facility failed to properly store a nebulizer and Bi-Pap mask for two residents (R109 and R110). Findings include: R109A review of the medical record revealed R109 was admitted into the facility on 6/4/2026 with the following medical diagnoses, Insomnia and Seizures. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental status (BIMS) score of 6/15 indicating an impaired cognition. R109 required staff assistance with bed mobility and transfers.On 6/9/2026 at 10:19 AM, R109's Bi-Pap (breathing machine) mask was observed sitting on the nightstand. On 6/10/2026 at 12:03 PM and 3:26 PM, R109's Bi-Pap mask was observed sitting on the nightstand. A review of the physician's orders noted the following, Order: Wipe clean mask frame daily with soap and water. Dry well and put inside of a plastic bag .Status: Active.On 6/10/2026 at 3:36 PM, an interview was conducted with R109, and they said they use their Bi-Pap nightly, and staff help them if needed to put it on and take it off due to their left arm being in a sling. R109 was unsure if staff were cleaning the mask or not. R110A review of the medical record revealed that R110 admitted into the facility on 5/22/2026 with the following medical diagnoses, Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure with Hypoxia. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental status (BIMS) score of 11/15 indicating an impaired cognition. R110 required staff assistance with bed mobility and transfers. On 6/10/2026 at 10:32 AM, 12:03 PM and 3:26 PM, R110's nebulizer mask was observed sitting on the nightstand.At 1:45 PM, an interview was completed with Infection Control Preventionist (ICP) C who reported the masks should stored in a bag, and it was not acceptable to be out on a table. ICP C reported the masks shouldn't sit out to dry after cleaning because it can be put back in the storage bag with a towel. On 6/10/2026 at 3:27 PM, R110 reported they used their nebulizer machine that morning because they were having trouble breathing and only use it when necessary. A review of a facility policy titled, Nebulizer Small use and Maintenance noted the following, Store separated equipment - mouthpiece, mask, reservoir, in plastic bag in basin lined with a paper towel, open to air to allow air drying. Coil tubing and place in handle of compressor.

Based on observation, interview, and record review, the facility failed to ensure two (R14, R105) of three residents reviewed for care conferences (meeting designed to individualize residents plan of care) were provided the opportunity to attend and participate in their care conference. Findings include: R14 On 6/09/2026 at 3:30 PM, a review of R14's medical record revealed a progress note dated 06/01/26 authored by Social Worker (SW) H documenting, Son was notified of the upcoming care conference for June 9th. Due to [R14] significant mental illness [R14] was not notified. On 06/10/2026 at 11:00 AM, R14 was interviewed in their room and asked if they were aware of what a care conference was or if they could recall being invited to or participating in their care conference and reported they were not sure what a care conference was and they could not recall being invited or participating in one. R14 reported their son and daughter-in-law visit and may attend the care conferences. A review of R14's medical record revealed they were admitted into the facility 06/20/26 with the primary diagnosis of Paranoid Schizophrenia. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] was scored 10/15 indicating moderate cognitive impairment. On 06/10/2026 at 12:55 PM, SW I was interviewed in the Social Service office reporting SW H was on vacation for the week. SW I reported care conferences for long term care residents are held quarterly (four times per year) and residents are notified and invited as well as their responsible party or guardian if they have one. SW I reported a paper notice/reminder of the conference is posted in the resident's room and the notice is reviewed with the resident unless the resident was too cognitively impaired to participate or if the resident's guardian requested the resident not be present. On 06/11/26 at approximately 11:15 AM, R14 was interviewed in their room and asked if they could recall ever seeing a notice posted in their room or talking to staff about their care conference and they replied they could not recall that taking place. A 06/08/26 social service progress note authored by SW I included [R14] has been pleasant and friendly on approach and seems to enjoy talking to someone .Mental illness seems stable at this time .No behavior problems noted. Further review of R14's medical record revealed no documentation indicating R14 had experienced any recent cognitive, behavioral, or psychiatric symptoms suggestive the resident should not be offered the opportunity to participate in their care conference. A Resident Preferences Evaluation dated 06/09/26 indicated R14 provided meaningful and appropriate feedback regarding their day-to-day life preferences. On 06/11/2026 at 12:50 PM, the Assistant Director of Nursing (ADON) J was interviewed in the Unit Manager's office and reported a resident would not be excluded solely based on a mental health diagnosis. ADON J reviewed the 06/01/26 progress note authored by SW H and acknowledged the note did not provide an explanation for R14 not being invited to the care conference other than the documented significant mental illness. On 06/11/2026 at 12:55 PM, R14's family member (FM) K was interviewed via phone and reported they never asked for R14 to be excluded, and the resident was never present in the conference, so they assumed that's how the conferences worked. R105 On 06/09/2026 at 10:28 AM, an interview was conducted with R105. R105 stated they were concerned they were supposed to have participated in a care conference on 6/4/2026, but they had not been included in that meeting. R105 provided a paper invitation that indicated they were invited to a care conference 6/4/2026 at 11:45AM. R105 further stated their daughter had talked with the facility about their care on 6/4, but no one came to bring them to the conference. Review of R105's electronic medical record (EMR) revealed they were admitted into the facility 5/27/2026 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, and depression. A review of R105's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. On 06/10/2026 at 12:30 PM, an interview was conducted with Social Worker I, they stated they came to R105's room on 6/4/2026 to bring them to the scheduled care conference, but R105 was wet and needed to be changed first they offered to wait for R105 to get changed or get other staff to assist them, but R105 asked for the conference to continue without them and that their daughter would handle it. Review of R105's EMR on 6/10/2026 did not reveal documentation of them declining to attend the care conference. Further review of the EMR revealed a care conference summary, with a note entered by social work dated 6/3/2026 indicating daughter attended via telephone and pt [patient] was in attendance as well. On 06/10/2026 at 1:22 PM, an interview was conducted with Unit Manager (UM) M who stated they were present during R105's care conference and R105 did not attend. UM M then accessed the video footage of the entryway to the room the care conference was held and revealed R105 was not present during the care conference meeting. On 06/11/2026 at 9:53 AM, an interview was conducted with the Director of Nursing (DON). When asked to provide documentation of R105 declining to attend their care conference, the DON said a late progress note was being added to R105's file. Review of the facility's policy Interdisciplinary Care Conference Procedure dated 12/2025, revealed, It is the policy of (name of facility) to support the resident's right to be informed of, participate in, his or her care planning and implementation of care or treatment. The facility will inform the resident, in a language he or she can understand, of his or her rights regarding planning and implementing care . The care conference process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. The facility will honor the resident's choice in individuals to be included in the care conference process. The facility will honor requests for care conference meetings and acknowledge requests for revisions to the person-centered plan of care.

Based on observation, interview and record review, the facility failed to provide adaptive eating equipment for one resident (R73) out of two reviewed for Activities of Daily Living (ADLs). Findings include:A review of the medical record revealed R73 was admitted into the facility on 1/20/2025 with the following diagnoses, Muscle Weakness and Contracture, Right Hand. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12/15 indicating an impaired cognition. R73 also required staff assistance with bed mobility and transfers. Further review of the physicians' orders noted the following, Orders: Provide divided dish for patient to improve independence with self feeding.Status: Active.Order Date:6/24/2025. Orders: Ensure patient has left hand universal cuff and assist to place fork or spoon on left hand for self-feeding per patient's tolerance. Patient has cuff on their bedside table.Status: Active.Order Date:6/24/2025.On 6/10/2026 at 1:55 PM, R73 was observed sitting in their bed and eating lunch. Their plate was on top of a towel and on their lap and they were eating with their hands. R73 stated they had eaten a little, but wanted their plate removed. The tray ticket was observed to note a divided plate and left-hand universal cuff listed in the special instructions. No divided plate or left-hand universal cuff was noted in use at the time. R73 was asked about the left-hand cuff and divided plate and stated the equipment helps them eat better independently.On 6/11/2026 at 9:57 AM, R73 was observed sitting in their bed and eating breakfast. No left-hand cuff or divided plate was observed. Certified Nursing Assistant (CNA) B was asked about the divided plate and left-hand cuff. CNA B reported they did not pass out the meal tray.On 6/11/026 at 11:17 AM, an interview was conducted with Certified Occupational Therapy Assistant (COTA) E reported R73 had orders for the left-hand cuff and divided plate because after their stroke, they had decreased strength in the left hand, and the devices promote the ability to eat independently. A request for a facility policy related to adaptive equipment was requested but not received by end of survey.

Based on observation, interview, and record review, the facility failed to empty an indwelling catheter drainage bag for one resident (R82) out of one reviewed for indwelling catheters. Findings include:A review of the medical record revealed R82 was admitted into the facility on [DATE] with the following medical diagnoses, Obstructive and Reflux Uropathy and Neuromuscular Dysfunction of Bladder. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental status (BIMS) score of 11/15, indicating an impaired cognition. R82 required staff assistance and bed mobility. On 6/10/2026 at 10:27 AM, R82 observed to be sleeping in their wheelchair. R82 was noted to have an indwelling catheter drainage bag that appeared to be halfway full. On 6/10/2026 at 12:20 PM, R82 was observed in the wheelchair, and their indwelling catheter drainage bag was noted to be full and touching the ground. R82 reported the staff emptied their catheter drainage bag last night, but it hasn't been emptied on the day shift saying they sometimes have to remind staff to empty it.On 6/10/2026 at 1:06PM, R82 was observed going down to the dining room in their wheelchair. R82's catheter drainage bag was observed to be full, and the bag and tubing were observed to be touching the floor. On 6/10/2026 at 3:22 PM, an interview was conducted with Unit Manager (UM) A and they reported drainage bags are emptied according to the resident's needs. UM A reported staff should be checking on residents and emptying the drainage bags as needed. UM A reported the drainage bags and tubing definitely should not be dragging on the floor.A review of a facility policy titled, Appropriate use of Indwelling Catheter noted the following, Make sure catheter bag is covered with a Privacy bag, and tubing and catheter bag are not touching the floor, and leg strap is in place.

This citation pertains to Intake 2688079.Based on observation, interview, and record review, the facility failed to ensure two persons assisted with toileting assistance for one (R901) resident of three transfer-dependent residents reviewed for assistance. Findings include: Review of a complaint called into the State Agency revealed a concern from R901's family member that on 11/30/25, after the family member requested toileting assistance for the resident, the resident was manually transferred to the toilet by one staff person then manually transferred from the toilet by two staff rather than via two-person assistance using a mechanical lift as physician ordered.Review of the facility record for R901 revealed they were admitted into the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, and Osteoarthritis. Review of R901's Activities of Daily Living (ADL) care plan revealed the resident required direct assistance with all ADLs including transfers.Review of R901's physician orders revealed an order dated 11/20/25 stating Transfer with (name of) Lift and 2 persons assist. The (name of) lift is also known as a Sit to Stand lift and refers to a mechanical transfer assistance device that brings the individual from a seated to/from a standing position with mechanical support and assistance and requires the presence and assistance of staff. On 12/22/25 at 1:45 PM, R901 was observed in the common area sitting in the wheelchair. The resident was not able to respond to questions regarding the reported situation in a coherent manner.On 12/22/25 at 2:03 PM, Licensed Practical Nurse (LPN) and Unit Manager B was interviewed and reported they were aware that on 11/30/25 Certified Nursing Assistant (CNA) A did complete a one-person manual transfer onto the toilet with R901, then requested assistance of another CNA to complete another manual transfer from the toilet. LPN B reported their understanding was that CNA A was aware of the physician ordered transfer status and chose to complete the transfer manually because they felt the resident was safe to do so that day and added but that would still not be appropriate. LPN B confirmed residents should always be transferred according to the current physician order. On 12/22/25 at 2:15 PM, CNA A was interviewed and reported during the incident in question, they transferred the resident manually to the toilet without assistance from other staff. CENA A indicated they realized they were supposed to have used the mechanical lift after R901's daughter commented about the lack of the lift. CNA A reported they did receive assistance from another CNA to transfer the resident off the toilet but did so manually rather than using the lift. On 12/22/25 at 2:55 PM, the facility Director of Nursing (DON) was interviewed and reported the expectation is staff will complete resident transfers according to the physician order.Review of the facility policy Transfer Activities, with a most recent review date of 11/15, revealed the policy statement To transfer the resident from the bed to chair, toilet or tub safely. Review of the facility disciplinary report related to the incident revealed the statement [CENA A] failed to follow the ordered transfer status of a resident that requires a [NAME] lift and two persons assist. For safety reasons, it is imperative that residents are transferred per their ordered transfer status.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: In the dry storage room, there was a buildup of trash on the floor underneath the racks, and the ceiling vent cover was coated with dust. According to the 2017 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. In the walk-in cooler, there was raw beef and raw chicken stored next to fully cooked ham. DM confirmed the meat items were not stored appropriately, and moved the items to a different rack. According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation, (A) Food shall be protected from cross contamination by: .(2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: .(b) Arranging each type of food in equipment so that cross contamination of one type with another is prevented,. The flooring underneath the table holding the juice machines, was observed with a thick layer of brown, syrupy sludge. In addition, the drip pans on both juice machines were observed with a thick layer of gelatinous, pooled juice. DM made note of the soiled flooring, but provided no explanation. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. In the dish machine room, there was a leaking pipe underneath the soiled drainboard. The flooring underneath the leak was observed with standing water, and the surface of the tiles was stained with a black, slimy substance. In addition, the drain pipe for the garbage grinder was leaking liquid onto the floor underneath. There was a thick layer of slime on the floor tiles, and swarms of gnats were observed underneath and adjacent to the garbage grinder. DM confirmed the 2 leaks, but provided no further explanation for the soiled flooring or the gnats. According to the 2017 FDA Food code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to law; P and(B) Maintained in good repair. According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions. At 9:00 AM and 11:45 AM, [NAME] H. observed preparing food, with a beard and no beard restraint. When queried, [NAME] stated he should be wearing a beard restraint. According to the FDA Food Code section 2-402.11 Effectiveness, (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. At 9:30 AM, in the Ontario kitchenette, the interior of the microwave was soiled with splattered food, and the wall behind the counter was observed with large areas of peeling paint. Dietary Aide [NAME] was observed operating the dish machine. When queried about how the staff tests the dish machine for adequate sanitization, [NAME] pointed to the digital temperature display on the front of the dish machine. [NAME] further stated that the temperature display was not getting up to the proper temperature, so they were going to bring the dishes down to the main kitchen to be cleaned. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. At 12:25 PM The microwave located in the [NAME] kitchenette was heavily soiled on the inside. [NAME] confirmed that it needed to be cleaned. When queried about the dish machine log in the [NAME] kitchenette, [NAME] looked in the binder, couldn't find a log, and stated that they really don't use the machine. Stated they bring their dishes back to the main kitchen. Staff was queried, and stated that she uses the dish machine for the coffee pots. 4-703.11 Hot Water and Chemical, After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: (A) Hot water manual operations by immersion for at least 30 seconds and as specified under S 4-501.111; P (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator; P.

Based on interview and record review, the facility failed to provide eight consecutive hours of Registered Nurse (RN) coverage for five days of the period from 10/01/24 until 04/01/25 potentially affecting all 92 residents that residen in the facility. Findings include: Review of the Payroll-Based Journal (PBJ) data submission revealed the facility had been identified as having four or more days without adequate RN coverage for the most recent annual quarter. Review of the facility daily nursing staff postings revealed a total of 39 days during the quarter showing no RN hours for the day. The facility Director of Nursing (DON) was made aware of the staff posting days identified as having no RN coverage and was asked to provide any documentation supporting the presence of RN coverage that would not show on the daily posting such as a Minimum Data Set (MDS) RN or Staff Education RN. Documentation supporting additional RN coverage was reviewed including timeclock punch records with staff identifying information. This review verified a total of five days being identified as having no RN coverage including 10/13/24, 10/26/24, 11/23/24, 12/25/24, and 01/4/25. On 04/02/25 at 12:33 PM, the DON was interviewed and acknowledged the facility has some difficulty in securing RN coverage at times and identified the issue is being addressed in the facility Quality Assurance and Performance Improvement (QAPI) process. The DON reported the expectation and goal is there will be adequate RN coverage seven days per week. A facility policy addressing RN coverage was requested and the facility indicated they did not have one.

Based on observation, interview, and record review, the facility failed to ensure a cervical [NAME] and thoracic lumbar support orthotic (TLSO) was properly applied for two residents (R261 and R256) of two residents reviewed for protective orthotic devices. Findings include: R261 On 3/31/2025 at 10:49 AM, R261 was observed sitting in a wheelchair in their room with a rigid cervical collar in place. The chin portion of the collar was approximately 3 inches to the left of her chin. R261 was also observed with a left arm sling. The arm sling straps were across the right side, bottom of the rigid collar. R261 was observed moving their head side to side. There was no support to her chin which would allow her to nod her head forward. An inquiry to their comfort revealed the collar is uncomfortable. A review of the electronic medical record (EMR) revealed R261 was admitted to the facility on [DATE] with the following pertinent diagnoses: Non-displaced fracture of the first cervical vertebra, fracture of surgical neck of left humerus after a fall. Further record review revealed R261 had a Basic Interview for Mental Status score of 13/15 indicating an intact cognition. The record further revealed R261 required Maximum/Substantial Assistance for toileting, bathing, and dressing. On 3/31/2025 at 4:30 PM a therapist was asked about the positioning of the rigid cervical collar. The therapist explained that the collar should be snuggly positioned under the chin to restrict movement side to side and forward and back. On 4/1/2025 at 12:56 PM R261 was observed sitting in her wheelchair at lunch. R261 was noted to have the rigid cervical collar aligned with the chin, about two inches of space between the chin area on the collar and the resident chin, allowed some forward movement. On 4/1/2025 at 8:30 AM Registered Nurse (RN) E was interviewed and asked about how devices are supposed to be applied. RN E said most staff know how the secure the protective devices and most devices come with instructions or we can ask therapists. On 4/1/2025 a review of the electronic medical record (EMR) physician's orders dated 3/21/2025 revealed R261 was to wear the cervical collar, on at all times. On 4/1/2025 at 12:56 PM, Rehabilitation Unit Manager (RUM) D was queried regarding application of protective medical devices. RUM D said staff were familiar with most medical devices and that instructions were not posted unless the device is unusual or new. R256 On 4/1/2025 at 9:53 AM, R256 was observed with Physical Therapy Assistant (PTA) F in a reclining chair in their room. R256 was observed with a Thoracic Lumbar Support Orthotic (TLSO) very high on the torso and no wrist splint. R256 was queried regarding the device and revealed it was not doing any good and was very uncomfortable. PTA F was queried about the device placement and said R256 should really not be sitting in the recliner and this could cause R256's device to ride up as resident slides down. PTA F was queried inquired why they were not wearing their wrist splint, and had no response. A review of the EMR revealed R256 was admitted to the facility on [DATE] with the following pertinent diagnoses: Fracture of the right radius and wedge compression fracture of the second lumbar vertebrae. Further review revealed a Basic Interview for Mental Status Score of 8/15 indicating moderately impaired cognition and required Maximum/Substantial Assistance for toileting, bathing, and dressing. A review of the physician order, dated 3/22/2025 revealed R256 should wear TLSO when out of bed and wrist splint at all times. On 4/2/2025 the Director of Nursing (DON) was queried regarding how specific medical device application was communicated to the staff and confirmed all of the professional staff received training during school so should know the correct way to use the devices. A review of the policy Splints, Braces and Slings did not reveal information about devices that accompany residents on admission.

Based on observation, interview, and record review, the facility failed to label and store medication properly in one of four medication carts and in one (R3) of one resident room. Finding include: On 3/31/25 at 09:57 AM, an observation of Brimonidine Tartrate Ophthalmic eye drops were located on the overbed table of R3. The medication was not labeled with R3's name and was available to anyone passing by. Review of the physician orders did not reveal an order for self administration. On 4/1/2025 at 10:45 AM, in top drawer of Cart 2 on 300 Hall, there was a previously opened bottle of Nuplazid 34 without an open date. On 4/1/2025 at 7:30 AM, an interview with Licensed Practical Nurse (LPN) H revealed upon inquiry no eye drops or medications of any kind should be at resident bedside. On 4/1/2025 at 8:15 AM, an interview with LPN I upon inquiry revealed the medication that was not labeled should have been dated and labeled when opened.

Based on observation, interview, and record review the facility failed to ensure space heaters were not in use for two residents (R49 and R51) out of nineteen residents reviewed for safe, clean, homelike environment. Findings include: R49 On 3/31/25 at 10:36 AM, R49 was observed in bed with a space heater near the room heating and cooling unit. When queried about the space heater R49 stated, We have had to use space heaters in our room since the fall because the heat wasn't working properly. Someone from maintenance brought in the heaters for us to use. The room heating and cooling unit was observed not blowing air. On 4/01/25 at 8:24 AM, two space heaters were observed in use in R49 and R51's room. The room heating unit was not blowing air. On 4/01/25 at 8:28 AM, Licensed Practical Nurse (LPN) A was interviewed regarding R49's room heating unit and said they were not sure how long the room heating unit wasn't working. On 4/01/25 at 3:44 PM, Certified Nursing Assistant (CNA) B was interviewed and said the room heater in R49 and R51's room hasn't been working for at least two months, and staff have been using space heaters to heat the room. Record review of R49's Electronic Health Record (EHR) revealed R49 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis and muscles weakness. Review of R49's Brief interview for Mental Status assessment performed on 2/10/2025 revealed a score of 15/15, intact cognition. Review of R49's functional mobility assessment dated [DATE] revealed dependent for bed mobility and transfers. R51 On 4/02/25 at 9:06 AM, R51 was interviewed and said the room heater unit was broken since early winter and they have been using a space heater all winter. On 4/01/25 at 8:52 AM, Maintenance Director (MD) C was interviewed and said there has been a problem with the heating unit in R49 and R51's room. When asked how long the heating unit was not working (MD) C could not give an exact timeline and said space heaters are used for emergency use only. Record review of R51's Electronic Health Record (EHR) revealed R51 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (one sided weakness) following Cerebral infarction (stroke). Review of R51's Brief interview for Mental Status assessment performed on 1/3/25 revealed a BIMS of 11/15, moderately impaired cognition. On 4/2/2025 at 11:30 AM, the Nursing Home Administrator (NHA) was queried about the heating unit in room [ROOM NUMBER] and the use of space heaters. The NHA said he was aware of the heater not working and was waiting for a room to become available to transfer R49 and R51. When queried about space heater use the NHA said space heaters are used for short term and emergency use only. Review of the facility policy Resident Rights undated noted: 9. Safe Environment: The resident has a right to a safe, clean, comfortable and homelike environment.

Based on interview and record review, the facility failed to provide six residents, who wish to remain anonymous and regularly attend the resident council meetings, with the grievance procedure or document resolution of concerns identified during the resident council meetings. Findings include: On 04/17/24 at 1:30 PM, the six residents in attendance at the resident council meeting were asked if they had been informed about the grievance procedure and how to file a grievance and all denied a working knowledge of the process. The residents agreed all complaints had been verbal and written follow up or resolution was not provided. The residents had voiced repeated concerns with staffing agency and nighttime staff not wearing name badges, unmet care needs, being left for extended periods on the toilet, clothes damaged, call light wait times, staff coming in and turning off the call light and not coming back, or poor attitude from staff. There were also questions on resident rights. A review of the Resident Council notes dated 04/13/23 revealed, .Do not like doing the kids crafts. CENA (nursing assistants): Would like (Certified Nursing Assistant) CNA's to introduce themselves when they start their shift, call lights not being answered. (Resident) had her call light on for 2 hours at 3 a.m. when she needed assistance to the bathroom. CNA's talking on their phones during patient care. Ice water not being giving passed and laundry not being picked up for a week. Dining Services: Food is sometimes cold. Fruit is being put on plate and gets juice from the fruit on the toast or rolls and even into the food. Soup has been watery, condiments are not consistent, they run out of crackers or do not have croutons or cheese for onion soup. Residents would like things like cheese sticks served on occasion. Housekeeping: Floors have been sticky, substitute housekeeper (name) only empties trash in rooms. Laundry: (Resident) says she has not received her laundry back from last week. A review of the Resident Council notes dated 05/03/23 revealed, .CNA's not answering each other's call lights when one is on break, turning off call lights and not returning. Wet brief was laid on dresser, trash not being picked up and thrown out after doing care, resident had to pick up trash: Why can't agency CNA's wear name badges? Dining Services: (Resident) said she has not been receiving her proper bowl and utensils at mealtime. (Resident) said she is thickened liquid and it was so thick that the spoon stood upright. Housekeeping: Pop was spilled on floor of room [ROOM NUMBER] on Sunday night, resident had to clean it up on Tuesday night. When do floors get mopped? Laundry: CNA's are not picking up laundry at night . A review of the Resident Council notes dated 06/06/23 revealed, .CENA: Agency not wearing name tags. CENA-(name) told resident to wheel herself to shower room and didn't give shower until 11 p.m. CENA left size small brief for resident to put on that is an XX Iarge, and did not offer to help with it, also CENA's not washing private areas when changing residents in the morning. CENA's wearing earbuds and taking personal calls on their phones during patient care. Beds not being changed on shower day. Still turning off call light and never return. A review of the Resident Council notes dated 07/10/23 revealed: . CENA: CENA has bad attitude, one yelling from the doorway-what do you need, you still have a hand and that's a one handed job. CENA's talking on their phones while doing care. Laundry: Short on washcloths: Ink spots on 3 tops of (R1) . A review of the Resident Council notes dated 08/02/23 revealed: .CENA: Some are good, some are bad. (CENA) has been mean and rude to (R1) and tries to get other CENA's to care for (R1) so she doesn't have to. No ice water is being passed. The care by aides on Michigan is not as good as on [NAME] . A review of the Resident Council notes dated 08/02/23 revealed: .CENA: We only receive water when pills are passed, no ice water being passed. Not enough CNA's in dining room to feed during mealtime. You have to ask for your bed to be made and if day shift doesn't make it, night shift says (it's not my job). You have to wait 45 mins. to l hour to use the bathroom. When call light is on CNA will say I'll get your aide and no one comes back. Call lights are not being left where they can be reached. Residents being left in dining room after meals. Agency CNA's not wearing name badge. Looking for a CNA between 7 and 730 p.m. and they were all sitting in Station 2 nursing office. Agency CNA took 3 hours to give bed bath, she kept leaving and coming back and resident would fall asleep. On 8/5 resident was not checked or changed by CNA and her food tray was left next to bed and she was not assisted with feeding. Dining Services: Food has been cold, (Resident) stated that her tray was left on counter and not given to her and food was cold . A review of the Resident Council notes dated 10/04/23 revealed: .CENA: Residents are requesting to have a shower team. CENA's are on their cell phones and also do not come in to introduce themselves as being our aide for that shift. On 10/2 day shift (R4) asked to be changed and waited 4 hrs. for CENA to assist her, also (R26) waited 45 mins to be changed. CENA's still sitting in nurses office on (Station) 2 on night shift. The weekend of 9/30 and 10/1 was terrible for CENA care. (Resident) complaining she does not get fed on evening meals. No lids for cups, cups collapse when you grab them, running out of briefs and pads, out of thickened water and (Resident) was given thickened juice and caused her sugar to go up. On 10/3 CENA was rough with (resident) on nights . A review of the Resident Council notes dated 11/01/23 revealed: .CENA (nursing assistants): Residents trays that are served in the rooms are not being set up and residents are not eating. Michigan CENA's need to work more as a team and help each other. (Resident) said he was left on the toilet for 1 hour and then 2-3 CENA's come in and they are talking to each other and he felt very uncomfortable because he was not dressed . A review of the Resident Council notes dated 12/06/23 revealed: .When CENA is providing care and nurse comes into the room they need to shut the door when leaving the room. Also when CENA is changing resident they are throwing blankets on the floor and resident then wants the blanket washed. Dining Services: Always out of nectar, and food is still cold on trays delivered to rooms. Nurse: Agency staff told residents on Thanksgiving that no one was getting up and they are concerned that will happen on Christmas . A review of the Resident Council notes dated 01/12/24 revealed: .Nursing (R4) feels there is no consistency in the staff on Michigan unit. (R1) states that it takes forever for staff to answer call lights on midnights . Activities some childish . A review of the Resident Council notes dated 02/16/24 revealed: .CENA: CENA's still talking to each other about personal things while giving care. Residents being left in dining room after dark. Nurse: Don't always shut the room door when exiting and CENA is providing care. Dining Services: Running out of food lately Iike, cottage cheese, peaches and different salad dressings . A review of the Resident Council notes dated 03/06/24 revealed: Call lights still being turned off and CENA leaving and stated I will be back and does not return. Still running out of cottage cheese and also had no lemonade. Some residents would like their French fries fried not baked. (Resident) would like smaller portions. Residents and visitors going behind the counter and helping themselves to snacks in the cupboard and things in the refrigerator . A review of the Resident Council notes dated 04/03/24 revealed: Some residents are getting French vanilla creamer and would like plain. (Resident) having issues with what is being put on her tray and dietician discussed with resident during meeting. A review of the above minutes revealed all had the following statement at the end: Ombudsman Posters: Are laminated and are displayed on the wall at wheelchair level near each nurse's station. Recent survey results located in binders labeled with the year and survey results. Those binders located on each unit in a clear front wall file box at wheelchair level. Resident's rights reviewed and copies offered. Copies of What I do Matters slips given to residents and explanation of program was explained. It is not uncommon to wait up to 10 mins. before your call light is answered, we are not staffed the same as a hospital is, but staff will do their best to get to you as quick as possible. Further acknowledgement or resolution of prior resident concerns was not documented in the minutes. On 04/17/24 at 4:32 PM, a review of the complaint and grievance procedures were reviewed with the Wellness Coordinator (WC). The WC reported they take attendence and proceed down the list of departments to identify any concerns. When concerns are identified copies of the minutes are made and sent to the appropriate department for resolution. The department manager then should come up with a plan and respond back to the WC which is then brought to the residents. The WC acknowledged the concern with the use of agency staff and reported residents prefer house staff and they thought the last two months had gone a little smoother. The WC further reported they had reviewed the grievance procedure and handed out forms at past meetings but had not had any resident fill one out. On 04/18/24 at 8:33 AM, the Director of Nursing (DON) confirmed the use of agency mostly on the night shift and just for the CNAs and that they have regular badges for these staff. The DON reported they take the resident complaints at their word and act on them. The DON reported they receive a copy of the resident council minutes and they are reviewed at the Quality Assurance meetings. A review of the facility policy titled, Complaint Assistance/Grievance with effective date of April 2002 revealed, .We are committed to providing the highest quality of care to residents in our facility. We want you to feel safe in a homelike environment. In order for us to assist you, please follow the procedure identified below if you have any concerns about your care, treatment by staff, or anything else related to your stay in our facility. Step 1. Tell the Social Worker (Mon a Fri during business hours), the Unit Manager or the Charge Nurse (on off shifts) of your concerns. For off shifts and weekends, check the complaint contact information calendar for complaint and grievance contact person. Step 2. If not satisfied with the staff person's response, complete our Resident Concern Form. Let us know if you need help in completing the form. Step 3. Submit the form to Social Worker. Step 4. If not satisfied with the facility's written response, complete a request for the Director of Nursing or Administrator to review the investigation findings. Step 5. If not satisfied with their solution, you may contact the State Ombudsman or the Michigan Department of Consumer & Industry Services, Bureau of Health Systems, to file a formal complaint . A review of the facility policy titled, Resident Council Meetings with last revised date of March 2013, revealed, It is the policy of the Village of East Harbor that resident council will be held and conducted monthly by the Social Worker or designee with council permission. All meetings will be conducted in accordance with Presbyterian Village East Bylaw's for resident council. Meeting notes are to be recorded and reviewed by the Social Worker or designee. Any concerns or complaints voiced by the residents during this meeting will be forwarded to the respective department head for follow up.

Based on interview and record review, the facility failed to document and include residents and resident representatives in care conferences for six residents (R1, R4, R21, R26, R47, R50) of seven residents reviewed for care planning participation. Findings include: Resident #50 (R50) On 4/18/24 at 9:06 AM, a review of R50's electronic medical record (EMR) ninety day review of R50's care conferences revealed no documentation of R50 being invited and included in their care conferences on 10/24/23, 1/12/24, and 4/11/24. On 4/18/24 at 9:13 AM, a further review of R50's EMR revealed that R50 was originally admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes and Schizoaffective disorder. R50's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R50 had a moderately impaired cognition. On 4/18/24 at 11:23 AM, R50 was interviewed regarding their level of participation and invitations to their care conferences at the facility. R50 stated, I've never been invited to a care conference. R50 further expressed their desire to be included in their care conferences. On 4/18/24 at 11:30 AM, Social Worker (SW) B was interviewed regarding the process for inviting and including residents and resident representatives in care conferences. SW B indicated that families are invited and residents should be invited and included in care conferences, As long as they can understand things. SW B was asked to provide documentation of R50's invitation and participation in their care conferences. SW B was unable to provide the requested documentation prior to survey exit. On 4/18/24 at 12:01 PM, the Director of Nursing (DON) was interviewed regarding their expectations for inviting and including residents and resident representatives in care conferences. The DON indicated that a letter should be sent to resident representatives with enough time for them to respond. If they cannot make it, then they need to be provided with another opportunity to attend. 32220 On 04/17/24 at 1:30 PM, during the group meeting, the six residents in attendance were asked if they had been included in their care conference and reported they had not been routinely included or invited to attend. They further reported on query they were not provided or offered a copy of their care plans. One resident reported they did not become aware of their care conference until informed by their representative. A review of the record for R47 revealed R47 was admitted into the facility on [DATE]. Diagnoses included Respiratory Failure. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 14/15 Brief Interview for Mental Status (BIMS) score and the need for assistance with all Activities of Daily Living (ADLs), bed mobility and transfer. A review of the Care Conference/Baseline Care Plan Summaries revealed on 04/04/24 and 12/19/23 the resident was not documented as present and no resident or responsible signature was documented; On 09/26/23 resident attendance was documented; On 06/27/23 a niece was present but not the resident. A review of the record for R26 revealed R26 was admitted into the facility on [DATE]. Diagnoses included the Need for Assistance with Personal Care and Stroke. The MDS dated [DATE] documented intact cognition with a 14/15 Brief Interview for Mental Status (BIMS) score and the need for assistance with all Activities of Daily Living (ADLs), bed mobility and transfer. A review of the Care Conference/Baseline Care Plan Summaries revealed: Resident attendance was documented on 01/16/24; A sister was present, but not the resident; On 10/24/23 and 07/25/23; And no family, nor the resident attended on 04/25/23. A review of the record for R1 revealed R1 was admitted into the facility on [DATE]. Diagnoses included Respiratory Failure and Stroke. The MDS dated [DATE] documented intact cognition with a 13/15 Brief Interview for Mental Status (BIMS) score and the need for assistance with all Activities of Daily Living (ADLs), bed mobility and transfer. A review of the Care Conference Baseline Care Plan Summaries revealed: On 04/04/24, resident attendance was documented; On 01/09/24 a box was checked I agree with the care plan but resident attendance was not documented; And on 10/17/23, 07/18/23 and 04/12/23 resident attendance was not documented. A review of the record for R4 revealed R4 was admitted into the facility on [DATE]. Diagnoses include Multiple Sclerosis. The MDS dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status (BIMS) score and the need for assistance with all Activities of Daily Living (ADLs), bed mobility and transfer. A review of the Care Conference Baseline Care Plan Summaries revealed: On 02/13/24, 11/22/23, 08/29/23, and 05/30/23 attendance by multiple daughters was documented, but no resident attendance was documented. A review of the record for R21 revealed R21 was admitted into the facility on [DATE]. Diagnoses included Multiple Sclerosis and Heart Disease. The MDS dated [DATE] documented intact cognition with a 14/15 Brief Interview for Mental Status (BIMS) score and the need for assistance with all Activities of Daily Living (ADLs), bed mobility and transfer. A review of the Care Conference Baseline Care Plan Summaries revealed: On 03/19/24 a voicemail was left for a daughter and neither the daughter nor the resident was documented as attended; On 12/28/23 was not documented as attended; On 10/2/23 the facility documented the resident declined care conference attendance; On 08/22/23 the facility documented the family/resident declined attendance; And on 05/23/23 the facility documented the resident and family declined care conference attendance. A review of the facility policy titled Interdisciplinary Care Conference Procedure last reviewed 12/2016 revealed, It is the policy of the (the facility) to allow each Resident Representative, and the Resident if mentally able, the opportunity to attend the Interdisciplinary Team Meeting (Care Conference) on a quarterly basis .Schedule: A calendar will be maintained by the Social Worker to inform participants of resident's having care plan reviews and when, Letters inviting Resident Representatives are posted and/or given to the responsible party prior to Care Conference by the Social Worker, Competent residents are invited in person by the Social Worker, Resident Representative and resident if appropriate will be noted to be in attendance .

Based on observation, interview, and record review, the facility failed to ensure inhalers were labeled with a resident identifier and dated when opened in one of four medication carts. Findings include: On 04/17/24 at 8:54 AM, in the Michigan 2A medication cart, one Trelegy inhaler did not have the name or the date opened on the inhaler; Two of the three other Trelegy inhalers did not have the name and the third did not have a date on the inhaler. On 04/18/24 at 3:58 PM, the Director of Nursing (DON) was asked about label and dates on inhalers and reported, My expectation is to date and initial; with the date opened and resident initials. A review of the facility policy titled, Medication Storage with last reviewed date of 04/24, revealed, Policy: It is the policy of (the facility) to store medications properly in accordance with clinical best practice and according to drug manufacturer instructions . 3. Date opened: All flushes, multi-dose Vials, irrigation solution and IV fluids must be marked with date opened or first used . 5. Inhalers: Store in the original box from pharmacy. Label the device with resident name . A review of the manufacturer's prescribing information for the Trelegy inhaler dated December 2022 revealed, Safely throw away Trelegy Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler.

Based on observation, interview, and record review, the facility failed to implement interventions from the fall care plan for one resident (R32) out of three reviewed for care plan interventions. Findings include: On 4/16/2024 at 9:20 AM, R32 was interviewed regarding their care in the facility. R32 stated that they had just moved to the long-term care side. R32 stated that they had a broken hip that is healing nicely. R32 stated they often transfer themselves, but the staff try and remind them to use the call light. A review of the medical record revealed that R32 admitted into the facility on [DATE] with the following diagnoses, Fracture of Right Femur, Muscle Weakness, and Difficulty in Walking. Further review of the Minimum Data Set assessment (MDS) revealed a Brief Interview for Mental score of 10/15 indicating an impaired cognition. R32 also required one person assist with bed mobility and transfers. A review of the fall risk assessment revealed that R32 was a high fall risk. Further review of the care plan revealed the following fall interventions, I have a landing strip next to my bed- Date Initiated: 3/17/2024. I have an antiroll back on my wheelchair-Date Initiate: 3/17/2024. Dycem (nonskid pad) to my wheelchair, cut to fit, must be intact, clean and in place at all times to increase my safety-Date Initiated: 3/17/2024. On 4/18/2024 at 9:15 AM, R32 was helped to stand up with Licensed Practical Nurse (LPN) C. Upon observation, no dycem was noted to be in the wheelchair. Upon further review, no landing strips were noted by the bed and there were no anti rollbacks on the wheelchair. On 4/18/2024 at 11:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated their expectation is that fall interventions from the care plan are implemented. The DON stated that R32 just moved to their room from another side of the facility. A review of a facility policy titled, Comprehensive Fall Risk Reduction Program noted the following, It is the policy of the [Facility] to ensure that the resident environment remains free of accidents hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents falls.

This citation pertains to Intake: MI00136749. Based on interview, and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement for one resident (R901) who had a severe cognitive impairment, was a known elopement risk, and wore a WanderGuard (a bracelet used to set off an alarm restricting a resident from walking out of the door). R901 eloped from the facility on 5/15/2023 at approximately 3:25pm without facility staff being aware of the resident's whereabouts. R901 was allowed to exit the facility by a staff member that was unfamiliar with the resident at approximately 3:25pm. R901 exited through doors that were unequipped with a WanderGuard alarm system, crossed a high traffic four-lane street, while heading toward their house of origin which is approximately 2 miles away from the facility. R901 was found by their neighbors, and driven to the resident's home at approximately 4:46pm. R901 returned to the facility at approximately 5:30pm, combative and agitated. This deficient practice resulted in the likelihood of serious injury, serious harm, serious impairment, or death. Immediate Jeopardy: The Immediate Jeopardy (IJ) started on 5/15/23 and the immediacy was removed 5/17/23 when the resident was discharged from the facility and per review of the facility's responding interventions as verified on 10/4/23. The IJ was identified on 10/3/23 during an abbreviated survey. The facility was notified of the IJ on 10/4/23 at 2:40 PM and was asked for an abatement plan. The IJ was removed on 7/10/23, based on the facility's implementation of the abatement plan as verified onsite on 10/4/23. Findings Include: A review of R901's electronic medical record revealed that the resident was admitted into the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction (stroke) affecting right dominant side, Cerebral Edema, Respiratory Failure, Seizure-Like Activity, and Aphasia (loss of ability to understand or express speech). A review of R901's Brief Interview for Mental Status score dated 5/10/23 revealed that the resident had a 0/15 score indicating a severe cognitive impairment. A review of the admission Minimum Data Set (MDS) assessment revealed that the resident required limited assistance for bed mobility, transfers and toilet use. Further review of the MDS revealed that the resident was, Not steady, only able to stabilize with staff assistance when walking, and utilized both a walker and wheelchair, which was described as normally used. Further review of R901's electronic medical record revealed an Elopement Care Plan created on 5/10/23 indicating the following: Problem: I am an elopement risk/wanderer r/t (related to) Impaired safety awareness. Date Initiated: 05/10/2023 .Interventions: Distract me from wandering by offering pleasant diversions. Date Initiated: 05/10/2023 .Identify my pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 05/10/2023 .WANDER ALERT: Applied to L (left) ankle. Date Initiated: 05/10/2023 . Further review of the electronic medical record revealed the following progress note: 5/15/2023 19:30 (7:30pm) Alert Note Late Entry: Note Text: At 1612 (4:12pm) writer pulled residents afternoon medications for administration, writer went to residents' room to administer medications and noticed resident was not in their room but noticed resident's wheelchair and shoes where still in room. Writer questioned CNAs (certified nursing assistants) of resident's whereabouts, but CNAs were unaware of resident's whereabouts. Writer began to look for resident immediately throughout the building and courtyard. At approximately 1625 (4:25pm) writer contacted resident's [spouse]. Writer asked the [spouse] if [they were] still present with the resident, [spouse] stated [they were] not. [Spouse] then stated their neighbors had found [R901] walking down the street, on [street name] towards home. The [spouse] also stated once the neighbors arrived at their home, [they] would bring [R901] back to the facility . The DON (Director of Nursing) and Administrator were notified immediately of the situation. At 1646 (4:46pm). Writer contacted [spouse] again to see if the resident had arrived safely to [them], [spouse] stated that [R901] was with [them],was safe, and unharmed, but very agitated and fighting the [spouse] about returning to the facility. The [spouse] stated they were going to get [R901] calmed down and once [they were], they would bring [R901] back to the facility. [Spouse] did confirm that the wonderguard (WanderGuard) was still in place and located on the left ankle. At 1730 (5:30pm) Resident arrived to back to the facility safely via vehicle with [spouse] and neighbors. Resident was very combative and agitated, writer was unable to perform a head-to-toe assessment .Resident receiving 1:1 supervision at all times. On 10/3/23 at 10:34 AM, Nurse A was interviewed via phone regarding the elopement of R901. Nurse A explained that R901 had family visiting most of the day, and explained that [R901] was supposed to have 1:1 supervision but as a result of staffing, they couldn't provide the resident with one, so as a precaution the family was supposed to notify R901's assigned nurse when they were leaving for the day. Nurse A was asked why R901 need 1:1 supervision, and explained that she did not know. Nurse A further explained that the family informed another nurse they were leaving, and that the other nurse failed to inform her. Nurse A explained that between 3:30-4pm, she entered the resident's room noticing that the resident's wheelchair and shoes were in their room, but they were not. Nurse A explained that she asked the assigned CNA if they knew where R901 was located, and they indicated that they did not know, and that the last time they saw R901, they were with family. Nurse A explained that R901 was eventually located by a high traffic road heading toward their home. Nurse A was asked about R901's cognition, and explained that R901 couldn't speak, and their words were jumbled. On 10/3/23 at 11:15 AM, an attempt to reach R901's assigned CNA the date of the elopement was to no avail, and a message was left. On 10/3/23 at 11:20 AM, the DON was asked to demonstrate how R901 exited the building. An observation of the door R901 exited through was a locked door that could only be opened by an employee with an access card. On the other side of the door was an entry way that led to independent living high rise apartments located on the facility's campus, in addition to a bistro, and two sets of electric sliding doors leading to the outside. The DON explained that an employee working in the bistro thought that the resident was a visitor, allowing them access through the door where the resident ultimately exited the building. The DON explained that there was not a WanderGuard alarm on the door R901 was let out of due to fire safety regulations, specifically the locking mechanism that are on the other doors within the facility with a WanderGuard system. The DON explained that following the incident, a WanderGuard sound alarm was placed on the door (on 7/10/23). On 10/4/23 at 8:25 AM, Employee B was asked about the elopement of R901, and she explained that she works in the bistro and that on that date, she had just returned from her break which was sometime between 3:15-3:30pm. Employee B explained that she observed R901 standing by the door staring out of the window, and thought that they were a visitor. Employee B explained that she used her access card to open the door for the resident and walked away, not paying attention to where the resident was going or the resident's attire, as she was later informed that the resident had on pajamas pants. Employee B explained that she only looked at the resident from the waist up, and was unaware that she was responsible for the resident exiting the building until the next day, 5/16/23. A review of the facility's investigation regarding the elopement revealed the following investigative outcome, In conclusion, based on the facility investigation, the staff responded appropriately per facility protocol and ensured [R901's] safe return to the facility. At the time of incident, the resident knew [their] outdoor location in proximity to [their] home. The resident also knew [their] exact way home. The resident returned to facility unharmed. The facility staff did not deviate from resident's plan of care. Currently, resident remains on 1:1 supervision around the clock and [their] wander-guard is in place. The resident is having periods of agitation and attempts to leave the building multiple times per day, and [R901] is not easily redirected. The resident's [spouse] and son are very involved with the resident's care. [R901's spouse] has decided to take resident home where [they feel R901] will be less agitated and more cooperative. The resident's [spouse] declined hospital transfer for a further psych evaluation as recommended by [their] physician. The facility discharged the resident on 5/17/23 at approximately 16:00 (4:00pm) with homecare. On 10/4/23 at 8:35 AM, the DON and Nursing Home Administrator (NHA) were asked about the date the WanderGuard sound alarm was placed on the door R901 exited out of. The DON explained that the alarm was placed on the door 7/10/23. The NHA explained that the incident was unfortunate, but that they implemented additional security measures, and monitored the door until the supply chain issue were resolved, and the sound alarm was placed on the door. A review of the facility's Elopement/Wandering Risk policy revealed the following, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .Policy: Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . Facility Abatement Plan ELEMENT 1 Resident no longer resides in the facility. Resident was reassessed for elopement immediately upon return on May 15th, 2023 with a score of 8 indicating at risk for elopement. Wander guard intact to left lower extremity. A visual head to toe assessment and pain assessment was completed due to residents agitation. No concerns were identified. Residents physician notified and evaluated resident immediately upon return. New orders were initiated for agitation. Care plans reviewed, modified and deemed appropriate. Medical Director and guardian made aware immediately. Resident was seen by Social Services on 5/16/2023, and there are no identified changes in psychosocial wellbeing and quality of life. Resident was immediately assigned 1:1 around the clock supervision. Resident evaluated by [physician] from [mental health agency] on 5/15/2023. Exit doors remain locked and wander-guard door alarms remain activated. The Director of Nursing provided 1:1 education to the employee who was incidentally involved in the residents' elopement. An emphasis was placed on identifying wandering and elopement residents. ELEMENT 2 All residents who reside in the facility have the potential to be affected by this practice. On the day of the event 5/15/2023, all remaining residents were accounted for. Ninety three (93) residents were confirmed to be present in the building. Door and wander guard alarms were also checked by staff, on the day of the incident, to ensure safety of all other residents. Like resident's who self-propel around facility, and have wander guards, were reassessed for risk of elopement to ensure proper safety measures were in place per individual care plans and no concerns identified. Elopement books located at each nurse's station and front desk were reviewed and deemed appropriate by DON on 5/16/2023. ELEMENT 3 The Facility Interdisciplinary team held an Ad hoc Quality Assurance Performance and Improvement meeting on 5/16/2023. Policy and procedure for Elopement/Wandering Risk was updated, reviewed and deemed appropriate for implementation and staff education. The Director of Nursing and management team re-educated all nursing staff regarding the facility's policy and procedure for elopement/wondering risk, and how to identify residents at risk for elopement. Department leadership team educated inner department employees on how to identify residents at risk for elopement and wandering. Future agency staff will be educated regarding elopement/wandering policy and procedure, by way of a Purple Welcome Binder, prior to receiving shift assignment. ELEMENT 4 In order to monitor our procedure and ensure the facility's plan of correction is effective and specific deficiency cited remain corrected, Director of Nursing or designee, will review new admission elopement risk assessment at daily clinical meeting, and any reports of elopement occurrence, to ensure appropriate interventions are implemented and updated plan of care is complete.

Based on observation, interview, and record review the facility failed to ensure full visual privacy was provided during a blood draw for one resident (R67) of one reviewed for privacy concerns, resulting in a concern for privacy and potential embarrassment. Findings include: On 03/28/23 at 9:08 AM, R67 was observed to be seated in their wheelchair in the dining room on the [NAME] unit. Additional residents were observed eating their meals. R67 was away from the main dining table at one end of the sofa. R67 had their back to the hall and was seated with the phlebotomist (technician that collects blood). The phlebotomist cart was next to them and R67 was in the process of having their blood drawn. 03/29/23 at 9:20 AM, R67 was asked resident about their blood having been drawn in the dining area and reported it was one of those things that should be done in their room. R67 reported they felt they were not given a choice to return to their room. R67 further reported on query that the phlebotomist had excuses for drawing the blood in the dining area and mentioned time as one of them. On 03/29/23 at 9:28 AM, Unit nurse manager A was asked about R67's blood draw and reported blood draws should be done in the resident's room. A review of the record for R67 revealed, R67 was admitted into the facility on [DATE]. Diagnoses included Osteomyelitis (infection) of the foot and ankle, Diabetes and Heart Disease. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition, and independent for locomotion on the unit. Lab results documented a blood draw on 03/28/23 with received time of 9:10 AM and a run time on 03/28/23 of 9:54 AM. On 03/29/23 at 2:55 PM, the Director of Nursing (DON) reported, We do not have a policy specific for privacy during care.

Based on observation, interview, and record review, the facility failed to meet the care needs of a resident (R36) out of five reviewed for Activities of Daily Living (ADL's), resulting being left soiled for an extended time. Findings include: On 3/27/23 at 9:41 AM, R36 was observed in bed and watching television. R36's bed sheets were observed to have a large brown stained area that went down the side of R36's leg. The stain appeared to be from a bowel movement (BM). R36 was asked if staff had been in to see them and stated, No. I just woke up. On 3/27/23 at 10:42 AM, R36 was observed in the same condition as before, soiled with BM through the sheets. R36 was asked if they had been changed and stated, Not yet. They will be in. On 3/27/23 at 12:18 PM, R36 was observed in the same condition, R36 explained that staff had not come in to change them. On 3/27/23 at 12:45 PM, Licensed Practical Nurse (Nurse B) was asked to observe R36 sheets. LPN B stated, Looks like you had a BM and need to be cleaned up. R36 replied, Yea. I can't do it. LPN B stated, I know, we will. You have to tell us. LPN B explained that she would get someone to help R36. LPN B was asked how often the Certified Nursing Assistants (CNAs) come in to check on the residents. LPN B explained that the CNAs are to come in a do their rounds and check or change the residents if needed. A review of R36's medical record noted, R36 was admitted to the facility on [DATE] with diagnosis of Hemplegia. A review of R36's Minimum Data Set (MDS) assessment revealed, R36's activities of daily living (ADL), bed mobility was listed as extensive assistance by one staff person. A review of R36's care plan revealed, Problem: I have an ADL self-care performance deficit r/t (related to) pericardial effusion, aortic abdominal aneurysm, CVA (cerebrovascular accident) and vertigo. Date Initiated: 03/15/2021. Goal: I will improve current level of function in all ADL's through the review date or maintain function. Date Initiated: 03/15/2021. Intervention: I require 1 PA (person assist) for bed mobility. Clean and change every 3 hours and prn (as needed), offer a bedpan for BM. Date Initiated: 3/15/2021. On 3/29/23 at 2:21 PM, the Director of Nursing (DON) was asked the facility's expectation to ensure residents are clean and dry. The DON stated, I expect my CNA's to do their q2hrs (every 2 hours) rounds to check and change the residents. A review of the facility's policy, CNA REPORT / ROUNDS dated, 11/15 noted, POLICY: It is the policy of the Village of East Harbor for CNA's to complete walking rounds at change of shift. They are also responsible for completing report sheets; in order to effectively provide care for residents they have been assigned. PROCEDURE: 1. On coming CNA and off going CNA are to do walking rounds, and report, at change of shift. 2. All alarms are to be checked during walking rounds.

Based upon observation, interview and record review, the facility failed to develop and/or implement the care plan for 1. wrist/hand splint (R5) and 2. frequency of resident repositioning for two (R15, R54) of three residents reviewed for repositioning, resulting in the potential for contractures and new or worsened skin breakdown. Findings include: R5 Review of the facility record for R5 revealed an admitted [DATE] with diagnoses that included Multiple Sclerosis and Muscle Weakness. The Minimum Data Set (MDS) assessment dated [DATE] indicated R5 required set up for eating and was dependent for self care otherwise. The Brief Interview for Mental Status (BIMS) score was 15/15 indicating intact cognition. On 3/27/23 at 12:21 PM, It was observed that R5's right wrist was resting in an extended (bent backwards) position. R5 was not wearing any type of splint or orthosis and one was not observed in the room. On 3/28/23 at 10:40 AM, R5 was observed with the right wrist maintained in extension. When asked about any history of splint use R5 reported that they thought they had used a splint in the past but they believed it had been at least three weeks since it had been put on. R5 could not recall if a splint was kept in the room and gave this surveyor permission to check the drawers. A right wrist/hand splint with a soft blue cover was located in the drawer. R5 reported that they did not recall wearing it for some time and did not realize it was in the drawer. On 3/29/23 at 8:59 AM, R5 was observed in their room sitting up in the wheelchair eating breakfast. The right wrist/hand splint was not on and remained in the drawer. R5 reported that no one had offered to apply the splint since the previous day. When asked whether they had ever refused use of the splint R5 stated not that I can recall. Review of R5's physician orders with a review date of 1/15/23 revealed the following order with active status: Staff to don (apply) resting hand splint 2-4 hours daily or as tolerated to promote/maintain proper wrist positioning. Review of R5's facility care plan dated 3/6/23 revealed the Problem area stating I have an ADL (Activities of Daily Living) selfcare performance deficit related to musculoskeletal impairment. Interventions related to this area included apply right hand splint as ordered. Review of R5's Treatment Administration Record (TAR) for March 2023 revealed no documentation or task area related to hand splint application or resident refusal. On 3/29/23 at 1:20 PM, the facility Director of Nursing (DON) stated that their expectation for application of splints is that staff apply splints according to the physician order and care plan. Review of the facility Policy titled Splints, Braces, Slings (undated) included under the Procedures listing 3. Apply and remove as ordered and 5. Enter device on TAR as an FYI. R15 Review of the facility record for R15 revealed an admitted [DATE] with diagnoses that included Duchenne/[NAME] Muscular Dystrophy, Diabetes Mellitus, Congestive Heart Failure, Peripheral Vascular Disease and Osteoarthritis of the left ankle/foot. It was also noted that R15 currently had multiple lower extremity wounds. The Minimum Data Set (MDS) assessment dated [DATE] indicated R5 required maximum/total assistance for bed mobility. The BIMS (Brief Interview for Mental Status) score of 14/15 indicated intact cognition. On 3/28/23 at 11:23 AM, R15 reported that they developed wounds on the right leg at a prior facility and stated that their condition was improving. R15 stated that there was some re-injury of the wounds related to contact with the wheelchair during pivot transfers but that this was no longer the case as transfers are now completed via mechanical lift. When asked if they are able to reposition themselves in the bed R15 stated No, I need help and they don't do it. When asked if they are ever repositioned R15 stated rarely, sometimes they will if I ask. It was noted that reposition Q3 [every 3 hours] sinage was posted for R15 outside the door. On 3/29/23 at 8:50 AM, when asked if they had been repositioned during their time in bed since being interviewed the previous day R15 stated Maybe once before they got me up for the morning. Review of the physician orders for R15 with review date of 1/15/23 revealed no order for repositioning. Review of the facility care plan for R15 dated 1/23/23 revealed no problem, goal or intervention for repositioning. It was noted that the ADL portion of the care plan specified that R15 required extensive assistance for bed mobility. Review of the R15's bed mobility task checklist in the electronic medical record (EMR) between the dates of 2/28/23 and 3/28/23 revealed that bed mobility assistance was documented as completed on a total of 26 days. One day had three episodes of bed mobility assistance documented, 22 days had two episodes of bed mobility assistance documented and three days had one episode of bed mobility assistance documented. R54 Review of the facility record for R54 revealed an admitted [DATE] with diagnoses that included Quadriplegia, Diabetes Mellitus, Lymphedema and Congestive Heart Failure. The MDS assessment dated [DATE] indicated R54 was dependent for bed mobility. The BIMS score was 14/15 indicated intact cognition. On 3/27/23 at 11:45 AM, R54 reported that staff do not reposition them during the night unless they wake up and call for help to do so. R54 reported that if they do wake up it is usually only once per night. On 3/28/23 at 8:18 AM, R54 reported that they were repositioned during the night at approximately three AM after requesting that it be completed. R54 reported that this was the only repositioning completed since being assisted into bed the previous evening. It was observed that sinage was posted outside R54's door indicating that they require repositioning Q3 [every 3 hours]. On 3/29/23 at 9:15 AM, R54 reported that they were repositioned one time during the night since being assisted to bed the previous evening. Review of R54's active physician orders revealed no orders related to repositioning. Review of R54's care plan (undated) revealed that the ADL self care problem area included the intervention Turn and reposition Q3 hours and PRN. Review of R54's bed mobility task checklist in the EMR (electronic medical record) revealed that between 2/28/23 and 3/28/23 the bed mobility task was documented on 28 days. One episode of repositioning was documented on five days, two episodes were documented on 19 days and three episodes were documented on four days. On 3/29/23 at 1:20 PM, the facility DON reported that the expectation for residents who require repositioning is that the task be ordered, included in the care plan and completed as indicated. Review of the facility policy titled Turning/Repositioning Program (undated) revealed that the Procedure section includes the following entries: 2. If the need exists for a turning/repositioning program, the nurse will write an order .4. If resident is sitting upright in chair, reposition frequently .7. The restorative nurse is responsible for monitoring and reassessing the effectiveness of the interventions.

This citation pertains to intake #MI 173. Based on observation, interview, and record review the facility failed to safely reposition one sampled Resident (#602) of three reviewed for accidents, resulting in a left arm fracture. Findings include: On 7/1/19 at 10:17 AM, Resident #602 was observed sleeping in bed and was unable to be interviewed at that time. On 7/1/19 at 12:11 PM, Resident #602 was observed in the dining room in a reclined wheelchair waiting for lunch to start. Resident #602's arms were not visible and were under a blanket, up to their chest area, and a food protector on top of the blanket. Resident #602 was asked if they had any injuries or accidents at the facility. Resident #602 stated, Yes, my arm was caught in this chair. Resident #602 did not offer any additional information about the incident. On 7/1/19 at 12:33 PM, Resident #602's lunch was placed on the table. An Unknown Staff stated, Where are your hands at so you can eat. Resident #602 was observed to start feeding them self. On 7/1/19 at 1:34 PM, Certified Nursing Assistant (CNA D) was asked about the incident with Resident #602's arm on 4/21/19. CNA D stated, It happened during lunch. The chair was reclined back, so I wanted to raise (R602's chair) for the meal. CNA D was asked how did they move the chair. CNA D stated, I took the chair back and then up, but it stopped. I looked under the blanket and saw (their) arm in the space. CNA D was asked if they checked to see where Resident #602's arm was before they raised the back of the chair up. CNA D stated, No. CNA D was asked how did Resident #602's arm look. CNA D stated, It was just a red mark. I reported it to the Nurse (Nurse B) and she told me that CNA A had reported it to her. Closer to dinner is when it started to bleed. On 7/1/19 at 2:18 PM, an attempt was made via phone to interview CNA A, a voice mail was left. A return call was not returned by the end of this survey. On 7/1/19 at 2:20 PM, Nurse B was interviewed via phone. Nurse B was asked about Resident #602's fractured arm on 4/21/19. Nurse B stated, The fracture occurred prior to my shift. (CNA A) came to me during the afternoon shift and said that (R602's) left arm had a scratch with dried blood. I assessed it and cleaned it. No range of motion because that arm is paralyzed. The next day x-rays were done, because (R602) complained of shoulder pain and was getting [MEDICATION NAME] more than usual. A review of Resident #602's medical record revealed, Resident #602 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #602 with an impaired cognition, required set up with eating and assistance with all activities of daily living. Care plan noted, Problem: I had a([MEDICAL CONDITION]/Stroke) Date Initiated: 03/31/2018. Intervention Turn and reposition q (every) 2 hours and PRN (as needed). Keep body in good alignment. Date Initiated: 03/31/2018. Further review of Resident #602's medical record revealed the following progress notes: 4/3/2019 12:55 (PM) Hospice Note: (R602) in dining room, in good spirits joking. Large bruise noted, 5 cm (centimeters) X (by) 5 cm, on left arm between the elbow & (and) wrist. Writer spoke with aide, he saw it this a.m. Writer spoke with Nurse to notify aides about making sure (R602's) is straight in Broda (reclining wheelchair) and they move (R602's) left arm to (their) waist to prevent pinching in chair. No c/o (complaint of) pain or discomfort at this time. 4/3/2019 13:08 (1:08 PM) General Nursing Note: Dark colored bruise to left posterior forearm reported this am by CENA (CNA). Son was notified. 4/9/2019 11:57 (AM) Hospice Note: Up in Broda leaning to the left side, quilt placed under arm for comfort b/c (because) (their) left arm falls into the crack of the chair behind the left arm rest. Bruise healing on left arm between wrist & elbow from pinching arm in arm rest . 4/21/2019 18:00 (6:00 PM) General Nursing Note Late Entry: During dinner service res (resident) was brought to my attention that (they) had dried blood on (their) left forearm. CNA showed me (R602's) arm on (R602's) way back to bedroom. I saw dried blood but no bruising or redness. After resident was back in room I was going in to give bedtime meds and evaluate arm. I cleaned arm and noticed a scratch. Res has no c/o pain. 4/22/2019 11:39 (AM) General Nursing Note: Left elbow noted to be swollen with 2 quarter size bruises near swollen area. Denies pain, states no feeling d/t (due to) past stroke. Does say, that aid was moving (them), and didn't pay attention to (their) arm, and it got caught in (their) Broda chair. 4/22/2019 23:35 (11:35 PM) General Nursing: 1845 (6:45 PM) x ray of left elbow no fracture and mod arthritic changes and left humerus is impacted humeral neck fracture. (Physician) ordered for left arm sling at all times, ortho eval . 4/23/2019 10:38 (AM) General Nursing Note: Writer spoke with resident regarding (their) left arm today. Writer asked, what happened? Resident stated, my arm got stuck in the chair, I didn't move it fast enough. Usually I grab my left arm with my right and move it out of the way to not get it caught. Resident indicated visually how (they) usually moves arm out of the way. Resident stated the only time (they) had pain in the arm was during the X-ray, when (their) arm was raised above (their) head, which was relieved after x-ray was completed. 4/23/2019 12:49 (PM) Social Service Note: I went in to see (R602) to find out how (R602) was doing after (their) injury. This sw (Social Worker) entered (R602's) room and (they) stated another inspector, I stated no I just wanted to check on (them). I asked (them) how (they) was and (R602) stated no pain, I stated well that is good. When I asked (R602) what happened (they) stated see that chair there (pointing to the specialty chair) well I was getting moved and my arm got stuck between the back and the armrest. I have no feeling so I had no idea what was happening by the time we both realized it what was done was done . It was an accident. (R602) then stated, someone just needs to develop something to stick in that hole . (R602) was cognitively aware of the incident, able to tell me where (R602) is but (their) recall of time and date seemed to be impaired. overall (their) insight into what happened seemed intact. A review of Resident #602's care plan noted, Problem: I had an alteration in musculoskeletal status (decreased mobility) r/t fracture of the (L (left)-humeral neck.) Date Initiated: 04/30/2019. Intervention I have L-sided [MEDICAL CONDITION]. Be extra careful to have proper body alignment for my L-arm during any type of care. Date Initiated: 06/18/2019. A review of the facility's investigation revealed, the following written statement: (CNA A) Sunday the 21st of (MONTH) around 5:30 pm Dinner time, (R602) was in Dining Room sitting around the corner of (R602's) table try to reach (their) food. So, I moved (them) a little bit sit (R602) upright position on (their) high back chair so (they) can reach (their) food and feed (self). While assisting other Resident's a few minutes later (a visitor) called me and said that she saw blood on (R602's) left arm almost dry. She told me that she saw it earlier when (CNA D) took him to Dining room. And I called the nurse (Nurse B) that check on (R602's) left arm I told her that (R602's) left arm is bleeding and its almost dry, looks like it's been there a while. As far as I know that's all I can remember that day. On 4/22/2019 I (CNA E) . had patient (R602) on the midnight shift. When I went into the room to do care on (R602) I noticed a black bruise on (R602's) elbow. So I asked (R602) were (they) in pain and (they) said no then I asked (R602) what happened (they) said they keep hitting my arm when they put me into the chair so I told the nurse . and she took a look at it so instead of getting (R602) up I dressed (them) and left (them) in bed. (Nurse F) I was the Station 1, Hall B, floor nurse from 10:30 pm to 7:00 am both Saturday, (MONTH) 20, and Sunday, (MONTH) 21 . On Sunday night I was in the resident's room when (their) CNA, (CNA E), was cleaning (R602) up. (R602) was awake, and I spoke with (them) about how (their) day was. (R602) said everything was good, but that (their) elbow was sore, that it had rubbed or hit the arm of the wheel chair. There were some dried scratches, and the skin was red . I told (them) that we would get some skin protector sleeves for (them) in the morning, to stop it from getting scratched up . A review of the facility Investigation report noted, Camera footage watched to observe mealtime during dinner for 4/21/19 to determine if resident's statement of how injury occurred match up with injury. At 4:26 PM (CNA D) is seen bringing resident out of resident room to the dining room. 4:26 PM Resident observed in dining room in Broda chair with blanket covering (R602's) upper body in reclined position. 4:27 PM (CAN D) sits resident chair into upright position. (CNA D) observed lifting blanket, moving left arm under blanket and reclining chair back to down position. Continued review of the facility's Investigation Summary noted, Conclusion Unit Manager, Director of Nursing, and Administrator reviewed all statements, nurses' notes, and camera footage to evaluate root cause of injury. It was concluded that resident statements of injury occurring from left flaccid arm falling between back-rest and arm-rest as staff member was sitting his chair upright in preparation for his dinner meal to be accurate . 4/23/2019 14:43 (2:00 PM) Skin/Wound Note: I performed a head to toe skin assessment today. Upon assessment, scattered small bruises of multiple ages noted on left forearm. No signs of finger marks, hand prints, or indications of abuse observed. Resident stated, My arm got stuck in the gap of the wheelchair when asked what happened. Resident asked if anyone has hit or pulled on his arm and resident stated, No. On 7/1/19 at 3:44 PM, the Director of Nursing (DON) was asked with Resident #602's history of arm getting stuck in the gap of the chair would the CNA need to check placement before repositioning. The DON stated, Yes, it would have been helpful. The DON continued and stated, We reviewed the video and saw the chair was reclined back and then forward. In the move back we think the arm may have slipped down. She (CNA D) reported it right away. On 7/1/19 at 4:11 PM, the DON and Administrator was asked should Resident #602's arm be visible when repositioning. The DON stated, They should be checking for placement. A review of the facility's policy titled, Positioning The Resident dated 4/18 and a review of a policy titled Turning/Repositioning Program dated 2/19, did not address repositioning a resident in reclining wheelchair.

This citation refers to MI 045. Based on interview and record review the facility failed to ensure fall safety alarms were working and activated for two (#901, #902) of four sampled residents reviewed for falls out of a total sample of four resulting in, a resident falling and fracturing a lumbar vertebrae that required hospitalization and the potential for injury related to a fall. Findings include: On 11/05/14 at 10:35 a.m., A review of the facility "Occurrence Report" for Resident # 901 dated 10/04/14 was completed and revealed: "Resident's wheelchair seat alarm was heard going off in dining room at 1700. Writer came to in to check on resident and observed him walking, lose balance, fall backward and hit head on the floor. Resident had ambulated from his chair to another table and lost his balance and fell backwards and hit his head. Wheelchair seat alarm was put in place on 10/03/14 order was clarified on 10/04/14 at that time a personal alarm was added to wheelchair." The facility "Occurrence Report" for Resident #901 dated 10/24/14 was reviewed and revealed: "Resident noted on floor, complaint of back pain, skin tear left upper arm. Resident up throughout night, multiple attempts to toilet and lay down, resident refused to lay down, resident brought to nurse's station. Preventative measures at time of fall: Alarm: not sounding. Conclusion: On 10/24/14 resident sustained [REDACTED]. Staff member then attempted to enter breakroom and noted resident on floor. Resident sent out to hospital complaining of back pain. Root cause: Human Error (Staff Error)." On 11/05/14 at 10:45 a.m. and 4:50 p.m., the medical record for Resident #901 was reviewed and revealed: Resident #901 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment ((MDS) dated [DATE] revealed: Resident #901 had a severe cognitive impairment and required extensive assist of two persons for transfer, toileting and hygiene and noted the history of falls. The Safety Care Plan with effective date of 10/03/14 revealed: (Resident #901) is at risk for injury R/T (related to) Altered Safety Awareness, Decreased Cognition, Impaired Judgement , Generalized Weakness, Medical Condition. Interventions: "Initiate appropriate safety device. Specify: FBA (flat bed alarm), w/c (wheel chair) seat alarm (a pressure pad alarm which activates when a resident rises or moves enough to activate and resets when pressure is reapplied), PA to wheelchair, PA to bed (Personal Alarm (an alarm in which the resident is attached to the alarm via an adjustable string, a magnet at one end, a clip at the other, when the resident moves forward or rises enough the magnet is pulled from the alarm and is activated.)) Status: Active (Current)" Resident #901 was discharged to the hospital on [DATE] and did not return to the facility. On 11/05/14 at 11:15 a.m. an observation of the door to the breakroom revealed there was was no locking device on the door to prevent access to the breakroom by residents and the door required minimal pressure to open once the handle was turned. On 11/05/14 at 12:18 p.m. Nurse "D" was queried about Resident #901's wheelchair seat alarm and stated, "The alarm would go off if (resident #901) repositioned (their) bottom." Nurse "D" was further queried if the alarm was activated if the resident leaned forward or side to side and indicated, "Yes." On 11/05/14 at 12:30 p.m. Certified Nursing Assistant (CNA) "E" was queried if the wheelchair seat alarm could be turned off and stated, "Yes. There is a switch on the bottom." CNA "E" further indicated the alarm had to be turned off for toileting or it would keep sounding after the resident was placed on the commode. On 11/05/14 at 1:00 p.m. the facility video of the fall on 10/24/14 was reviewed with the Director of Nursing (DON) and Restorative Manager Nurse "F" and revealed: Resident #901 was at the nurse's station at 5:45 a.m. restless and attempting to lean forward. At 5:57 a.m. Resident #901 was seated in the wheelchair and calm. Resident #901 looks around, stands up, leans over slightly while adjusting the hospital gown and then walks approximately 10 feet to the door of the breakroom, enters and the door closes. Later a CNA attempts to enter the breakroom and Resident #901 was discovered on the floor. After review of the video, the DON and Nurse "F" were queried if the PA and wheelchair sensor alarm should have been in place and working and stated, "Yes." They were further queried if there was a Physician order [REDACTED]." The type and operation of the alarms in place for Resident #901 at the time of the fall were reviewed with the DON and Nurse "F" and revealed: the PA alarm with an magnet attached which released when pulled and a sensor pad which could be depressed by hand and upon a slight release of the pressure would sound. An on off switch was observed on the bottom of the sensor alarm and the alarm would not function in the off position. The DON indicated this alarm would be turned off during toileting and the PA alarm could be detached and the CNA was responsible for turning the alarms back on. On 11/05/14 at 1:20 p.m., Physical Therapist "G" was queried if they had worked with resident #901 and stated, "Yes." Physical Therapist "G" was further queried if Resident #901 was able to independently walk safely and stated, "No." A further query if Physical Therapist "G" would have recommended alarms for Resident #901 and stated, "Yes." On 11/05/14 at 2:00 p.m., CNA "H" was queried about their knowledge of the incident with Resident #901 and stated, "The alarms are checked every Tuesday. They are numbered. (Resident #901) had a seat alarm and a PA alarm. As soon as pressure comes off the pad (placed under the resident's buttocks in the wheelchair) it is going to make a sound. As I was coming in I heard someone say help as I approached the breakroom. I heard it more, then when I attempted to open the door I couldn't open it enough. I could see the feet (of the resident) and went to get the nurse." CNA "H" was further queried if any alarms were sounding at the time she found Resident #901 and stated, "No. None." CNA "H" was further queried if the magnet for the PA alarm was still attached to the alarm and stated, "Yes. You have to clip it to the thick part (of the clothes). It was not (clipped to anything)." On 11/05/14 at 2:25 p.m., the DON was queried about how the facility learned about the condition of Resident#901 after the fall and stated, "Just a phone call from the hospital. They said is was an acute (recent) lumbar fracture." On 11/05/14 at 2:35 p.m., Admission Nurse "I" was queried about the injury to Resident #901 and stated, "Social work (from the hospital) called about a bed hold and I asked how (Resident #901) was doing and the hospital social worker said (Resident #901) had an acute fracture at L1 (lumbar vertebrae fracture of the spine)." On 11/05/14 at 2:45 p.m., MDS Nurse "J" was queried about a [DIAGNOSES REDACTED].#901 and stated, "That was put in when we thought (Resident #901) was coming back." MDS Nurse "J" was further queried if Resident #901 had that [DIAGNOSES REDACTED]." On 11/05/14 at 3:20 p.m., Nurse "C" was queried about the incident with Resident #901 and stated, "It took and hour to get through report because we had to redirect (Resident #901). Nurse "C" was further queried if the alarms for Resident #901 were checked when coming on shift at 3:00 a.m. on 10/24/14 and if they were sounding at the time of the fall and stated, "No." On 11/05/14 at 3:30 p.m., the facility "Occurrence Reports" for Resident # 902 were reviewed and revealed: An Occurrence report dated 08/22/14 at 7:00 a.m. revealed: "Resident was attempting to lay down in bed from wheelchair and was noted lying on the floor next to bed. Resident denied pain or discomfort. Alarms were not sounding due to being off, disciplinary action taken with CNA r/t alarms in place but not being turned on. Root cause: Staff did not follow plan." No injury was noted. An Occurrence report dated 10/15/14 at 3:43 p.m. revealed: "CNA in training had toileted resident prior to fall. Both alarms were not on while in wheelchair after the fall, CNA stated she had forgotten to turn them back on." No injury was noted. On 11/05/14 at 3:40 p.m., the medical record for Resident #902 was reviewed and revealed: Resident #902 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #902 had a severe cognitive impairment and required extensive assistance of one person for transfer, walking, hygiene and bathing. On 11/05/14 at 4:30 p.m., the facility policies were reviewed and revealed: The "Comprehensive Fall Risk Reduction Program" policy with date of 8/14 revealed: "It is the policy of the (Facility name) to ensure that the resident environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistive devices to prevent accidents (and) falls. The Restorative Nurse/Nurse will initiate the least restrictive device. The least restrictive device includes: Personal safety alarm, Bed alarm, Chair / seat alarm. 11. All residents are considered at risk for falls." The facility policy on "Alarms" with a date of 4/14 revealed: "Policy: To help ensure the safety of the resident when assessed to be at risk for falls." The policy titled "Accidents and Supervision" dated 6/14 revealed: "Interventions are immediately implemented on admission if resident is identified to be at risk, these include: floor mats, bed and chair alarms, low bed." ( )

Based on observation, interview, and record review, the facility failed to implement interventions for one (#706) of two sampled residents reviewed for pressure sores from a total sample of 18, resulting in the development of a new pressure sore due to pressure on the skin from tubing connected to a wound care device and from skin shearing. Findings include: On 6/4/14 at 10:35 AM, resident #706's skin was observed with the facility's wound care nurse (nurse 'B'). The resident had a healed, left leg [MEDICAL CONDITION]. There was a blue, pressure relief boot on the right foot. When the boot was removed, there was a large, healing wound on the right heel with long tubing attached that was connected to a [DEVICE] (vac) used to remove excess fluid/drainage from the site. Resident #706's right calf was wrapped in gauze. Nurse 'B' attempted to remove a "non-adhesive" dressing on the lateral calf underneath the gauze, but the dressing had adhered to an underlying wound and had to be repeatedly doused with normal saline solution to pry it away. The resident appeared to be asleep, but winced slightly as the dressing was removed that revealed one necrotic (black, dead skin), linear-shaped pressure sore measuring approximately 8.4 centimeters (cm) in length by 5.4 cm in width. When asked how the pressure sore developed, nurse 'B' said, "It was a skin tear from the wound vac tubing. The tubing was underneath the boot. The (nurse aide) scraped (sheared) it in the shower and the skin just rolled up." On 6/5/14 at 10 AM, resident #706's clinical record was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted that the resident had no cognitive deficits, was non-ambulatory, required extensive assistance for repositioning and bed mobility, and had impaired range of motion to one arm and both legs. The MDS noted that the resident was admitted with the (one) pressure sore on the right heel. Resident #706's braden (pressure ulcer risk) scales were reviewed. A score of 12 or less represented high risk for development. On 4/23/14, a score of "14" was noted (meaning moderate risk). On 5/9/14, a score of "15" was noted (meaning at risk, but not at high risk). Resident #706 was being treated by a wound care (physician) specialist who documented regarding the right lower extremity per review of notes dated 5/16/14: "Good" circulation, "no venous stasis changes (signs of poor blood flow)," "pulses not palpable (felt)," and "numbness of the right side." The specialist noted, Impression: pressure sore right heel. Plan: Keep pressure off the heel, continue the wound vac, and protect the area with the pressure relief boot. There was no mention of a right lateral calf wound indicating that it had not yet occurred. Notes by the wound specialist dated 5/23/14 noted: "(Resident #706) has a skin tear on the right leg laterally. No necrosis....There is some tissue loss more than 25%....Apply (a shear, waterproof, protective dressing) to the skin tear." Orders from the specialist, written by nurse 'B' dated 5/23/14, noted upon review: "Wrap right lower leg with (gauze) for protection of skin-do not let wound vac tubing lay on bare skin....change on shower days and PRN (as needed)." Shower days were scheduled for twice a week. Notes dated 5/23/14 by nurse 'B', did not mentioned the calf wound. There were no documented nurses notes regarding the pressure sore on resident #706's calf until 5/27/14. A review of notes dated 5/27/14 by a day shift nurse revealed: "(waterproof dressing) to right outer lower leg....observed white fluid filled areas under (waterproof dressing) approximately 4 inches by 2 inches in length and width....Tubing from wound vac placed on top of (gauze) dressing" (after the wound was re-dressed). The fluid filled areas represented blisters, stage II pressure areas. Wound nurse 'B' documented in notes dated 5/28/14: "....3 areas necrotic tissue observed surrounded by deep red tissue with no blanching. Drainage on (waterproof dressing) was foul smelling." The non-blanchable tissue represented persistently red, stage I pressure areas. An order dated 5/28/14 noted: "No tubing....on right lower extremity." An order dated 5/29/14 noted to change the waterproof dressing to the following: "Apply non-adhesive (dressing) to necrotic areas, wrap with (gauze), do every morning" rather than on shower days, and no tubing to rest against the necrotic areas. Per review of notes by the wound specialist dated 5/30/14: "(Resident #706) also has two areas of the right lower leg laterally that have open (ed) since last week. Both are eschars (dead, leathery tissue)....They measure 3.5 cm by 1.8 cm and 4.9 by 3.6 cm. These new ulcers may be secondary to pressure from the wound vac tubing and the (waterproof dressing)." Plans included, "Apply dry dressings to the leg ulcers and protect them from further trauma." Nurse 'B' noted however, on 5/30/14, that these wounds were "non-pressure sites." An order dated 5/30/14 noted: Place a thick pad over the pressure sores between the non-adhesive dressing and the gauze wrap daily and PRN. (By the time the sores were observed with nurse 'B' on 6/4/14, the two sores had combined measuring approximately 8.4 cm by 5.4 cm). On 6/5/14 at 3:50 PM, when queried regarding the development of resident #706's avoidable pressure sore from the wound vac tubing used for a different pressure sore, the Director of Nursing did not comment. At 4:30 PM, review of facility policy on "Pressure Ulcer Prevention" dated 5/2011 revealed the following: "Resident specific strategies will be implemented and monitored for outcome;" "Pressure reduction strategies will be utilized to support and redistribute pressure...." ( )

This citatation pertains to Intake # MI 835 Based on observation, interview and record review, the facility failed to provide a consistently functioning personal safety device for two (#501 and 502) of three residents reviewed for falls, out of a total sample of three, resulting in a cervical fracture (broken neck) and a skin tear. Findings include: On 5/6/14 at 9:45 A.M., Resident #501 was observed in the hallway in a wheelchair. The resident was confused, and was wearing a neck brace, and a right ankle wanderguard (a personal safety device to alert the staff of attempts to leave the building). A Certified Nursing Assistant was providing one to one supervision for Resident #501. On 5/6/14 at 10:00 A.M., review of a facility incident report (I&A) for Resident #501, dated 4/23/14 at 4:15 A.M., with the Director of Nursing (DON) and the facility Administrator revealed Resident #501 fell , sustaining head lacerations (deep cuts) and a fractured cervical vertebra. The flat bed alarm (personal safety device) did not sound to alert staff that the resident was getting up without assistance. The report noted that Resident #501 was found on the floor in the room, with a laceration (deep cut) 1.5 centimeters (cm) long to the forehead, and a 0.5 cm laceration to the posterior head. The report noted that the alarm (personal safety device) "was not sounding", and documented that the resident was sent to the hospital emergency room per physician's orders [REDACTED]. "Resident has [DIAGNOSES REDACTED]. Resident had flat bed alarm placed to bed for safety due to (R/t) unsafe self transfers. Resident triggered bed alarm twice prior to fall. At 3:59, staff heard a loud noise and noted resident on floor at foot of bed, Alarm box was turned to the "ON" position, but alarm was not sounding, Upon interview with staff, three staff members who were all present in the room directly after incident stated that they had each checked the (alarm) box, (CNA"A") tested the flat bed alarm and it continued not to sound." At 10:10 A.M., the Administrator stated that Resident #501 's hospital X-ray revealed the resident had a fracture of the first cervical vertebra (C1). The DON stated that the investigation had determined that the alarm was turned on but was not working at the time Resident #501 fell , and that the resident had been found several steps away from the bed, near the radiator. The DON reported that the resident's alarm had sounded twice during that shift, and that staff were able to reach the resident and stop her from getting up both times. The DON was unable to explain why the alarm did not sound at the time of the incident, but stated that the alarm had been removed by the Restorative department. At 10:15 A.M., the Restorative CNA "E" was interviewed and Resident #501's alarm in question was inspected. CNA "E" removed the alarm from a plastic bag and demonstrated that the alarm battery was charged, and the alarm sounded when activated. When queried, CNA "E" demonstrated that if the alarm pad wire was not completely inserted into the jack on the alarm box, the alarm would fail to operate. At 12:00 P.M., CNA "A", Resident #501's care giver at the time of the incident, was interviewed and stated, "When I put her back to bed after the last time the alarm went off, the alarm was on. Later that night, we heard something fall, but didn't hear an alarm or a yell. She (Resident #501) doesn't use her call light. She'll get up when she has to got to the bathroom. We have her in the room next to the desk so when she starts moving, we can hear the alarm right away and we could run and see her. She made it away from the bed, almost by the window. I don't know why the alarm didn't go off, It was going off all night, why not then?" When asked if the wire connecting the alarm pad to the alarm box was checked to be sure it wasn't loose, CNA "A" stated, "I did not check that, no." At 12:10 P.M., Review of Resident #501's clinical record with the DON revealed the following: A face sheet documented that Resident #501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An updated [DIAGNOSES REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #501 had difficulty speaking and understanding speech, had severely impaired cognition, needed extensive assistance for transfers and ambulation, and had impaired balance. Review of a fall risk assessment for Resident #501 dated 4/15/14, revealed the resident was at risk for falls with a score of 18 (greater than 10 indicates at risk). Review of a fall risk nursing care plan for Resident #501, dated 4/14, revealed the following interventions were ordered on admission, "flat bed alarm, wheelchair seat alarm." An update to the Nursing care plan for fall risk for Resident #501, dated 4/17/14, noted, "Resident makes frequent self transfers out of wheelchair, self releasing seat belt added." A policy on personal safety devices was requested but not received by survey exit ( ) On 5/7/14 at 12:25 P.M., Resident # 502 was observed, in the room, asleep in the wheelchair. The personal safety alarm wire was not attached to the resident, but was wound around the box attached to the back of the chair. At 12:35, per request, the DON entered Resident #502's room to inspect the resident's personal safety alarm and stated, "It won't do any good like this. The certified Nursing Assistants (CNA) are required to sign off on a sheet twice a shift that they've checked that the alarm was on and functioning." On 5/7/14 at 2:00 P.M., Resident #502's clinical record was reviewed and revealed the following: A face sheet documented that Resident #502 was readmitted into the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #502 had difficulty comprehending speech, and had moderately impaired cognition. The MDS documented that Resident #502 needed extensive assistance for transfers to the wheelchair, dressing, toileting and hygiene, did not walk, and had impaired balance. A fall risk assessment dated [DATE] documented that Resident #502 was at risk for falls with a score of 26 (greater than ten indicates risk). A nursing care plan for risk for injury, (no initiation date indicated), contained notations dated 4/12/13, and the following intervention dated 3/28/14, "personal alarm to bed and wheelchair." On 5/7/14 at 2:00 P.M., Resident #502's facility accident and Incident reports (I&A) were reviewed and revealed the resident had fallen four times since march of 2014, on 3/28/14, on 4/1414, and twice on 4/19/14. The following was revealed: An I&A dated 4/14/14 at 12:30 A.M. for Resident #502., noted, "Resident observed on floor at bedside. Resident sitting on butt, legs extended, leaning up against bed. Small skin tear noted on right outer calf," The I&A documented, "alarm not sounding." On 5/7/14 at 3:35 P.M., the Restorative Nurse "F" was interviewed regarding Resident #502's fall on 4/14/14, and said, "There was only one alarm available on the unit. I verbally told the aide to take the alarm off (Resident #502)'s chair and switch it to the bed when she put her to bed. She didn't do it." On 5/7/14 at 4:00 P.M., the DON was interviewed regarding Resident #502's fall, and stated. "It was unfortunate. There was only one alarm available on the unit, and the CNA was told to switch it to the bed when she put the resident to bed, but it wasn't done." A facility policy on fall prevention and personal safety devices was requested but not received prior to survey exit. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO ASSESS, PLACE A BED IN THE LOWEST POSTION AND IMPLEMENT NEW INTERVENTIONS TO PREVENT FALLS FOR THREE (#'S 402, 404, AND 407) OF 12 SAMPLED RESIDENTS WHO WERE REVIEWED FOR FALLS IN A TOTAL OF 17 SAMPLED RESIDENTS, RESULTING IN MULTIPLE FALLS, ARM FRACTURE, AND LACERATIONS. FINDINGS INCLUDE: ON 8/2/11 AT 12:30 P.M., RESIDENT #407 WAS OBSERVED SITTING IN HER WHEELCHAIR IN THE DINING ROOM. THE RESIDENT'S RIGHT ARM WAS IN A SLING AND A SHORT ARM CAST (FROM THE ELBOW TO THE WRIST) WAS OBSERVED. RESIDENT #407 WAS FEEDING HERSELF WITH HER LEFT HAND. ON 8/3/11 AT 8:45 A.M., RESIDENT #407 WAS OBSERVED IN HER WHEELCHAIR SITTING UP IN HER ROOM. THE RESIDENT WAS QUESTIONED ABOUT THE CAST AND SLING ON HER RIGHT ARM AND REVEALED THAT SHE HAD FALLEN RECENTLY. SHE STATED "I PUT THE BELL ON, BUT NO ONE CAME, SO I GOT UP BY MYSELF. THAT'S WHEN I fell ". THE RESIDENT ALSO REVEALED THAT SHE HAD FRACTURED HER WRIST IN THE FALL. WHEN QUESTIONED FURTHER ABOUT PAIN IN HER WRIST, THE RESIDENT STATED THAT THE PAIN LEVEL WAS OCCASIONAL AT A "6" LEVEL (USING A 0-10 PAIN SCALE, WITH "0" INDICATING NO PAIN, AND "10" THE WORST PAIN). A REVIEW OF THE ACTIVE MEDICAL RECORDS ON 8/3/11 AT 2:15 P.M., REVEALED THAT THE RESIDENT #407 WAS admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. RESIDENT #407 WAS readmitted INto the facility on [DATE], THEN AGAIN ON 7/29/11 WITH AN ADDITIONAL [DIAGNOSES REDACTED]. THE ADMISSION MINIMUM DATA SET ASSESSMENT (MDS), WITH AN ASSESSMENT REFERENCE DATE OF 6/28/11, IDENTIFIED THE RESIDENT AS COGNITIVELY INTACT AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS, DRESSING AND HYGIENE. THE MDS ALSO INDICATED THAT THE RESIDENT WAS NOT STEADY WHEN MOVING FROM A SEATED TO A STANDING POSITION OR BETWEEN SURFACE-TO-SURFACE TRANSFERS (E.G.-BED TO WHEELCHAIR). THE FALLS CAA (CARE AREA ASSESSMENT) DOCUMENTED "RESIDENT AT RISK FOR FALLS, RELATED TO GENERALIZED WEAKNESS. RESIDENTS GENERALIZED WEAKNESS IS AGGRAVATED BY [DIAGNOSES REDACTED]. UPON ADMIT, LOW BED AND DO NOT LEAVE ALONE IN THE BATHROOM PUT INTO PLACE. STAFF STATE RESIDENT DOES USE THE BEDSIDE CALL LIGHT SYSTEM WITHOUT PROBLEMS...". REVIEW OF THE NURSING NOTES, DATED 7/16/11 AT 4:00 A.M., CONFIRMED THAT THE RESIDENT HAD FALLEN AND WAS OBSERVED ON FLOOR WITH "RIGHT ARM EXTENDED BEHIND HER POINTING TOWARD FEET AND LEFT ARM EXTENDED OUT IN FRONT OF HER". RESIDENT STATES "I THINK I BROKE MY ARM". THE NURSING NOTE DOCUMENTED "UNABLE TO MOVE RIGHT ARM", RESIDENT STATES I WAS TRYING TO GO TO THE BATHROOM, NO ONE WAS ANSWERING MY CALL LIGHT". A REVIEW OF THE INCIDENT AND ACCIDENT REPORT, DATED 7/16/11, NOTED THAT "RESIDENT UNABLE TO MOVE RIGHT ARM WITHOUT PAIN. RIGHT CHEEK REDDENED, ORDERED STAT (AS SOON AS POSSIBLE) RIGHT ARM AND FACIAL X-RAYS". REVIEW OF THE NURSING NOTES, DATED 7/16/11 AT 12:30 P.M., DOCUMENTED THE X-RAY RESULTS "IMPACT FRACTURE RIGHT HUMERAL, IMPACT FRACTURE RIGHT SHOULDER, LIGAMENT TEAR RIGHT WRIST, DOCTOR NOTIFIED SEND TO HOSPITAL. DAUGHTER NOTIFIED". FACIAL X-RAYS WERE NEGATIVE THE 7/15/11 RE-ADMISSION physician's orders [REDACTED]. THE RE-ADMISSION NURSING ASSESSMENT FORM DATED 7/15/1, PRIOR TO THE ARM INJURY, REVEALED THAT RESIDENT #407 REQUIRED A ONE PERSON ASSIST WITH TRANSFERS AND THERE WAS "NO OBVIOUS PROBLEMS" WITH THE UROLOGICAL SYSTEM. ON 8/4/11 AT 9:05 A.M., MIDNIGHT CNA (CERTIFIED NURSE ASSISTANT) "A" WAS QUESTIONED VIA PHONE INTERVIEW REGARDING THE EVENTS FROM THE EARLY MORNING HOURS OF 7/16/11. SHE SAID THE RESIDENT USED THE CALL LIGHT "MOST OF THE TIME". CNA "A" ALSO SAID THAT RESIDENT #407'S BED WAS "ABOUT HALF WAY UP" AT THE TIME OF THE INCIDENT. AT 9:10 A.M., AN ATTEMPT WAS MADE TO REACH THE NURSE ON DUTY THE EARLY MORNING HOURS OF 7/16/11, BUT THERE WAS NO ANSWER WHEN PHONED. ON 8/4/11 AT 9:30 A.M., RESIDENT #407 WAS OBSERVED UP DOZING IN HER WHEELCHAIR, IN HER ROOM. SHE STATED THAT THE RIGHT HAND WAS HER DOMINANT HAND, AND JUST EATING A MEAL WITH HER LEFT HAND, "EXHAUSTS" HER. ON 8/4/11 AT 9:50 A.M., THE SAFETY COORDINATOR/RESTORATIVE NURSE "B" WAS INTERVIEWED REGARDING THE RESIDENT'S FALL. THE SAFETY COORDINATOR STATED THAT SHE DID NOT DOCUMENT ON THE INCIDENT. SHE JUST SPOKE TO THE NURSE ON DUTY THAT NIGHT, AND "READ HER NURSES NOTES". NURSE "B", WAS NOT AWARE THAT THE RESIDENT'S BED WAS NOT AT THE LOWEST POSITION AT THE TIME OF THE INCIDENT. NURSE "B" SAID "I WOULD CONCUR THAT THE BED SHOULD HAVE BEEN IN LOW POSITION". ON 8/4/11 AT 10:00 A.M., THE "RESIDENT AT RISK FOR INJURY CARE PLAN" DATED 6/21/11 AS REVIEWED WITH NURSE "B", SHE STATED THE INTERVENTION OF "LOW BED WHILE OCCUPIED" WAS PUT INTO PLACE ON THE RESIDENT'S INITIAL ADMISSION INTO THE FACILITY. THE FALL RISK ASSESSMENT FROM THE 6/21/11 ADMISSION SCORED RESIDENT #407 AT A "20", (A RESIDENT WHO SCORES A "10" OR HIGHER IS AT RISK). NO FALL RISK ASSESSMENT WAS FOUND FOR THE 7/15/11 RE-ADMISSION. PER THE FACILITY'S "FALL PREVENTION PROGRAM" POLICY DATED 10/97, REVISED 2/2011: "1. A FALL RISK ASSESSMENT WILL BE COMPLETED UPON ADMISSION, READMISSION FROM A HOSPITAL STAY AND QUARTERLY BY THE RESTORATIVE NURSE. 2. ALL RESIDENTS UPON ADMISSION HAVE ORDERS FOR LOW BED, AND DO NOT LEAVE ALONE IN BATHROOM...". ( ) ON 8/2/11 AT 9:40 A.M., DURING INITIAL ROUNDS, RESIDENT #402 WAS OBSERVED SITTING IN HIS WHEELCHAIR ON UNIT THREE JUST OUTSIDE OF HIS ROOM. MULTIPLE DARK/BLACK BRUISES WERE NOTED TO BILATERAL PERIORBITAL AREAS (BRUISES NOTED AROUND BOTH HIS EYES), A SCAB WAS NOTED ABOVE HIS RIGHT BROW, TWO SCABBED AREAS WERE NOTED TO HIS RIGHT BELOW THE KNEE AMPUTATION, AND DARK/BLACK BRUISES WERE ALSO NOTED TO HIS RIGHT AND LEFT CHEEKS. RESIDENT #402 WAS ALERT BUT ONLY ANSWERED SIMPLE QUESTIONS IN A LOW SOFT VOICE. ON 8/2/11 AT 2:30 P.M., RECORD REVIEW OF RESIDENT #402'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MOST RECENT MINIMUM DATA SET (MDS), dated [DATE], INDICATED A SEVERELY IMPAIRED COGNITION, REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADL'S), AND TRANSFERS. ON 8/3/11 AT 1:55 P.M., REVIEW OF THE INCIDENT AND ACCIDENT REPORTS, WITH THE RESTORATIVE NURSE (NURSE 'B'), REVEALED THE FOLLOWING FALLS: REVIEW OF AN INCIDENT AND ACCIDENT REPORT, DATED 7/19/11 AT 5:30 P.M., READ, "RESIDENT ALARM SOUNDING. UPON ENTERING ROOM OBSERVED RESIDENT ON THE FLOOR IN FRONT OF HIS WHEELCHAIR ON HIS KNEES..." NURSE 'B,' STATED, "IT WAS REQUESTED THAT THE RESIDENT BE EVALUATED FOR A REACHER DEVICE. AN OCCUPATIONAL THERAPY SCREEN WAS ordered on [DATE], BUT IT WAS NOT DONE." REVIEW OF THE THERAPY NOTES DID NOT REVEAL AN EVALUATION. THERE WAS NO DOCUMENTATION OF THE RESIDENT EVER RECEIVING THE REACHER DEVICE. THERE WERE NO OTHER DOCUMENTED POST FALL INTERVENTIONS. THE FALL CARE PLAN WAS NOT UPDATED NOR DID IT INDICATE IT WAS REVIEWED. TWO FALLS OCCURRED ON 7/24/11. THE FIRST FALL OCCURRED AT 8:45 A.M. THE INCIDENT AND ACCIDENT REPORT REVEALED DOCUMENTATION THAT READ, "ENTERED PATIENT ROOM AND PATIENT OBSERVED LYING ON FLOOR ON RIGHT SIDE. BLOOD NOTED ON FLOOR. WHEELCHAIR BEHIND PATIENT. TWO MILLIMETER (MM) SKIN TEAR TO NOSE AT BRIDGE. BRUISE...BLOODY NOSE AND RIGHT OUTER KNEE ABRASION." ON THE SAME DAY AT 7:30 P.M. (PER THE INCIDENT/ACCIDENT REPORT), RESIDENT #402 HAD ANOTHER FALL. THE INCIDENT AND ACCIDENT REPORT REVEALED DOCUMENTATION THAT READ, "PATIENT OBSERVED LYING ON FLOOR IN FRONT OF WHEELCHAIR. BLOOD FROM HEAD NOTED. LACERATION TO RIGHT BROW. PATIENT STATED HE HIT HIS HEAD ON THE OVERBED TABLE." NURSE 'B' REPORTED THAT RESIDENT #402 WAS SENT OUT FOR SUTURES (TO RIGHT EYE BROW) TO THE HOSPITAL THAT EVENING AFTER THE SECOND FALL ON SAME DAY. AFTER THE FIRST FALL, RESIDENT WAS PUT TO BED, ICE PACKS WERE APPLIED, AND NEUROLOGICAL CHECKS WERE DONE. NURSE 'B' STATED, "WE ATTEMPTED TO PUT ON HIS LEG PROSTHESIS, BUT HE SUSTAINED THREE ABRASIONS TO HIS STUMP AFTER HIS FALL. THE LEG PROSTHESIS WAS NOT APPLIED DUE TO THE STUMP ABRASIONS." REVIEW OF THE physician's orders [REDACTED]. THE FALL CARE PLAN WAS NOT UPDATED AND THERE WAS NO INDICATION THAT IT WAS REVIEWED. RESIDENT #402 HAD ANOTHER FALL ON 7/31/11 AT 4:30 P.M. PER THE INCIDENT AND ACCIDENT REPORT (DATED 7/31/11) REVEALED DOCUMENTATION THAT READ, "OBSERVED RESIDENT SITTING ON THE FLOOR ON HIS BUTTOCKS WITH HIS BACK AGAINST WHEELCHAIR SEAT." NURSE 'B' STATED, "WE ORDERED FRONT ANTI TIPPERS FOR HIS WHEELCHAIR." THE FALL CARE PLAN WAS NOT UPDATED NOR WERE THERE INDICATIONS THAT THE CARE PLAN WAS REVIEWED. NURSE 'B' OFFERED NO EXPLANATION. ON 8/4/11 AT 2:55 P.M., REVIEW OF THE FACILITY'S POLICY ENTITLED, "FALL PREVENTION PROGRAM," DATED 10/1997 AND LAST REVISED 2/2011, STATED, 'WHEN A RESIDENT SUSTAINS A FALL THE CHARGE NURSE WILL NOTIFY THERAPY FOR A SCREEN TO BE DONE. CARE PLANS WILL BE UPDATED TO REFLECT CURRENT INTERVENTIONS." ( ) THROUGHOUT EACH DAY OF THE SURVEY, RESIDENT #404 WAS OBSERVED TO BE ALERT BUT WEAK, UNABLE TO FEED HERSELF, NON-AMBULATORY, AND REQUIRED TOTAL ASSISTANCE FROM STAFF FOR MOBILITY AND TRANSFERS. THE RESIDENT'S CLINICAL RECORD AND I/A (INCIDENT/ ACCIDENT) REPORTS WERE REVIEWED WITH RESTORATIVE NURSE 'B,' WHO WAS DESIGNATED AS THE FALL COORDINATOR. RESIDENT #404 WAS admitted on [DATE] WITH DIAGNOSES, ACCORDING TO THE ADMISSION FACE SHEET, THAT INCLUDED: RHEUMATOID ARTHRITIS, ANGINA, DEPRESSION, AND PARKINSON'S DISEASE. THE MDS (MINIMUM DATA SET) DATED 2/6/11 NOTED THAT THE RESIDENT HAD IMPAIRED RANGE OF MOTION TO BILATERAL UPPER EXTREMITIES AND ONE LOWER EXTREMITY; SHE REQUIRED EXTENSIVE ASSISTANCE FOR TOILETING, WAS UNSTEADY, AND WAS ONLY ABLE TO STABILIZE HERSELF WHEN MOVING ON AND OFF THE TOILET, WITH HUMAN ASSISTANCE; SHE WAS FREQUENTLY IN PAIN WITH A PAIN LEVEL OF 5 ON A SCALE OF 0-10. FALL RISK ASSESSMENTS DATED 8/1/10, 11/2/10, AND 2/1/11, NOTED THAT RESIDENT #404 WAS AT HIGH RISK. PER I/A REPORTS: 1. ON 9/29/10, RESIDENT #404 WAS FOUND ON THE BATHROOM FLOOR AFTER A SELF-TRANSFER. SHE WAS WEARING SLIPPERS AND WAS NOTED TO BE "VERY WEAK." THE CORRECTIVE MEASURE TAKEN TO PREVENT REOCCURRENCE: ASSESS FOOTWEAR. THE RESIDENT COMPLAINED OF RIGHT HIP PAIN. AN X-RAY OF THE HIP WAS NEGATIVE FOR FRACTURE. 2. ON 12/19/10, RESIDENT #404 WAS BEING ASSISTED OFF OF THE TOILET BY A NURSE AIDE. THE RESIDENT SLIPPED ON A TISSUE ON THE FLOOR AND fell . SHE COMPLAINED OF PAIN TO THE TAILBONE AREA. X-RAYS WERE NEGATIVE FOR FRACTURE. THE CORRECTIVE MEASURE: "REVIEWED THIS WITH (NURSE AIDE) STAFF-STAFF TO BE OBSERVANT OF CLUTTER ON FLOOR AND REMOVE CLUTTER PRIOR TO TRANSFERRING/AMBULATING RESIDENT." EMPLOYEE 'B' WAS UNABLE TO EXPLAIN WHY THE AIDE DID NOT OBSERVE FOR ACCIDENT HAZARDS PRIOR TO THE TRANSFER. 3. ON 2/9/11, RESIDENT #404 "WAS HEARD BY NURSE YELLING FOR HELP-WENT INTO BATHROOM AND OBSERVED RESIDENT LYING ON BACK ON FLOOR WITH COMMODE KNOCKED OVER." PER NURSES NOTES, THE RESIDENT STATED THAT SHE WAS TRYING TO PULL UP HER PANTS AND fell . SHE COMPLAINED OF PAIN TO THE RIGHT HIP AND SHOULDER. SHE ALSO SUSTAINED A FOUR CENTIMETER LACERATION TO THE POSTERIOR HEAD AND A HEAD HEMATOMA. THE CORRECTIVE MEASURE: "DO NOT LEAVE ALONE IN BATHROOM." WHEN QUERIED ABOUT THE CORRECTIVE MEASURE, EMPLOYEE 'B' STATED THAT THE RESIDENT WAS NOT SUPPOSED TO BE LEFT ALONE WHEN TOILETED BY STAFF. SHE WAS UNABLE TO EXPLAIN WHY STAFF FAILED TO REMAIN WITH THE RESIDENT. RESIDENT #404 WAS TRANSPORTED TO THE hospital on [DATE] AND RETURNED THE SAME DAY WITH A LARGE AMOUNT OF DRIED BLOOD ON A HEAD DRESSING. THE RESIDENT WAS "SHAKING" AND STATED THAT SHE WAS "SCARED." EMPLOYEE 'B' LOOKED AT DOCUMENTATION IN THE RESIDENT'S CHART NOTING THAT STAPLES WERE IN PLACE TO CLOSE THE WOUND. PER NURSES NOTES, ON 2/10/11, RESIDENT #404 COMPLAINED OF A HEADACHE. ON 2/14/11, THE RESIDENT WAS OBSERVED LEANING TO THE RIGHT IN THE WHEELCHAIR AND COULD NOT BE STRAIGHTENED UP. HER APPETITE WAS POOR AND SHE COMPLAINED OF PAIN DURING A SHOWER. PER NOTES, THE RESIDENT'S "RIGHT SHOULDER HAS BRUISING, ENTIRE AREA AND LEFT SIDE OF NECK BRUISED." X-RAYS OF THE SHOULDER WERE NEGATIVE FOR FRACTURE. RESIDENT #404'S "RISK FOR INJURY" CARE PLAN DATED 8/16/10, NOTED THAT THE RESIDENT HAD AN UNSTEADY GAIT AND WAS UNABLE TO TRANSFER SAFELY. THE CARE PLAN HAD NOT BEEN UPDATED WITH SAFETY MEASURES, SUCH AS SUPERVISION WHEN TOILETING, SINCE 8/16/10. EMPLOYEE 'B' WAS UNABLE TO STATE WHY. PER THE "FACILITY'S FALL PREVENTION PROGRAM" POLICY DATED 2/2011: -ALL RESIDENTS ARE CONSIDERED AT RISK FOR FALLS. -CARE PLANS MUST BE UPDATED TO REFLECT CURRENT INTERVENTIONS. -ALL RESIDENTS UPON ADMISSION MUST HAVE an order for [REDACTED]." THE POLICY DID NOT ADDRESS CONTINUATION OF THIS MEASURE POST ADMISSION. ( )