Every finding on record at Woodland Hills Healthcare and Rehabilitation

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to electronically transmit encoded, accurate, and complete MDS data to the Centers for Medicare and Medicaid Services (CMS) System for 9 (Resident #5, Resident #14, Resident #19, Resident #20, Resident #30, Resident #42, Resident #45, Resident #54, and Resident #58) of 9 residents reviewed for Minimum Data Set (MDS) completion and submission within the timeframe of 14 calendar days per CMS guidelines. The findings include: A review of a Resident Assessment Instrument (RAI)-required Assessment Summary dated 10/01/2025 provided by the facility, indicated, MDS completion Date is not later than the Assessment Reference Date (ARD) plus 14 calendar days for an annual (comprehensive) MDS, a quarterly (noncomprehensive) MDS and a discharge assessment MDS. Resident #5A review of Resident #5's Face Sheet revealed the facility admitted Resident #5 on 06/05/2025 with diagnoses that included stroke, kidney failure and anxiety. A review of a document titled MDS 3.0 Resident Assessments revealed the quarterly MDS with an ARD of 06/20/2026 for Resident #5 was still in process as of 07/30/2026 and had not been completed or submitted to CMS. Resident #14A review of Resident #14's Face Sheet revealed the facility admitted Resident #14 on 03/20/2026 with diagnoses that included right tibia fracture, osteoarthritis, heart failure and dementia.A review of a document titled MDS 3.0 Resident Assessments revealed the discharge-return not anticipated MDS, with an ARD of 04/11/2026, for Resident #14 was still in process as of 07/30/2026 and had not been completed or submitted to CMS. Resident #19Review of the admission MDS with an ARD of 03/23/2026 revealed Resident #19 had a Brief Interview for Mental Status BIMS score of 15, which indicated the resident was cognitively intact.A review of a document titled MDS 3.0 Resident Assessments revealed the quarterly MDS with an ARD of 06/23/2026 for Resident #19 and a discharge return anticipated MDS from 07/25/2026 that were still in process as of 07/30/2026 and had not been completed or submitted to CMS.Resident #20Review of the admission MDS with an ARD of 03/19/2026 revealed Resident #20 had a Brief Interview for Mental Status BIMS score of 15, which indicated the resident was cognitively intact. The MDS also indicated Resident #20 had active diagnoses of heart failure, neurogenic bladder and UTI. A review of a document titled MDS 3.0 Resident Assessments revealed the quarterly MDS with an ARD of 06/18/2026 for Resident #20 was still in process as of 07/30/2026 and had not been completed or submitted to CMS.Resident #30A review of the Resident #30's Face Sheet revealed the facility admitted Resident #30 on 05/10/2024 with diagnoses that included cancer, anemia, coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia, dementia, anxiety, and depression. A review of the last completed quarterly MDS with an ARD of 02/24/2026, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident cognitively intact, with verbal behaviors, independence in self-care and mobility and no special treatments needed. A review of a document titled MDS 3.0 Resident Assessments revealed Resident #30 had an annual MDS in process since 05/25/2026.The annual MDS had not been completed or submitted to CMS. Resident #45 A review of the Face Sheet revealed the facility admitted Resident #45 with diagnoses that included heart failure, hypertension, peripheral vascular disease, neurogenic bladder, diabetes mellitus, hyperlipidemia, depression and chronic obstructive pulmonary disease. The quarterly MDS with an ARD of 03/19/2026, revealed Resident #45 had a BIMS score of 13 which indicated the resident was cognitively intact. Resident #45's MDS revealed the resident was impaired in all extremities, self-care was dependent for showers, personal hygiene, toileting hygiene, putting on and taking off shoes, and lower body dressing, and mobility was dependent and substantial/maximal assistance. A review of the documented titled MDS 3.0 Resident Assessments revealed Resident #45 had a quarterly MDS in process since 06/19/2026.The quarterly MDS had not been completed or submitted to CMS. Resident #54A review of the Face Sheet indicated the facility admitted Resident #54 on 08/09/2024 with diagnoses that included cerebral palsy and dementia. A review of the documented titled MDS 3.0 Resident Assessments revealed the quarterly MDS with an ARD of 06/22/2026 for Resident #54 was still in process as of 07/30/2026 and had not been completed or submitted to CMS. Resident #58A review of the Face Sheet revealed the facility admitted Resident #58 on 08/26/2025 with diagnoses that included depression, atrial fibrillation, anxiety, and hypertension. A review of the documented titled MDS 3.0 Resident Assessments revealed the quarterly MDS, with an ARD of 07/11/2026 for Resident #58 was still in process as of 07/30/2026 and had not been completed or submitted to CMS. Resident #62A review of the Face Sheet revealed the facility admitted Resident #62 on 02/27/2026 with diagnoses that included tuberculosis, anxiety, hypertension, atrial fibrillation and heart failure.A review of the documented titled MDS 3.0 Resident Assessments revealed the discharge-return not anticipated MDS, with an ARD of 03/12/2026 for Resident #62 was still in process as of 07/30/2026 and had not been completed or submitted to CMS.During an interview on 07/30/2026 at 12:35 PM, the Director of Reimbursement for Health Systems/Corporate (Director) #9 confirmed the following assessments were late:-The quarterly assessment for Resident #58 dated 07/11/2026-The quarterly assessment for Resident #5 dated 06/20/2026 -The annual assessment for Resident #30 dated 05/25/2026-The quarterly assessment for Resident #20 dated 06/18/2026-The quarterly assessment for Resident #19 dated 06/23/2026-The discharge- return anticipated assessment for Resident #19 dated 06/23/2026-The quarterly assessment for Resident #45 dated 06/19/2026-The quarterly assessment for Resident #54 dated 06/22/2026-The discharge assessment for Resident #14 dated 07/11/2026 Director #9 stated, the MDS should be finalized within 14 days per the rules outlined in the RAI manual. She stated that she was not aware the assessments were late. Director #9 stated she was also not aware of who was responsible for making sure the MDSs were completed on time but that there was a report that could be run to see what MDSs were behind. During an interview on 07/30/2026 at 12:45 PM, Financial Consultant (Consultant) #10 stated that she was standing in for the administrator in his absence. Consultant #10 indicated the facility did not have an MDS consultant to ensure assessments were submitted timely but that there was a report that could be run to see what MDSs were due.

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to appropriately put on Personal Protective Equipment (PPE) while providing peri care, indwelling urinary catheter care and a tube feeding for one (Resident #3) of one resident reviewed for Infection Control. The findings include: A review of the Resident #3's face sheet indicated the facility admitted Resident #3 with diagnoses that included amyotrophic lateral sclerosis (ALS), epilepsy, dysphagia, retention of urine, and disturbances of salivary system. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/01/2026, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS also indicated Resident #3 was dependent on all self-care and bed mobility. A review of Resident #3's Care Plan, dated 12/18/2025, revealed the resident had a (percutaneous endoscopic gastrostomy) PEG tube. Interventions included change syringe and tubing daily/as needed, provide dressing changes per medical provider orders, follow medication provider orders for administration, report to medical provider any noted complications such as dislodgement, sign and symptoms of infection to insertion site. There was no documentation in the care plan regarding EBP precaution for Resident #3. The Care Plan also revealed the resident required an indwelling urinary catheter. A review of Physician's Orders revealed Resident #3 was admitted to a hospice company for their diagnosis of ALS on 12/17/2024. The orders indicated Resident #3 were on continuous tube feeding started on 07/13/2026. May crush and administer all medications concurrently unless clinically contraindicated dated 7/27/2026.The Physician's Orders also revealed the resident had an order for indwelling urinary care every shift with a start date of 05/01/2026. Additional orders indicated to flush the indwelling urinary catheter each shift and as needed with start date of 06/22/2026. There was no order for Resident #3 to be put on EBP precautions.During an observation on 07/29/2026 at 8:59 AM, this surveyor observed LPN #1 using alcohol-based hand sanitizer before preparing medications on the medication cart. LPN#1 verified the orders before removing medications from the package, then crushed the medications and placed the medication mixture in the plastic cup. LPN #1 then entered Resident #3's room without wearing any PPE, and set the medication cup on the bedside table, which had barrier paper on it. LPN #1 used an alcohol-based hand sanitizer again and put on gloves. LPN#1 stopped the feeding pump, disconnected the tubing from the PEG tube, flushed the tube with water, administered medications, flushed with water again, connected the feeding tube to the PEG tube, and restarted the feeding pump. There were also a Registered Nurse (RN) #2 and two nursing students present in the room during observations. This surveyor noted EBP signage of what PPE to wear on the wall outside of Resident #3's room beside the resident's name. The signage indicated gowns and gloves should be used when providing care for residents on EBP precautions. There were no PPE supplies available in front of the room or inside of the room during this observation. During a second observation on 07/29/2026 at 10:48 AM, CNA #3 and CNA #4 went into Resident #3's room to transfer and perform incontinent care for Resident #3. Resident #3 had a feeding tube and an indwelling urinary catheter. CNA #4 stated Resident #3's indwelling urinary catheter was leaking, and Resident #3 was wet with urine. CNA #3 and CNA #4 transferred Resident #3 with a mechanical lift onto the bed. During the transfer, and as CNA #3 and CNA #4 proceeded to perform incontinence care the only PPE worn by CNA #3 and CNA #4 were gloves. During a third observation on 07/29/2026 at 11:15 AM, LPN #1 came into Resident #3's room to check their indwelling urinary catheter and RN #2 assisted LPN #1 with care. LPN #1 flushed the indwelling urinary catheter to check for patency wearing only gloves for PPE. After LPN #1 checked the indwelling urinary catheter, RN #2, wearing only gloves as PPE, used wipes to perform perineal care for Resident #3. CNA #3 and CNA #4 then dressed Resident #3 and got the resident out of bed and back into wheelchair wearing only gloves. During an interview on 07/29/2026 at 1:35 PM, LPN#1 stated the facility used EBP for residents who had catheters, feeding tubes or contact precautions to prevent infection. She stated for EBP staff wear gowns and gloves when providing care to residents. LPN #1 stated Resident #3 was on EBP, and she was aware that there was signage in front of the room. LPN #1 confirmed that she did not wear a gown during the process of administering medications via PEG tube for Resident #3 during this surveyor's observation. She stated that failing to wear PPE could pose an infection risk to residents. She stated she did not recall when the last time she had a gown on while caring for Resident #3. LPN#1 stated she received education and training from the facility provided in-service on EBP in the past. During an interview on 07/29/2026 at 1:38 PM, RN #2 stated that Enhanced Barrier Precautions were for residents who have catheters or tube feedings. She stated there would be a sign in front of the room for residents who were on EBP or other isolation types. RN #2 indicated the appropriate PPE to wear would be listed in the signage. For EBP, it required gowns and gloves. RN #2 stated she was aware that LPN#1 did not wear a gown during medication administration today. She stated that if staff did not wear PPE, that could cause infection for residents. During an interview on 07/30/2026 at 11:27 AM, CNA #4 reported that PPE such as gloves, gown, shoe covers if needed, mask, eye shields should be worn if a resident had an indwelling urinary catheter, colostomy bag, feeding tube, or contagious with some type of infection. CNA #4 stated he should have worn PPE while performing care for Resident #3 due to the resident having a feeding tube and an indwelling urinary catheter. CNA #4 reported that wearing proper PPE prevented cross contamination and protected the resident and the staff. During an interview on 07/30/2026 at 12:33 PM, the Director of Nursing (DON), stated she expected staff to follow all policies and procedures and to use PPE for residents who are on EBP. She stated she was not aware that there was no PPE available in front of or in Resident #3' room During an interview on 07/30/2026 1:35 PM, CNA #3 stated that proper PPE should be worn if someone had an indwelling urinary catheter, feeding tube, open wounds, colostomy or an infection and care was being performed. CNA #3 stated she should have put on PPE such as a gown, when providing care for Resident #3. CNA #3 indicated that if PPE was not worn correctly then infections could spread from staff to resident or resident to staff. During a follow up interview on 07/30/2026 at 3:25 PM, the DON stated her expectations of staff were for them to use the PPE that was readily available for use. The DON stated PPE was located in a storage room on 200 hall if staff needed them. The DON indicated that the consequences of not wearing PPE properly could be a write up or suspension. A review of In-Service Reporting form completed on 01/18/2026 by the Infection Control Preventionist revealed signatures for CNA #3, CNA #4 and License Practical Nurse (LPN) #1 indicating they were present in the training that covered EBP/Infection control. The in-service provided a Center for Disease Control (CDC) consideration of use of EBP and implementation of EBP in nursing homes. A review of a facility policy titled, Enhanced Barrier Precautions to Infection Control Guidance, updated on 03/01/2024, indicated, To prevent broader transmission of Multidrug Resistance Organisms (MRDO) and to help protect patients with chronic wounds and indwelling devices, Enhanced Barrier Precautions (EBP) should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed. Residents with an indwelling medical device including the following: central venous catheter, urinary catheter, feeding tube (Percutaneous Endoscopic Gastrostomy (PEG) tube, Gastrostomy (G) tube), tracheostomy/ventilator regardless of their MDRO status. Equipment included gloves and gown. Residents that are placed on EBP should have Personal Protective Equipment (PPE) in close proximity outside the door and a trash can in residents' room for disposal prior to leaving the room.

Number of residents sampled: Number of residents cited: Based on interviews, record review and facility policy review, it was determined that the facility failed to keep a resident free from verbal abuse for one (Resident #30) of one resident reviewed for abuse. The findings include: A review of the facility's undated policy titled Residents Rights, revealed As a resident of this facility, you have the right to a dignified existence and You have the right to be free from verbal, sexual, physical, and mental abuse. A review of a facility policy titled Resident Abuse, Neglect, and Misappropriation of Property, revised on 02/05/2018, revealed that Each resident of this facility has the right to be free from verbal, sexual, physical, and mental abuse. Accordingly, this facility prohibits the abuse of a resident by anyone including but not limited to, facility staff. A review of the Resident #30's Face Sheet revealed the facility admitted Resident #30 on 05/10/2024 with diagnoses that included diabetes, dementia, high blood pressure, coronary artery disease, hearing loss, pain, mood disorder, depression, muscle wasting and atrophy, and breast cancer. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/24/2026, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed that Resident #30 displayed verbal behaviors towards others such as screaming and cussing at others one to three days out of seven of the look back period. The MDS also indicated that Resident #30 was independent with all self-care and mobility other than bathing. A review of Resident #30's Care Plan dated 09/08/2025, revealed the resident made repetitive anxious complaints/concerns that were non-health related, repetitive complaints against staff members and attempts to play staff against each other. The Care Plan also revealed Resident #30 provoked other residents to make complaints with Resident #30, as well as loudly voicing complaints against other residents. Interventions included staff to intervene as needed, maintain a calm environment and approach the resident, establish a trusting relationship with the resident and communicate with family as needed. A review of the facility's Medication Administration Record (MAR) dated July 2026, revealed Resident #30 had active orders for daily medication to treat antianxiety, depression, and dementia. The MAR also indicated an order for behavior monitoring with zero behaviors displayed for the month of July. A review of a CNA #11's employee file, revealed a statement contained in the file titled Employee Memorandum that indicated a written warning was given to Certified Nursing Assistant (CNA) #11 by the Director of Nursing (DON) signed on 07/27/2026. The memorandum indicated that the code of conduct rule that was violated was that CNA #11 had failed to maintain acceptable standards of respect to residents, visitors' coworkers and supervisors. The memorandum indicated, Employee became involved in a verbal confrontation with a resident, during the interaction communication became inappropriate and escalated beyond expected professional standards. The employee file contained two statements from CNA #11. The first statement on 07/21/2026 indicated Resident #30 is mad because I said [the resident] sounded racist. CNA #11 stated she asked Resident #30 to shut up and indicated that she should not have done that. On the second statement of the OLTC witness statement form, CNA #11 indicated that There is a misunderstanding of this situation. I was caught in a verbal dispute with Resident #30. She got verbal with me and I got caught in an emotional. CNA #11 indicated she was aware she should have walked away and not said anything back to the resident. The form labeled Job Description signed by CNA #11 on 05/12/2026 indicated abuse training was completed per the policy listed above. CNA #11's employee file also included a copy of the facility's Resident Rights. During an interview on 07/30/2026 at 10:45 AM, CNA #11 stated on 07/19/2026 when she returned from break she heard Resident #30 shouting that she was lazy. CNA #11 stated at different times during the shift Resident #30 continued to shout at her that she was just absolutely lazy. She stated that Resident #30 demanded she put another resident to bed, and CNA #11 responded with If you have such a problem with putting [pronoun] to bed, you can put [pronoun] to bed. CNA #11 stated Resident #30 moved their walker to the side, approached CNA #11 and Resident #30 put her finger in CNA #11's face. CNA #11 stated she told Resident #30 to get away from her and to shut up and that she was acting racist. CNA #11 reported verbal abuse was a form of abuse and that she received training on abuse in May 2026 upon hire. CNA #11 stated she was trained to be calm, not interact, do not respond, walk away, do not shout back, avoid the situation and allow the residents to calm down. During an interview on 07/30/2026 at 11:07 AM, CNA #12 stated that on 07/19/2026 there was a lot of hollering and arguing back and forth between Resident #30 and CNA #11. CNA #12 stated CNA #11 did call Resident #30 racist. During an interview on 07/30/2026 at 11:19 AM, Licensed Practical Nurse (LPN) #13 stated she was in a resident's room providing care and walked out into the hall because she heard yelling. LPN #13 indicated Resident #30 and CNA #11 were standing directly in front of each other in the hall with CNA #11 and Resident #30 yelling at each other. LPN #13 advised CNA #11 to walk away. LPN #13 reported CNA #11 told Resident #30 You can shut up talking to me. LPN #13 indicated CNA #11 was on the phone and continued to state, She needs to shut up talking to me. LPN #13 indicated she has had in-services on abuse, and abuse information was also in the employee handbook. LPN #13 reported verbal abuse was a form of abuse and stated that you do not yell back at a resident. We de-escalate the situation. During an interview on 07/30/2026 at 4:19 PM, the Director of Nursing (DON) stated forms of abuse were verbal, physical, sexual, mental and financial. The DON stated she had no firsthand knowledge of the incident that occurred on 07/19/2026 between CNA #11 and Resident #30 but was only aware of what was discovered in the facility's investigation. She stated that Resident #30 called CNA #11 lazy, and CNA #11 told Resident #30 to shut up. She stated, Resident #30 did have a diagnosis of dementia, but the diagnosis was low, and Resident #30 was fully aware of what is going on. The DON stated CNA #11 was written up, counseled to walk away from altercations and removed from the hall Resident #30 resided on.

Based on interviews and record review, it was determined that the facility failed to accurately code a resident as receiving hemodialysis on the Minimum Data Set (MDS) for one (Resident #42) of one resident reviewed. The findings include:A review of Section O of the Center for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Manual dated 10/01/2025 revealed, Code Peritoneal or renal dialysis which occurs at the nursing home or at another facility. O0110J2, Hemodialysis- check when the dialysis was hemodialysis. In hemodialysis the patient's blood is circulated directly through a dialysis machine that uses special filters to remove waste products and excess fluid from the blood. A review of Resident #42's Face Sheet indicated the facility admitted Resident #42 on 02/11/2026 with diagnoses that included chronic kidney disease stage 5 and end stage renal disease.A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2026, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed that special treatments, procedures, and programs was marked as none of the above.A review of a quarterly MDS, with an ARD of 05/20/2026, revealed Resident #42's special treatments, procedures and programs which included an option for hemodialysis was marked as none of the above.A review of Resident #42's Care Plan, initiated on 02/24/2026, revealed the resident had dialysis Monday Wednesday and Friday at a dialysis center related to renal failure.A review of an Order Summary revealed Resident #42 had an order for dialysis at a dialysis center Monday, Wednesday and Friday.During a telephone interview on 07/30/2026 at 12:35 PM, the Director of Reimbursement Health Systems, Corporate (Director) #9 stated that the facility used the RAI manual for guidance when coding the MDS. During an interview on 07/30/2026 at 3:27 PM, the Director of Nursing (DON) reported that she expected the MDSs to be coded correctly and timely. The DON reported that MDSs were how the facility gets reimbursed and that staff may not know how to take care of a resident if the MDS was coded incorrectly. The DON stated that the MDS and Care Plans go together.This surveyor was unable to interview the MDS coordinator due to the MDS Coordinator being out of the facility and unable to reached by phone.

Number of residents sampled: Number of residents cited: Based on interviews, and facility document review, it was determined that the facility failed to prevent a resident from falling while being transferred with a mechanical lift for one (Resident #60) of one resident reviewed for accidents. The findings include: During an interview on 07/30/2026 at 9:00 AM, the DON stated the facility did not have a policy for accidents but did hand this surveyor a policy on Event investigation. The Event Investigation policy did not cover relevant information regarding accidents. A review of the Face sheet, indicated the facility admitted Resident #60 on 06/08/2019 with diagnoses that included right hip fracture, pressure ulcers, weakness, unsteadiness on feet. A review of the significate change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2026, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The MDS also indicated Resident #60 was dependent for all mobility functional abilities. A review of Resident #60's Care plan, dated 05/27/2026, revealed the resident required a mechanical lift for transfers. Interventions included two staff members to assist with transfers, and ensure equipment was in proper working condition. A review of Resident #60's reportable revealed that CNA #5 had put two lift pads under Resident and two other staff members used mechanical lift to get resident up causing the two pads to separate causing Resident #60 to fall onto floor. During an interview on 07/29/2026 at 2:35 PM, CNA #5 stated she put two lift pads under Resident #60 before getting the resident into a wheelchair to leave for an appointment. CNA #5 stated Resident #60 slides down in wheelchair so she thought two lift pads would help staff pull Resident #60 up in wheelchair. The idea was that Resident #60 would have the second lift pad under them just in case the first one came out when pulling Resident #60 up. CNA #5 then told the oncoming shift that Resident #60 had two lift pads under them. CNA revealed she had not been trained to use two lift pads for a transfer. CNA #5 indicated she was trying to prevent any problems with getting Resident #60 out of the chair. CNA #5 stated she was disciplined for the incident with a written write up and staff were in serviced with hands training on mechanical lifts. During an interview on 07/29/2026 at 7:35 PM, CNA #7 revealed that she watched two other staff members use a mechanical lift to get Resident #60 out of their wheelchair and back into bed. CNA #7 stated staff got Resident #60 up out of chair and were starting to move the lift when the resident fell out of the lift pads onto the floor hitting their head on lift and falling on their right side. CNA #7 revealed that Resident #60 had two lift pads under them one pad was connected to the top hooks and the other pad was connected to the back hooks causing the lift pads to separate and the resident to fall out of the lift pads. CNA #7 indicated staff complete checkoffs on lifts yearly and as needed. CNA #7 revealed after the incident staff were checked off again on lifts by completing the check-off in front of staff right after the incident. A review of an Employee Memorandum for CNA#6 indicated a written warning for breaking of company policy, date of violation was indicated as 05/27/2026. Under the section to indicate corrective action taken the memorandum indicated the employee will follow correct procedure and only place one sling under a resident. The Employee Memorandum was signed by CNA#6 and dated 05/28/2026 to indicate receipt of notification. During interview on 07/29/2026 at 8:07 PM, CNA #6 stated she had hooked the lift pads up to the mechanical lift before the transfer knowing that Resident #60 had two lift pads under them. CNA #6 revealed that she used the mechanical lift to get the resident up out of their wheelchair and Resident #60 slid out of the lift pads falling onto floor hitting their head and landing on their right side. CNA #6 stated that facility policy did not say to use two lift pads for the resident and they were not trained to use the mechanical lift with two lift pads under resident. Review of an in-service dated 05/27/2026 over the subject of proper mechanical lift operation conducted by the DON, revealed how to properly place a sling, attach the patient to the lift, and lifting and transferring. Attached to this in-service were Mechanical Lift Competency Checklists for all CNAs employed where the CNAs had given a return demonstration to the DON of understanding the instruction. The return demonstration checklists were all signed and dated 05/28/2026. During interview on 07/30/2026 3:14 PM, LPN #8 revealed she assessed Resident #60 due to a fall during mechanical lift transfer. LPN indicated that two lift pads were hanging on the mechanical lift, with one lift pad hanging on each lift arm. LPN #8 stated Resident #60 was sent to ER for evaluation after the incident.Review of Resident #60's hospital records with an admission date of 05/28/2026 indicated an admitting diagnoses of closed right hip fracture (broken right hip) and a discharge date of 06/09/2026.Review of an orthopedic surgery visit note with an encounter date of 07/15/2026 indicated Resident #60 was bedbound and dropped out of bed at the nursing home in May 2026 resulting in a right femur fracture, and was status post-surgery for intramuscular nail fixation (to stabilize the hip). The facility re-educated all direct care staff including CNA #5 on how to properly place a sling, attach the patient to the lift, lifting and transferring and how to use a mechanical lift with return demonstration provided on 05/28/2026. CNA #5 received disciplinary action on 05/28/2026 by written warning for the incident and not following company policy and procedure. These actions were performed before the survey team entered the facility, resulting in this finding being cited at past non-compliance.

Number of residents sampled: Number of residents cited: Based on observation, and interviews, the facility failed to ensure Daily Nurse Staffing Reports containing facility name, census, date and actual hours worked for licensed and unlicensed staff were displayed in a prominent place and readily available for residents and resident representatives with the potential to affect all 55 residents. The findings include: During an observation of the facility on 07/30/2026 at 2:30 PM, this surveyor looked near the entry, and two nursing stations for the Daily Nurse Staffing Report and was unable to locate the document containing the facility name, census, date, and total hours worked per shift for licensed and unlicensed staff. During an interview on 07/30/2026 at 3:12 PM, the Director of Nursing [DON] stated the facility did not have anything hanging up or available for residents or resident representatives that included facility name, census, date, time, and total hours worked per shift for licensed and unlicensed staff. The DON stated, we do not have anything like that, and have not been tracking actual hours worked on licensed and unlicensed staff. During an interview on 07/30/2026 at 3:17 PM, Consultant #10 revealed the Director of Nursing [DON] was not aware that she was responsible for the Daily Nurse Staffing Reports and was not familiar with the report. Consultant #10 confirmed no one had been keeping up with the hours worked by licensed and unlicensed staff. Consultant #10 stated she would provide guidance to the DON to make sure she knew how to fill out and post nurse staffing information. Consultant #10 stated Daily Nurse Staffing Reports should be posted so staff information was available to all residents and their representatives.

Number of residents sampled: Number of residents cited: Based on facility document review, observations, and interviews, it was determined that the facility failed to ensure food stored in the dry food storage room was covered, sealed, and labeled to maintain food quality and prevent contamination for 54 of 55 residents who received meals from the kitchen. The findings include: A review of an undated facility policy titled, Food Storage, indicated, Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. A review of a facility in-service report dated 09/09/2025, titled, Food storage, revealed Please read your guide on refrigerator, on how many days of storage and freezer, dry storage. Handouts given. The in-service was conducted by the dietary supervisor. During a tour of the kitchen on 07/29/2026 at 10:33 AM, this surveyor observed an open plastic bag of dry food on the shelf in the dry food storage which left it open to possible contaminants. The bag had no label nor open date on it. During an interview on 07/29/2026 at 10:35 AM, the Dietary Supervisor, who was present during the kitchen tour stated, Oh, I did that yesterday, and I forgot about it. It's my fault. The Dietary Supervisor stated she knew that the food left open with no date would need to be discarded. During an interview on 07/30/2026 3:03 PM, the Financial Consultant, covering in the absence of the Administrator, stated the Dietary Supervisor just got distracted and forgot that she left the food bag open. She stated that the Dietary Supervisor was responsible for providing training to kitchen staff to follow all kitchen and dietary policies.

Surveyor: [NAME], [NAME] Based on document review and interviews, the facility failed to ensure the necessary care, and resources were allocated to meet the needs of the residents. The facility failed to ensure the amount of hours worked by the Infection Preventionist, based on the facility and resident population, was addressed in the Facility Assessment in order to meet resident needs. This deficient practice had the potential to affect all residents of the facility. The total census was 52 residents. 1. On 12/17/2024 at 3:30 PM, this surveyor interviewed the Administrator regarding low weekend staffing. The Administrator was aware of low weekend staffing for Certified Nursing Assistants for the weekend for the 4th quarter. Several call-ins for the weekend with no replacement found. The Administrator had hired 3 weekend only staff to rectify the problem. 2. On 12/18/2024 at 8:24 AM, this surveyor noted the Facility Assessment Tool Staffing Plan indicated the Staffing plan for Direct care staff revealed, 1:x6 Direct Care ratio Days, 1:x9 Direct Care ratio Evenings, 1:x14 Direct Care ratio Nights. 3. On 12/17/24 at 1:20 PM, the Administer was asked about the availability of the Infection Preventionist (IP) for interview. He stated, she is only part time, and I'm not sure when I can get her in here, but I could try to get her on the phone. Later that day the Administrator stated, I can get her here on Wednesday (12/18/24) by 11:00 AM. 4. Upon review of the attendance/time clock data for the IP, the hours worked in the last 3 months varied, and the average number of hours worked per week were approximately 8.25. Typically ranging from 5-10 hours per week. 5. Upon review of the State Operations Manual regarding the specifications/regulation regarding an Infection Preventionist ' s working part time, the regulation stated the following: IP hours of work per week can vary based on the facility and its resident population. Therefore, the amount of time required to fulfill the role must be at least part-time and should be determined by the facility assessment, conducted according to S483.70(e). 6. Upon review of the Facility Assessment, the Infection Preventionist was not included in the staff, and it does not address the minimum amount of working hours needed for the IP specific to the facility ' s current census or resident needs. 7. On 12/18/24 at 11:23 AM, the Infection Preventionist was interviewed regarding her position and duties. When asked when she worked at the facility, the IP stated, I work part time here, typically on the weekends. She confirmed her average hours she worked for [Facility name] were under 10 hours a week, and that her main focus was the antibiotic stewardship and tracking and trending. 8. On 12/18/24 at 11:45 AM, the administrator was interviewed regarding the IP and the Facility Assessment. The Administrator confirmed the Facility Assessment did not include the IP and did not discuss the minimum working hours the facility would require for the IP to work related to their current census and specific needs.

50580 Based on observations, interviews, and facility policy review, the facility failed to ensure shower rooms were locked to ensure residents were prevented from having access to equipment or substances that could result in accidents or injuries. The facility failed to ensure the personal care storeroom, and treatment/oxygen room remained locked to prevent resident access to razors, scissors, and chemicals to reduce the risk for injury. This failed practice had the potential to cause harm to cognitive impaired residents if entry was gained. The facility failed to ensure the resident environment remains as free of accidents hazards as is possible. Findings Include: 1.On 12/15/2024 at 10:14 AM, the surveyor observed the shower room door unlocked and not closed. The surveyor noted shampoo, body wash, soap and razors inside. 2. On 12/16/2024 at 12:25 PM, the surveyor interviewed Certified Nursing Assistant (CNA) # 3 regarding the shower door open and not locked. CNA #3 confirmed the shower door is supposed to be locked, and stated If a resident gets in the shower room, they can hurt themselves or get locked in. 3. On 12/17/2024 at 9:30 AM, the surveyor noted the shower room door on 100 hall was unlocked. The surveyor interviewed the Director of Nursing (DON) regarding shower door unlocked. The DON confirmed the shower door was supposed to be locked and stated that risks included, a resident could fall in shower room or get into unlocked cabinet where supplies are stored. 4. On 12/15/24 at 10:25 AM, the surveyor observed an unlocked door titled Treatment and Oxygen on the right of the hallway between 2 nursing stations that revealed an unlocked, open box containing keys to doors in the facility including showers, water heater access, and the laundry room. There were 5 bottles of hydrogen peroxide, 3 bottles of iodine, and 4 bottles of 70% isopropyl alcohol located in the cabinet. A bottle of hydrogen peroxide was resting on the left side of the sink. The neighboring door titled storeroom was ajar and contained tall metal cabinets across from each other with medical supplies including hypodermic needles, and a third door marked Personal care (beauty shop) was unlocked. 5. On 12/15/24 at 10:29 AM, upon entering the Personal Care room observed various hair appliances with tangled cords hanging from a table and spread out across the floor. The top of the table contained hair creme, conditioner, shampoo and a container of shaving cream that stated, keep out of reach of children. The sink had an open razor resting on the right side of the cold-water valve. To the right of the sink was a brown plastic container with a small lidless green container of edging gel stating, keep out of reach of children, and a lidless bottle of hair conditioner resting on top. To the left of the sink was a small white wire rack containing cleaning spray, chlorine disinfectant spray, glass cleaner, and a neutralizing cleaner stating to keep out of reach of children, instructions on washing the eyes when contact is made, and instructions on calling poison control. The counter to the left of the sink held several open bottles of shampoos, and a container of fluid with combs soaking. In the left-hand corner was a brown top cabinet with black handled scissors, and two pair of clippers resting near the front edge with the cords dangling from the right side to the floor. A green shelf was noted hanging on the wall with lamp base, fan, and a lampshade resting on top nearly reaching the ceiling. On exiting the personal care room, Licensed Practical Nurse (LPN) #2 stated the door did not shut to the storeroom and there were things in there as well as the personal care room, that needed to be seen. 6. On 12/16/2024 at 8:45 AM, the Administrator provided a policy titled Medications, Storage of, revealing Resident medications should be locked in a medication room, medication cart, or in a locked cabinet. 7. On 12/17/2024 at 8:44 AM, the Director of Nursing (DON) accompanied surveyors down the hallway near the 400-hall nursing station. The DON confirmed that the treatment and oxygen, storeroom and personal care doors should be locked to keep residents out. The DON was able to open the unlocked treatment and oxygen room door and revealed that the open key box should be locked to prevent unauthorized access, and noted hydrogen peroxide was at the sink, and the cabinet held alcohol, iodine, and peroxide that she would not want residents to have access too because they could ingest it. The DON confirmed that the door was not staying shut and was not locked to the storeroom, and she would not want residents to have access because they could harm themselves with the supplies that are stored there. Syringes, unopened needles, tube feeding, new sharps container, and boxes of supplies were observed in the storeroom. The DON accompanied surveyors into the personal care room and confirmed that residents should not have access to razors, scissors, cords should not rest in the floor that could be tripped on, the lampshade should not rest against the ceiling, and the cleaning chemicals were at risk of residents ingesting them when the door is left unlocked. The surveyor requested policies. 8. On 12/17/2024 at 9:20 AM, the DON revealed that the facility did not have any policies that address doors not being locked, or razors. The DON was checking to see if any policy addressed chemicals not being secured from residents. 9. On 12/17/24 at 11:36 AM, the DON provided a policy titled Beautician / Barber Services revealing chemicals are to be stored to prevent accidental ingestion or misuse. 10. On 12/17/24 at 4:10 PM, during an interview, the DON revealed the facility did not have any other policy addressing cleaning supply storage. 11. On 12/15/24 at 10:28 AM, a medication cart (med-cart) was observed to be unlocked located just outside the dining room, in the hallway across from the nurse's station for hall 300/400. LPN #2 was behind the nurse's station gathering the resident's smoking items. LPN #2 left the nurse's station and walked up the hallway into an office adjacent to the 100/200 hall nurse's station. The Med-cart was not in her line of site due to her turning and walking away from the nurse's station and her going into an office. Affixed to the left side of the cart was a red sharp's container with the lid of the container missing the safety flap, exposing the used/contaminated needles, syringes, lancets, and other used winged type blood draw devices and tubing. b. On 12/15/24 at 10:30 AM, LPN #2 came back to the nurse's station and went outside with the residents for their smoke break, without locking/securing the Med-cart. c. On 12/15/24 at 10:36 AM, LPN #2 came back inside the building and walked behind the nurse's station. Surveyor asked LPN #2 to come to the medication cart. LPN #2 said she saw the Med-cart unlocked at 10:30 AM. LPN #2 identified the following items inside the drawers of the unlocked/unsecured Med-cart: 1. Numerous Hypodermic needles. 2. Numerous Individual packages of antiseptic wipes 3. Numerous Individual packages of bleach wipes. 4. Numerous Insulin Syringes. d. On 12/15/24, at 11:00 a.m., LPN #2 visually looked inside red Sharp's container affixed to the Med-cart on the left side. LPN #2 said I can see used needles, used lancets, used winged type blood draw needles with tubing and a razor. LPN #2 said anybody could stick their hand in there and get stuck with one of the items and be exposed to any blood born pathogen on the item. LPN #2 said she did not know what the reddish-brown substance smear on the top of the container was or the dried reddish-brown substance running down the outside of the container was. e. On 12/15/24 at 11:38 AM, the Assistant Director of Nursing (ADON) identified the following items inside the drawers of the med-cart: 1. Numerous hypodermic needles. 2. Numerous Individual packages of antiseptic wipes. 3. Numerous Individual bleach wipes. 4. A pair of nail clippers were in the top drawer. 5. Numerous Insulin Syringes. 6. Numerous safety syringes. f. On 12/15/24 at 11:40 AM, the ADON said her concerns with the Sharps container not having a lid was someone could get stuck with any of those items in there and get anything from Hepatitis to a Human immunodeficiency virus (HIV), or any other blood borne pathogen infection that was on it. The ADON said she was not sure who all has keys to the Med-cart, and this was the only place she has ever seen this cart. g. On 12/18/24 at 3:10 PM, the Director of Nursing (DON) provided a copy of the Storage Policy for Sharps. The policy stated The Occupational Safety and Health Administration (OSHA) has several guidelines for storing sharps, including: 1. Container type - Containers must be closable. 2. Container placement - Must be in a secure place. 3. Container maintenance - Must be replaced regularly. 4. Container handling - Containers should be closed immediately before removing or replacing. h. On 12/18/24 at 3:10 PM, the DON provided a copy of the Injection (Intradermal) policy and the Injection (Subcutaneous) Policy. These policies provided directions for insertion of needles: (Intradermal) policy. The policy guidelines: item 3: Slow injection will reduce discomfort. 5: cleanse site with antiseptic. 8. Position syringe so needle is almost parallel with resident's skin. 9. Insert needle bevel up; the bevel of the needle should be visible through the skin. 13. Access injection site for bleeding. (Subcutaneous) policy. The policy guidelines: item 2. Preferred sites for injection are listed. 8. Expel air from syringe. 9. Aspirate by pulling back on plunger gently. 12. Access area for bleeding.

Based on observations, interviews, and facility policy review, the facility failed to ensure all drugs and biologicals were stored in a locked compartment and permit only authorized personnel to have access for one of one medication cart. The findings are: 1. On [DATE] at 10:28 AM, a medication cart (med-cart) was observed to be unlocked, located just outside the dining room, in the hallway across from the nurse's station for hall ,d+[DATE]. Licensed Practical Nurse (LPN) #2 was behind the nurse's station gathering the resident's smoking items. LPN #2 left the nurse's station and walked up the hallway into an office adjacent to the ,d+[DATE] hall nurse's station. The medication cart was not in her line of site due to her turning and walking away from the nurse's station and her going into an office. 2. On [DATE] at 10:29 AM, the surveyor opened the top drawer of the medication cart and observed medications in the drawer. 3. On [DATE] at 10:30 AM, LPN #2 came back to the nurse's station and went outside with the residents for their smoke break, without locking/securing the med-cart. 4. At 10:36 AM, LPN #2 came back inside the building and walked behind the nurse's station. The surveyor asked LPN #2 to come to the medication cart. LPN #2 said she had noticed the cart was unlocked at 10:30 AM, when she picked up the resident's smoking box. The surveyor asked LPN #2 to identify the medications in the cart and identify the number of pills or tablets in each container. 5. On [DATE], at 10:43 AM, LPN #2 identified the following items and counts: a. Aspirin 325 microgram (mcg), expiration date of Apr/2025 - 91 pills. With WARNING: if nausea and vomiting occur, consult a doctor. Allergy alert: Aspirin may cause a severe allergic reaction, which may include facial swelling, shock hives, asthma (wheezing). Stomach Bleeding WARNING: This product contains a non-steroidal anti-inflammatory drug (NSAID), which may cause severe stomach bleeding. The chance is higher if you are age 60 or older, if you take other drugs containing prescription or non-prescription NSAIDs (aspirin, ibuprofen, naproxen, or others) have 3 or more alcoholic drinks every day while using this product; take more or for a longer time than directed. b. Vitamin D3, 125 mcg microgram (5000 International Unit [IU]), expiration date ,d+[DATE], - 50 tablets. Directions to consult your healthcare provider prior to taking high dose vitamin D supplements. Adults take one (1) table with any meal or as directed by a healthcare provider. Do not exceed recommended dosage. WARNING: consult a healthcare provide if taking any medication, have a medical condition (especially hypercalcemia, kidney disease or hypercalcemia, kidney disease or hyperparathyroidism) or are planning a medical procedure. Do not take with other supplements that contain vitamin D, such as multivitamins. Keep out of reach of children. Do not use if product appears to be tampered with or seal is broken. c. Vitamin D3 1250 mcg (50,000 IU), 5 tablets. Directions: adults take one (1) tablet weekly with any meal or as directed by a healthcare provider. Not intended for daily use. Warning: Consult a healthcare provider prior to use if on medications, have a medical condition or planning a medical procedure. Not intended for individuals with liver, kidney or bone disease, calcium disorder or malignancies, unless under the direct supervision of a physician. d. Thiamin Vitamin B-1, 100 milligrams (mg), expiration date ,d+[DATE], - 22 tablets. Instructions to ask your health professional before use if taking other medications. e. Vitamin E 90 mg (200 IU) expiration date ,d+[DATE]; 95 soft gels. WARNING: consult your doctor before use. Keep out of reach of children. Do not use if seal under cap is broken or missing. f. Quercetin 500 mg, expiration date ,d+[DATE], 60 capsules. WARNING: Consult your doctor before use if you have any medical condition. Keep out of reach of children. Do not use if seal under cap is broken or missing. g. Non-steroidal anti-inflammatory Tablets 200 mg, expiration date ,d+[DATE], 13 tablets. WARNINGS: Allergy alert: Non-steroidal anti-inflammatory may cause severe allergic reaction. Symptoms may include hives, facial swelling, asthma (wheezing), shock, skin reddening, rash, blisters. If allergy occurs seek medical help right away. STOMACH BLEEDING WARNING: contains an NSAID, which may cause severe stomach bleeding .if taking other drugs for blood thinning (anticoagulant) or steroid drug. HEART ATTACH AND STROKE WARNING: NSAIDs, except aspirin, increase the risk of heart attack, heart failure, and stroke. These can be fatal. h. Stool Softener docusate sodium 100 mg stool softener laxative - 55 soft gels, DRUG FACTS: stop use and ask a doctor if you have rectal bleeding or fail to have a bowel movement after use of a laxative. i. Allergy Relief Loratadine 10 mg Tablets Antihistamine, 24 hour non-drowsy - expiration date ,d+[DATE]: 4 tablets. WARNING: Do not use if have ever had an allergic reaction to this product or any of its ingredients. j. Vitamin B-12, 500 mcg, expiration date ,d+[DATE], -7 tablets, take one tablet daily. k. Ferrous Sulfate, 325 mcg, expiration date ,d+[DATE], 19 tablets, WARNING: Accidental overdose of iron containing products is a leading cause of fatal poisoning in children under 6. Keep this product out of reach of children. In case of accidental overdose, call a doctor or poison control center immediately. DRUG INTERACTION PRECAUTION: Since oral iron products interfere with absorption of oral tetracycline antibiotics, these products should not be taken within 2 hours of each other. l. One-Daily Multi-Vitamin with Minerals expiration date ,d+[DATE], -69 tablets. WARNING: Accidental overdose of iron containing products is a leading cause of fatal poisoning in children under 6. Keep this product out of reach of children. In case of accidental overdose, call a doctor or Poison Control Center immediately. m. Vitamin D3 25 mcg (1000IU), expiration date ,d+[DATE], - 58 ,d+[DATE] tablets, Keep out of reach of children. n. Cetirizine HCI Tablets, USP 10 mg, Antihistamine, expiration date ,d+[DATE], - 88 tablets, WARNINGS: Do not use if you have an allergic reaction to this product. Ask your doctor before using if you have liver or kidney disease, using sedatives or tranquilizers. o. Antiemetic 12.5 mg Antiemetic, expiration date ,d+[DATE], 12.5 mg - 98 tablets. WARNINGS: Do not use this product, unless directed by a physician if you have glaucoma, a breathing problem such as emphysema or chronic bronchitis, trouble urinating due to an enlarged prostate gland. p. Fish Oil 1000 mg Omega-3 300 mg, 4 soft gels, WARNING: Consult a healthcare provider prior to use if . taking medications, including blood thinners, have a medical condition or are planning a medical procedure. Keep out of reach of children. q. Stool Softener docusate sodium 100 mg stool softener laxative, expiration date ,d+[DATE] - 12 soft gels, DRUG FACTS: do not exceed recommended dose. r. Vitamin D3 50 mcg (2000 IU), expiration date ,d+[DATE], 100 soft gels. Keep out of reach of children, s. Laxative .5 mg, stimulant laxative enteric coated tablets, expiration date ,d+[DATE], 71 tablets, WARNINGS: Do not use if you cannot swallow without chewing. Keep out of reach of children. In case of overdose, get medical help or contact a Poison Control Center right away. t. Vitamin B-12 1000 mcg; 82 ,d+[DATE] tablets total, 23 were pink round tablets, 59 ,d+[DATE] were pink oblong tablets, 2 of the tablets were breaking down in bottle, u. Chewable Gas Relief Tablets Simethicone 80 mg, expiration date ,d+[DATE] - 89 tablets, v. Folic Acid 1000 mcg, expiration date ,d+[DATE], 76 tablets, WARNING: High potency Folic Acid may mask certain Vitamin B-12 deficiency symptoms. Before taking high potency of Folic Acid consult your physician. w. Zinc 50 mg, expiration date ,d+[DATE], 78 tablets, Keep out of reach of children. x. Tube of Clotrimazole & Betamethasone Dipropionate Cream - Resident label attached Resident #37, LPN #2 said this medication has been discontinued. For Topical use only. Expiration date ,d+[DATE]. y. A short acting bronchodilator inhaler 3mg/5ml, 85 inhalers with no name. z. Anti-fungal Powder with Miconazole Nitrate 2%, WARNING: For external use only. - 2 bottles. aa. Vitamin B-12 500 mcg; - bottle shows 100 tablets came in the bottle but the actual count is 131 tablets. Expiration date ,d+[DATE], bb. Calcium 600+D5 mcg, expiration date ,d+[DATE], 54 tablets, cc. Aspirin 325 microgram (mg), expiration date of ,d+[DATE] - approx. ,d+[DATE] bottle. With a WARNING: if nausea and vomiting occur, consult a doctor. Allergy alert: Aspirin may cause a severe allergic reaction, which may include facial swelling, shock hives, asthma (wheezing). Stomach Bleeding WARNING: This product contains a non-steroidal anti-inflammatory drug (NSAID), which may cause severe stomach bleeding. The chance is higher if you are age 60 or older, if you take other drugs containing prescription or non-prescription NSAIDs (aspirin, Non-steroidal anti-inflammatory or others) have 3 or more alcoholic drinks every day while using this product; take more or for a longer time than directed. 6. On [DATE] at 11:38 AM, the Director of Nursing (DON) asked if the Assistant Director of Nursing (ADON) could count the remainder of items in the cart. LPN #2 stopped identifying medications and the ADON identified the remainder of the medication and other items in the med-cart: a. Acetaminophen 500 mg, expiration date ,d+[DATE], 99 tablets, WARNINGS: Liver warning - Severe liver damage may occur if you take more than 8 tablets in a 24-hour period. Allergy alert: may cause severe skin reaction. b. Vitamin D3 50 mcg (2000 IU), expiration date ,d+[DATE], 97 soft gels. Keep out of reach of children. c. Fish Oil 500 mg, expiration date ,d+[DATE], 117 soft gels, No lid. The bottle of fish oil was sitting in the med-cart drawer without a lid. 12 soft gels and the lid were lying in the bottom of the drawer. d. Antihistamine Injection 25 MG/ML with a resident name - Resident #8, - 2 vials of 1 ml each. Expiration date of [DATE]. e. Cinnamon 1000 mg, 179 capsules, expiration date ,d+[DATE], WARNING: If you take a prescription medication or have any medical condition, consult a physician before using this product. f. A short acting bronchodilator unit dose vials .5 mg & 3 mg*/3 ml. identified as Resident #8 - 5 vials and a discharged resident - 20 vials. g. Mucus Relief 600 mg extended-release bi-layer tablets; 30 tablets, WARNINGS: Ask a doctor before use if you have persistent or chronic cough such as occurs with smoking, asthma, chronic bronchitis, or emphysema, cough accompanied by too much phlegm, in case of an overdose, get medical help or contact a Poison Control Center right away. h. A short acting bronchodilator nebulizer liquid medication, 25 vials for a discharged resident. i. Mucus Relief 400 mg, expiration date ,d+[DATE], 80 tablets. WARNINGS: Ask doctor before use if you have persistent or chronic cough, asthma, chronic bronchitis, or emphysema. In case of overdose get medical help or contact Poison Control Center right away. A second bottle with 87 tablets, expiration date ,d+[DATE]. j. Gas Relief - Simethicone 80 mg, expiration date ,d+[DATE], WARNINGS: In case of overdose, get medical help or contact a Poison Control Center right away. k. Antihistamine HCI 50 mg, expiration date ,d+[DATE], 97 capsules, WARNINGS: Ask doctor before use if you have a breathing problem such as emphysema or chronic bronchitis, glaucoma, trouble urinating due to an enlarged prostate gland. l. Acetaminophen 500 mg tablets, ,d+[DATE], 100 tablets; WARNING Liver warning. Severe liver damage may occur if you take more than 4000 mg of acetaminophen in 24 hrs. Contains allergy alerts. m. Heartburn Relief, Famotidine tablets, 10 mg, 34 pills, WARNING: Allergy alert: Do not use if you are allergic to famotidine or other acid reducers. Expiration date ,d+[DATE]. n. Antihistamine Injection 25 mg/ml, expiration date [DATE], 1 vial. A second vial belonging to Resident #38. o. Nicotine Transdermal System Patch, 14 mg. note: If swallowed, get medical help, or contact a Poison Control Center. p. Triple antibiotic ointment .1 oz. WARNING: For external use only, ADON confirmed approximately ,d+[DATE] of the tube was remaining in tube. q. Regular strength antacid & Anti-gas liquid. ADON confirmed it is ,d+[DATE] bottle of a 12 oz bottle. WARNING: Ask a doctor before us if you have kidney disease or a magnesium-restricted diet. r. An antibiotic Injection 750 mg 100ML/HR, Quantity 600 of 600, Unopened, expired [DATE], belonging to a resident - 1 large bag flush saline 11 syringes, Bag of IV Primary set/sigma set up, 4 kits. s. There were numerous unidentified loose pills in the bottom of the drawers of the Med-cart. There was a total of 73 whole pills/tablets and 22 half pills/tablets scattered loose in the Med-cart. ADON said she would need to send these to the Pharmacy for identification. 7. On [DATE] at 10:36 AM, LPN #2 stated the facility did not use this cart anymore because they had moved all the resident's medications to the other halls where the residents from 400 hall moved. LPN #2 could not tell the surveyor who unlocked the cart or how long it had been unlocked but she had noticed it unlocked when she was gathering the resident's smoking items. LPN #2 said she was concerned with the residents having access to these medications because some, like the aspirin, could cause internal bleeding. LPN #2 stated if a resident got into these and overdosed it would be bad or if they fell the bleeding could be significant or if a resident got something they were allergic to it would be bad. 8. On [DATE] at 10:38 AM, RN #5 stated she had not been in the cart today and did not know it was unlocked because they never use that cart. 9. On [DATE] at 11:38 AM, the Assistant Director of Nursing (ADON) said she did not know how long this cart had not been in use, but it had not been used since she started here, and she had only been here a couple weeks. The ADON said the cart should be locked at all times due to the medications in the cart, because if a resident got in the cart and took some of these medications, or was allergic to them, it would be bad. The ADON said if they took too much acetaminophen it could be toxic to their liver, and we would send them to hospital emergency room . The ADON said if a resident got into the aspirin, it could cause significant bleeding. 10. On [DATE] at 12:10 PM, the Director of Nursing (DON) said if a resident had gotten into the cart and took the aspirin the resident could sustain a brain bleed, the acetaminophen could cause liver failure, the stool softener could cause excessive diarrhea, the vitamins could cause a number of different issues, the meclizine could be deadly and too much of anything could cause major injuries. The DON said she did not know who all had keys to the cart, but she did not have a key to this cart. 11. On [DATE] at 3:00 PM, the DON said she did not know how long it had been left unlocked. The DON said RN #6 reported to her on [DATE], the cart was locked. 12. On [DATE] at 3:00 PM, RN #6 said she had not gone to the cart today and she did not work yesterday. RN #6 said the last day she worked was the 8th, and the 6th, before that and that day she noticed it locked. 13. On [DATE] at 3:10 PM, the Administrator said the cart had last been accessed when they moved the residents off 400 hall, to the other two halls, and all the resident's medications had been moved. The Administrator said that move took place back in June and July. The Administrator said Pharmacy Services checks things like the med-carts being secured when they come but they would not have been checking that cart since June or July because they were not using that cart. The Administrator said the only person he knew to have a key was the DON but that some other nurses must have a key to the cart. The Administrator said his concern with the cart being unlocked was a fear of someone accessing the cart that should not and accessing the medications because a myriad of things could happen; like aspirin could cause an internal bleed out. 14. On [DATE] at 8:45 AM, the Administrator provided a copy of the Medication Storage Policy. The guidelines items: I. All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts. II. No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines. III. Drugs must be stored in an orderly manner in cabinets, drawers, or carts. IV. An unattended medication cart must remain locked, at all times. In the event the nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it. Or secured in a locked medication room.

Based on observation and interview, the facility failed to ensure kitchen vents were cleaned to provide a sanitary environment for food preparation; that floors, dish washer and kitchen walls, door and frames were free of rotten wood, chipped floor tiles, debris, dirt, grease, rust, stains, wall tiles were replaced; food items stored in the refrigerator were covered or sealed; expired food items were promptly removed from stock; ice machine and ice scoop holder were maintained in clean and sanitary condition; dietary staff washed their hands before handling clean equipment or food items and hot food items were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service for 1 of 2 meals observed. The Findings are: 1. On [DATE] at 10:17 AM, the following observations were made in the walk-in refrigerator: a. An opened box of sausage on a shelf. The box was not covered or sealed. b. An opened box of bacon. The box was not covered or sealed. c. Unopened 21-pound box of white bread dated [DATE] was on a cart. The manufacturer speciation on the box indicated to avoid refrigeration, as it tends to stale the product 2. On [DATE] at 10:31 AM, inside the back wall of the ice machine and the ice machine panel in the kitchen had buildup of wet black residue on them. The surveyor asked Dietary [NAME] (DC) #1 if she could wipe the area where wet black residue was observed. She did so, accumulation of black residue easily transferred to the white rag. The surveyor asked Dietary [NAME] (DC) #1 if she could describe what she saw on the back wall of the ice machine, where ice cubes were resting and the panel, where ice touches before dropping into the ice, collect. She stated it was wet, black residue. DC #1was interviewed and was asked how often the ice machine was cleaned and who used the ice from the ice machine. She stated it was cleaned once a week. The kitchen staff used it to fill beverages served to the residents at mealtimes. The Certified Nursing Assistants (CNA) used it to fill the water pitchers in the residents' rooms. 3. On [DATE] at 10:34 AM, the scoop holder attached to the body of the ice machine had wet black residue at the bottom of it and the ice scoop was resting directly on it. DC #1 was interviewed and was asked if she could wipe the wet black residue at the bottom of the scoop holder and if she could describe what she saw at the bottom of the scoop holder, how often does she clean the scoop holder. She stated it had been cleaned daily. DC #1 took it to washing machine. When the wash cycle finished, DA #2 removed the scoop holder, and the stains were gone. 4. On [DATE] at 10:58 AM, the following observations were made in the kitchen: a. There were serval gaps observed throughout the kitchen floor. The areas that had gaps had multiple stains on them. b. The wall by the Janitor's closet was chipped, exposing the concrete. c. The ceiling air vent, above the ice machine and beverages machine, had accumulation of greasy dirt on it. d. The wall below the ice machine and behind them had buildup of greasy dirt on them. e. The Fluorescent light covers, close to the door leading to the dining room had dirty lint on it. f. Air vent around the Janitor closet and wall above the janitor's closet had black and grayish spots on them. g. Both sides of the oven were covered in rust. A knob was missing at the middle of the stove. One knob was loose, and the area exposed had buildup of greasy white film on it. The floor drainage by the oven had accumulation of dirt in it. Dietary Supervisor stated it doesn't work. h. The walls leading to the walk-in refrigerator were chipped, exposing the cement. i. The edges of the deep fryer had grease build up hanging down from them. j. The walls by the 3-compartment sink had peeling paint exposing the cement. k. The air vent and ceiling tiles around the vent hood had grease dirt, sage color, and rust build up on it. l. The ceiling tiles, above the counter close to the steam table, had water damage in 4 different areas. m. The wall above the hand washing sink had peeling paint, exposing the cement. n. The pipe attached behind the oven, and deep fryer had black and brown greasy stains on it 5. On 12XXX,d+[DATE] at 11:07 AM, the following observations were made in the storage room. a. Thirty -two cartons of nectar thickened cranberry cocktail on a shelf in the storage room had expiration date of [DATE]. b. A container of ground nutmeg on the spice rack had best use by [DATE]. 6. On [DATE] at 11:42 AM, the following observations were made in the dish washing machine: a. One vent in the dish washing machine had buildup of greasy stains in them b. The ceiling panels in the dish washing machine had rust on them. c. The wall of the dish machine had two of two bottom door frames in the dish washing machine leading to the dining room were missing, exposing the metal. d. The wall in the dish machine room had sage color. e. The ceiling vent in the dish washing machine had buildup of greasy dirt on it. f. The door frames leading to the dining room from the dish washing machine had rust on them. g. The wall on the dirty side of the dish washing machine was chipped, exposing the cement. 7. On [DATE] at 11:50 AM, Dietary Aide (DA) #2 picked up a pitcher turned on the sink faucet and poured beverages in each glass to be served to the residents for supper. Dietary Aid was interviewed and was asked what she should have done after touching dirty and before handling clean equipment; she stated she should have washed her hands. 8. On [DATE] at 12:12 PM, Food temperatures on the steam table when checked and read by DC #1 were: a. Pureed cut green beans, 120 degrees Fahrenheit. b. gravy, 120 degrees Fahrenheit. c. Pureed bread with milk, 100 degrees Fahrenheit. d. Fortified mashed potatoes, 121 degrees Fahrenheit. e. Brussel sprouts, 125 degrees Fahrenheit. The above food items were not reheated before being served to the residents for supper meal. 9. A review of facility policy titled, Hand washing not dated and provided by the Dietary Supervisor indicated hands should be washed when entering the kitchen at the start of a shift and after engaging in other activities contaminating the hands.

Based on observations, record review, and interviews, the facility failed to provide a safe and sanitary environment for residents. In addition, the facility failed to clean and sanitize equipment such as shower beds/chairs, electric clippers used to cut facial hair, wheelchairs, walkers, and lift equipment. These findings have the potential to affect all 52 residents. The findings are: On 12/15/24 at approximately 10:15 AM, observed a medication cart labeled 400 hall nurse , with a sharps container attached to the side with a reddish-brown substance dried on the outside. On 12/15/24 at 10:30 AM, observed the beauty shop was unlocked and observed the trash can was overflowing with a pile of plastic and hair. What appeared to be a long dark hair extension/weave resting on top of the trash can. There was a large pile of different colored hair laying in the sink approximately 2 inches deep along with a red paddle brush, yellow comb, and black hairbrush, all with hair in the bristles. There were baskets containing attachments and other hairbrushes/combs, all covered in hair. The countertops were dirty and dusty, and other equipment such as electric trimmers and clippers covered in hair of many different textures and colors. There was no disinfectant solution or disinfectant wipes present used to disinfect supplies or equipment. On 12/15/24 at approximately 12:00 PM, the surveyor observed the 100-hall shower room was unlocked. The room had a foul musty odor, also smelled like urine. The shower floor was covered with a black and brown substance and had a slippery residue without moisture present. The shower heads were laying in the floor. The shower bed and shower chairs present had black and brown marks down the sides of the white plastic frame. The stretchy mesh portion (the area a resident would sit or lay on) showed areas of discoloration of black and brown spots. The countertop and sink had dust, hair, and other unknown substances. There were several used toothbrushes sitting in a cup next to the sink. On 12/15/24 at 11:00, the surveyor observed the resident rooms on 100 hall. The rooms smelled like a bleach type odor, that was strongest in the bathrooms. An unknown substance was in the toilet bowl. The floors appeared to be clean in areas, but several areas had sticky substances within the grout and on the tile. The bathroom floor bullnose area (functional area where the tile floor extends up the wall) was darker with what appeared to be dirt and hair. On 12/15/24 at approximately 12:45 PM, the surveyor observed the supplemental snack room, close to the nurse ' s station, for 100 and 200 halls. When the surveyor stepped inside, the countertops were noted to have a thick layer of dirt and dust present. The sink was not draining and had a slimy residue around the drain with water standing. When the refrigerator was opened, there was a tray of drinks and snacks for the residents on the bottom shelf. Inside the door, several opened drinks were noted including an opened can of lemon lime drink, an opened bottle of muscle milk, an opened bottle of water, and an opened energy drink. On 12/15/24 at 1:20 PM, the surveyor observed the bathrooms on 100 hall. The bathrooms appeared to have dust and hair covering the safety bar, and portions of the countertops. The walls and floor were dirty with hair and dust, and the trash was overflowing with paper towels. On 12/16/24 at 9:26 AM, the surveyor observed the supplemental snack room near the 100 and 200 nurse ' s station. Inside the refrigerator, there was a tray with snacks and drinks for the residents. The refrigerator had several opened drinks in the door including: a clear cup with a red liquid, an opened water bottle, and an unopened energy drink can. On 12/16/24 at 9:45 AM, the Director of Nursing (DON) was interviewed, regarding the refrigerator contents. The DON confirmed the drinks in the refrigerator were employees ' drinks and they used that refrigerator to keep their food and drink items. The surveyor walked with the DON and CNA #4 to the beauty shop to discuss equipment used by the staff to shave residents. CNA #4 stated they used two different clippers located in the beauty shop for longer facial hair to remove or trim. CNA #4 stated, Just last week I used them, a black one and a smaller white one on a resident to trim their beard up. The surveyor pointed to the clippers and asked CNA #4 if these were the ones she had used, and she stated, Yes, the black one and the white one. Upon inspection of both, many different colors and textures of hair were noted on the clippers. When asked about their process of cleaning the clippers before and after using, CNA #4 confirmed they were not cleaning either before or after but said they should have been cleaned. On 12/17/24 at approximately 12:30 PM, the surveyor observed both the 100 hall and the 300 hall lifts were soiled with a deep layer (approximately 0.5 inch) of dust, and other unknown substances. Several large (approximately 12 to 20) dark stains were also noted on the carpet on 100 hall. Several residents ' rooms were noted to have staining along the wall, dust and hair in the corners of the rooms and under the beds. On 12/17/24 at 10:20 AM, the surveyor walked with the Administrator to the shower room on 100 hall. The door was unlocked again, and it appeared the room had been cleaned some since the first observation, but the shower floor continued to have a black substance on the tile and in the grout. The room continued to have a foul odor and was musty. During an interview with the Administrator, at that time regarding housekeeping issues, he confirmed they were working with their housekeeping staff and issues with areas within the facility which required deep cleaning. The Administrator stated steps were being taken to improve the cleanliness of the facility included: 1. Hiring additional staff to ensure adequate staffing. 2. Administration and managers more closely monitor the cleaning process. 3. Create a more team-like environment for employees to work together. On 12/17/24 at 9:20 AM, when asked for an infection control policy that addressed housekeeping, the DON stated there was not a policy they could provide specific to these concerns.

Based on observation, interview, and facility policy review, the facility failed to ensure residents had a functioning call light system that would alarm, light up, and could be reset by staff, or a way to contact staff to ensure needs were met for 2 of 2 sampled (Resident #7, and Resident #30) residents. The findings include: 1. A review of an in-service training report, dated 11/18/2024, revealed staff were instructed to answer call lights in a timely manner. 2. On 12/15/2024 at 2:38 PM, Resident #7 stated the call light is not working. The call light button was pushed and did not light up outside the door for Resident #30, but Resident #7's call light functioned. Certified Nursing Assistant (CNA) #9 pressed Resident #30's call light and the call light was not lighting up above the door, and no alarm was heard. CNA #9 revealed that she would attempt to fix the call light because if she does not try nobody else will do it. CNA #9 confirmed in an emergency or if resident #30 needed something the resident would not be able to use the call light. 3. On 12/15/2024 at 11:50 PM, the surveyor observed Resident #30 resting quietly, with call light resting on Resident #30's chest, and Resident #7 was sitting in a recliner with call light in reach. Resident #7 confirmed they do not have a bell or way to reach staff. The call light control panel was hanging down by 2 red, and 2 white wires. The red bulbs on the panel were lit up. The reset button was pushed, and the lights stayed on the panel, and the light did not work outside Resident #7 and Resident #30's door. CNA #10 walked in and stated that she was asked to check on Resident #30 and Resident #7 frequently and make sure they were not playing with the wires hanging from the wall or needed anything. They cannot get to the panel. 4. On 12/16/2024 at 9:16 AM, Resident #30 was moved to a room with functioning call lights, and the call light control panel was back in the wall. 5. During an interview with the Director of Nursing (DON) on 12/17/24 at 4:00 PM, the DON was asked the process for identifying call lights that do not work. The DON revealed that during the daytime hours staff called the Maintenance Director and told him when something was not working. After hours staff called the DON or mainly the Administrator and they will let the Maintenance Director know call lights are not working so he can fix them. The surveyor asked when maintenance reports were filled out. The DON stated staff call the Administrator for the most part. The DON said that staff called Sunday night and said that Resident #30's call light was out, and she bought a bell for Resident #30 ' s room, and as soon as the nurse found out, they started monitoring the room and documenting. Resident #30 did not have a bell when she was seen at midnight. The surveyor asked when Resident #30 received the bell. The DON revealed that she did not have a bell at that time but brought them in the next morning. The DON confirmed that there was a concern that Resident #30 might not get their needs meet during the time they did not have a functioning call light. The surveyor requested a call light policy, Resident #30 ' s monitoring log, and any maintenance reports they might have. 6. On 12/17/2024 at 04:19 PM, the Administrator provided a Monitoring Log for Resident #7 and Resident #30 showing that nursing knew the call light did not work at 1245 AM, with one-hour checks, and revealed a bell was given to resident at 7:45 AM. A review of Maintenance Request Log Sheets, dated 09/21/2024-12/02/2024, from the nurse ' s station revealed no reports of broken or non-functioning call lights were provided to maintenance. 7. On 12/18/2024 at 12:33 PM, a review of a policy titled Call Light, Use Of, revealing bedside call lights should light up above the door/and or sound above the door and light up at the nurse's station. Staff must turn the call light off at the control panel where the alarm originated from. Defective call lights should be reported to the charge nurse and reported to maintenance immediately and logged in the maintenance log. The Call light system should be checked regularly. 8. On 12/18/2024 at 3:10 PM, the Maintenance Director was asked the process for reporting broken call lights and things that needed to be repaired and stated, Honestly, most people just tell me in the hallway. The surveyor asked if repairs ever got overlooked because they were not documented. The Maintenance Director confirmed that he had sometimes forgotten what he was told since it is not written down.

Based on observations, record review, and interviews, it was determined the facility failed to provide snacks that were previously offered and appropriate for residents with diabetes, therefore failing to accommodate their needs, which affected the resident's quality of life for 1 (Resident #34) of 1 resident reviewed. Specifically, the facility failed to ensure Resident #34, a resident with type I diabetes, was provided snacks, other than high sugar/simple carbohydrates. The findings are: Upon review of the Admission Record, the facility admitted Resident #34 on 05/10/24 with an admitting diagnosis of type I diabetes. Upon review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/26/2024, Resident #15 was assessed with a Brief Interview for Mental Status (BIMS) score of 15, (BIMS score 13-15 indicates cognitively intact). Per section GG of this MDS, the resident required supervision for ambulation and the use of a rolling walker. Resident #34 required minimal assistance with Activities of Daily Living (ADLs). On 12/15/24 at approximately 11:20 AM, this surveyor observed Resident #34 in the resident ' s room with spouse. During an interview, Resident #34 stated, I'm a type I diabetic, and have an issue with the snacks that are offered are all high sugar content. I realize they don't have to serve all our meals as diabetic meals, but I need at least a decent snack when my sugar drops, and I'm not the only one here with diabetes. On 12/16/24 at 9:20 AM, an interview was conducted with the Administrator, regarding snacks offered for residents with diabetes. The Administrator stated the facility offered peanut butter with crackers, fresh fruit, and small blocks of cheese such as cheddar cheese with crackers. When asked about anything sugar free such as sugar free pudding or unsweetened apple sauce, the Administrator stated, We will at times, especially if someone requests them. On 12/18/24 at 10:50 AM, Resident #34 was in the hall requesting to speak to someone. The resident's hands were shaking. Resident #34 stated, I just came from the kitchen asking for some peanut butter and crackers. I was told there was not any. I asked them what they had to offer because my blood sugar was too low, and they told me we can give you a snack cake or a fruit cup. I explained to them I prefer something with some protein in it, or a complex carbohydrate, but they said they did not have any cheese or peanut butter. This is the second time I have asked for it in the last few months, and they did not have any then either. I was told that was supposed to be one of our choices, so I do not understand why they would not have any. On 12/18/24 at 11:15 AM, during a concurrent observation of the kitchen area and interview, the Dietary Manager stated they were out of peanut butter and cheese but could give a snack cake. The Dietary Manager also stated they could order peanut butter and have in, possibly by the end of the week. This surveyor requested invoices for the facility's orders since mid-October. Upon review of the invoices, there was no peanut butter or peanut butter crackers ordered on any of their [vendor name] invoices from 10/22/24 through 12/13/24.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a resident without self-administration rights was not self-administering an inhaler and updraft without approval or staff presence to prevent improper usage, storage, and misappropriation of resident's own medication affecting 1 sampled (Resident #351) resident of 1 sampled. The findings include: a. A review of Resident #351 ' s Physician Orders dated 12/03/2024, revealed an order for inhaled nebulizer 1 vial every 4 hours as needed for shortness of breath or wheezing. b. A review of Resident #351 ' s Care Plan dated 12/03/2024, revealed Resident #351 was shown to have flare ups that caused the resident to become short of breath related to chronic obstructive pulmonary disease (COPD) diagnosis and being a current smoker. As needed medications were available for times of anxiousness. c. On 12/15/2024 at 11:15 AM, an inhaler was observed resting on the overbed table of Resident #351. Resident #351 stated, I was told I could keep the medication on person for when I need it. d. On 12/15/2024 at 3:30 PM, Resident #351 was observed alone, sitting in the resident ' s room, holding an updraft mask to [pronoun] face with fumes coming from the mask, and an inhaler remained in reach at the bedside. Licensed Practical Nurse (LPN) #1 stated LPN #2 gave Resident #351 the updraft medication. LPN #1 revealed Resident #351 would need to complete an assessment before the inhaler or updraft medication could be returned for self-administration. e. During an interview with the Director of Nursing (DON) on 12/15/2024 at 3:33 PM, the DON stated a nurse, or respiratory therapist was supposed to stay in the room until treatment was complete and there needed to be an order to have medication at bedside and an assessment completed to ensure residents were capable. The DON stated there had been no in-service on self-administration, updraft, and medical administration. The DON was asked to provide a policy on self-administration and a list of residents with self-administration rights. f. On 12/15/2024 at 4:24 PM, the DON provided a census report with a message stating they had no residents with self-administration rights. The DON also provided a policy titled Medications, Self-Administration, Self-Storage, Leave at Bedside. It revealed any resident wanting to self-administer must be assessed by a licensed nurse or respiratory therapist. It required a physician's order for any medication to be kept at the bedside. The medication administration record (MAR) would display the medications and whether they were self-administered. The care plan would inform staff where the medication was to be kept. The resident's current self-administration status would be shown on the physician's order sheet. g. On 12/16/2024 at 8:45 AM, the Storage of Medications guidelines were provided and revealed all medications must be stored at or near the nurse's station and locked away. The medication must be stored in a cabinet, drawer, or cart. They must have a specific contained spot for medication to prevent it from being used by someone else. h. On 12/16/2024 at 3:03 PM, after review, there were no orders or indication if an updraft needed to be administered by the resident or staff.

Based on interview and record review, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASRR) for 1 (Resident #15) of 1 resident reviewed for PASRR. The findings are: Upon review of the Admission Record, Resident #15 was admitted to the facility on [DATE] with a primary diagnosis of diabetes mellitus II with unspecified complications. Resident #15 also had a diagnosis of bipolar disorder, severe, with psychotic features and panic episodes. Upon review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/2024, Resident #15 was assessed with a Brief Interview for Mental Status (BIMS) score of 14, (BIMS score 13-15 indicates cognitively intact). Per section GG of this MDS, the resident required extensive assistance and was dependent on staff for transfers, dressing, and bathing. They required set-up assistance for meals. Upon review of Resident #15's scanned documents, a Level 1 Preadmission Screening and Resident Review was not found. On 12/18/24 at 12:45 PM, during an interview with the Social Services Director (SSD), the SSD confirmed there was not a PASRR pre-screening determination within the chart and stated she would call [the contracted company name] to get a copy. On 12/18/24 at 1:36 PM, the Social Services Director notified this surveyor she had spoken with [the contracted company name] and the resident was considered a PASRR I, but the facility could not provide documentation regarding this status.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a recapitulation, or summary, of stay upon discharge affecting 1of 1 sampled (Resident #49) resident to ensure sufficient information was given for safe care on discharge. Findings include: a. On 12/18/2024 at 11:00 AM, a review of Resident #49's medical record revealed, a 10/16/2024 discharge summary that revealed resident went home with medications. b. On 12/18/2024 at 11:06 AM, the Social Services Director (SSD) was asked who was responsible for the discharge summary for Resident #49. The SSD printed the Post Discharge Plan of Care and Discharging a Resident from Facility form and stated she filled those out and nursing was responsible for the discharge summary. The SSD confirmed that her documentation did not include medication reconciliation or a summary of Resident #49's care. c. On 12/18/2024 at 11:09 AM, the SSD was asked if there was a discharge summary for Resident #49. The SSD stated, Nursing did not put one in. d. On 12/18/2024 at 11:30 AM, Licensed Practical Nurse (LPN) #11 was asked who was responsible for Resident #49's discharge summary, and what should be documented. LPN #11 revealed nursing is responsible, and it should be where they went, who picked them up, medications and belongings returned. This surveyor asked LPN #11 if there should be a summary of the residents stay including reconciliation of medications. LPN #11 stated that she did not know. LPN #11 was asked for a copy of the discharge summary she put in the computer on discharge. e. On 12/18/2024 at 11:32 AM, LPN #11 provided Resident #49's discharge summary stating discharged home with meds, and a second discharge summary revealing that Resident #49 went home via ambulance. Meds and belongings went with resident. LPN #11 was asked if there was a summary of the resident ' s stay and medication reconciliation. LPN #11 left to check with administration. f. On 12/18/2024 at 11:38 AM, during an interview with the Director of Nursing (DON) and the Administrator, it was confirmed the two discharge summary notes were all that was documented for Resident #49's discharge. This surveyor asked if there should have been a summary or recapitulation of Resident #49's care. The DON was not sure. The DON and Administrator stated they would review the regulation. This surveyor requested the facility ' s discharge policy. g. On 12/18/2024 at 12:33 PM, a review of a policy titled Discharge/Transfer of Resident revealed sufficient information was given to the resident on discharge so that it is safe for the resident ' s aftercare.

Based on observation, interview, and record review, the facility failed to provide consistent bathing and personal hygiene for 4 (Residents #1, #3, #4, and #5) dependent residents to maintain hygiene, prevent infection and possible skin issues. The findings are: 1. Review of Medical Diagnoses revealed Resident #1 had diagnoses of neoplasm of uncertain behavior of the brain, contracture of muscle multiple sites, and dementia. a. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/20/2024 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 08 (08-12 indicates moderately impaired mental status) and dependent for bathing. b. Resident #1's Care Plan with a revision date of 04/23/2023 documented, .BATHING/SHOWERING: The resident requires assistance by (1-2) staff with bathing/showering 3 times weekly and as necessary . c. Resident #1's Monthly Summary dated 05/11/2024 documented Resident #1 was dependent for bathing. d. On 05/23/2024, Resident #1's Task Sheet documented Resident #1 was to have a shower every Monday, Wednesday, and Friday. Documentation showed Resident #1 received a shower only 5 days in May with an 11 day span in-between. 2. Review of Medical Diagnoses revealed Resident #3 had diagnoses of fibromyalgia, diabetes, and impaired motility. a. The Annual MDS with an ARD of 02/17/2024 documented a BIMS of 15 (13-15 indicates cognitively intact) and that the resident was dependent for bathing. b. On 05/22/2024 at 10:30 AM, Resident #3 was in the resident's room. Resident #3 stated, .I haven't had a bath in two weeks .I feel like I've been abandoned. c. Resident #3's Care Plan with a revision date of 02/17/2023 documented, .BATHING/SHOWERING: The resident requires assistance by 2 staff with bathing/showering 3 times weekly and as necessary . d. Resident #3's Monthly Summary dated 04/23/2024 documented Resident #3 was dependent for bathing. e. On 05/23/2024, Resident #3's Task Sheet documented Resident #3 was to receive a shower every Monday, Wednesday, and Friday. Four showers were documented as given in May of 2024, with the last shower documented as given on Monday 05/06/2024. 3. Review of Medical Diagnoses revealed Resident #4 had diagnoses of dementia and muscle wasting and atrophy. a. The Admission MDS with an ARD of 04/18/2024 documented a BIMS of 01 (0-7 indicates severely cognitively impaired) and was dependent for bathing. b. On 05/22/2024 at 10:17 AM, Resident #4 was in the resident's room and had whisker growth of 1/4 inch on the chin and cheeks. c. Resident #4's Care Plan with an initiation date of 04/19/2024 documented, . BATHING/SHOWERING: The resident requires assistance by (1-2) staff with showering 3 times weekly and as necessary . d. Resident #4's Monthly Summary dated 05/20/2024 documented, Resident #4 is dependent for bathing. e. On 05/23/2024, Resident #4's Task Sheet only documented 2 bathes for May 2024. 4. Resident #5 had diagnoses of Parkinson's Disease and Atherosclerotic Heart Disease. The Quarterly MDS with an ARD of 04/03/2024 documented a BIMS of 05 (0-7 indicates severely cognitively impaired) and was dependent for bathing. a. On 05/22/2024 at 10:15 AM, Resident #5 was lying in bed, there were 1/4 inch whiskers on the resident's chin and cheeks. When asked if the resident would like a shave, Resident #5 stated, Yes, but I'm just not able to do it anymore. b. Resident #5's Care Plan with a revision date of 01/02/2023 documented, .The resident has an ADL self-care performance deficit r/t Pain, Parkinson, Neuropathy, Dementia, and the disease process . PERSONAL HYGIENE: The resident requires assistance by (1) staff with personal hygiene and oral care . c. Resident #5's Monthly Summary dated 05/18/2024 documented Resident #5 was dependent for bathing and ADLs. 5. Review of Resident Council Meeting Minutes documented resident concerns, during February, April, and May of 2024, about not receiving baths/showers. 6. Review of the Grievances for January, February and April of 2024, documented concerns from family and residents about not receiving a bath/shower. 7. On 05/22/2024 at 12:45 PM, during an interview with Certified Nursing Assistant (CNA) #1, the Surveyor asked if they have enough time to get all their work and baths done. CNA #1 stated, This week has been good, usually don't have enough time to get all our baths done. 8. On 05/23/2024 at 3:25 PM, the Director of Nursing (DON) provided a facility policy titled, Giving a Bedbath which documented, .The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the residents skin .

Based on observation, interview, and record review, the facility failed to maintain a safe and palatable food temperature for trays served to residents who receive meals in their room. The findings are: On 05/22/2024 at 11:50 AM, the temperatures of the food items on the steam table prior to lunch service were checked by the dietary staff. The following temperatures were documented: Regular and Mechanical Soft: Lasagna - 175 degrees Fahrenheit Tossed Salad - 40 degrees Fahrenheit. Garlic Bread - 160 degrees Fahrenheit Cheesecake - 40 degrees Fahrenheit Pureed: Lasagna - 170 degrees Fahrenheit Greens - 170 degrees Fahrenheit Garlic Bread - 170 degrees Fahrenheit Cheesecake - 40 degrees Fahrenheit On 05/22/2024 at 12:15 PM, during the lunch meal service, lunch trays were observed being loaded onto an open sided cart to transport to the residents on the 300 Hall who eat meals in their room. At 12:30 PM, the Dietary Manager accompanied this Surveyor down the 300 Hall, to check the temperatures on the last tray to be delivered to the 300 Hall. The temperatures were as follows: Pureed Lasagna - 102 degrees Fahrenheit Pureed Greens - 90 degrees Fahrenheit Pureed Bread - 90 degrees Fahrenheit. Pureed Cheesecake - 41 degrees Fahrenheit After checking the temperatures, the Dietary Manager commented that she thought that the food was going to be out of temperature range. Review of the Resident Council Minutes documented resident concerns with food being served cold at the February, March, and April 2024 meetings. On 05/23/2024 at 3:25 PM, while talking with the Director of Nursing (DON), the DON stated they were aware of the resident's concerns about food temperatures and had been working to resolve this issue. The facility Food Safety Policy and Procedure documented, .Note: The U.S. Department of Health and Human Services Food Code uses 41 Degrees Fahrenheit for cold food and 135 degrees Fahrenheit for hot foods .

48483 Based on observations, record review and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for Residents in Room #'s 311-B, 405-A & B, and 414-A. This failed practice had the potential to affect all 47 residents. The findings are: 2. On 11/20/23 at 11:09 AM, the Surveyor observed room [ROOM NUMBER] bathroom. There was a Blue Geri chair stored in the bathroom. The toilet had large amounts of toilet paper floating in the water, and there were brown streaks, and specks of debris visible on the sides of toilet bowl. 2a. On 11/21/23 at 8:36 AM, the Surveyor observed room [ROOM NUMBER]-B bathroom The bathroom smelled of old urine, and the toilet bowl had brown specks, and streaks of brown debris visible on the surface of the bowl. The water in the toilet bowl was cloudy and there was a liquid substance on the floor in front of the toilet, on the toilet seat, and 2 drops of liquid were on the surface of the blue Geri chair seat that was in the bathroom. 2b. On 11/21/23 at 9:38 AM, the Surveyor asked the housekeeper to describe room [ROOM NUMBER]-B ' s bathroom. The housekeeper stated No I haven't gotten to it. Her toilet is clogged. I wrote it in the maintenance book last night. The Surveyor asked if the HK cleaned the bathroom last night or today. The HK answered, no. 3. On 11/20/23 at 9:59 PM, during observation of room [ROOM NUMBER]-B, the wall to the left upon entrance was scraped above the baseboard the entire length of the wall. The scrape was down to the white sheetrock in places, with beige wall paint peeling, and cracks visible in the white sheetrock underneath. The Surveyor asked Resident in the room if she liked the way the walls looked in her room. Resident replied, No. I would fix it if that was in my house. 3a. On 11/21/23 at 8:14 AM, the Surveyor asked the Resident in room [ROOM NUMBER]-B if anyone had been in to address the areas in the room that needed to be repaired and painted? The Resident answered, no. The Surveyor measured the area just inside the door on the lower left wall to be 4 feet and 4 inches long, and 2 inches wide. 3b. On 11/21/23 at 2:20 PM, the Surveyor checked the Maintenance log at the central nurses ' desk. There was no staff documentation for room [ROOM NUMBER] maintenance/repair needs related to the wall repairs and painting. 4. On 11/20/23 at 10:52 AM, the Surveyor observed a hole in the wall by the head of the bed in room [ROOM NUMBER]-A. 4A. On 11/20/23 at 12:52 PM, the Surveyor observed a large hole in the wall by the head of the bed in room [ROOM NUMBER]-A. 4B. On 11/21/23 at 8:27 AM, the Surveyor observed a large hole in the wall by the head of the bed in room [ROOM NUMBER]-A. 4C. On 11/21/23 at 08:32 AM, during observation of room [ROOM NUMBER]-A maintenance stated, There is a hole in the wall. Maintenance measured the hole and stated, It's 6 1/4 inches x 8 1/2 inches. The Surveyor asked, does this look homelike to you? Maintenance stated, no. 4D. On 11/21/23 at 8:36 AM, the Surveyor asked the Administrator if the room looked homelike. The Administrator stated, No. It probably happened when they got the resident up this morning. It looks like the bed slid over and hit the wall. 4E. On 11/21/23 at 2:20 PM, the Surveyor observed documentation in the Maintenance logbook. No sheet had been filled out for the hole in the wall for room [ROOM NUMBER]-A. The Resident Rights provided by the Administrator on 11/21/23 at 2:10 PM showed, .The facility must provide a safe, clean comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible .

A. Based on observation, record review, and interview, the facility failed to ensure interventions were planned and implemented to prevent falls, fall risk assessments were completed to identify risk factors that could contribute to falls, and planned fall prevention interventions were promptly and consistently implemented and added to the care plan to prevent further falls and injuries for 1 (Resident #42) of 8 (Residents #18, 26, 27, 37, 42, 45, 47 and 60) sampled residents who had a history of [REDACTED].#42, who had multiple falls that involved head injuries, and had the potential to cause more than minimal harm to 10 residents who had a history of [REDACTED]. 1. The facility's, Falls Policy, provided by the Administrator on 12/6/18 at 7:59 a.m., documented, .Treatment/Management 1. Based on the preceding assessment, the facility staff will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling . Monitoring and Follow-Up . 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling . and will re-evaluate the continued relevance of current interventions . 2. Resident #42 had [DIAGNOSES REDACTED]. A Significant Change (SC) Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/18 documented the resident scored 7 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required limited assistance of one person for bed mobility, transfers, and personal hygiene and had no history of falls. a. The Care Plan, dated as reviewed 6/18/18, documented, At risk for falls . Approaches . Quarterly and prn (as needed) Fall Risk Assessments and ADL (activities of daily living) Functional/Restorative Assessments by licensed staff to determine appropriateness of plan of care . 1/4 (quarter) side rails in bed to assist with turning/repositioning and for safety to remind resident to call for assist . Encourage resident to request assist before ambulation . b. A Morse Fall Risk assessment dated [DATE] (no time) documented, .score NA (not applicable) . All of the questions on this form were left blank. c. An Incident Report dated 10/28/18 at 12:33 (12:33 p.m.) documented, .Incident Description . Reported to this nurse resident was sitting on floor. Reported resident attempted to transfer self without assistance and slid from end of recliner chair onto floor . Immediate Action Taken . Assessed resident for injury and pain. No apparent injuries noted. This nurse explained to resident that she should request help resident stated, 'ok' . Notes 10/29/18 Interventions reviewed. No new interventions at this time D/T (due to) inability to educate resident. There was no documentation of any interventions other than reminding the severely cognitively impaired resident to request assistance with transfers, and there was no documentation a fall risk assessment was completed to identify the resident's risk factors for further falls. d. An Incident Report dated 11/4/18 at 10:40 (a.m.) documented, .Incident Description . Resident found on floor in seated position. Resident was apparently trying to transfer herself from her recliner to the bed without assistance. States that she was trying to transfer herself from recliner to bed without assistance . Immediate Action Taken . Resident moved from floor to bed. Vital signs taken. Assessment performed. Reinforced need to call for assistance for all transfers . Injuries observed at time of Incident Injury Type Bruise Injury Location 23) Coccyx . Notes 11/4/2018 . Reinforced need to call for help. Will continue to monitor. 11/5/18 All interventions reviewed and in place. Resident is unable to be educated regarding fall precautions. No new interventions at this time. There was no documentation of any interventions other than reminding the severely cognitively impaired resident to request assistance with transfers, and there was no documentation a fall risk assessment was completed to identify the resident's risk factors for further falls. The resident's electronic health record indicated a fall risk assessment task was initiated on 11/5/18; however, the assessment was not completed as of 11/29/18 at 11:36 a.m. e. An Incident Report dated 11/9/18 at 21:32 (9:32 p.m.) documented, .Incident Description . Resident found in hallway on floor at 1810 (6:10 p.m.). Abrasion noted to forehead 2.5 cm (centimeters) x (by) 3 cm. Area cleansed with NS (normal saline) and left open to air. Resident AAO (awake/alert/oriented) X (times) 1. Confusion noted. Not of new onset . Assisted back to w/c (wheelchair) and placed behind nurses' desk with nurses . Bed in lowest position call light within reach . Immediate Action Taken Assess for pain/injury. ROM (range of motion) intact . Injuries observed at time of incident no injuries observed . Injuries Report Post Incident Abrasion Face . Resident placed behind nurse's station (with) nursing, until ready to go back to bed. Bed placed in lowest position. Call light within reach. The interventions to place the bed in the lowest position and the call light within reach are standard interventions for any resident at risk for falls, per nursing standards of practice. There was no documentation of any resident-specific interventions, based on an evaluation of the circumstances and causative factors for this fall, to prevent further falls or minimize the risk of further fall-related injuries, other than temporarily placing the resident at the nurse's station and again reminding the severely cognitively impaired resident to request assistance with transfers. There was no documentation a fall risk assessment was completed to identify the resident's risk factors for further falls. The resident's electronic health record indicated a fall risk assessment task was initiated on 11/10/18; however, the assessment was not completed as of 11/29/18 at 11:36 a.m. f. An Incident Report dated 11/17/18 at 03:10 (3:10 a.m.) documented, .Went to resident's room after hearing a loud thump and observed resident on floor, lying on top of a pillow. Resident stated, 'To tell you the truth, I don't know what I was trying to do' . Immediate Action Taken . Assessed resident and notified Hospice. They are going to try and get concave mattress out to facility . Injuries observed at time of Incident . No injuries observed . Injuries Report Post Incident . Bruise 1) Top of Scalp . Notes 11/17/18 concave mattress ordered per Hospice in an attempt to prevent resident from further falls out of bed when attempting to get up without assistance. Resident is not compliant with fall precautions and is unable to be educated regarding fall precautions. 11/20/18 Low bed for resident to facilitate fall prevention. There was no documentation a fall risk assessment was completed to identify the resident's risk factors for further falls. The resident's electronic health record indicated a fall risk assessment task was initiated on 11/18/18; however, the assessment was not completed as of 11/29/18 at 11:36 a.m. g. On 11/26/18 at 3:04 p.m., the resident was sitting in her recliner, awake. There was a yellowish bruise to her forehead and a reddish/purple/black bruise on the right side of her face. A fall mat was on the floor on the right side of the bed. There was no concave mattress in place. The resident was asked if she knew how she got the bruises on her face and stated, I fell off the bed in my sleep. h. On 11/28/18 at 3:33 p.m., the Director of Nursing (DON) was asked, Where do you keep the fall assessments, in the charts, or are they on the computer? She stated, They would be in the computer. There may be some in the charts. The DON was asked, Do you keep them in a separate book? She stated, No. i. On 11/28/18 at 3:46 p.m., the resident's paper clinical record was reviewed. There were no fall assessments found in the record, and the Care Plan, dated as reviewed 6/18/18 did not include the planned interventions for a fall mat, low bed, and concave mattress. j. On 11/29/18 at 11:50 a.m., the resident was sitting in her recliner with her feet elevated. Her bed had no side rails and there was no concave mattress in place. k. On 11/29/18 at 2:13 p.m., the resident was sitting in her recliner, awake. The resident's daughter was in the room and the surveyor informed the daughter that she was looking at the resident's mattress. The resident's daughter stated, Oh, you're looking for the concave mattress? The surveyor stated, Yes ma'am. Are you aware if she had one? The daughter stated, No, it hasn't come yet. l. On 11/29/18 at 2:26 p.m., the DON was asked, Regarding the resident's fall on 10/28/18, what was her long-term intervention? She stated, A fall mat that she already had in place. The DON was asked if she could determine the date that the fall mat was initially put in place, since it was not addressed on the Care Plan. The DON began searching for the requested information while the surveyor retrieved the resident's paper clinical record. When the surveyor returned to the room, the DON was asked about the side rails, which were documented on the Care Plan, but were not currently in place on the resident's bed. The DON stated, We changed her bed, but they were going to put the quarter rails to the low bed. We just got the low bed Thursday or Friday (11/22/18 or 11/23/18), because we padded her side rails 11/3/18. The DON was then asked about the concave mattress, which was documented as a planned intervention on the Incident Report dated 11/17/18, but was not currently on the resident's bed. The DON stated, She had one on there. The surveyor and the DON went to the resident's room to observe the bed. There were no side rails in place and no concave mattress on the resident's bed. The DON walked down the 200 Hall and checked unoccupied resident rooms to attempt to locate a concave mattress. She located a bed with a concave mattress in one of the rooms, then went to the nursing station and asked a staff nurse if the resident had received a concave mattress. The DON was informed by the nurse that the concave mattress had not yet come in for this resident. The DON asked the nurse if she knew when the fall mat was initially put in place for this resident. The nurse stated the fall mat was put in place after the resident's last fall on 11/17/18. The surveyor and the DON returned to the DON's office and continued to review the Incident Reports and interventions for the resident. The DON was asked, On 11/4/18, the Incident Report showed the resident was found sitting in the floor and that she fell while trying to transfer from the recliner to the bed alone and had a reddened area on her coccyx. Was any intervention put in place? She stated, No. She was asked, The Incident Report for 11/9/18 documented the resident was found in the hallway on the floor and an abrasion was noted to her forehead that measured 2.5 cm by 3 cm. There was also an abrasion and bruising to the right side of the resident's face. Was an intervention put in place at that time? The DON stated, No. She was asked, On 11/17/18, the Incident Report documented a staff member went to the resident's room after hearing a loud thump and the resident was on the floor, lying on top of a pillow. There was no documentation as to whether the resident had fallen from the bed or the chair, and the immediate action was that Hospice was notified and they were going to order a concave mattress. Do you know if the concave mattress was ever delivered for this resident? She stated, I thought she had one on her bed. The DON was asked, Will you pull up the Fall Risk assessment dated [DATE] and look at it and tell me if it was completed? The DON reviewed the assessment and stated, It was not completed. She was asked, Do you do a fall assessment after each fall or just quarterly? She stated, I just learned today that yes, we are to supposed to be doing one after each fall. We do them quarterly. She was asked, Who is responsible for doing the fall assessments? She stated, The nurse that does the I and A (Incident and Accident Report) after the fall and the MDS (Coordinator) does it quarterly with the MDS. m. The immediate jeopardy was removed and the scope and severity reduced to E on 11/29/18 at 4:37 p.m., when the facility implemented the following Plan of Removal: 1.) RN (Registered Nurse) will assess (Resident #42) to determine resident free from injury. A fall assessment will be conducted and documented immediately on 11/29/18. The Concave mattress will be in place 11/29/18. DON (Director of Nursing) will review all falls for this resident and ensure all interventions are implemented on 11/29/18. 2.) Ensure all interventions are in place for (Resident #42). 3.) Review 30 days of I and As (Incident and Accident Reports) on all residents and ensure those interventions are in place and any negative findings will be immediately corrected. This review will be completed immediately on 11/29/18 by the DON and Administrator. All residents with history of falls will have their fall assessment reviewed to ensure accurate and up to date. Any residents whose fall assessments are past due will be completed by 11/30/18 by DON or designee. 4.) All nursing staff on duty will be in-serviced on 11/29/18 by DON or designee regards (sic) to the need to implement and document appropriate interventions after a resident experiences a fall. Any nursing staff not on duty will be in-serviced when they report for the next shift. 5.) DON/designee will make observation rounds on 5 residents weekly on varying shifts to ensure all planned fall interventions are in place. Any negative findings will be corrected immediately. DON/designee will review all Fall/Incident reports weekly to ensure appropriate interventions are implemented and documented. B. Based on observation, record review, and interview, the facility failed to ensure the armrest of a resident's wheelchair was maintained in good repair and was free of protruding metal that could cause skin tears or other injuries for 1 (Resident #72) of 22 (Residents #1, 10, 19, 21, 22, 28, 33, 35, 36, 42, 45, 46, 48, 49, 50, 54, 65, 68, 72, 73, 74 and 231) sampled residents who used a wheelchair (w/c) for locomotion. The failed practice had the potential to affect 72 residents who utilized a wheelchair, according to a list provided by the Director of Nursing (DON) on 11/30/18 at 7:59 a.m. The findings are: Resident #72 had [DIAGNOSES REDACTED]. The Annual MDS with an Assessment Reference Date (ARD) of 9/8/18 documented of the resident scored 3 (0-7 indicates severely impaired) on a brief interview for mental status, required extensive assistance of 2 plus persons for transfers, and required a wheelchair for a mobility. a. The Care Plan dated 11/14/18 documented, Focus: The resident is at risk for falls r/t (related to) impaired mobility, weakness and fall History . Interventions/Tasks: .The resident needs a safe environment . Wheelchair used for locomotion propelled by self . b. On 11/26/18 at 2:11 p.m., the resident was in her room, sitting in a wheelchair. The armrest of the wheelchair was missing an approximately 3-inch section of the vinyl upholstery and padding, which left a metal post exposed and protruding upward from the wheelchair armrest. The armrest of the wheelchair was photographed by the surveyor at this time. c. On 11/26/18 at 2:49 p.m., the DON was asked, Who repairs, cleans and inspects the wheelchairs? The DON stated, The CNAs clean the wheelchairs on Sunday night, the 11-7 (11:00 p.m. to 7:00 a.m.) shift; they report any repairs that maintenance needs to repair or replace. The DON accompanied the surveyor to the dining room, where the resident was sitting in a wheelchair. A section of her forearm was resting on the armrest with the missing vinyl and padding. The DON was asked, Should the wheelchair armrest be replaced or fixed? She stated, Yes, she could get a skin tear.

Complaint # (AR 616) was substantiated (all or in part) with this findings. Based on record review and interview, the facility failed to ensure all wandering behaviors were documented and reported to appropriate persons; to ensure direct care staff were consulted and risk assessment reviewed prior to Wander-Guard removal; and to ensure that interventions were developed and implemented to assure monitoring after Wander-Guard removal and to reduce the risk of elopement for 1 (Residents #1) of 4 case mix residents (Residents #1, #3, #4 and #5) who were at risk for elopement. These failures resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Resident #1, who eloped from the facility and fell in the hospital parking lot next door, and had the potential to cause more than minimal harm to 36 residents, who were at risk for elopement, according to a list provided by the Administrator dated 10/29/14 at 1:15 p.m. The facility removed the immediate jeopardy prior to the survey but did not correct the underlying failed practices. On 10/30/14 at 2:55 p.m., the Administrator was informed of the Immediate Jeopardy (removed). The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/23/14 documented the resident scored 3(0-7 indicates severe impairment) on a Brief Interview for Mental Status, exhibited behaviors of wandering, and had been assessed as being independent with locomotion on and off unit with supervision. a. A Physician order [REDACTED]." b. An Elopement Risk assessment dated [DATE] documented, "Elopement risk indicated if score is greater than or equal to 8, Elopement Risk Care Plan not indicated." Resident #1's grand total was a score of 8. c. A Physician order [REDACTED]." d. The Resident Care Plan conference summary dated 10/22/14 documented, "Wander-Guard Dc'd 9/30 (2014) D/T - no attempts to elope..." e. A statement documented by the Administrator dated 10/30/14 documented, "I received a phone call from (ambulance company) employee. I asked if she was the one that found my resident on 10/25/14. She stated she had just dropped off a patient, and was walking to the entrance and a person she believed may have been staff member of hospital, said "Oh my, that person is going to fall." They go out and the resident had fallen, they assessed her and she was okay and they put her back in the wheelchair. The caller stated she could tell that the resident was not with it, so she checked and she found a breakfast slip with room number on it and called the nursing home. This caller stated that she remembered transferring this person before. The caller stated that the resident was on the sidewalk, when this happened." f. Nurse's notes dated 10/25/14 documented, "2:42 p.m. - 120/80, 76, 20, 97.7 Pulse ox = 96% to room air at 9:30 (a.m.) RN (Registered Nurse) supervisor informed this nurse that resident had got out of facility and was at (hospital). RN supervisor had sent staff member to go pick up resident. RN supervisor notified administrator. At 9:40 (a.m.) this nurse notified (doctor). At 9:45 (a.m.) Resident returned to facility, transported by facility van. Skin audit reveals abrasion to right elbow. Resident is otherwise at baseline. Resident denies pain or discomfort. This nurse wrote treatment order; cleanse abrasion to right elbow with wound cleanser... At 9:50(a.m.) order for resident to be transferred to ER (emergency room ) per facility policy. Notified DON (Director of Nursing), at 10:00 (a.m.) resident left facility for (hospital), transported by ambulance. At 12:30 (p.m.) resident returned to facility Wander-Guard was applied...LE (late entry) for 7-3(shift) 9:50 (a.m.) (police department) at facility per request for report." The DMS-7734 dated 10/25/14 at 8:44 a.m. documented, "Date & Time of Discovery: 10/25/14 at 9:15 a.m. ...Resident left front entrance of facility on 10/25/14 at 8:44 a.m. in wheelchair. Resident found at approx. (approximately) 9:10 a.m. about 2 blocks from facility. Resident was brought back to facility by facility staff members. RN on duty notified about 9:10 (a.m.) - 9:15 (a.m.) Administrator notified at 9:24 a.m. Physician notified at 9:40 (a.m.) Family notified at 9:50 (a.m.) Resident returned to facility in wheelchair by 2 staff members. Resident body assessment completed and identified. Abrasion to right elbow, unknown as to exact cause. Resident was sent to hospital for further evaluation. No other complications revealed from hospital visit. Census was run immediately to ensure all residents were accounted for and all residents were accounted for. A new elopement assessment was conducted on all residents in facility, with care plans updated as needed. In-service began for all staff on elopement." g. On 10/29/14 at 3:15 p.m., the Assistant Director of Nursing (ADON) stated, "Resident #1 had not made any attempts to leave for any reason. She is very easy to tell what to do, redirect. "I have never seen her go out the door." The ADON was asked if she agreed with the elopement risk dated 9/30/14. The ADON stated, "I agree with the fact she is no longer at risk. ...We go through the charts every 3 to 6 months. We will go through and see who has had falls or made comments they want to leave." The ADON indicated that Resident #1 had not made attempts to leave or say she wanted to leave. h. On 10/29/14 at 3:47 p.m., Certified Nursing Assistant (CNA) #1 stated, "(Resident #1) is confused. She asks where my room is. Can I go home? She used to have a Wander-Guard. Nobody let us know they had taken the Wander-Guard off her until after she got out." CNA #1 was asked would it have made a difference if you had known the Wander-Guard had been taken off her. CNA #1 stated, "I think it would've made us keep an eye on her, watch her more closely. I don't understand why they took off the Wander-Guard knowing how confused she was. No one ever asked me what I thought about taking the Wander-Guard off." i. On 10/29/14 at 3:52 p.m., Licensed Practical Nurse (LPN) #1 stated, "They changed it because she had not tried to elope. Although she talked a lot about going home, she had not tried. People had said rumors, I couldn't state who said, but (Resident #1) had gotten out. I wasn't here that day. I don't agree they took the Wander-Guard off her. She is always wandering around..." LPN #1 was asked did you express your feelings about the Wander-Guard coming off the resident. LPN #1 stated, "No. They didn't ask me. I wish they would because the CNAs and nurses know them (residents) best. ...The Wander-Guard lets staff know when they get near the doors. It (elopement) could've been prevented. That hurt me when I heard about it (the elopement)." j. On 10/29/14 at 4:40 p.m., LPN #2 stated she was not aware the Wander-Guard was taken off (Resident #1). I don't think that she tries to leave, she gets lost. She will say where I am supposed to be. She is easily redirected frequently. She was asked as a nurse caring for Resident #1, did she feel the Wander-Guard should have been discontinued. LPN #2 stated, "No, I do not think they should have taken the Wander-Guard off because she is so confused." k. On 10/29/14 at 5:06 p.m., CNA #2 stated, "I feel like (Resident #1) needs one (Wander-Guard). I think that anyone who is confused should have one. I was not aware (Wander-Guard discontinued). I had no idea. No one told us. I think that anyone who is confused should have a Wander-Guard. As much as she (Resident #1) wanders around, she should have one just for her own good. No one asked me what I thought about taking the Wander-Guard off her. If they would've asked, this never would've have happened. It's hard to keep an eye on every resident. I think if they had asked everyone would have said not to take it off." l. On 10/29/14 at 5:15 p.m., CNA #3 stated, "I was not aware they took the Wander-Guard off (Resident #1)." She was asked if she thought the resident was at risk. CNA #3 stated, "Yes, because she is confused, asked where I go. We redirect her all the time." She was asked if she thought Resident #1 should have a Wander-Guard. CNA #3 stated, "I think she needs one at all times." m. On 10/30/14 at 10:30 a.m., Restorative CNA #4 stated, "(Resident #1) was mostly confused, always asks where my room is every 5 minutes. If you guide her away, she will come back around 5 minutes asking the same thing again." CNA #4 was asked do you know if she was at risk for elopement. CNA #4 stated, "Yes, she is very active, always on the go." CNA #4 was asked do you know if her Wander-Guard was dc'd. CNA #4 stated, "Yes, it was on 10/1/14. I check all the Wander-Guard bracelets. I was given a list of all residents they wanted to d/c. Now she has it on again 10/25/14. They said she was no longer at risk because she had not tried to leave the building. I didn't think they should have d/c'd it." CNA #4 was asked why? CNA #4 stated, "Because she is very confused, active and into everything. She always wonders what is out there. I told them (ADON) I did not agree. But (ADON) said that if a resident doesn't show signs of attempts to leave the building in a certain time period it is ok to d/c. When she eloped this time, people were saying how did she elope if she had a Wander-Guard bracelet on, so that tells you staff didn't know her Wander-Guard had been d/c'd." n. On 10/30/14 at 11:02 a.m., CNA #5 stated,"(Resident #1) gets lost, she will ask multiple times where she is, where she needs to go, where her room is. She will get by the doors and ask I am supposed to go here? If she is by a door, she will ask do I go out there or can I go out there? We have to redirect her a lot. When she is bored, she wants to go home, wanting to leave. Before the I/A (incident), I had no knowledge the bracelet was off. No one had told me. ...If they would have asked me about the Wander-Guard I would have said no because her cognitive ability is worse than it was when she first got here. She's gone downhill." CNA #5 was asked if she knew anything about Resident #1 attempting to elope prior to 10/25/14. CNA #5 stated, "Somebody said she had gotten out on 100 hall parking lot. It was (CNA #7) and (CNA #8)." o. On 10/30/14 at 11:25 a.m., CNA #7 was asked if she had heard if Resident #1 had ever made an attempt to elope prior to 10/25/14. CNA #7 stated, "We were outside the 300 hall exit door. When we (CNA #8 and I) were going to lunch. (Resident #1) was down the hall, she was starting to go out the door. The alarm was sounding (beeping). (Resident #1) had the door open if we had not been there she would have gotten completely out. (Resident #1) said they told me to come out here. I said to her, no they didn't. I assisted her back in. Her nurse was in the hall. We wheeled her back in the door." CNA #7 was asked would you consider that an elopement attempt. CNA #7 stated, "Yes. The nurse said we got her after we pushed her back into the hallway. I pushed the door shut. (Physical Therapy Assistant) was there. She didn't see what happened; she just asked what was going on." She was asked if she reported the resident's attempt to elope. She said the nurse was in the hall. p. On 10/30/14 at 11:55 a.m., CNA #6 stated she did not know they had taken the Wander-Guard off Resident #1. She stated, "If I had been asked if the Wander-Guard should be taken off, I would have told them it was not a good idea because she's confused, acute Dementia. When she asked questions all the time like where am I supposed to be? Where is my room? Where do I go? What do I do? It was about a week before the I/A (10/25/14), I was coming back to the nursing home from going to an appointment, the shower aide (CNA #7) was telling me, "Guess who got out?" I said, "Who?" She said, "(Resident #1)." I said, "Are you serious?" q. On 10/30/14 at 12:12 p.m., CNA #8 was asked if she had heard if Resident #1 had ever made an attempt to elope prior to 10/25/14? CNA #8 stated, "We (CNA #7 and I) were going to lunch. We were just outside 300 hall exit door. We heard the alarm. She (Resident #1) didn't make it out all the way. We pushed her back in the door. (CNA #7) said (to a staff member) hey she is trying to get out this door. I was still outside so I didn't know who she spoke to." r. On 10/30/14 at 12:28 p.m., ADON stated we go through every quarter we will see and evaluate the Wander-Guards, alarms, see how any falls the residents may have had, if any. We see if there had been attempts to go home or had any changes in condition. We try to make reductions. I and the (DON) have restorative meetings to determine who we want to take off. We discuss if we think it's a good idea, we watch the residents." Did anyone think to consider asking the staff who routinely cares for Resident #1 day in and day out whether or not to d/c the Wander-Guard? ADON stated, "No, I didn't ask staff. I just went to the documentation. The nurse knows when we write an order. We automatically would think they would come and tell us they have issues with the orders such as a Wander-Guard. The head restorative (CNA #9), we discussed it with her. I honestly believe if they had an issue with it they would say something." The ADON was asked about the elopement risk assessment dated [DATE]. The ADON stated the DON had conducted the assessment. The ADON also stated no one had reported Resident #1 had attempted an elopement a week prior to actual elopement on 10/25/14. s. On 10/30/14 at 12:56 p.m., the Head Restorative CNA #9 stated she was off the day (10/25/14) Resident #1 had eloped out of the building. CNA #9 stated, "(Resident #1) is confused. I don't think she should have had her Wander-Guard dc'd. If you watch her she ask where (her room is), she doesn't really know where anything is at. She wanders aimlessly about the facility. They normally ask me what I think about taking a Wander-Guard off a resident. If they had, I would have told them, no." t. On 10/30/14 at 1:09 p.m., the Director of Nursing (DON) was asked how the facility determines to discontinue devices such as Wander-Guards. The DON stated, "We had a group meeting, got with restorative, reviewed the chart and made the decision." She was asked who in restorative? DON stated, "(Restorative Nursing Assistant (RNA) #1.)" She was asked if she had talked to any other staff, like the CNAs who routinely takes care of (Resident #1) her, or nurses. DON stated, "I did not document it, but like I said, I would not made any changes without consulting staff. And I'm very flexible. If anyone would've said they didn't think it was a good idea, I would've listened to them. I can't give you any names because I didn't document it." The elopement assessment shows the resident as being at risk on 9/30/14, yet her Wander-Guard was D/c'd. DON stated, "We did consult with the staff and I wouldn't lie about that. Just because someone is confused doesn't mean they need a Wander-Guard." The DON was informed that the staff interviewed indicated Resident #1 exhibited behaviors of wandering aimlessly and needing constant redirection. Also, that staff stated Resident #1 had made an attempt to elope from 300 hall exit door approximately a week before she eloped on 10/25/14. The DON stated, "If I had been aware of that, I would've taken care of it." u. A Physician order [REDACTED]." v. The Resident Care Plan with a review date of 10/26/14 documented, "Problem On set: 10/26/14 ...Wanders with potential for injury and/or elopement ... Approaches: Place resident in an area where constant observation is possible as needed for safety. Provide diversional activities for resident when wandering attempting to leave facility unattended. Elicit family input for best approach(es) to resident, Monitor behavior, mood change when new medications are added or changed, Wander-Guard bracelet as indicated, monitor for working order and effectiveness, monitor and document moods/behaviors; notify physician of changes, Monitor resident's whereabouts frequently when in wandering mood, with visual checks at least every 2 hours. Assist in reorientation to room and facility with verbal cues. Encourage group activities and attempt to keep occupied..." w. The facility removed Immediate Jeopardy on 10/25/14 and reduced the scope/severity to "D" prior to the survey entrance date by implementing the following: 1) Ran Census and verified all residents were accounted for. This was run at 9:40 a.m. Witness statements were obtained when last seen resident. 2) RN (Registered Nurse) had Restorative Aide check all Wander-Guards to be working. 3) Body Audit on Resident #1 and sent to ER because of abrasion. Sent out before 10:00 a.m. 4) Elopement Assessments on all residents at 10:00 a.m. all before 10:16 a.m. 5) Residents that triggered were or will be provided Wander-Guards (once the remainder are in the facility). The extra ones needed has been ordered and shipment is expected this week. 6) Until the remainder Wander-Guards are in the facility, there will be someone posted at the front desk to ensure that residents are not going out the front door until 8:00 p.m. 7) At 8:00 p.m., the front doors will be locked and sign posted on the front door to ring doorbell for assistance. 8) RN supervisor verbalized in-service to staff. Education to staff related to any resident that attempts to elope from the facility. Topics include: Reporting wandering behaviors to nursing staff. Maintenance of code alert bracelets ... Reporting occurrences of attempted elopement. Responding in a timely manner to any alarms or reports of residents outside the facility to charge nurses. Proper documentation of wandering or attempts to leave facility unattended. Care of confused or disoriented residents that report being lost or unsure of location. 9) Replaced Wander-Guards back on Resident #1 before going to ER at 10:00 a.m.

Complaint # (AR 131) was substantiated (all or in part) in these findings: Based on record review and interview, the facility failed to ensure the physician was immediately consulted for a fall and subsequent deterioration in condition to ensure prompt treatment for 1 (Resident #1) of 2 (Residents #1 and #2) case mix residents who had a significant change of condition in the last 30 days. This failed practice caused a pattern of harm to Resident #1 who experienced a fall, was assessed to have elevated blood pressure readings for 12 hours post-fall and was hospitalized with a [MEDICAL CONDITION] and had the potential to cause more than minimal harm for 10 residents who were identified as having a significant change in condition in the last 30 days, according to a list provided by the Director of Nursing (DON) on 5/30/14 at 11:10 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The 14-Day Medicare Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/12/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the brief interview for mental status (BIMS); required limited physical assistance of one person for bed mobility and dressing; was independent with setup help only for transfers, walking in the room and corridor, locomotion on and off the unit, toilet use, personal hygiene and eating; required supervision and the physical assistance of one person for bathing; was not steady but able to stabilize without staff assistance when moving from a seated to standing position, walking, turning around while walking, moving on and off the toilet and during surface-to-surface transfers;had no limitation in range of motion; was continent of bowel and bladder; and had experienced no falls since admission or prior assessment. a. The Daily Vital Sign Sheet for May 2014 documented vital signs as follows: 1) 5/1/14-- Blood pressure 132/78, Pulse 82, Respirations 22 and Temperature 98.9 2) 5/2/14-- Blood pressure 140/76, Pulse 81, Respirations 21 and Temperature 98.6 3) 5/4/14-- Blood pressure 150/60, Pulse 60, Respirations 18 and Temperature 97.4 4) 5/11/14-- Blood pressure 118/70, Pulse 83, Respirations 22 and Temperature 98.2 b. The Resident Incident Report dated 5/16/14 at 2:30 p.m. documented, "...Report Prepared by; Licensed Practical Nurse (LPN) #1)... Narrative of incident and description of injuries: Resident was getting out of bed stumbled and lost her balance and fell on right knee then fell on her right side. Her head was against the wall and she was in the fetal position. Bruise to right knee... Immediate Actions Taken: ROM (range of motion) to all extremities. Checked head, no hematoma started neuro (neurological) checks)... Actions Taken... Temp (temperature): 97.7... Pulse: 80... Resp (respirations): 22... B/P (blood pressure): 162/110... Pain Scale: 0... Physician notified: ...5/16/14 (no time documented)... Family notified: ...5/16/14 (no time documented)." 1) The Resident Incident Report was faxed to the doctor; the faxed copy was initialed by the physician and dated 5/17/14. 2) The Departmental Notes dated 5/16/14 at 3:47 p.m. documented, "Resident was getting out of bed stumbled and lost her balance and fell on right knee then fell on her right side. Her head was against the wall and she was in the fetal position. Refused to lay down got up in w/c (wheelchair) to go to smoke break. VS (vital signs) (blood pressure) 162/110, (pulse) 80, (respirations) 22, (temperature) 97.7. Notified daughter (name) of fall. Signed by: (LPN #1)." 3) The Neuro/Vital Signs sheet documented the following: 5/16/14 at 2:30 p.m.--Temperature 97.7; Oxygen Saturation 96%, Blood Pressure 162/110; Pulse 80; Respirations 22; Level of Consciousness AV (alert and verbal); Speech N (no wrong words, no slurring); questions 2 (both answers correct); commands y (able to close, open eyes); facial droop N (within normal limits, equal and teeth seen on both sides when smiling); visual fields N (no deficit noted, recognizes finger); horizontal gaze N (no deficit); coordination N (normal finger to nose and heel to shin); limbs motor N (no drift, weakness; limbs sensory N (no deficit feels light touch); right pupil size 5 mm; left pupil size 5 mm; right pupil response P (prompt); and left pupil response P (prompt). 5/16/14 at 2:45 p.m.--Temperature 97.7; Oxygen Saturation 95%, Blood Pressure 180/110; Pulse 80; Respirations 22; and all other neuro signs remain the same as 5/16/14 at 2:30 p.m. 5/16/14 at 3:00 p.m.--Temperature 98.7; Oxygen Saturation 95%, Blood Pressure 170/112; Pulse 74; Respirations 26; and all other neuro signs remain the same as 5/16/14 at 2:30 p.m. 5/16/14 at 3:15 p.m.--Temperature 96.9; Oxygen Saturation 94%, Blood Pressure 170/95; Pulse 80; Respirations 18; and all other neuro signs remain the same as 5/16/14 at 2:30 p.m. with the exception of the right pupil size at 4 mm and left pupil size of 4 mm. 5/16/14 at 3:30 p.m.--Temperature 98.2; Oxygen Saturation 94%, Blood Pressure 170/105; Pulse 79; Respirations 16; and all other neuro signs remain the same as 5/16/14 at 2:30 p.m. with the exception of the right pupil size at 4 mm and left pupil size of 4 mm. 5/16/14 at 4:00 p.m.--Temperature 97.7; Oxygen Saturation 94%, Blood Pressure 180/100; Pulse 82; Respirations 16; and all other neuro signs remain the same as 5/16/14 at 2:30 p.m. with the exception of the right pupil size at 4 mm and left pupil size of 4 mm. 5/16/14 at 4:30 p.m.--Temperature 99; Oxygen Saturation 95%, Blood Pressure 140/80; Pulse 80; Respirations 16; and all other neuro signs remain the same as 5/16/14 at 2:30 p.m. with the exception of the right pupil size at 4 mm and left pupil size of 4 mm. 5/16/14 at 5:30 p.m.--Temperature 98; Oxygen Saturation 94%, Blood Pressure 145/85; Pulse 78; Respirations 18; and all other neuro signs remain the same as 5/16/14 at 2:30 p.m. with the exception of the right pupil size at 4 mm and left pupil size of 4 mm. 5/16/14 at 6:30 p.m.--Temperature 97.8; Oxygen Saturation 96%, Blood Pressure 150/90; Pulse 80; Respirations 16; and all other neuro signs remain the same as 5/16/14 at 2:30 p.m. with the exception of the right pupil size at 4 mm and left pupil size of 4 mm. 5/16/14 at 10:30 p.m.--Temperature 96.5; Oxygen Saturation 93%, Blood Pressure 173/92; Pulse 63; Respirations 18; and all other neuro signs remain the same as 5/16/14 at 2:30 p.m. with the exception of the right pupil size at 4 mm and left pupil size of 4 mm. 4) On 5/28/14 at 12:45 p.m., Licensed Practical Nurse (LPN) #1 stated, "(Resident #1) fell [DATE] at 2:30 p.m. I did the neuro checks and a CNA (Certified Nursing Assistant) did the vital signs. I documented at 2:30 p.m., 2:45 p.m. and 3:00 p.m. All blood pressures were higher than her normal. The pupils were large to me. I did not call the doctor. I sent a copy of the Resident Incident Report to the doctor by fax. I did call the family. Her blood pressure and respirations went up by my documentation. Her pupil size was not normal. I told the oncoming nurse of her fall. The next Monday after that happened on Friday, the Director of Nursing suspended me for two days for failure to call the doctor. I was told what I should have done and called the doctor. In my mind I knew the blood pressure was high." 5) On 5/29/14 at 2:45 p.m., LPN #2 (3:00 p.m. to 11:00 p.m. shift charge nurse caring for Resident #1 on 5/16/14) stated, "I was told that she had fallen. She complained of pain in her shoulder. She did not go out to smoke on my shift. Her blood pressure was a little higher, but not drastic. She was alert and oriented and could move all extremities equally. Her pupils were equal and reactive to light. She complained of pain and shoulder pain. I gave her a [MEDICATION NAME] 10/325. She was not abnormal when I left." 6) On 5/30/14 at 9:00 a.m., Certified Nursing Assistant (CNA) #1 (who cared for Resident #1 from 3:00 p.m. on 5/16/14 until 7:00 a.m. on 5/17/14) stated, "On the night she was sent to the hospital, I worked 3-11 (3:00 p.m. to 11:00 p.m.) and 11-7 (11:00 p.m. to 7:00 a.m.) that night. On 3-11 she kept using her call light and she would say 'I'm hurting' and point to her right arm and leg and the right side of her face. I went and told (LPN #2). Her vital signs were very high with her blood pressure of about 220/180. I gave the blood pressure to the nurse and her pulse was over 100. (Resident #1) wanted to go to the bathroom. She was very weak on her right side. I brought her back (from the bathroom) to bed in a wheelchair. I went and told the nurse (LPN #2). After shift change on 11-7 I told (LPN #3) about how the resident was weak on her right side and her elevated blood pressure and pulse. This was about 12:00 midnight till 12:30 a.m. She checked her and called the doctor and sent her to the hospital." 7) On 5/30/14 at 9:30 a.m., CNA #2 (CNA who provided some care for Resident #1 on 5/16/14 from 10:30 p.m. until 5/17/14 at 7:00 a.m.) stated, "I worked the hall the night (Resident #1) went to the hospital. Around 10:30 p.m., I saw her. I took her vital signs. Her blood pressure was high and the pulse was high. I took the vital signs to the nurse right then. She, (LPN #3), went and checked (Resident #1). She was incontinent once of urine and that was not normal for her. She did not get up with me at any time (that night)." c. The Departmental Notes dated 5/17/14 at 3:25 a.m. were authored by LPN #3 and documented, "At 2:20 a.m. was called to resident's room by CNA reporting (resident) unable to move right side. This nurse evaluated (resident) and noted bilateral grips uneven, unable to squeeze with right hand, unable to move right arm, right leg and right side of face. Speech slurred. Obtained VS blood pressure 190/120, pulse 197 respirations 20 temperature 97 and spo2 (Peripheral capillary oxygen saturation) 93% on room air. Had C.N.A. stay with resident while this nurse notified MD (Medical Doctor) and called 911. Daughter notified sent to (major metropolitan hospital) for further evaluation r/t (related to) possible stroke." On 5/29/14 at 9:30 a.m., LPN #3 stated, "I worked 11-7 the night (5/16/14-5/17/14) I sent (Resident #1) out. About 1:00 a.m. she woke up screaming. She could not move her right side. Her blood pressure was 190/120 and her pulse was 127. She stated she had been asking (LPN #2) on the evening shift to send her to the hospital that something was wrong. In report (LPN #2) said she had fallen at 2:30 p.m. and that she had been cranky. So, she gave her a pain pill. After I assessed her, I looked at the prior neuro checks and blood pressure which were out of limits. I sent her to the ER (emergency room ), notified the physician, family and Director of Nursing and left a message on the Administrator's phone. This, my part, happened on 5/17/14 on Saturday." d. The magnetic resonance imaging (MRI) of the brain dated 5/17/14 documented, "(impression) ...Acute infarct in the left posterior limb of the internal capsule is noted without hemorrhage." The emergency room physician documented, "acute ischemic stroke." e. On 5/29/14 at 1:21 p.m., Resident #1 stated, "I think I had a stroke and then fell . The nurses checked me every few minutes afterwards. I never asked to go to the hospital. The nurse that sent me said my blood pressure was high and she sent me to the hospital. They, of course, said I had a stroke." f. The Significant Change MDS with an ARD of 5/29/14 documented the resident scored 12 (8-12 indicates moderate cognitive impairment) on the BIMS; required extensive physical assistance of one person for bed mobility, transfers, dressing and personal hygiene; did not walk in the room or corridor, was totally dependent on the physical assistance of one person for locomotion on and off the unit; required limited physical assistance of one person for eating; required physical help of one person in part of bathing; was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, when moving on and off the toilet and during surface-to-surface transfers; did not walk; had limitation in range of motion of one upper and one lower extremity; was frequently incontinent of bladder; and was occasionally incontinent of bowel.

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to immediately consult with a physician regarding treatment of [REDACTED].#4, #2 and #8) of 6 (Residents #1, #2, #4, # 6, #8 and #14) case mix residents with pressure ulcers. These failed practices resulted in a pattern of actual harm for Resident #4 whose pressure sores deteriorated and had the potential to cause more than minimal harm 6 facility residents with pressure ulcers and 45 residents identified to be at risk for pressure ulcers, as documented on a list provided by the Administrator on 1/7/11 at 11:55 a.m. The findings are: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 14-Day Medicare Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/7/10 documented the resident had a brief interview for mental status (BIMS) score of 14 (cognitively intact), required extensive assistance for bed mobility, transfers and personal hygiene and was at risk for pressure ulcers. a. A Nurses Note dated 12/13/10 documented "wound to right heel remains dry (and) intact. Wound bed is scabbed over measuring .3 cm (centimeters) X .3 cm ...surrounding area is dry and scaly. Md (Doctor of medicine) notified of res(ident's) current skin condition. New orders noted to ...d/c Tx (discontinue treatment) to (Right) heel, apply a thin layer of [MEDICATION NAME] oint(ment) to bil(ateral) feet (every other day) - dryness." b. Nurses Notes dated 12/20/10 at 12:44 p.m. documented, "Wound remains to (right) heel scabbed over measuring (less than) .3 cm x (less than) .3 cm. periwound (surrounding tissue) is dry and surrounding area is normal for skin. Odor and exudates absent..." c. Nurses Notes dated 12/21/10 at 5:54 p.m. documented, "Resident seen by Dr. (name)" with new order to transfer to the emergency room for evaluation and treatment "as indicated for elevated Temp(erature) and vomiting." The resident remained in the hospital from 12/21/10 through 12/27/10. d. An Admission Nursing assessment dated [DATE] documented the resident's readmission to the facility. The assessment documented pressure ulcers to right heel "dry and open"; right great toe "2 cm x 4 cm dk (dark) area (at) tip"; right foot second digit "1 cm red area (at) joint"; left foot .1 cm scabbed (at) joint; "1cm open area lt (left) buttock (at) sacral; and "1 cm open rt (right) buttock on upper cheek." The assessment documented other skin concerns: "Rt (right) toenails dark"; "callous ball of lt foot"; "toes crossed lt foot"; "groin, peri area, abd (abdominal) fold excoriated"; and "tissue (at) rt antecubital red, swollen." The Admission Narrative documented: " ...Res (resident) has numerous sores to bil (bilateral) toes and denies pain to toes. States they are not tender to touch. c/o (complains) of tenderness to rt heel. Tissue surrounding rt antecubital is red, swollen, c/o tenderness (at) site ..." e. Re-Admission physician's orders dated 12/27/10 did not document treatments for any of the [MEDICAL CONDITION] documented in the admission nursing assessment. There was no documentation in the December Treatment Administration Record that treatments were conducted after the resident was readmitted to the facility on [DATE] until 12/31/10. f. Nurses Notes dated 12/30/10 documented a late entry for 12/29/10 at 9:30 p.m., "Called (physician) re (regarding) res lab results. Also notified MD: res(ident) having red, swollen 3rd digit Rt foot; no open areas or drainage noted (at) this time. Res denies pain. States she can't feel her toes. Hx (history): diabetes. nno (no new orders) rec'd (received) at this time." g. Nurses Notes dated 12/30/10 at 10:24 p.m. documented, "Called (physician) d/t (due to) 3rd digit rt foot previously reddened, swollen now open, seeping bloody drainage ...T(emperature) 99.4" The notes documented the resident was sent to the emergency room for evaluation and treatment. h. A Radiology Report dated 12/30/10 documented: "Procedure "Three View Right Foot ...An examination was performed with soft tissue technique. There is a lucency involving the medial margin of the navicular bone. This does appear to represent a change and would be worrisome for osteo[DIAGNOSES REDACTED]. When compared with the prior examination, there appears to be also interval near complete reabsorption of the third middle phalanx and the fifth middle phalanx. Extensive soft tissue swelling is noted." i. Nurses Notes dated 12/31/10 at 12:30 a.m. documented the resident returned from the emergency room with new orders for "Keflex 500 mg (milligram) QID (four times daily) for (R) (right) great toe osteo[DIAGNOSES REDACTED]. j. A Nurses Note dated 12/31/10 at 3:35 a.m. documented "Checked right heel and see a scab with no redness or swelling around it and buttocks slightly red with barrier cream applied." k. A Nurses Note dated 12/31/11 at 2:06 p.m. documented an order was received to "cleanse 3rd toe on (right) foot with wc (wound cleanser) apply Vaseline gauze and a dry dressing (every day) until resolved." l. On 1/5/11 at 8:00 a.m., the resident was observed in bed on her back. Her heels were not off loaded. The comforter and top sheet were tucked under the mattress and were tight over the resident's toes resulting in pressure to the toes. m. On 1/5/11 at 8:50 a.m., CNA #1 and a Nurse Aide Student performed incontinent care. When the resident was turned to her right side, there was a Stage II pressure ulcer to the left buttocks and 2 Stage II's to the right buttocks. CNA # 1 washed the area and applied a barrier cream. The right great toe had a necrotic area on the tip approximately 0.25 cm circular. The 3rd toe on the right foot had a gauze dressing on it. One-half of the 4th toe-nail was black. The top sheet and the comforter were tucked under the mattress and were tight on the resident's feet. The comforter was folded back over the resident's feet and a red dotted fleece wrap were over her toes. There was no bed cradle or mechanism to relieve pressure to the toes. n. On 1/5/11 at 9:15 a.m., CNA #2 and CNA #3 performed incontinent care. The resident was turned to the right side. CNA #3 washed the resident's buttocks and then applied a barrier cream. CNA #3 was asked, "How long has she (resident) had them (open areas to buttocks)?" She stated: "Not, very long." She further stated that the area was identified around the first of the month and that she had notified her Charge Nurse. The right heel had a brown necrotic area approximately 1cm x .5 cm. There were no pillows or a wedge to off load the heels. o. On 1/5/11 at 10:10 a.m., the Treatment Nurse was asked to measure the areas. She stated that she was not aware of any open areas on the buttocks and that when the resident went to the hospital the right heel was closed. She described the heel as red that measured 0.9 cm x .05 cm dry flaky skin with a 0.2 area that she described as " Dark Purple." She was asked, "How should the pressure have been relieved?" She replied, "They should be bridged." She was then asked, "What would have been done if you had been notified?" She replied, "No treatment, turned and bridged." She then measured the right great toe as 1.5 cm x 1.2cm red with black area on the tip of the toe as 0.5 cm circular. The Treatment Nurse removed the dressing to the 3rd toe and the toe was swelled twice its side and was a deep red. The treatment nurse stated she did not know there was a problem with her toes until it started draining. She contacted the physician and the physician ordered antibiotics for Osteo[DIAGNOSES REDACTED]. She was asked, "How is the pressure relieved for the toes?" She replied, "I don't know, I will have to check." p. CNA #3 was in the room and she was asked, "How have you been relieving the pressure off her (resident) toes?" She replied, "We have just been putting the sheet slightly over it." q. A body audit report dated 1/5/11 (1/6/11 at 9:40 a.m.) documented the following areas and measurements: 1) Upper left buttocks 0.5 cm x 0.5 cm. No stage was documented. 2) Left lower buttocks 1 cm x 0.3 cm. No stage was documented. 3) Right lower buttocks 0.5 cm x 0.4 cm. No stage was documented. r. As of 1/6/11 at 9:40 a.m., the physician orders did not include a treatment order for the open areas to the buttocks nor did the Nurses Notes document the physician was consulted regarding the open areas. s. On 1/5/11 at 10:30 a.m., the Director of Nursing (DON) entered the room and was asked, "Have you been using a bed cradle or mechanism to keep the linens off her toes?" She replied, "No." She further stated that there was a bed cradle out in storage and she would get it. t. The Plan of Care, with development date 12/16/10, identified a problem of "I am at risk for pressure ulcers" with interventions "I need daily observation of skin with routine care and use my pillows or other supportive/protective devices to assist with position and avoid my use of restrictive clothing." As of 1/6/11 at 9:40 a.m., the care plan did not address actual pressure sores or interventions to promote healing of the pressure sores. u. On 1/7/11 at 9:00 a.m., the Director of Nurses, Treatment Nurse and Nurse consultant were interviewed and the following questions were asked: 1)" Did any of you know about the open areas to Resident #4's buttocks?" They all replied, "No." 2)" Is there any documentation of the physician being notified of the open areas prior to 1/5/11?" They all replied, "No." 3)" Do you think that the right 3rd toe on Resident #4 should have been identified before it began draining?" The nurse consultant stated, "Yes." 2. Resident #2 had [DIAGNOSES REDACTED]. a. A re-admission physician order dated 12/16/10 documented, " Podus boot (R) (right lower) ext (extremity) at all x's (times)...q (every) shift (check) placement." b. A Weekly Skin Report dated 12/16/10 documented the resident was in the hospital 12/10/10 - 12/16/10 and documented the following [MEDICAL CONDITION] when readmitted to the facility: 1) Right heel 6 cm x 5 cm semi hard black intact; 2) Right great toe 1cm x 1.4 cm dark purple intact; 3) Left cheek < (less than) 0.3 cm open area. A podus boot was documented on the heel. c. Nurses Notes dated 12/20/10 at 7:28 p.m. documented the resident was sent to the emergency room for evaluation and treatment as indicated for nausea/vomiting. d. The Admission Nursing assessment dated [DATE] documented the resident's right heel was "Unstageable". There was no documentation of any [MEDICAL CONDITION] on the right great toe. e. On 1/5/10 at 7:05 a.m., and 9:10 a.m., the resident was observed in bed on his back. The resident had a comforter and two fleece blankets over his body including his feet. There was no bed cradle or mechanism to relieve pressure from the weight of the bed covers directly on his feet. f. On 1/5/10 at 11:00 a.m., a body audit was requested. The Treatment Nurse removed the resident's sock and the right great toe had a hard leathery dark purplish brown area on the end that measured 1.1 cm x 1.3 cm. The proximal sole of the right foot was black (not the heel) and measured 6 cm x 4.5 cm. The Treatment Nurse stated that she had measured the wound on the sole of the foot that morning and did not notice the toe. g. As of 3:11 p.m., there was no documentation in the nurses notes, physician orders, progress notes or treatment record or weekly skin report dated 12/29/10 that addressed the right great toe first noted by facility on 12/16/10. There was no documentation in the weekly skin audit sheets of the area on the bottom of the foot. h. On 1/5/10 at 3:40 p.m., LPN #3 was measuring the [MEDICAL CONDITION] on the foot again. When she put the podus boot back on, she was asked, "Is this boot relieving the pressure on the sole of the foot?" She replied, "No." i. At 4:55 p.m., LPN #3 stated that she took the podus boot off, curled a pillow under his ankle and would order a device to relieve the pressure. j. The Plan of Care last reviewed on 11/3/11 and a temporary problem list last updated on 1/5/11 did not address a problem of risk for pressure ulcers or interventions to prevent the development of pressure ulcers. 3. On 1/7/11 at 9:00 a.m., the Director of Nurses, Treatment Nurse and Nurse Consultant were interviewed and the following questions were asked: a. "When a resident is admitted /readmitted , who is responsible for identifying, measuring, obtaining orders for open area?" The Director of Nursing stated, "The LPN should have measured the areas, notified the physician and should have implemented a pressure relieving device." b. "Who is responsible for monitoring, to ensure pressure relieving devices are used correctly?" The DON stated, "The charge Nurse." The Nurse Consultant stated, "I think we have a communication problem here." 4. Resident #8 had [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented the resident had a score of 7 (Severe Cognitive Impairment) on the Brief Interview for Mental Status, required extensive/total assistance of at least one staff member for all Activities of Daily Living, was occasionally incontinent of bowel and bladder, was at risk for developing pressure ulcers and was on a turning/repositioning program. a. The Plan of Care dated 6/8/10 documented, "...Problem/Need: Requires extensive to total care for dressing, bathing, toileting, hygiene, transfers, and mobility ...Approaches: ...Observe for changes in skin condition during daily care and on bath days, Turn and/or reposition every 2 hours. Urinary Incontinence: Provide incontinent care every 2 hours and prn. Apply topical barrier cream... Unable to reposition self while in wheelchair. Provide repositioning assistance... Problem/Need: Potential for skin breakdown/impairment related to: decreased mobility, fragile skin, bowel/bladder incontinence, cognitive impairment... Approaches: Weekly skin checks per licensed staff; quarterly pressure ulcer risk assessments to ensure appropriate plan of care; Assist with turning/repositioning Q (every) 2 hours and PRN..." b. The Nursing Assistant Assessment Closet Care Plan observed 1/5/11 at 2:55 pm documented, "...SKIN INTEGRITY" Turn and reposition Q (every) 2 hrs. (hours) checked..." c. On 1/5/11 at 7:08 a.m., the resident was up in a wheelchair in the Restorative Dining Room to be fed breakfast. The resident was sitting on a lift pad. d. On 1/5/11 at 8:17 a.m., the resident was pushed by Certified Nursing Assistant (CNA) #6 from the Restorative Dining Room and down the hallway. The resident was left in front of her bedroom due to Housekeeping cleaning her room. The resident was leaning to her right, with a pillow tucked down by the right side of her head, shoulder and waist. The resident was hollering "help me, help me". When asked what was wrong she stated, "I need a CNA". When the CNA told the resident that she was a CNA, the resident stated, "That's all I need is a CNA". The CNA left the resident, still out in the hallway, immediately afterwards. e. On 1/5/11 at 8:25 a.m., the resident was pushed into her room by CNA #6 and placed directly in front of her television with her call light clipped on her right shoulder. f. On 1/5/11 at 9:20 a.m., the resident remained in the same position in the wheelchair in front of the television. g. On 1/5/11 at 10:10 a.m., two CNAs entered her room and were overheard asking the resident if she wanted to go to Group exercise. As she exited the room one of the CNAs stated the resident refused. h. On 1/5/11 at 11:02 a.m., the resident turned on her call light. CNA #8 answered call light and was overheard stating, "I can't come in here right now." At this time, the resident started constantly utilizing her call light and calling out for help repeatedly. CNA #5 was observed either calling out to the resident from the hallway, "What do you need?", or going in and turning off the call light and repeatedly asking her "What do you need?" without repositioning or changing the resident. The resident remained in the wheelchair. i. On 1/5/11 at 11:10 a.m., Licensed Practical Nurse (LPN) #1 answered the resident's call light by turning the call light off and leaving the resident's room. The resident remained in same position in the wheelchair. j. On 1/5/11 at 11:20 a.m., CNA #5 pushed the resident from her bedroom, out into the hallway and down to the Dining Room stating to the resident, "I'm not your Private Duty Nurse. I can't just sit with you. I have all of these other residents to take care of." The CNA left the resident sitting in the Dining Room with the resident yelling out repeatedly, "Help me, help me." k. On 1/5/11 at 11:25 a.m., the resident was pushed back to her bedroom from the Dining Room by the Social Services manager. The resident was calling out, "Help me, help me". CNA #6 and CNA #7 took the Resident from Social Services, returned her to her room and transferred her with the mechanical lift from the wheelchair to her bed. Both CNAs stated as the soiled brief was removed, "She's wet." During incontinent care, CNA #6 stated, "She sure is red." while CNA #7 left the room to retrieve protectant cream. When the surveyor asked if this was normal, CNA #6 stated, "No, I tell you this is from her being up too long and not changed." The Director of Nursing observed the resident's buttocks and sacral area and stated, "This is a Stage I." The resident had remained in the same position in the wheelchair for 4 hours and 17 minutes. l. On 1/5/11 at 11:35 a.m., CNA #6 was asked how often she should reposition and provide incontinent care for a resident at risk for skin breakdown and dependent on staff for incontinent care. She stated, "They should be changed every 2 hours and repositioned every 1 hour." The CNA was then asked when she last changed or repositioned the resident. She stated, "I don't know."