Ingham County Medical Care Facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents were treated with dignity and respect when residents were required to use plastic silverware for meals which diminished the homelike dining experience in two (Resident #33 and #73) and the potential to affect all residents that utilize utensils during meal service. Findings include:Review of the medical record reflected R33 was admitted to the facility on [DATE] and readmitted on [DATE]. The Minimum Data Set (MDS) reflected R33 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
On 12/09/2025 at 2:36 PM, R33 was observed in bed. R33 was dressed, however, multiple orange stains on R33's shirt were observed. R33 stated that she struggled feeding herself lunch that day. R33 explained that she utilized adaptive equipment and can feed herself when it is provided, except more recently, the facility had been utilizing plastic spoons instead of actual silverware, making it difficult to feed herself without spilling food all over herself. R33 explained that the difference in utensil weight and the spoon handle make a significant difference when self-feeding. R33 confirmed that the spots on her shirt were content of her lunch earlier that day. R33 stated that it made her feel humiliated.
During an observation, interview and record review on 12/09/2025 at 12:10 PM several residents were sitting in Main Dining Room and staff were present appearing to be getting ready to serve lunch. Review of the posted menu located behind the silverware at the serving window reflected tomato Florentine soup, Korean BBQ chicken, moist fluffy rice, curried cauliflower, [NAME] gelatin, margarin, and 2% milk was on the menu for lunch. Continued observation with limited silverware noted in holder and several plastic silverware observed in room trays in carts located by the kitchenette. During an interview, Certified Nurse Aid DD reported staff must use plastic silverware when they run out when preparing room trays. Observed some trays with mix of metal and plastic with about half of trays (about 15 to 20 trays) with plastic silverware. CNA DD reported ran out of metal silverware about halfway through room tray prep. CNA DD reported had been issue for about one month and staff have reported to management that they run out of real silverware but continues to be an issue and residents' complaint because difficult to eat with flimsy plastic. CNA DD reported kitchen often runs out of food as well including that morning when several residents had ordered the pancakes, but kitchen ran out and served toast instead and times when they start to run low residents get smaller portions. CNA DD reported residents choose what they want when they arrive at the dining room from meal ticket that has only one choice on it for entrée and reported facility has alternative options, but kitchen staff often say they are not available at least daily. CNA K verified issues with not enough metal silverware and food and reported staff do not have enough blue handled cups with lids to pass water to resident or serve during meals and most don't have lids and have to use poor fitting disposable lids and observed use of thin clear plastic disposable lid used on several cups. CNA K reported if residents require two handled mugs and not available, they do the best they can and provide one handled mugs. Observed clear two handled mugs with lids that do not fit. CNA K reported food service has been a problem for months that frequently run out of food and often do not serve what is on the menu with at least four to five changes in kitchen management since contracted company change. CNA K reported residents complain about having to eat from plastic silverware and ask staff, are we in kindergarten? CNA K reported not homelike and alternative menu items not available except peanut butter and jelly or maybe tuna fish sandwich. CNA K and J reported often run out of 8-ounce glasses and must use two four-ounce glasses for residents that require 8 ounces of milk, with meal or give two four-ounce cups of juice if residents request more juice. CNA J and K reported facility had run out of milk in past as well and reported kitchen staff have had issues with staffing and not enough staff, and facility staff have had to assist in the kitchen over within past two months. CNA J reported one day cinnamon rolls were on the menus and the kitchen had run out and so they served Hawaiian rolls with cinnamon on the top and resident were disappointed.
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R73 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included heart disease, congestive heart failure, diabetic, diverticulosis, irritable bowel, and depression. The MDS reflected R73 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required assist with meal set up and clean up.
During an observation and interview on 12/09/2025 at 2:29 PM, R73 was in room sitting in a wheelchair and appeared calm, pleasant and able to answer questions without difficulty. R73 reported food at facility was bad and stated was served hot dogs 3 times last week. R73 stated, It is bad enough I have to be here, then I get bad food. R73 reported chooses to eat meals in room and two to three times a week has to eat meals with plastic silverware and stated, I pay a lot of money to be here and should not have to eat with plastic silverware. R73 reported was served corn last week and should not have been related to diagnosis and had lost weight recently. R73 stated, food is just not good, after starting to appear upset. R73 reported daughter was working on completing grievance form for food issues.
During an observation, interview and record review on 12/10/2025 at 2:00 PM R73 was sitting in room with meal tray at side that had been delivered to room recently. There appeared to be wide egg noodles with ground white meat and pesto, with gravy. asparagus, puree cabbage soup, roll, and Strawberry Bavarian. R73 reported was finished stated, I ate something because I knew I had to eat something. R73 ate roll about 75% asparagus, and 25% entrée. The pureed cabbage soup was untouched as well as dessert. The strawberry dessert appeared to be pureed strawberry over pudding and pureed soup looked like dark mashed potatoes. R73 reported she really liked soup but not like that and did not care for looks of dessert and reported enjoyed sherbet but never offered. R73 meal ticket included entrée of 1 each S. Beef Hot Dog (turkey written in), garlic noodles, 6 ounces puree cabbage soup, roll, and Strawberry Bavarian with texture of regular ground.
During an interview on 12/11/2025 at 11:15 am, Licensed Practical Nurse (LPN) NN reported shortage of cups, lids and silverware for about 2 weeks and residents complain and staff assist with grievance reports.
During an interview on 12/11/2025 11:55 PM R73 observed in room drinking from broken blue mug with disposable lid. R73 demonstrated handle was broken and lid was leaking. R73 reported daughter had brought dinner it last evening and verified weight loss since facility admission because she does not always eat food because often does not like served food.
During an observation on 12/11/2025 at 12:40 p.m., in main dining room residents observed eating with plastic silverware.
During an observation, interview and record review on 12/11/25 at 2:45 p.m., observed R73 meal tray at the bedside untouched with R73 in bed with eyes closed. The meal ticket reflected puree chicken noodle soup, stuffed pork chop, Brussel Sprouts, apple crisp. The tray included what appeared to be mashed potatoes, brown substance that looked like consistency of mashed potatoes, scoop of large grain multi color item, green beans and apple crisp with regular ground texture. R73 daughter entered room about 2:50 p.m. and reported R73 had ground meat because it was easier to chew not related to choking concerns and verified unsure why facility would puree pork chop or soup. R73 daughter reported R73 really likes soup.
During an interview on 12/11/2025 at 3:10 PM, CNA GG reported alternative meals posted but told by kitchen staff not available at least daily including grilled cheese and mashed potatoes. CNA GG reported residents should have choices for meals and have basic options available. CNA GG reported facility has shortage of blue mugs and lids that fit properly for several weeks.
During an interview on 12/11/2025 at 4:00 PM Kitchen Manager (KM) F reported had worked at the facility for about three months. KM F reported food modifications were ordered by Speech Therapy and kitchen staff are expected to follow meal tickets. KM F reported R73 had a hot dog on her meal ticket yesterday at lunch because maybe that is what she wanted and reported main entrée was pesto turkey and should have been R73 main entree on ticket with meat ground per order. KM F was unable to say why R73 had hot dog on ticket as main entrée and unable to say why R73's meal ticket had pureed chicken noodle soup today (12/11/25). KM F reported ground meal should look like ground meat and reported Brussel Sprouts were on the lunch menu today but kitchen staff had to substitute for green beans for quality reasons at the last minute. KM F reported couscous was served with lunch today (not on menu) but unable to say why it was served to R73 and verified was not on R73 meal ticket. KM F reported had ordered metal silverware three times since September and received more on 12/9/25 and reported was unsure where they go and may be issue with residents' hording silverware.
During an interview on 12/15/2025 at 8:54 AM, Dietician H reported was familiar with R73. Dietician H reported R73 had several food eversions on admission and regular diet with ground meat was current texture order for meats only not related to swallowing issues. Dietician H reported if chunks of meat in soup would puree even if ground meat. Dietician H verified R73 had significant weight loss and was not on supplements currently. Dietician H reported alternate menu always available.
During an observation on 12/15/2025 at 9:52 AM, R73 was observed in bed with eyes closed and untouched meal tray on bedside table. R73 meal ticket, dated 12/15/25 breakfast, included circled fresh grapes and corn flakes. Observed applesauce and corn flakes with no fresh grapes.
Review of R73 Speech Therapy Evaluation, dated 10/23/25, reflected, Regular solids with ground meats, thin liquids. Inadequate mastication of tough meats .Pt's[patients] diet prior to ST[speech therapy] was regular solid, thin liquids. Pt's diet was downgraded to regular solids with ground meats due to pt's preference and inconsistency of cook on eat in the facility .
Review of R73 Nutritional Assessment, dated 10/24/25, reflected grapes were on R73 list of liked foods. Continued review of the assessment reflected, Resident denies chewing or swallowing issues with current texture, Recent downgraded to ground meats r/t troubles with chewing some.
Review of R73 Dietary Note, dated 11/18/25, reflected, Inadequate oral intakes r/t[related to] poor appetite AEB [as evidenced by] highly variable intakes and 10% weight loss x 6 mos. [times six months] .
Review of the Grievance Log, dated 9/1/25 through 11/24/25, reflected over 25 kitchen/food complaints related to plastic silverware, food preferences not being honored, available alternatives, lack of cups with lids, food temps and modifications.
During a second interview on 12/15/25 at about 10:15 a.m. Dietician H reported was unsure why R73 was provided applesauce instead of requested fresh grapes and verified grapes were liked items.
During an interview on 12/15/2025 at 11:03 AM, Speech Therapy (ST)HH reported R73 did not have swallowing issues but was started after request of resident on 10/24/25 visits with speech therapy because resident was tiring with chewing and was easier for resident. ST HH reported was unsure why soup was puree and stated that would be kitchen staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure resident safety during staff assisted mechanical lift transfer for 1 of 3 sampled residents (Resident #3) reviewed for accidents, resulting in Resident #3 right lower leg laceration that required hospital transfer and sutures. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R3 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included chronic osteomyelitis, heart failure, morbidly obese, diabetes, venous insufficiency, and depression. The MDS reflected R3 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required staff assist with dressing, hygiene, bathing and transfers.During an observation and interview on 12/09/2025 at 4:05 PM, R3 was sitting in wheelchair in resident room and appeared calm, pleasant and able to answer questions without difficulty. R3 reported an incident on 12/5/25, when staff were transferring her from the bed to the wheelchair and her right lower leg was cut when the lift tipped over during the transfer. R3 reported three staff were present including Certified Nurse Aid (CNA) MM, nurse and another CNA. R3 reported staff were unable to control the bleeding and had to emergency room for stitches. R3 had large dressing in place on right lower leg. R3 requested staff to get her back to bed and R3 granted this surveyor permission to observe. CNA DD reported planned to transfer R3 to bed after another CNA arrived.During an observation on 12/09/2025 at 4:15 PM, this surveyor entered R3's open door room and observe CNA DD hooking up R3 sling, placed under resident in wheelchair, to mechanical life. No other staff was present in the room. CNA DD transferred R3 from the wheelchair to the bed with the use of the mechanical life alone and resident tolerated well. This surveyor continued to observe from doorway area. Review of R3 Progress Notes, dated 12/5/2025, reflected, While transferring resident from bed to chair, staff was trying to reposition resident as she was upset that she was leaning to far to the left and while trying to reposition her the hoyer started to lift up and while we got the hoyer level again as resident was still up in the air nurse notice a large stream of dark red blood streaming from residents leg. Two CNA Staff unlocked wheel and pulled hoyer forward so nurse who was guiding from the back, could asses and apply press to the laceration on residents right calf. Quick assessment nurse assessed that there was an upside down J shaped laceration approximately seven cm from top to bottom. Nurse applied pressure, Cna alerted unit manager and nurse on green who brought ABD pads and colban to wrap leg tight. Once leg was wrapped tight we hoyered resident back onto bed. Resident was unaware that anything had happened to her leg until she realized nurse was concerned as she could not see what had happened. Resident has no feeling bilaterally from the Paramedics arrived and we call [named R3] sister for permission about going to hospital for stitches as resident did not want to go as she did not want to miss bingo. Both sisters were contacted and both stated she should go. Notified [named physician] that resident needed to be sent out for stitches and then called and left a message for PACE hospice on the general mail box. The only area we could think was she had hit with leg on top section of leg rest. So padding was added to her current wheelchair. It was discussed with unit manager and nurse that it might be reasonable to contact her hospice company about getting her a broda chair since she does not ambulated.Review of the Progress Noted, dated 12/5/2025, reflected, Resident returned just before dinner today. [named] hospital called and gave report that residents vitals were stable and that she received four stitches to the laceration on right lower from of shin. Resident returned and was very hungry so staff got her an early dinner. Resident is in bed , call light is within reach and resident can make her needs known. Follow up for an order for stitches removal on 12/12/2025.Review of R3 Care Plan, dated 9/4/24, reflected, TRANSFER: Dependent x 2 with mechanical lift and blue/XL trim sling.During an interview on 12/11/2025 at 11:15 am, Licensed Practical Nurse (LPN) NN reported was present on 12/5/25 and in room when R3s right lower leg was cut during mechanical lift transfer. LPN NN reported she was behind R3 guiding into wheelchair and CNA MM and OO were on each side of the lift. LPN NN reported the lift tipped when one leg of the lift came off the ground and one of the CNA staff stepped on lift leg quickly. LPN NN reported that is when they noticed R3 right lower leg was bleeding, and she applied pressure after R3 was lowered into wheelchair and lift was moved. LPN NN reported mechanical lift transfers require two staff and reported received re-education after incident to removed foot pedals prior to transfer.During an observation and interview on 12/11/2025 at 11:21 am, R3 was observed in room in bed, denied discomfort and reported there was usually two staff in the room when using mechanical lift for transfers.During an interview on 12/11/2025 at 12:15 PM, CNA OO reported was present on 12/5/25 when R3's leg was cut during transfer. CNA OO reported entered R3 room after R3 was in mechanical lift to assist and LPN NN was behind R3, and CNA MM was on the front left. CNA OO reported R3 was being transferred from the bed to the wheelchair positioned at the foot of the bed. CNA OO reported R3 was almost in the wheelchair when R3 was pushed to back of wheelchair the lift tipped, she grabbed lift and stood on it and it tipped back. CNA OO reported was unsure what caused bleeding, but right lower leg was bleeding and LPN NN was present and tended to that. CNA OO reported mechanical lift was positioned from side of wheelchair with leg of lift between front and back wheel of wheelchair toward the wall. CNA OO reported R3 was a two to three person assist with mechanical lift transfer and never one because requires at least 2 for safety. CNA OO reported received re-education after the incident of proper use of mechanical lift including positioning directly in front of the wheelchair.During an interview on 12/11/2025 at 11:50 AM, CNA MM reported was present when R3 had incident during staff assisted transfer with mechanical lift on 12/5/25. CNA MM reported LPN NN was positioned behind R3, and CNA OO had entered R3 room during the transfer. CNA MM reported the R3 was being transferred from the bed to the wheelchair at the foot of the bed and reported the legs of the mechanical lift were not in widest position because one leg of lift was position between front and back wheel of wheelchair and was not enough room between wall. CNA MM reported received re-education after incident on proper use of mechanical lift including using with legs positioned widest position and straight into wheelchair. CNA MM reported R3 requires two staff with use of mechanical lift transfers. During an observation and interview on 12/11/2025 at 1:55 pm, CNA GG demonstrated mechanical lift in Red Hall and verified exposed orange aluminum sharp areas about 16-18 inches up from floor on piston area of lift. CNA GG demonstrated use of lift and reported lift legs should be wide with transfer including lowering residents into wheelchair. CNA GG demonstrated use with wide legs positioned between front and back wheels of wheelchair indicated it was highly unlikely that lift legs were wide and more likely that legs were narrow on mechanical lift when staff attempted to position R3 to back of wheelchair (pushing R3 sideways in lift) when lift tipped sideways toward wheelchair.During an interview on 12/15/2025 at 2:05 PM, Director of Nursing (DON) B reported Unit Manager and Staff Educator PP completed investigation for R3 incident on 12/5/25. DON B reported would expect staff to use wide legs on lift during transfer and use of two person assist with mechanical lift transfer. During an interview on 12/15/2025 at 2:23 PM, Staff Educator (SE) PP reported was unsure who R3 cut the front of right leg when transfer from bed to wheelchair on 12/5/25 and was responsible for investigation. SE PP reported after speaking was everyone involved thought possibly R3's anterior right leg was cut on wheelchair pedal area but did not make sense. SE PP reported did not notice sharp area on mechanical lift. SE PP reported provided staff re-education related to proper mechanical lift use including proper positioning of lift legs in wide position and wheelchair positioning. SE PP reported would expect staff to always use two staff for all mechanical lift transfers. Review of the facility, MECHANICAL LIFT Policy, dated 12/28/22, reflected, OBJECTIVE: To transfer a Resident/Patient between two surfaces using a mechanical lift .PROCEDURE.Obtain assistance. The minimum number for a safe transfer is two people.Bring lift to the bed.Roll the base, spread wide open under the bed.Make sure there is room to maneuver the lift in the room.Make sure wheelchair is in position for transfer and brakes are locked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement and document interventions designed to prevent further weight loss, including consistent monitoring and documentation of dietary intake, nutritional supplements, and snacks in two (Resident #10, Resident #116) out of 4 reviewed for nutrition. Findings include:
Resident #10 (R10)
Review of the medical record revealed R10 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, anxiety disorder, and insomnia. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/25 revealed R10 scored 00 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), ate a mechanically altered diet, and required setup or clean-up assistance with eating.
On 12/15/25 at 9:58 AM. R10 was observed ambulating independently exiting the lounge and walking down the hallway. On 12/15/25 at 10:22 AM, R10 continued wandering the hallway while a group of residents were in the lounge eating applesauce and drinking coffee. A staff member approached R10, took her by the hand and walked briefly with her before redirecting her down another hall. The staff member did not attempt to redirect R10 into the lounge for a snack and coffee.
Review of R10's weight history revealed on 11/5/25 R10 weighed 127.2 pounds and on 12/2/25, R10 weighed 119.2 pounds which was a 6.29% significant weight loss.
Review of the Nutrition assessment dated [DATE] revealed R10's usual body weight was 130's and adding snacks TID [three times per day] & magic cup BID [twice per day] (290 kcal, 9g protein) r/t [related to] inconsistent intakes. The assessment revealed R10 disliked raisins, bacon, and pork.
Review of the Physician's Orders revealed no orders for magic cup twice per day or snacks three times per day.
Review of R10's Nutrition Care Plan revealed interventions that included:
Provide and serve supplements and snacks as ordered see meal tickets for details (initiated 11/6/25)
Provide, serve regular diet/mechanical soft texture/thin liquids as ordered. Monitor intake and record every meal (initiated 11/6/25.
Food preferences to be reflected onto meal tickets (initiated 11/6/25)
Review of the Nutrition/Dietary Note dated 12/11/25 revealed Resident with -6.3% weight loss x 1 month. Resident frequently walking around unit, increasing her nutritional needs. Currently receiving magic cup BID (290 kcal, 9g pro [grams of protein]). RD [Registered Dietitian] to add fortified smoothie qd [every day] (230 kcal, 6g pro). Will continue to monitor.
Review of R10's meal tickets revealed 4-ounce magic cup with lunch and dinner. The lunch tray ticket dated 12/11/25 revealed the entree was 5-ounce ground stuffed pork chop. Pork was listed as one of R10's dislikes on the Nutrition assessment dated [DATE].
Review of Documentation Survey Report revealed the following missing Nutrition-Amount Eaten documentation:
11/7/25-dinner not documented
11/10/25-dinner not documented
11/13/25-lunch and dinner not documented
11/14/25-breakfast, lunch, and dinner all documented as not applicable
11/16/25-dinner not documented
11/18/25-lunch and dinner not documented
11/19/25-breakfast, lunch, and dinner not documented
11/21/25-lunch not documented
11/24/25-lunch and dinner not documented
11/25/25-dinner not documented
11/26/25-dinner not documented
11/27/25-dinner not documented
11/30/25-lunch and dinner not documented
12/1/25-lunch documented as not applicable
12/2/25-breafkast and dinner not documented
12/3/25-lunch and dinner not documented
12/4/25-dinner not documented
12/9/25-dinner not documented
12/10/25-dinner not documented
12/11/25-lunch and dinner not documented
12/14/25-lunch and dinner not documented
Review of Documentation Survey Report revealed there were four opportunities to document supplement intake each day that included 12:00 PM day nurse, 12:00 PM day Certified Nursing Assistant (CNA), 5:30 PM day CNA and 5:30 PM evening nurse. The report revealed the following missing documentation for Nutrition: Supplements:
11/21/25 5:30 PM CNA and nurse documented as not applicable
11/22/35 12:00 PM CNA and nurse documented as not applicable
11/24/25-no documentation
11/25/25 12:00 CNA and nurse documented as not applicable and 5:30 PM CNA and nurse did not document
11/26/25 12:00 PM CNA and nurse documented as not applicable and 5:30 PM CNA and nurse did not document
11/27/25 5:30 PM CNA and nurse did not document
11/28/25-no documentation
11/29/25 12:00 PM CNA and nurse documented as not applicable
11/30/25-no documentation
12/1/25 12:00 PM and 5:30 PM CNA and Nurse documented as not applicable
12/2/25 5:30 PM CNA and nurse did not document
12/3/25-no documentation
12/4/25 12:00 PM CNA and nurse documented as not applicable and 5:30 PM CNA and nurse did not document. There was a PRN (as needed) documentation at 4:28 AM
12/5/25, 12/6/25, 12/7/25, 12/8/25-12:00 PM and 5:30 PM CNA and nurse documented as not applicable
12/9/25 5:30 PM CNA and nurse did not document
12/10/25 12:00PM CNA and nurse documented as not applicable and 5:30 PM nurse and CNA did not document
12/11/25-no documentation
12/12/25 12:00PM and 5:30 PM CNA and nurse all documented as not applicable
12/14/25-no documentation
Review of the Nutrition-Snacks documentation revealed there was no documentation related to snacks in the last 30 days.
In an interview on 12/15/2025 at 8:56 AM, RD H reported a resident's preferences and dislikes should be reflected on the meal ticket. When asked why R10 was served a pork on 12/11/25 when pork was listed as a dislike, RD H reported R10 may have requested it and that R10's dislike may have been pulled pork, but she would have to verify with R10's daughter. When asked what R10's intake was for that meal, RD H reported it appeared R10 did not eat that meal. When asked how a true intake was being monitored and evaluated when not all meal intakes, snacks, and supplements were documented, RD H agreed there was missing documentation and reported they would have to average the amounts that were documented and speak with staff. When asked what not applicable documentation meant, RD H reported she was unsure and that it could mean too many different things.
In an interview on 12/15/25 at 2:02 PM, Director of Nursing (DON) B agreed there was missing documentation related to R10's meal, supplement, and snack intake.
Review of the medical record reflected R116 was admitted to the facility on [DATE], with diagnoses that included dementia. R116 was interview able and answered questions appropriately.
On 12/9/25 at 10:00 AM, R116 was observed in bed. R116 was conversant and discussing events when a staff member was observed delivering a small cup and spoon for R116. R116 explained that the cup contained a smoothie, and he does not eat the smoothies.
On 12/09/2025 at 1:33 PM R116 was observed in his room. A staff member provided R116 with his lunch and assisted R116 with consuming his meal.
On 12/11/2025 at 10:24 AM, R116 was observed in bed. A smoothie was observed on his bedside table, untouched. R116 and a family member confirmed that R116 does not touch the smoothies and they are better off in the trash. R116's family member confirmed that the smoothies are provided in an attempt to assist with R116's weight loss.
Review of a Nutrition/Dietary Note dated 12/11/25 revealed Resident (116) with -12.4% (precent) weight loss [in] 6 mos. Resident with highly variable meal intakes. Currently receiving fortified smoothie . and pm (night) snack. Intakes encouraged.
Review of R116's weight loss care plan revealed interventions including Provide and serve snacks per preference . Provide and serve supplement as ordered, and . Monitor and record meal intakes.
Review of the task documentation revealed inconsistent data documentation completion for meal intake and supplement intake documentation, including multiple dates where not applicable was selected as an option for supplement intake and several dates where the amount consumed for meals was not completed.
Further review of the task documentation revealed no evidence that R116 was being provided a nightly snack and no documentation for snack acceptance and/or consumption.
In an interview on 12/15/2025 at 9:09 AM, Registered Dietician (RD) H states that the dieticians rely on meal consumption, including snacks, all three meals, and supplements, to determine the individual intake needs for the residents. RD H confirmed that R116 was on the significant weight loss list which is what prompted the intervention for smoothies and nightly snacks. RD 'H stated that the staff should be documenting the amounts consumed and should not be selecting not applicable as a response for consumption amounts.

Based on observation, interview, and record review the facility failed to ensure that bed rails were assessed and measured to prevent possible entrapment for one Resident (#7) of one resident reviewed for Residents using bed rails. Findings Included:Resident #7 (R7)Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. Review of R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and attempted interview on 12/11/2025 at 09:31 a.m. R7 was observed lying down in her bed. A half-length side rail was observed on the right side of the bed and on the left side of the bed. R7 did not respond to verbal questions. Review of the R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed section P-Restraints and Alarms A. Bed Rail was documented as 0.not used. Review of R7's plan of care did not demonstrate the use of bilateral side rails. Review of R7's physician orders did not include an order for the use of side rails. Review of R7's medical record did not demonstrate a side rail evaluation or that measurements of the bilateral side rails had been conducted. During an interview on 12/11/2025 at 10:22 a.m. Director of Nursing (DON) B explained that residents using side rails would have the following actions completed: - Assist Device/Bed Rail Assessment- Nursing 5 Day Assist Device/bed Rail Monitoring Form- A physician's order for the use of the assist device/bed rail. - The resident care plan would include the use of the assist device/bed railDON B was asked to review R7's medical record. DON B confirmed that R7 did not have any of the above documented actions completed in her medical record. DON B explained that the facility was currently conducting a Quality Improvement Project for the use of Assistive Device/ Bed Rails. DON B explained that currently R7 was not incompliance with the requirements of using assistive devices/bed rails at this time. During an interview on 12/11/2025 at 10:32 a.m. Minimum Data Set (MDS) Coordinator S explained that she was responsible for the coordination of the facility MDS's. MDS Coordinator S was asked to review R7's MDS with an Assessment Reference Date (ARD) of 11/24/2025 and the review section P-Restraints and Alarms A. Bed Rail. MDS Coordinator S confirmed that it had been coded that R7 was not using side rails. MDS Coordinator S also confirmed that R7's plan of care did not include the use of bilateral side rails. MDS Coordinator S could not explain why R7's MDS was inaccurate regarding the use of side rails. During observation with MDS Coordinator S on 12/11/2025 at 10:41 a.m. R7 was observed lying in bed. MDS Coordinator S confirmed that R7's bed had two half rails position on the right and left sides of her bed. MDS Coordinator S explained that it was her opinion that R7 could not be using the observed side rails as positioning devices. During an interview on 12/11/2025 at 11:07 a.m. Director of Nursing (DON) B re-confirmed that R7 did not have a physician's order for the use of side rails, did not have a plan of care for the use of side rails, and did have a Nursing 5 Day Assist Device/bed Rail Monitoring Form. DON B did provide a copy of Assist Device/bed Rail Assessment which had been completed 12/11/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to: (1) provide palatable food products, and (2) provide consistent dietary glassware and flatware affecting 131 residents who consume food, resulting in the increased likelihood for resident decreased food acceptance, nutritional decline, and undignified dining.Findings include:During an observation, interview and record review on 12/09/2025 at 12:10 PM several residents were sitting in Main Dining Room and staff were present appearing to be getting ready to serve lunch. Review of the posted menu located behind the silverware at the serving window reflected tomato Florentine soup, Korean BBQ chicken, moist fluffy rice, curried cauliflower, [NAME] gelatin, margarin, and 2% milk was on the menu for lunch. Continued observation with limited silverware noted in holder and several plastic silverware observed in room trays in carts located by the kitchenette. During an interview, Certified Nurse Aid DD reported staff must use plastic silverware when they run out when preparing room trays. Observed some trays with mix of metal and plastic with about half of trays (about 15 to 20 trays) with plastic silverware. CNA DD reported ran out of metal silverware about halfway through room tray prep. CNA DD reported had been issue for about one month and staff have reported to management that they run out of real silverware but continues to be an issue and residents' complaint because difficult to eat with flimsy plastic. CNA DD reported kitchen often runs out of food as well including that morning when several residents had ordered the pancakes, but kitchen ran out and served toast instead and times when they start to run low residents get smaller portions. CNA DD reported residents choose what they want when they arrive at the dining room from meal ticket that has only one choice on it for entrée and reported facility has alternative options, but kitchen staff often say they are not available at least daily. CNA K verified issues with not enough metal silverware and food and reported staff do not have enough blue handled cups with lids to pass water to resident or serve during meals and most don't have lids and have to use poor fitting disposable lids and observed use of thin clear plastic disposable lid used on several cups. CNA K reported if residents require two handled mugs and not available, they do the best they can and provide one handled mugs. Observed clear two handled mugs with lids that do not fit. CNA K reported food service has been a problem for months that frequently run out of food and often do not serve what is on the menu with at least four to five changes in kitchen management since contracted company change. CNA K reported residents complain about having to eat from plastic silverware and ask staff, are we in kindergarten? CNA K reported not homelike and alternative menu items not available except peanut butter and jelly or maybe tuna fish sandwich. CNA K and J reported often run out of 8-ounce glasses and must use two four-ounce glasses for residents that require 8 ounces of milk, with meal or give two four-ounce cups of juice if residents request more juice. CNA J and K reported facility had run out of milk in past as well and reported kitchen staff have had issues with staffing and not enough staff, and facility staff have had to assist in the kitchen over within past two months. CNA J reported one day cinnamon rolls were on the menus and the kitchen had run out and so they served Hawaiian rolls with cinnamon on the top and resident were disappointed.
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R73 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included heart disease, congestive heart failure, diabetic, diverticulosis, irritable bowel, and depression. The MDS reflected R73 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required assist with meal set up and clean up.
During an observation and interview on 12/09/2025 at 2:29 PM, R73 was in room sitting in a wheelchair and appeared calm, pleasant and able to answer questions without difficulty. R73 reported food at facility was bad and stated was served hot dogs 3 times last week. R73 stated, It is bad enough I have to be here, then I get bad food. R73 reported chooses to eat meals in room and two to three times a week has to eat meals with plastic silverware and stated, I pay a lot of money to be here and should not have to eat with plastic silverware. R73 reported was served corn last week and should not have been related to diagnosis and had lost weight recently. R73 stated, food is just not good, after starting to appear upset. R73 reported daughter was working on completing grievance form for food issues.
During an observation, interview and record review on 12/10/2025 at 2:00 PM R73 was sitting in room with meal tray at side that had been delivered to room recently. There appeared to be wide egg noodles with ground white meat and pesto, with gravy. asparagus, puree cabbage soup, roll, and Strawberry Bavarian. R73 reported was finished stated, I ate something because I knew I had to eat something. R73 ate roll about 75% asparagus, and 25% entrée. The pureed cabbage soup was untouched as well as dessert. The strawberry dessert appeared to be pureed strawberry over pudding and pureed soup looked like dark mashed potatoes. R73 reported she really liked soup but not like that and did not care for looks of dessert and reported enjoyed sherbet but never offered. R73 meal ticket included entrée of 1 each S. Beef Hot Dog (turkey written in), garlic noodles, 6 ounces puree cabbage soup, roll, and Strawberry Bavarian with texture of regular ground.
During an observation, interview and record review on 12/11/25 at 2:45 p.m., observed R73 meal tray at the bedside untouched with R73 in bed with eyes closed. The meal ticket reflected puree chicken noodle soup, stuffed pork chop, Brussel Sprouts, apple crisp. The tray included what appeared to be mashed potatoes, brown substance that looked like consistency of mashed potatoes, scoop of large grain multi color item, green beans and apple crisp with regular ground texture. R73 daughter entered room about 2:50 p.m. and reported R73 had ground meat because it was easier to chew not related to choking concerns and verified unsure why facility would puree pork chop or soup. R73 daughter reported R73 really likes soup.
During an interview on 12/11/2025 at 3:10 PM, CNA GG reported alternative meals posted but told by kitchen staff not available at least daily including grilled cheese and mashed potatoes. CNA GG reported residents should have choices for meals and have basic options available. CNA GG reported facility has shortage of blue mugs and lids that fit properly for several weeks.
During an interview on 12/11/2025 at 4:00 PM Kitchen Manager (KM) F reported had worked at the facility for about three months. KM F reported food modifications were ordered by Speech Therapy and kitchen staff are expected to follow meal tickets. KM F reported R73 had a hot dog on her meal ticket yesterday at lunch because maybe that is what she wanted and reported main entrée was pesto turkey and should have been R73 main entree on ticket with meat ground per order. KM F was unable to say why R73 had hot dog on ticket as main entrée and unable to say why R73's meal ticket had pureed chicken noodle soup today (12/11/25). KM F reported ground meal should look like ground meat and reported Brussel Sprouts were on the lunch menu today but kitchen staff had to substitute for green beans for quality reasons at the last minute. KM F reported couscous was served with lunch today (not on menu) but unable to say why it was served to R73 and verified was not on R73 meal ticket. KM F reported had ordered metal silverware three times since September and received more on 12/9/25 and reported was unsure where they go and may be issue with residents' hording silverware.
During an interview on 12/15/2025 at 8:54 AM, Dietician H reported was familiar with R73. Dietician H reported R73 had several food eversions on admission and regular diet with ground meat was current texture order for meats only not related to swallowing issues. Dietician H reported if chunks of meat in soup would puree even if ground meat. Dietician H verified R73 had significant weight loss and was not on supplements currently. Dietician H reported alternate menu always available.
During an observation on 12/15/2025 at 9:52 AM, R73 was observed in bed with eyes closed and untouched meal tray on bedside table. R73 meal ticket, dated 12/15/25 breakfast, included circled fresh grapes and corn flakes. Observed applesauce and corn flakes with no fresh grapes.
Review of R73 Speech Therapy Evaluation, dated 10/23/25, reflected, Regular solids with ground meats, thin liquids. Inadequate mastication of tough meats .Pt's[patients] diet prior to ST[speech therapy] was regular solid, thin liquids. Pt's diet was downgraded to regular solids with ground meats due to pt's preference and inconsistency of cook on eat in the facility .
Review of R73 Nutritional Assessment, dated 10/24/25, reflected grapes were on R73 list of liked foods. Continued review of the assessment reflected, Resident denies chewing or swallowing issues with current texture, Recent downgraded to ground meats r/t troubles with chewing some.
Review of R73 Dietary Note, dated 11/18/25, reflected, Inadequate oral intakes r/t[related to] poor appetite AEB [as evidenced by] highly variable intakes and 10% weight loss x 6 mos. [times six months] .
Review of the Grievance Log, dated 9/1/25 through 11/24/25, reflected over 25 kitchen/food complaints related to plastic silverware, food preferences not honored, no alternative choices available, lack of cups with lids, food temps and modifications.
During a second interview on 12/15/25 at about 10:15 a.m. Dietician H reported was unsure why R73 was provided applesauce instead of requested fresh grapes and verified grapes were liked items.
During an interview on 12/15/2025 at 11:03 AM, Speech Therapy (ST)HH reported R73 did not have swallowing issues but was started after request of resident on 10/24/25 visits with speech therapy because resident was tiring with chewing and was easier for resident. ST HH reported was unsure why soup was puree and stated that would be kitchen staff.
On 12/10/2025 at 2:16 PM, a lunch test tray evaluation was conducted. The meal included cabbage soup, turkey with pesto, noodles, and asparagus. The cabbage soup was overcooked, resulting in the ingredients being excessively soft and mixed together. The noodles lacked flavor, and the turkey was notably dry.
On 12/09/2025 at 12:49 P.M., An interview was conducted with Dietary Aide G regarding dietary service flatware inventory. Dietary Aide G stated: We don't have enough flatware (spoons, knives, forks). Dietary Aide G additionally stated: Management stated new flatware (knives, forks, spoons) is currently on order.
On 12/09/2025 at 12:55 P.M., An interview was conducted with Registered Dietician (RD) H regarding dietary service flatware inventory. (RD) H stated: We order $400.00 worth of flatware a month. (RD) H also stated: We mainly order spoons and forks, rarely knives.
On 12/09/2025 at 01:30 P.M., An interview was conducted with Dining Service Director F regarding dietary service flatware inventory. Dining Service Director F stated: We have been doing weekly room sweeps for flatware. Dining Service Director F also stated: Some residents are care planned for plastic spoons, knives, and forks.
On 12/10/2025 at 11:52 P.M., Lunch meal food products were observed leaving the main food production kitchen, within an insulated stainless steel transport cart.
On 12/10/2025 at 11:55 A.M., Lunch meal food products were observed arriving to the South Pantry Kitchenette, within an insulated stainless steel transport cart.
On 12/10/2025 at 12:53 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #92's lunch meal:
Cabbage Soup - 143.7
Toasted Turkey Sandwich - 88.9
Strawberry Bavarian - 50.1*
Beverage (Coffee) - 151.0
The 2022 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 degrees C (135 degrees F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 degrees C (41 degrees F) or less.
On 12/10/2025 at 01:35 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #72's lunch meal:
Cabbage Soup - 137.0
Mashed Potatoes - 137.1
Grilled Cheese - 141.8
Lemon Asparagus - 119.7*
Strawberry Bavarian - 50.8*
Beverage (Apple Juice) - 51.0*
The 2022 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 degrees C (135 degrees F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 degrees C (41 degrees F) or less.
On 12/10/2025 at 03:01 P.M., An interview was conducted with Dining Service Director F regarding dietary service glass and flatware inventory. Dining Service Director F stated: I thought I only needed juice glasses. Dining Service Director F also stated: I will order new 8-ounce glasses for both dairy and water.
On 12/11/2025 at 08:30 A.M, Record review of the Policy/Procedure entitled: Ordering, Assembling, and Presenting a Meal dated (no date) revealed under Assembling the Order: (1) Collect all the serving equipment needed for the course(s) you are picking up. This includes plates, glasses, dollies, and silverware. (2) Get all the food accompaniments and garnishes for this course. For instance, sour cream for baked potato or mint jelly for sliced lamb. (3) Pick up cold food first, taking care to keep it away from hot food on the tray or the steamtable. (4) Pick up hot foods next, covering all hot food with an insulated plate cover (banquet cover) to retain the heat. Use heated underliners for hot foods and chilled underliners for cold foods and salads. (5) Plan the assembling order of the entrees so you can pick up the items as soon as they are ready. (8) Remember that the appearance and temperature of food perfectly prepared when it leaves the kitchen can be spoiled by a server/aide who is thoughtless, slow, or careless.
On 12/11/2025 at 08:45 A.M., Record review of the Policy/Procedure entitled: Meal Delivery dated 9/7/22 revealed under Description: Meals will be delivered to all residents/patients in a timely, organized, safe, and sanitary manner. Record review of the Policy/Procedure entitled: Meal Delivery dated 9/7/22 further revealed under Nursing: (1) Serves meals promptly upon delivery. (2) Clears, cleans, and sanitizes overbed tables in preparation for meal. (3) Positions resident/patient to ensure comfort and safety while eating and drinking. Aids with meal set-up as appropriate and assists residents/patients who require assistance. (4) Notifies Dining Services Department of any items missing or if a resident/patient requests a substitute. (5) Picks up the dishes after each meal and returns them to the designated area (Note: Used dishes will not be placed in carts containing unserved foods/beverages).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility to effectively clean and maintain food service equipment affecting 131 residents who consume food, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 12/09/2025 at 10:25 A.M., An initial tour of the food service was conducted with Dining Service Director F. The following items were noted: One 12-inch-wide by 12-inch-long return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits, adjacent to the mechanical dish machine. The 2022 FDA Model Food Code section 6-501.14 states: (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. (B) If vented to the outside, ventilation systems may not create a public health HAZARD or nuisance or unLAWful discharge. On 12/09/2025 at 11:10 A.M., An initial tour of the South Pantry Kitchenette was conducted with Dining Service Director F. The following items were noted: The [NAME] microwave oven interior was observed (etched, scored, particulate). The interior door frame and ceiling surface were also observed (etched, scored, corroded). Dining Service Director F stated: I will remove the microwave oven immediately. The 2022 FDA Model Food Code section 4-501.13 states: Microwave ovens shall meet the safety standards specified in 21 CFR 1030.10 Microwave ovens. The Manitowac ice machine undersplash and backsplash were observed soiled with accumulated and encrusted mineral (lime and calcium) deposits. The drip tray assembly was also observed soiled with accumulated and encrusted mineral (lime and calcium) deposits, dirt, and food residue. Dining Service Director F stated: I will have staff thoroughly clean and sanitize the ice machine as soon as possible. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The sole hand sink goose neck assembly was observed loose-to-mount. The interior vanity cabinetry was also observed severely (warped, particulate, discolored, and moist). The particle board was further observed separated from continuous moisture exposure. One red sanitization bucket was additionally observed stored directly beneath the polyvinyl chloride (PVC) wastewater plumbing. The red sanitization bucket was further observed completely full of water and overflowing onto the interior cabinetry flooring surface. Dining Service Director F stated: I will place a work order into the maintenance software system (ECHO). On 12/09/2025 at 12:40 P.M., An initial tour of the [NAME] Pantry Kitchenette was conducted with Dining Services Director F. The following items were noted: The Panasonic microwave oven interior was observed soiled with accumulated and encrusted food residue. Dining Service Director F stated: I will have staff thoroughly clean and sanitize the microwave oven as soon as possible. The [NAME] stainless steel commercial toaster interior was observed soiled with accumulated and encrusted food residue. Dining Service Director F stated: I will have staff thoroughly clean and sanitize the toaster as soon as possible. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 12/09/2025 at 2:59 P.M., A comprehensive tour of the South Pantry Kitchenette was conducted by this surveyor. The following item was noted: Dietary flatware (knives) was observed stored inverted, within a gray plastic caddy, with the food contact surface facing upward. The exposed food contact surface created a potential cross-contamination issue. The 2022 FDA Model Food Code section 4-903.11 states: (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. On 12/10/2025 at 11:38 A.M., A follow-up tour of the South Pantry Kitchenette was conducted by this surveyor. The following items were noted: The Manitowac ice machine undersplash and backsplash were observed soiled with accumulated and encrusted mineral (lime and calcium) deposits. Water was also observed dripping from the ice dispensing spout into the black drip tray. The drip tray assembly was also observed soiled with accumulated and encrusted mineral (lime and calcium) deposits, dirt, and food residue. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The flooring surface, located directly beneath the Manitowac ice machine was further observed severely soiled with dust, dirt, and debris (paper products, plastic lids, etc.). The 2022 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. On 12/11/2025 at 09:00 A.M, Record review of the Policy/Procedure entitled: Cleaning Schedule dated 9/7/22 revealed under Description: The health and safety of our associates and guests is of the utmost importance. Keeping clean and properly maintained cafe' and kitchens is critical to our success. On 12/11/2025 at 09:15 A.M., Record review of the Policy/Procedure entitled: Cleaning of Food and Non-Food Surfaces dated 9/7/22 revealed under Description: It is assumed that food contact surfaces within the facility/community are in good condition, made of non-toxic materials and are easily cleanable. It is assumed non-food contact surfaces of utensils and equipment within the facility/community must be made of materials that are safe, corrosion resistant, nonabsorbent, smooth, easily cleanable, and maintained in good condition.

Based on observation, interview, and record review the facility failed to ensure monitoring and inspection of resident bed frames and mattress for one resident (#7) of one resident reviewed for bed safety. Findings Included: Resident #7 (R7):Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. Review of R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and attempted interview on 12/11/2025 at 09:31 a.m. R7 was observed lying down in her bed. A half-length side rail was observed on the right side of the bed and on the left side of the bed. R7 did not respond to verbal questions. Review of the R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed section P-Restraints and Alarms A. Bed Rail was documented as 0.not used. Review of R7's plan of care did not demonstrate the use of bilateral side rails. Review of R7's physician orders did not include an order for the use of side rails. Review of R7's medical record did not demonstrate a side rail evaluation or that measurements of the bilateral side rails had been conducted. During an interview on 12/11/2025 at 10:22 a.m. Director of Nursing (DON) B explained that residents using side rails would have the following actions completed: - Assist Device/Bed Rail Assessment- Nursing 5 Day Assist Device/bed Rail Monitoring Form- A physician's order for the use of the assist device/bed rail. - The resident care plan would include the use of the assist device/bed railDON B was asked to review R7's medical record. DON B confirmed that R7 did not have any of the above documented actions completed in her medical record. DON B explained that the facility was currently conducting a Quality Improvement Project for the use of Assistive Device/ Bed Rails. DON B explained that currently R7 was not incompliance with the requirements of using assistive devices/bed rails at this time. During an interview on 12/11/2025 at 10:32 a.m. Minimum Data Set (MDS) Coordinator S explained that she was responsible for the coordination of the facility MDS's. MDS Coordinator S was asked to review R7's MDS with an Assessment Reference Date (ARD) of 11/24/2025 and the review section P-Restraints and Alarms A. Bed Rail. MDS Coordinator S confirmed that it had been coded that R7 was not using side rails. MDS Coordinator S also confirmed that R7's plan of care did not include the use of bilateral side rails. MDS Coordinator S could not explain why R7's MDS was inaccurate regarding the use of side rails. During observation with MDS Coordinator S on 12/11/2025 at 10:41 a.m. R7 was observed lying in bed. MDS Coordinator S confirmed that R7's bed had two half rails position on the right and left sides of her bed. MDS Coordinator S explained that it was her opinion that R7 could not be using the observed side rails as positioning devices. During an interview on 12/11/2025 at 11:07 a.m. Director of Nursing (DON) B re-confirmed that R7 did not have a physician's order for the use of side rails, did not have a plan of care for the use of side rails, and did have a Nursing 5 Day Assist Device/bed Rail Monitoring Form. DON B did provide a copy of Assist Device/bed Rail Assessment which had been completed 12/11/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During interviews, observations and record review the facility failed to provide meaningful activities to one of one resident (R86) resulting in boredom, isolation and disengagement. Findings Include Resident #86 (R86)Review of the medical record reflected that R86 was admitted to the facility on [DATE]. Diagnoses of traumatic subdural hemorrhage without loss of consciousness, fracture of left great toe, emphysema, atrial fibrillation, heart failure, dyspnea with repeated falls. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/07/2025 revealed R86 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15.Under section GG0115, Functional Limitation in Range of Motion reveals R86 had impairment on both sides, used a walker and wheelchair for ambulation and required substantial/maximal assistance for all care. During an observation and interview on 12/09/2025 at 1:44 PM, R86 did not have any activities, magazines, books, or coloring materials for her to do while spending time in her room. R86 stated nobody had talked to her about bringing her activities in her room since it's so painful to go down to the activities off this floor. During an interview on 12/15/2025 at 11:10 AM, activity aide II stated they do check ins on residents and see how they are doing. Then stated not on the room visits or check ins today. Writer asked what a check in was about. Activity aide II stated they just stop in the room to see if they need anything, then stated on the days they make a 1 on 1 visit, they spend about 10-15 minutes with the residents. During an observation and interview on 12/15/2025 at 11:15 AM, R86 and her youngest daughter JJ were sitting in R86's new room. Writer asked both of them if anyone had been by this morning to include R86 in the activities, both stated no, they haven't seen anyone. R86 stated activities do not do anything with her in her room. Writer stated if she had a calendar for the month to let her know when things are going on. R86 stated no. No observation of an activity calendar on the resident's side to show her what activities are offered. Daughter JJ stated someone asked yesterday but R86 wasn't up to it. R86's daughter JJ that was the first time someone has asked her. R86's daughter JJ stated they stick their head in the room, but do not do anything but tell R86 what activity going on but doesn't stay to visit. R86 stated she needs help getting down to the area they are doing activities, that she can't get there herself. During an interview on 12/15/2025 at 12:31 PM, Activity Director KK stated she did not have access to her computer but would try to help. Activity Director KK stated activity staff could provide in room visits, 10-15 minutes per resident, check ins to see how they are doing. Activity Director KK stated she completed that with R86's daughter JJ, and her daughter stated she would not be interested in large groups, after she was admitted on [DATE]. Writer reminded Activity Director that preferences were reviewed with daughter LL and not resident directly. However, R86 is of sound body and mind, and she can make her own decisions regarding how she would like to spend her days. Activity Director KK stated she is unaware of anyone looking into that, also stated they look at that as an unserved activity. Activity Director KK stated the activity calendar would be posted on the magnetic white board at the end of R86's bed. Activity Director KK stated there was a recent room move from short term rehab to long term care, stated that housekeeping most likely threw it, referring to the activities calendar, away. Activity Director KK stated they would look at the calendar when they did a check in so the resident would know which activities they can attend on that day. R86 did not have a calendar posted on her magnetic whiteboard to observe what activates were being offered. R86 was not participating in the activity program.

Based on observation, interview, and record review, the facility failed to provide bath/showers for one Residents (#13) of three Residents reviewed.Findings Included: Resident #13 (R13): Review of the medical record demonstrated that R13 was admitted to the facility 09/26/2023 with diagnoses that included cerebral infarction, schizoaffective disorder depressive, dementia, chronic obstructive pulmonary disease (COPD), atrial flutter, sleep disorder, hypertension, hyperlipidemia (high fat content in blood), and anxiety. Review of R13's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2025, revealed R13 had a Brief Interview for Mental Status (BIMS) of 09 (severe cognitive impairment) out of 15. During observation and interview on 12/09/2025 at 01:39 p.m. R13 was observed sitting up wheelchair. R13 explained that she had not been receiving showers as frequently she wanted. She explained that she wanted to shower twice per week.Review of R13's MDS, with an ARD of 12/02/2025, section GG- Functional Abilities revealed that she was dependent for showers. Review of R13's Point of Care (computerized documentation of the medical record used by the certified nurse aides), task revealed shower Wednesday and Sunday PM. During an interview on 12/11/2025 at 09:37 a.m. Certified Nurse Aide (CNA) R explained that she is given a paper assignment, which identified which residents are to be bathed/showered during her shift. CNA R explained that showers are recorded on a shower sheet and are given to the nurses. During an interview on 12/11/2025 at 12:04 p.m. Director of Nursing (DON) B explained that residents are given baths/shower according to their plan of care. DON B confirmed that R13 was to receive 2 showers per week to be given on Wednesday and Sunday on the afternoon/night shift. DON explained that paper skin assessment sheets are how the facility demonstrated that a bath/shower was completed. DON B presented skin assessment sheets of R13 for the period of October 2025 to present. DON B explained that the following skin assessments sheets could not be located and therefore R13 had not received a shower on those dates. Review of skin sheets 10/08/25-no shower, 10/12/2025-no shower, 10/15/2025-no shower,10/27/2025-no shower, 11/02/2025- no shower, 11/05/2025- no shower, 11/09/2025- no shower, 11/23/2025-no shower, 12/03/2025- no shower, 12/10/2025-no shower. 11 showers were completed out of a possible 21 days during October until present date. DON B could not explain why showers had not been completed as directed per the plan of care for R13.

Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plan for one resident R7 of 26 reviewed. Findings Included:Resident #7 (R7)Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. Review of R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and attempted interview on 12/11/2025 at 09:31 a.m. R7 was observed lying down in her bed. A half-length side rail was observed on the right side of the bed and on the left side of the bed. R7 did not respond to verbal questions. Review of the R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed section P-Restraints and Alarms A. Bed Rail was documented as 0.not used. Review of R7's plan of care did not demonstrate the use of bilateral side rails. Review of R7's physician orders did not include an order for the use of side rails. Review of R7's medical record did not demonstrate a side rail evaluation or that measurements of the bilateral side rails had been conducted. During an interview on 12/11/2025 at 10:22 a.m. Director of Nursing (DON) B explained that residents using side rails would have the following actions completed: - Assist Device/Bed Rail Assessment- Nursing 5 Day Assist Device/bed Rail Monitoring Form- A physician's order for the use of the assist device/bed rail. - The resident care plan would include the use of the assist device/bed railDON B was asked to review R7's medical record. DON B confirmed that R7 did not have any of the above documented actions completed in her medical record. DON B explained that the facility was currently conducting a Quality Improvement Project for the use of Assistive Device/ Bed Rails. DON B explained that currently R7 was not incompliance with the requirements of using assistive devices/bed rails at this time. During an interview on 12/11/2025 at 10:32 a.m. Minimum Data Set (MDS) Coordinator S explained that she was responsible for the coordination of the facility MDS's. MDS Coordinator S was asked to review R7's MDS with an Assessment Reference Date (ARD) of 11/24/2025 and the review section P-Restraints and Alarms A. Bed Rail. MDS Coordinator S confirmed that it had been coded that R7 was not using side rails. MDS Coordinator S also confirmed that R7's plan of care did not include the use of bilateral side rails. MDS Coordinator S could not explain why R7's MDS was inaccurate regarding the use of side rails. During observation with MDS Coordinator S on 12/11/2025 at 10:41 a.m. R7 was observed lying in bed. MDS Coordinator S confirmed that R7's bed had two half rails position on the right and left sides of her bed. MDS Coordinator S explained that it was her opinion that R7 could not be using the observed side rails as positioning devices. During an interview on 12/11/2025 at 11:07 a.m. Director of Nursing (DON) B re-confirmed that R7 did not have a physician's order for the use of side rails, did not have a plan of care for the use of side rails, and did have a Nursing 5 Day Assist Device/bed Rail Monitoring Form. DON B did provide a copy of Assist Device/bed Rail Assessment which had been completed 12/11/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete accurate Minimum Data Set (MDS) assessments for four resident (#7,#47,#72,#145) of 26 residents reviewed for MDS accuracy, resulting in inaccurate MDS assessments. Findings Include
Resident #47 (R#47)
Review of the medical record reflected that R47 was admitted to the facility on [DATE] and discharged on 12/10/2025. Diagnoses of displaced fracture of upper end of the left humerus, unspecified sequelae of cerebral infarction (a range of long-term effects and complications), Type 2 Diabetes Mellitus, heart failure and blindness in right eye.
The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/12/2025 revealed R47 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15.
Under section GG0115, Functioning Limitations in Range of Motions reveals R47 is independent for all care, used a walker for safe ambulation.
Record review of the Minimum Data Set (MDS) skin assessment with an ARD/Target Date of 11/12/2025, did not show accuracy for documentation on pressure ulcers on admission assessment.
According to the section within the MDS 3.0 Section M- Skin Conditions under MO100. Determination of Pressure Ulcer/Injury Risk, did resident had a pressure ulcer/injury, a scar over boney prominence, or a non-removeable dressing/device, MDS RN EE marked no, that the resident did not have any pressure ulcers. Then under MO210. Unhealed Pressure Ulcers/Injuries, MDS RN EE marked yes, that R 47 had unhealed pressure ulcers. Then marked R47 as having 1 pressure ulcer stage 1, was not on a turning and repositioning program, had nutrition and hydration interventions to manage skin problems and marked yes for pressure ulcer care. Application of non-surgical dressing (with or without topical medication) other than feet was marked no to any dressing used for the pressure ulcer.
12/15/2025 10:32 AM Interview with Minimum Data Set (MDS) Coordinator RN S and MDS RN EE, writer asked both nurses about MDS admission skin assessment on R47. MDS Coordinator S stated MDS RN EE did the assessment on R47 and MDS RN EE was looking back through the residents' notes in the EMR. Writer asked what tools she used to complete her assessment. MDS RN EE stated she read the nursing /wound care notes upon admission. MDS RN EE stated that R47 had 2 pressure ulcers on the head-to-toe assessment. Wound Care Nurse Practitioner (NP) FF documented R47 had a stage 3 to left buttock, and a stage 2 to the right buttock. MDS RN EE stated she must have marked it wrong because she marked them further down on the MDS skin assessment. Further down revealed MDS RN EE only documented that R47 only had a stage 1 pressure ulcer, and no others, which R47 did not have a stage 1 pressure ulcer.
Resident #145 (R145)
Review of the medical record reflected that R145 was admitted to the facility on [DATE] and discharged on 12/13/2025. Diagnoses of Pneumonia, respiratory failure, pleural effusion, severe malnutrition, fracture of upper end of left tibia and fusion of the spine.
The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2025 revealed R145 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15.
Under section GG0115, Functional Limitation in Range of Motion, reveals R145 was impaired on one side of her upper extremity, uses a walker for ambulation and requires a set up or clean up assistance and supervision for oral care. R145 is dependent on toileting or showers.
Record review of the MDS Skin Assessment documentation, R145 had Deep Tissue Injury (DTI) with open areas in the middle of the injury. MDS RN EE marked 3 DTIs, and the open areas that were measured and documented. R145 did not have 3 DTI's, she had 2 DTI's and a stage 3 pressure ulcer.
During an interview on 12/15/2025 at10:45 AM, MDS RN EE stated she did not have Wound Care NP FF assessment note on R145, so she looked at the nursing notes for wound details. MDS RN EE stated wound care NP FF comes into the facility1 day a week, he makes rounds with Licensed Practical Nurse (LPN) L who completes the wound care the other 3 days a week. Stated wound care NP FF did not do his assessment until 12/04/25.
Record review of hospital discharge report revealed that R145 came to the facility from the hospital with a stage 3 pressure ulcer of the sacral region. R145 also had a wound on the left ischium, right buttock and sacral region. The sacral region pressure ulcer was noted to have slough in the wound bed and area measured 11.3cm x 8.5cm scant drainage to area, wound base is 70% necrotic tissue, 10% slough and 10% granulating tissue, no malodor noted, wound edges attached. DTI noted on the right buttock, area measuring at 3.1cm x 8cm, wound base was 100% maroon in color. DTI noted on the left ischium measuring 3.6cm x 3.2cm with a bridge of good tissue, no drainage noted, no odor.
Record review of a wound care assessment completed by wound care NP FF on 12/04/2025:
Wound #1
Wound Assessment:
Wound- Sacral unstageable pressure
Measurements- 9 x 8.5 x unable to determine true depth
Tissue type- slough/subcutaneous
Peri Wound- fragile
Drainage- moderate serous exudate
Pain- moderate to severe
Infection- increased drainage, non-viable tissue, recent hx of wound deterioration
Overall Wound Condition- stable
Wound Plan of Care- Cleanse sacral wound with anasept, pat dry. Apply nickel-thick layer of Santyl to wound bed followed by alginate (NO SILVER), secured with sacral silicone foam dressing daily and prn
Wound Additional Orders- Frequent turning and repositioning to offload wounds
Wound #2
Wound Assessment:
Wound- Left ischium DTI
Measurements- 1.5 x 2 x 0cm
Tissue type- dark crusting
Peri Wound- fragile
Drainage- none
Pain- none
Infection- no observable signs
Overall Wound Condition- stable
Wound Plan of Care- skin prep daily and leave OTA
Wound Additional Orders- Frequent turning and repositioning to offload wounds
Wound #3
Wound Assessment:
Wound- Right ischium DTI
Measurements- 1.5 x 2 x 0cm
Tissue type- dark epithelial
Peri Wound- fragile
Drainage- none
Pain- none
Infection- no observable signs
Overall Wound Condition- stable
Wound Plan of Care- skin prep daily and leave OTA
Wound Additional Orders- Frequent turning and repositioning to offload wounds
R145's pressure ulcers were not identified correctly, making the assessment inaccurate and could have affected treatment.
Findings Included:
Resident #7 (R7)
Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. Review of R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15.
During observation and attempted interview on 12/11/2025 at 09:31 a.m. R7 was observed lying down in her bed. A half length side rail was observed on the right side of the bed and on the left side of the bed. R7 did not respond to verbal questions.
Review of the R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed section P-Restraints and Alarms A. Bed Rail was documented as 0.not used. Review of R7's plan of care did not demonstrate the use of bilateral side rails. Review of R7's physician orders did not include an order for the use of side rails. Review of R7's medical record did not demonstrate a side rail evaluation or that measurements of the bilateral side rails had been conducted.
During an interview on 12/11/2025 at 10:32 a.m. Minimum Data Set (MDS) Coordinator S explained that she was responsible for the coordination of the facility MDS's. MDS Coordinator S was asked to review R7's MDS with an Assessment Reference Date (ARD) of 11/24/2025 and the review section P-Restraints and Alarms A. Bed Rail. MDS Coordinator S confirmed that it had been coded that R7 was not using side rails. MDS Coordinator S also confirmed that R7's plan of care did not include the use of bilateral side rails. MDS Coordinator S could not explain why R7's MDS was inaccurate regarding the use of side rails.
During observation with MDS Coordinator S on 12/11/2025 at 10:41 a.m. R7 was observed lying in bed. MDS Coordinator S confirmed that R7's bed had two half rails position on the right and left sides of her bed. MDS Coordinator S explained that it was her opinion that R7 could not be using the observed side rails as positioning devices.
Resident 72 (R72)
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R72 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included cerebral vascular accident affecting left side, heart disease, anxiety and depression. The MDS reflected R72 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required assist with dressing, hygiene, bathing, and transfers.
During an observation and interview on 12/09/2025 at 10:28 AM R72 appeared calm, pleasant and able to answer questions without difficulty. R72 reported had history of stroke that effected left side with left arm contractures currently. R72 reported had worked with therapy in the past.
Review of R72 MDS, dated [DATE], reflected no impairment for upper extremity Range of Motion. Continued review of all MDS, section GG0115, reflected impairment on one side.
During an interview on 12/15/2025 at 1:43 PM, Therapy Manager LL reported R72 was currently receiving therapy including for left side impairment and verified had been same since admission and MDS range of motion documented as no impairment was incorrect on 2/24/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains To Intake #2649987 Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse for one resident (Resident #136) of seven residents reviewed for abuse. Findings include Review of the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/25, revealed Resident 136 (R136) was admitted to the facility on [DATE] and was discharged home on [DATE], with diagnoses that include congestive heart failure and chronic kidney disease. R136 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 12/10/2025 09:57 am, during a phone interview with R136 she reported on October second, she was on a diuretic and had to void her bladder frequently, R136 stated used the call light frequently on the midnight shift due to the medication. R136 stated the Certified Nursing Assistant (CNA) was angry that R136 kept asking for help, R136 stated the more she asked for the bedpan, tension and anger from the CNA grew. R136 stated she asked for her name, but the CNA refused to tell R136. Of note, R136 was able to give this writer a physical description. R136 stated as the night progressed the final time, she turned her call light on, the same unknown CNA entered the room and at this time became physically rough with her care and shoved the bedpan hard into R136's hip. R136 reported this was very painful and caused a large bruise resulting her to be sent to the emergency room the next morning. R136 stated she reported to the midnight nurse (name unknown) that the assigned CNA was mad, provided rough care and intentionally shoved the bedpan into her hip causing pain. R136 stated she was dismissed by midnight nurse and told Licensed Practical Nurse (LPN) P when she came on duty that morning. Review of the Unusual Occurrence report dated 10/03/25 at 8:45am, revealed LPN P observed R136 being tearful and complaining of extreme right hip pain, the note reflected LPN P observed a large edematous area on R136's right hip, the physician and the abuse hotline called. On 12/11/25 at 10:30 am, during a phone interview with LPN P she reported that R136 told made an allegation of abuse on the morning on 10/03/25. LPN P reported R136 was tearful and said the midnight was angry she kept turning her call light on and the CNA was rough and shoved the bedpan into her right side/hip. LPN P stated R136 was very vocal and clear this was an intentional act which was why she reported it to the facility's abuse hotline per protocol. LPN P stated she spoke with LPN Q who handles the investigations of abuse allegations and was told that R136's x-ray came back negative and she was already aware and looking into it. R136 was insistent it was a deliberate act on behalf of the CNA, and the abuse hotline was called again to make sure LPN Q was aware of R136's insistence of being a deliberate act but LPN Q stated the root cause of the right hip hematoma was a positioning issue. On 12/11/25 at 10:45am, during an interview with LPN Q she reported she had no recollection of R136 or LPN P reporting an allegation of abuse. When the unusual occurrence report was reviewed with LPN Q which stated the abuse hotline was contacted, LPN Q stated she had no recollection of being notified of the allegation. But will check to see if there was a soft file about the incident. LPN Q then stated was resident was care planned for and well known to change her story. Of note, there was no care plan in place that identified R136 as having behavior problems such as changing her story, embellishing or making false accusations. At 11:39 AM, LPN Q stated there was a soft file and it was determined that R136's right hip hematoma was determined to be more of a positioning issue opposed to an abuse concern. Review of LPN's Q soft file did not include an interview with R136, when queried why R136 was not interviewed, LPN Q stated R136 was at the hospital and not available. Of note, R136 was not admitted to the hospital. Review of the facility policy titled Resident-Abuse Neglect and Exploitation Prevention dated 09/01/21 Under the heading Investigating Alleged Abuse, Neglect and Exploitation1. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.2. Procedure to investigate include:a. Identifying staff responsible for the investigation;b. cautiously handling evidence that could be used in a criminal investigation;c. Investigating different types of alleged violations;d. Identifying and interviewing all persons i. Alleged victim ii. Victim roommates iii. Alleged perpetrators

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake #2649987 Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.Findings include: Review of the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/25, revealed Resident 136 (R136) was admitted to the facility on [DATE] and was discharged home on [DATE], with diagnoses that include congestive heart failure and chronic kidney disease. R136 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 12/10/2025 09:57 am, during a phone interview with R136 she reported on October second, she was on a diuretic and had to void her bladder frequently, R136 stated used the call light frequently on the midnight shift due to the medication. R136 stated the Certified Nursing Assistant (CNA) was angry that R136 kept asking for help, R136 stated the more she asked for the bedpan, tension and anger from the CNA grew. R136 stated she asked for her name, but the CNA refused to tell R136. Of note, R136 was able to give this writer a physical description. R136 stated as the night progressed the final time, she turned her call light on, the same unknown CNA entered the room and at this time became physically rough with her care and shoved the bedpan hard into R136's hip. R136 reported this was very painful and caused a large bruise resulting her to be sent to the emergency room the next morning. R136 stated she reported to the midnight nurse (name unknown) that the assigned CNA was mad, provided rough care and intentionally shoved the bedpan into her hip causing pain. R136 stated she was dismissed by midnight nurse and told Licensed Practical Nurse (LPN) P when she came on duty that morning. Review of the Unusual Occurrence report dated 10/03/25 at 8:45am, revealed LPN P observed R136 being tearful and complaining of extreme right hip pain, the note reflected LPN P observed a large edematous area on R136's right hip, the physician and the abuse hotline called. On 12/11/25 at 10:30 am, during a phone interview with LPN P she reported that R136 told made an allegation of abuse on the morning on 10/03/25. LPN P reported R136 was tearful and said the midnight was angry she kept turning her call light on and the CNA was rough and shoved the bedpan into her right side/hip. LPN P stated R136 was very vocal and clear this was an intentional act which was why she reported it to the facility's abuse hotline per protocol. LPN P stated she spoke with LPN Q who handles the investigations of abuse allegations and was told that R136's x-ray came back negative and she was already aware and looking into it. R136 was insistent it was a deliberate act on behalf of the CNA, and the abuse hotline was called again to make sure LPN Q was aware of R136's insistence of being a deliberate act but LPN Q stated the root cause of the right hip hematoma was a positioning issue. On 12/11/25 at 10:45am, during an interview with LPN Q she reported she had no recollection of R136 but may have a soft file about the incident. LPN Q then stated was resident was care planned for and well known to change her story. Of note, there was no care plan in place that identified R136 as having behavior problems such as changing her story, embellishing or making false accusations. At 11:39 AM, LPN Q stated there was a soft file and it was determined that R136's right hip hematoma was determined to be a positioning issue. LPN Q elaborated it was not reported to the State Agency because she knew it was related to positioning. Review of the facility policy titled Resident-Abuse Neglect and Exploitation Prevention dated 09/01/21 Under the heading Reporting and Response 1. Alleged violations will be reported to the Administrator and designee per facility reporting process, state agency, adult protective services and all other required agencies (Law enforcement when applicable) within specified time frames.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate monitoring of a resident prescribed an antipsychotic medication in one (Resident #93) out of 5 reviewed for medication review. Findings include: Review of the medical record reflected Resident #93 (R93) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included nondisplaced bimalleolar fracture of right lower leg. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/23/25, reflected R93 scored 7 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/10/2025 4:01 PM, R93 was observed in her room watching television. Review of R93's Physician Orders revealed an active order for Seroquel Oral Tablet 50 MG (antipsychotic medication). Review of R93's Antipsychotic medication care plan revealed an intervention dated 1/16/23 which stated, orthostatic blood pressures as ordered. Review of R93's Physician orders revealed no order for orthostatic blood pressures. Review of R93's vital signs revealed no completed orthostatic blood pressures. In an interview on 12/15/2025 at 1:58 PM, Director of Nursing (DON) B stated that residents taking antipsychotic medications had specific monitoring requirements, including orthostatic blood pressure monitoring which is to be completed once a month. DON B reviewed R93's electronic medical record and confirmed the absence of orthostatic blood pressure monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake 2575199.Based on observation, interview and record review, the facility failed to protect R1's right to be free from sexual abuse by R2 and R4.Findings Include: R1:Review of the medical record reflected R1 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/19/25, reflected R1 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was independent for transfers and walking at least 150 feet.R2:Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included dementia. The admission MDS, with an ARD of 6/2/25, reflected R2 scored eight out of 15 (moderate cognitive impairment) on the BIMS and was independent for transfers and walking at least 150 feet.R4:Review of the medical record reflected R4 admitted to the facility on [DATE], with diagnoses that included neurocognitive disorder with Lewy Bodies, Parksinson's and dementia. The Significant Change in Status MDS, with an ARD of 6/24/25, reflected R4 scored eight out of 15 (moderate cognitive impairment) on the BIMS. In an interview on 7/30/25 at 11:46 AM, Certified Nurse Aide (CNA) D stated they had previously received report that R2 had his hands in R1's pants, moving them around, and kissed her. CNA D stated R1 had just recently been touched by R4 as well. R1 and R4:On 7/30/25 at 11:14 AM, R1 was observed seated in a chair, attending an activity in the Lounge.In an interview on 7/30/25 at 3:58 PM, CNA E reported that R1 had two incidents with R4, on the same day, earlier in the month of July 2025 (7/9/25). CNA E reported R4 touched R1's buttocks from the outside of her pants. The same day, while in another resident's room, they observed R4 with his hand down R1's pants, inside her brief, touching her buttocks. CNA E reported they intervened and removed R4 from the room. An Incident Report, dated 7/9/25 at 3:15 PM, reflected R1 was in another resident's room, with R4, when R4 walked past R1 and touched her buttocks. A correlating Progress Note was not noted in R1's medical record. R1 and R2:A Progress Note for 7/24/25 at 10:33 PM reflected a CNA reported that while in the activity room, another resident was observed kissing R1's head and had one hand between R1's legs, rubbing her upper, inner thigh. According to the note, R1 was giggling, and the residents were separated. An Employee Statement Form, dated 7/24/25, reflected CNA F was walking by the Lounge area, looked in and observed R1 seated in a chair. R2 was seated on the arm of the same chair, with his left arm around R1 and his left hand on R1's shoulder. R2's right hand was observed between R1's upper thighs, making a rubbing motion, up and down. The form reflected CNA F also observed R2 kissing R1's forehead. An attempt was made to contact CNA F via phone on 7/31/25 at 8:27 AM. A return call was not received prior to the exit of the survey on 7/31/25. R1's Care Plan, initiated on 4/25/25, reflected she had a male friend on her unit and did not have the capacity to consent to a romantic relationship. Interventions dated 4/25/25 reflected to redirect male residents from entering or following R1 to her room and to redirect R1 to sit by other female residents during activities and meals. Interventions dated 7/25/25 reflected, separated the residents and wellness checks. On 7/30/25 at 11:21 AM, R2 was observed walking independently in the hallway, towards his room. On 7/30/25 at 11:25 AM, R2 was observed in his room. When asked about interactions with female residents, R2 reported being in the Lounge (on their unit) and rubbing R1's neck. R2 stated he was not supposed to do that and knew it at the time. R2 stated staff finally walked in on him. R2 denied touching any other part of R1's body. A Progress Note for 7/10/25 at 5:19 PM reflected R2 was seen holding hands with another resident and was successfully redirected. A Progress Note for 7/17/25 at 4:03 AM reflected R2 was attempting to wander into a female resident's room and was redirected. A Progress Note for 7/24/25 at 10:33 PM reflected R2 was observed kissing and rubbing the left upper, inner thigh of a female resident [R1]. According to the note, the residents were immediately separated.A Nurse Practitioner Progress Note for 7/29/25 reflected R2 was seen as follow-up to a recent resident to resident occurrence. According to the note, it was reported that R2 kissed another resident. The note reflected that R2 did not know why it happened and was remorseful. According to the note, R2 knew his behavior was inappropriate. Task documentation for behavior symptoms reflected R2 had sexually inappropriate behavior documented on 7/23/25 at 3:53 AM and on 7/25/25 at 6:29 AM. The documentation did not detail the behavior. In an interview on 7/31/25 at 8:34 AM, Social Worker (SW) H reported there was recently a kiss between R1 and R2. When something of that nature occurred, Care Plans were reviewed for any resident with direct involvement in the incident. SW H reported she had been in two meetings in which Care Plan changes were discussed, but she could not recall what the changes were. SW H acknowledged that a male resident wandering into a female resident room should have been addressed/documented on the Care Plan. Regarding CNA task documentation of sexually inappropriate behaviors for R2, SW H reported CNAs could only mark a box pertaining to the behavior. The CNAs were to notify the nurse, and the expectation was for a Progress Note of the behaviors to be documented. SW H reported they relied on a report for Progress Notes as notification of documented behaviors and did not typically review CNA task documentation for behaviors. In a phone interview on 7/31/25 at 9:03 AM, CNA I reported the Kardex (CNA Care Guide), which was part of the Care Plan, included information pertaining to resident care needs and behaviors. CNA I reported R2 had sexual behaviors, including touching females. According to CNA I, R2's task documentation pertaining to sexual behaviors on 7/23/25 included trying to touch the CNAs legs, as well as attempting to touch another CNA from the back. R2's Care Plan reflected he had a behavior problem of sundowning related to dementia. The Care Plan was updated on 7/25/25, with an intervention to offer movie night after dinner, with an iPad, in a supervised area. An intervention, dated 7/29/25, reflected R2 was noted to put his arm around staff and other residents as a sign of companionship.R2's Care Plan did not reflect a history of sexually inappropriate behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure witnesses observed the signing of a Do-Not-Resuscitate (DNR) document by one (Resident #78) of one reviewed.
Findings include:
Review of the medical record reflected Resident #78 (R78) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included encephalopathy and left side hemiplegia and hemiparesis following cerebral infarction (stroke).
R78's DNR form reflected the resident signed the form on 3/1/24, the Physician signed the form on 3/5/24, and two witnesses signed the form on 3/6/24.
The Attestation of Witnesses section of the DNR document reflected, The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence .
In an interview on 10/09/24 at 12:40 PM, Social Services Supervisor (SS) K reported two witnesses had to sign the DNR document, indicating the person signing on behalf of the resident was of sound mind at the time of signing. SS K reported they would sign as a witness if they talked to the person (resident or responsible party) that signed the DNR document but may not have actually witnessed them sign it. SS K stated they would confirm the person signing the document was of sound mind to make the decision for DNR and that the resident's wishes were DNR before signing as a witness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety.
Findings include:
An observation of the main kitchen reach in cooler on 10/08/24 at 08:36 AM with Dining Services Manager (DSM) P revealed the following:
- a container of chicken with a use by date of 10/4/24
- two containers of pureed vegetables with a use by date of 10/4/24
- a container of blue cheese dressing with a use by date of 10/7/24
- a container of pureed pasta with a use by date of 10/3/24
- an unlabeled/undated container of food.
DSM P removed the expired/undated food items from the cooler and reported they believed the unlabeled container was pumpkin pie filling.
On 10/08/24 at 08:50 AM, upon entrance into the rehab kitchen, a cloth hamper was observed overflowing with soiled rags and aprons. There were numerous fruit flies flying above the hamper. DSM P agreed there were fruit flies and reported the hamper should have been emptied the night before. An observation of the reach in cooler revealed the following:
- a tub of coffee creamer with a use by date of 10/4/24
- ready care thickened water with a use by date of 10/3/24
- an unlabeled/undated bowl of unidentified food
- an undated bowl of oatmeal
- two pitchers of smoothies with a use by date of 10/7/24
- a jug of barbeque sauce with a use by date of 10/6/24
- ketchup with a use by date of 10/4/24
- tub of vanilla pudding with a use by date of 10/3/24
Dry storage included two containers of dry cereal with a use by date of 10/6/24. An observation of the walk-in cooler revealed a tray of bedtime snacks which included three smoothies, four puddings, milk, a sandwich, and cottage cheese. The tray of items had a use by date of 10/6/24. The walk-in cooler also contained a container of blue cheese with a use by date of 10/7/24, vanilla pudding with a use by date of 10/4/24, and an unlabeled/undated bottle of what appeared to be ranch dressing. DSM P removed all identified expired food items. DSM P reported the tray of bedtime snacks were likely snacks that were refused in which case they should have been disposed of and not placed back in the cooler.
3-501.17 of the 2017 Food and Drug Administration (FDA) Food Code, revealed (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.
On 10/09/24 at 12:21 PM, the South Unit/[NAME] Ridge steam table service was observed. Dietary Aide (DA) Q was serving meals and reported they already took temperatures of the food items on the steam table. DA Q was asked to take temperatures again. The chicken breast had a temperature of 123 degrees Fahrenheit. DA Q reported the chicken was too cold and it would be sent back to the kitchen.
On 10/10/24 at 1:25 PM a test tray was given to the surveyor. All other trays on the unit had been passed; this was the last tray in the cart and was immediately handed to the surveyor after the previous tray had been passed. The food temperatures were as follows: Chicken Breast: 128 degrees Fahrenheit; Potatoes: 124 degrees Fahrenheit; [NAME] Beans: 120 degrees Fahrenheit; Milk: 43 degrees Fahrenheit.
3-501.16 of the 2017 FDA Food code revealed Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 [degrees Celsius] (135 [degrees Fahrenheit]) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 [degrees Celsius] (130 [degrees Fahrenheit]) or above; P or (2) At 5ºC (41ºF) or less.

Based on observation and interview, the facility failed to dispose of expired medications in one of four medication carts and one of three medication storage rooms reviewed, resulting in the potential for decreased efficacy of medications and adverse side effects in a current facility census of 132 residents.
Findings include:
During an observation on 10/09/24 at 08:50AM of Blue Cart a bottle of Thiamin Vitamin B-1 100mg with an expiration date of 03/24.
During an observation on 10/09/24 at 09:00AM in the Blue Medication Room, observed a bottle of Move+Vision+Bones+Supplement expired on 04/24.
During an observation on 10/09/24 at 09:10AM of the [NAME] Ridge Medication Room, two bottles of Calcium Carbonate 500mg with an expiration date of 04/24.
During an interview on 10/11/24 at 09:20 AM, DON B stated nurses checked them on the night shift. DON B also stated the central supply person was supposed to have helped monitor the medication carts and the medication rooms, but she did not the carts and rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drug regimens were reviewed at least once a month by a licensed pharmacist and provider, in one of five residents reviewed for medication management and monitoring (Resident #3), resulting in the potential for increased adverse consequences related to medication therapy.
Findings include:
Resident #3 (R3)
Review of the medical record reflected R3 was an initial admission to the facility on [DATE]. Diagnoses of Anxiety, Schizophrenia, Diabetes Mellitus, Coronary Artery Disease and other orthopedic conditions.
The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2024, revealed R3 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R3 was independent or required minimal assistance with personal care.
Record review revealed on the 04/17/24 Monthly Medication Review (MMR) pharmacy made recommendations to increase Eliquis from 2.5mg to 5mg daily, Nurse Practitioner U disagreed with the recommendation with no rational given.
Record review revealed on the 02/26/24 MMR pharmacy made recommendations made to increase Eliquis 2.5mg bid to 5mg bid. Nurse Practitioner U disagreed with the recommendation with no rational given.
Record review revealed on the 02/25/24 MMR pharmacist made recommendations to the attending/prescriber that the abnormal involuntary movement evaluation (AIMS) is due for this resident (due at baseline and q 6 months for residents on an antipsychotic or Reglan) Please chart the assessment once it is completed. No response from the attending/prescriber to the pharmacist, no signature or date.
Record review revealed on the 11/01/23 MMR pharmacy made recommendations to discontinue prn medications that had not been needed for over 30 days. Under follow through, note written by physician wrote LOA. R3 was currently taking pantoprazole 40mg bid for GERD. At this time would you consider a trial reduction to pantoprazole 20mg bid assess lowest effective dose. Prescribers' response was blank, no signature nor was it dated. At the bottom of the page, the words written in were Out of Facility 11/17/23-12/08/23.
Record review revealed on the 10/10/23 MMR, provider did not sign this form with the expected 7-day response, nor was it signed within 30 days.
During an interview on 10/09/24 at 02:08 PM, DON B stated the Nurse Practitioner (NP) U was terminated 2 weeks ago. DON B also stated NP U did not follow up on her documentation and rational for agreeing or not agreeing with pharmacy recommendations. DON B stated that her expectation was to have providers respond within 7 days and if not by 30 days, she herself called the provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a meaningful, diverse and engaging activity program for one resident (#58) of two reviewed for activities.
Findings include:
Review of the clinical record reflected Resident # 58 (R58) was admitted to the facility on [DATE] with diagnosis that included dementia and depression. Review of the Minimum Data Set (MDS) with an assessment reference date of 7/18/2024 and it was revealed R58 had long and short term memory impairment and severely impaired decision making skills.
On 10/08/24 at 10:30, PM R58 was observed in his room sitting in his wheel chair up against the wall, a television (TV) was above him and not on. R58 sat in the room which was dark, TV not on, music not on. R58 observed in the same position after lunch again no TV, sitting in his room in wheelchair.
On 10/09/24 at 01:22 PM, R 58 was observed being brought back from the dining room after lunch, staff observed leaving R58 in room sitting against wall under the TV, which was not offered to be put on, no music.
On 10/10/24 at 11:21 AM observed in his wheelchair sitting against wall underneath TV (not on) no music playing .
Review of R58's clinical record including the most recent Activity assessment dated [DATE] revealed R58 enjoyed exercise, music, TV, movies, wheeling outdoors, group activities, family and friend visits . Review of R58's group participation attendance record over the last 30 days reflected zero times attended. R58's 1 on 1 activity participation record reflected he had conversation on 09/19, 9/29 and 10/7, and watched TV one time - 10/02.
On 10/10/24 at 12:38 pm, during an interview with Nursing Home Administrator of [NAME] and Activity Director L she reported that activity participation records were done via computer program but was trialing something new as of 3 weeks ago. A request to view the system she was trialing was requested and reveled on 10/2 and 10/7 activity staff checked in with R 58 and 10/1 conversation and TV and 10/09 conversation. When asked to clarify check in as an activity Nursing Home Administrator of [NAME] and Activity Director L reported We pop in just to check on him. When queried why R58 had not been invited to his activity of interests as listed on his assessment Nursing Home Administrator of [NAME] and Activity Director L offered no response.
There was no evidence that R58 had been invited to and refused any exercise, music programs, taken outside or invited to group activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement care planned interventions to promote the healing of wounds for one (Resident #78) of 24 reviewed.
Findings include:
Review of the medical record reflected Resident #78 (R78) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included encephalopathy and left side hemiplegia and hemiparesis following cerebral infarction (stroke). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/20/24, reflected R78 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R78 was coded for one stage four pressure ulcer and one unstageable pressure, both present on admission/entry or reentry.
R78's Care Plan reflected they were dependent on two staff for repositioning and turning in bed. An intervention for 3/5/24 reflected R78 had an alternating pressure mattress.
On 10/08/24 at 9:03 AM, R78 was observed lying in bed, with the head of the bed elevated. R78 reported they admitted with a wound on the buttocks that was improving. An air mattress pump was observed hanging on the foot board of the bed. No lights were illuminated on the pump, indicating the air mattress was not powered on and/or not functioning.
On 10/08/24 at 12:24 PM, R78 was observed lying in bed, watching TV. An air mattress pump was hanging on the foot board of the bed. No lights were illuminated on the pump, indicating the air mattress was not powered on and/or not functioning. R78 reported they were not sure if the mattress was working at that time, and if it was, it was soft. R78 reported staff accidentally knocked the air mattress plug out of the wall at times when moving the bed.
On 10/08/24 at 12:57 PM, Licensed Practical Nurse (LPN) R went to R78's room, looked at the air mattress pump and stated it was off. LPN R reported the pump was plugged into the wall. When LPN R disconnected the power cord from the air mattress pump and plugged it back in, the pump turned on. LPN R reported they did not know how long the pump had been turned off for.
On 10/09/24 at 10:40 AM, R78 was observed lying in bed, watching TV. An air mattress pump was observed on the foot board of the bed. There were no lights illuminated on the pump, indicating it was not turned on and/or not functioning.
In an interview on 10/09/24 at 1:23 PM, Registered Nurse (RN) C reported the purpose of an air mattress was to alleviate pressure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Level II determination was completed for two residents (Resident #83 and Resident #104) of two reviewed.
Findings include:
Resident #83 (R83)
Review of the medical record revealed R83 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included schizoaffective disorder, vascular dementia with anxiety, dementia with psychotic disturbance, and anxiety disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/4/24 revealed R83 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
Review of the Physician's Orders revealed R83 had been prescribed Zyprexa (an antipsychotic medication) and Remeron (antidepressant medication) since admission to the facility.
Review of the Change in Condition Preadmission Screening (PAS)/Annual Resident Review (ARR) Level I Screening completed on 3/14/24 revealed R83 was marked yes for questions 1-4 in section II. The form revealed If any answer to items 1-6 in Section II is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative.
R83 did not have a Level II evaluation or exemption.
Resident #104 (R104)
Review of the medical record revealed R104 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD), vascular dementia with psychotic disturbance, anxiety disorder, and depression. The MDS with an ARD of 9/17/24 revealed R104 scored 3 out of 15 (severe cognitive impairment on the BIMS.
Review of the PASARR Level I Screening completed on 6/22/24, revealed R104 was marked Yes for questions 1-4 under Section II. The form revealed If any answer to items 1-6 in Section II is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative.
R104 did not have a Level II evaluation or an exemption.
In an interview on 10/9/24 at 11:34 AM, Social Services Supervisor (SSS) K reported R83 and R104's Level II evaluations were still in progress according to the CMHSP's website, but they were not sure why they were not completed yet. On 10/9/24 at 1:48 PM, SSS K reported they called the CMHSP who reported they were not able to see the in progress evaluations because the facility's physician had not yet provided their signature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00146701.
Based on interview and record review, the facility failed to permit timely readmission from the hospital for one (Resident #19) of two reviewed.
Findings include:
Review of the medical record reflected Resident #19 (R19) was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, diabetes and heart failure. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/9/24, reflected R19 scored eight out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
R19's medical record reflected they transferred to the hospital on 8/21/24 due to being unresponsive.
A Hospital Progress Note for 8/26/24 reflected R19 was stable to discharge, pending placement.
A Hospital Progress Note for 8/28/24 reflected R19 was medically stable for discharge. A Case Manager was assisting with placement, as prior placement was declined due to payment issues.
Documentation reflected the hospital sent a referral to the facility, for R19, on 8/28/24.
During a phone interview on 10/10/24 at 11:39 AM, Guardian I reported they received a phone call from facility staff on 8/22/24, notifying them that the facility would not be readmitting R19 from the hospital due to an outstanding balance with the facility. Guardian I reported R19 remained in the hospital while efforts were made to find placement in a facility.
During an interview on 10/10/24 at 12:06 PM, Social Services Supervisor (SS) K reported they, along with two other staff members, had a phone conversation with R19's Guardian on 8/22/24. SS K reported there was conversation that the facility would not readmit R19 until payment arrangements were made for their outstanding balance.
In a phone interview on 10/10/24 at 2:06 PM, Case Manager (CM) J reported hospital staff spoke with the facility's admissions department on 8/26/24 and were notified that R19 would not be permitted to return to the facility. CM J reported R19's discharge from the hospital was pending placement in a facility and was not due to an acute change in condition during the hospital stay. R19 remained in the hospital until discharged back to the facility on 9/6/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer an influenza immunization per consent for one (Resident #46) of five reviewed.
Findings include:
Review of the medical record revealed Resident #46 (R46) was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included dementia and heart failure. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/24 revealed R46 had moderately impaired cognitive skills for daily decision making. The medical record revealed R46 had a legal guardian.
Review of the Infection Note dated 10/13/24 revealed messages were left with R46's guardian to get consent for the influenza vaccine and that a letter was sent on 8/26/24 with no reply.
R46 was then hospitalized from [DATE] to 10/24/24. The hospital documents revealed no immunizations were given during hospitalization.
Review of the Influenza Vaccine Informed Consent/Declination revealed on 10/25/23, R46's guardian gave verbal consent for R46 to receive the influenza immunization.
Review of R46's medical record revealed the last influenza immunization received was on 10/13/22. An influenza immunization was not given for the 2023 influenza season.
In an interview on 10/11/24 at 9:33 AM, Director of Nursing (DON) B reported the facility did not have record that R46 received an influenza immunization after consent was given on 10/25/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #19 (R19)
Review of the medical record reflected R19 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, diabetes and heart failure. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/9/24, reflected R19 scored eight out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
R19's medical record reflected they transferred to the hospital on 8/21/24 due to being unresponsive.
During a phone interview on 10/10/24 at 11:11 AM, Admissions Director (AD) H reported the facility called (the responsible party) regarding the bed hold policy within 24 hours of a resident leaving the facility. AD H stated it was then documented if they did or did not want to hold the bed.
R19's medical record was not reflective of documentation that a bed notice had been provided to R19's responsible party upon transfer to the hospital.
During a phone interview on 10/10/24 at 11:39 AM, Guardian I reported they did not get notified of the bed hold policy when R19 was transferred to the hospital on 8/21/24. Guardian I stated they received a phone call from facility staff on 8/22/24, notifying them that the facility would not be readmitting R19 from the hospital due to an outstanding balance with the facility.
During an interview on 10/10/24 at 12:06 PM, Social Services Supervisor (SS) K reported they, along with two other staff members, had a phone conversation with R19's Guardian on 8/22/24. SS K reported there was conversation that the facility would not readmit R19 until payment arrangements were made for their outstanding balance.
This citation pertains to MI00146701
Based on interview and record review the facility failed to provide a written copy to two of two residents (R #19 and R#39) reviewed for bed hold notification in a language that was understandable, resulting in potential for lack of understanding and knowledge for and what the bed hold policy entailed.
Findings include:
Resident 39 (R39)
Review of the medical record reflected R39 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Respiratory Failure, Pneumonia, Kidney Failure, Heart Failure, Diabetes Mellitus, Heart Failure, Chronic Obstructive, Pulmonary Disease and schizophrenia.
The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/21/2024, revealed R39 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R39 requires maximum assistance to dependent with personal care.
Record review revealed R39 was transferred to the hospital on [DATE] for shortness of breath. R39 was readmitted to the facility on [DATE].
Record review revealed R39 did not reflect a transfer/discharge/bed hold notice being provided to R39 as she was her own person.
Record review revealed R39 was transferred to the hospital on [DATE] for low grade temperature, slurred speech, increased confusion. R39 was readmitted to the facility on [DATE].
Record review revealed R39 did not reflect a transfer/discharge/bed hold notice being provided to R39 as she was her own person.
During an interview on 10/10/24 at 11:36 AM, nursing Home Administrator (NHA) A stated the bed hold policy and transfer notices is part of the admissions office role.
During an interview on 10/10/24 at 11:42 AM, Licensed Practical Nurse (LPN) S stated the nurses had a transfer/discharge/bed hold packet that they give to the resident or family if they were with them on the way out of the door to the hospital. LPN S showed this writer the template that they used and reported it should be scanned into the chart under miscellaneous tab.
Email response dated 10/10/24 at 08:28AM received from NHA A included the forward email from the Chief Strategy Officer F.There was nothing documented in PCC, but I have the attached from discharge planner at [NAME] showing the daughter was aware of holding bed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00146701
Based on observation, interview, and record review, the facility failed to meet transfer/discharge documentation requirements for 2 of 2 reviewed (R#19 & R#39) from a total of 24 sampled residents, resulting in the potential for these residents and/or their representatives not obtaining their due rights.
Findings include:
Resident 39 (R39)
Review of the medical record reflected R39 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Respiratory Failure, Pneumonia, Kidney Failure, Heart Failure, Diabetes Mellitus, Heart Failure, Chronic Obstructive, Pulmonary Disease and schizophrenia.
The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/21/2024, revealed R39 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R39 requires maximum assistance to dependent with personal care.
Record review revealed R39 was transferred to the hospital on [DATE] for shortness of breath. R39 was readmitted to the facility on [DATE].
Record review revealed R39 did not reflect a transfer/discharge notice being provided to R39 as she was her own person.
Record review revealed R39 was transferred to the hospital on [DATE] for low grade temperature, slurred speech, increased confusion. R39 was readmitted to the facility on [DATE]. Record review revealed R39 did not reflect a transfer/discharge notice being provided to R39 as she was her own person.
During an interview on 10/10/24 at 11:36 AM, nursing Home Administrator (NHA) A stated the bed hold policy and transfer notices is part of the admissions office role.
During an interview on 10/10/24 at 11:42 AM, Licensed Practical Nurse (LPN) S stated the nurses had a transfer/discharge/bed hold packet that they give to the resident or family if they were with them on the way out of the door to the hospital. LPN S showed this writer the template that they used and reported it should be scanned into the chart under miscellaneous tab.
Email response dated 10/10/24 at 08:28AM received from NHA A included the forward email from the Chief Strategy Officer F.There was nothing documented in PCC, but I have the attached from discharge planner at [NAME] showing the daughter was aware of holding bed .
Resident #19 (R19)
Review of the medical record reflected R19 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, diabetes and heart failure. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/9/24, reflected R19 scored eight out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
R19's medical record reflected they transferred to the hospital on 8/21/24 due to being unresponsive.
R19's medical record was not reflective of a transfer/discharge notice being provided to the responsible party.
Upon inquiry, a Transfer Notice Form for R19's transfer to the hospital on 8/21/24 was provided by the facility. An email from Nursing Home Administrator (NHA) A on 10/10/24 at 12:39 PM reflected R19's transfer/discharge notice was mailed to R19's Guardian.
During a phone interview on 10/10/24 at 11:39 AM, Guardian I reported they had not received a written notice of transfer/discharge when R19 was sent to the hospital on 8/21/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement appropriate preventive measures and take corrective action for allegations of abuse for 3 of 3 residents (R#'s 9, 113 and 33) reviewed for abuse.
Findings include:
Resident #33
Review of the clinical record including the Minimum Data Set, dated [DATE] reflected Resident # 33 (R33) was admitted to the facility on [DATE] with fractured fibula. R33 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS).
On 10/08/24 01:56 PM during a bedside interview with R33 it was reported that things at the facility were going well with the exclusion of being molested by another resident (Resident #113) during bingo last week. Resident #33 stated while assisting R113 with the bingo cards, R113 allegedly touched R33's upper thigh, left breast and calf . R33 stated the incident was reported and investigated by management. When queried what was done to ensure the incident didn't happen again, R33 reported R113 now sits a few tables away at bingo.
Resident #113
Review of the medical record reflected R113 admitted to the facility on [DATE], with diagnoses that included traumatic brain injury and disorders of psychological development. The admission/Medicare 5 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/11/24, reflected R113 scored six out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
Review of the facility reported incident dated 9/30/24, revealed R113 was not able to be interviewed due to cognitive deficits and English being a second language. R33 written statement dated 9/30/24 written statement reflected during bingo R33 and R113 were holding hands and during bingo R113 pulled R33's blanket down touched R33's thigh and then squeezed R33's left breast. R33 directed R113 to not touch her again.
Activity Aide (AA) M written statement dated 10/01/24 reflected he witnessed the incident in which he observed R33 and R113 playing bingo and holding hands, AA M then witnessed R113 place a hand on R33 thigh. AA M then directed Resident Aide (RA) N to sit in between R33 and R113. RA N statement dated 10/01/24 reflected she say R113 move the blanket from R33 and I saw him picking at something on her left leg Then heard R33 say No Stop!
On 10/09/24 at 10:05 AM during an interview with AA M he reported sitting 6 to 8 feet in front of R33 and R113 and the two residents were holding hands and seemed content. AA M stated he then witnessed R113 touch R33's thigh and was in process of getting up to intervene when R33 said Stop R113 did stop and RA N was instructed to sit in between the two residents. R33 was fine after we separated them, this was in the afternoon no further incidents that day, never R113 touch or attempt to touch R33's breast. AA M stated he then reported the incident to R33's and R113's nurse.
When queried what was done to ensure other residents safety from this point forward AA M stated R113 was no longer able to sit by females while in Activities.
On 10/09/24 at 11:32 AM during an interview with RA N she reported RA's start in activities department and if they like it and do well may go on to be a Certified Nursing Assistant. RA N stated she was helping other resident with bingo cards on 9/30/24 and did not witness any interaction between R33 and R113. RA N was stated she sat in between the two residents as directed, when queried if she knew why RA N said no , she didn't need to know. When queried if she thought she should be aware of an allegation of sexual abuse and the possible need for increased supervision , RA N said yes she should know that information. When queried if there were special instructions or guidance for R113 RA N said yes R113 was not allowed in groups without activity staff present and when activity is over R113 was the first person to be escorted back. RA N had no knowledge of not being allowed to sit by female residents. RA N elaborated she was shown that guidance via the computer but does not have access to the computer and has no knowledge of R113 not being allowed to sit by female residents.
Review of R113's care plan initiated 7/09/24 revealed R113 was sexually inappropriate behavior. The care plan was updated on 10/02/24 to include hx (history) of touching female residents legs and breast Interventions included monitor episodes and determine underline cause, and redirect away from female residents while in dining room and multipurpose room. R113's activity care plan reflected R113 was to be placed by other male residents or activity staff during group activities. An intervention added to care plan on 10/04/24 was to ensure R113 was assisted back during the first wave.
Further review on the facility reported incident reflected Activity staff and 1 Nurse received education on group dynamics, inappropriate touching, monitoring interactions, proper spacing during groups. Of note, RA N was not reeducated per the facility sign in sheet.
R113's Care Plan reflected they had sexually inappropriate behaviors, which included but were not limited to a history of grabbing female caregivers, making inappropriate sexual comments to female staff and a history of touching a female resident's leg and breast. The care plan was initiated on 7/9/24 and revised on 10/2/24. An intervention dated 10/2/24 and revised on 10/3/24 reflected to tell R113 not to touch other residents and to redirect them from female residents in the dining room and multi-purpose room.
On 10/10/24 08:38 AM Quality Specialist/ Licensed Practical Nurse ( QS/LPN) E she reported R113 liked to be out and about and due to cognitive and language barrier was not able to be interviewed when she completed her investigation. When queried what steps the facility took to ensure R33 and other residents were protected during the facility investigation QS/LPN E stated R113 was no longer able to sit by females in group activities and should be the last resident brought to activities and the first one out as activity staff do transport residents to and from they would not be able to monitor R113 otherwise, along with a medication review and an evaluation by psychiatric group. When queried what interventions the Nursing staff, including the Certified Nursing Assistants were given, QS/LPN E revealed none because the incident occurred during an activity. Q'S/LPN E then elaborated the following day (after a separate allegation of sexual abuse that involved R113 and Resident # 9), staff were provided with education after an alleged incident on 9/30/24, when R113 allegedly touched Resident #33's thigh in an activity.
On 10/10/24 at 03:20 PM, R113 was observed in the multipurpose room music group was ending and R113 was sitting next to and in arms reach of an unidentified female resident.
Resident #9 (R9)
Review of the medical record reflected R9 admitted to the facility on [DATE], with diagnoses that included multiple sclerosis. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/11/24, reflected R9 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
On 10/09/24 at 10:44 AM, R9 was observed asleep, in a specialty chair, in their room.
A Progress note for 10/1/2024 at 7:40 PM reflected it was reported that Resident #113 was sitting next to R9, talking, then allegedly reached under R9's blanket, touched their thigh and asked R9 to come to come to his room that night.
A facility investigation file reflected R9 was seated at a dining table when the alleged interaction with R113 occurred. According to the investigation file, R9 reported the alleged interaction to Certified Nurse Aide (CNA) D while being assisted with their meal. The investigation file reflected R113 was seen by the Nurse Practitioner on 10/2/24 due to inappropriate behavior of touching another resident the night prior and was unable to recall the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains To Intake #MI00145470
Based on interview and record review, the facility failed to 1. ensure one resident (resident #7) of three residents reviewed were free of significant medication errors. 2. notify the physician of missed doses of physician ordered medication, resulting in the potential for increased seizure risk.
Findings include:
Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] revealed Resident 7 (R7) was admitted to the facility with diagnosis that included seizure disorder, muscular dystrophy. Resident 7 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS).
Review of R7's June and July 2024's monthly physician orders reflected acetazolamide 250 milligrams (mg) was ordered 3 times a day for seizure disorder. Review of R7's medication administration record for June and July 2024 reflected the acetazolamide afternoon and evening dose was not administered to R7 on June 30, 2024 and the morning dose of acetazolamide was not administered on 07/01/2024. Review of the nursing notes dated 6/30/24 at 10:32 PM reflected acetazolamide 250 mg was not available. Nursing progress notes dated 6/30/24 at 1:28 PM reflected acetazolamide 250 mg was on order and not available in back up. There was no documentation that the physician had been notified. Registered Nurse (RN) D did not administer the afternoon dose on 6/30/24 and RN E did not administer the following two doses. An attempt to interview both nurses were made via phone on 07/11/24 at approximately 2:15 pm voice mails were left for both RN D and RN E but no return call was received.
Review of the facility incident reported dated 07/01/24 reflected R7 missed 3 doses of acetazolamide, the incident report reflected R7's physician ordered acetazolamide was located in the medication cart but had been placed backward in the medication cart. The
Nurse Practitioner notified on 07/01/24 at 9:30 AM of the missed doses.
On 7/10/24 at 3:45 during an interview with Unit Manager/Licensed Practical Nurse (UM/LPN ) C she reported she became aware of the missed doses from R7's family. UM/LPN C stated she immediately followed up with the incident which included going through the medication cart which was where she located R7's acetazolamide which was turned backwards and one slot over from where it should have been. UM/LPN C offered no explanation as to why either nurse had not contacted physician for notification of the missed doses of acetazolamide.

This citation pertains to Intake MI00142898.
Based on observation, interview, and record review, the facility failed date mark all potentially hazardous ready-to-eat food products in two resident refrigerators of three reviewed.
Findings include:
An observation of the rehab unit resident refrigerator on 7/9/24 at 3:56 PM revealed signage that read STOP ANY PATIENT WHO WISHES TO HAVE FOOD IN THIS REFRIGERATOR MUST HAVE THEIR NAME, ROOM NUMBER, AND DATE THAT IS PLACED IN HERE ON THE CONTAINER
PLEASE MAKE SURE IT IS MARKED. Another sign included the Dining Services Department Food Storage Chart which indicated maximum storage timelines.
Inside the refrigerator, the following was observed:
a bowl of an unknown food that was undated
3 containers of Chobani blueberry Greek yogurt that expired 7/8/24
a squirt bottle of what appeared to be salad dressing that was not labeled or dated
a bowl of peas that was undated
a cup of milk that was undated
a container of a roasted turkey BLT from the facility's bistro with a date of 6/30/24
a container of salad that was undated
a container of thickened orange juice that was opened and undated
a container of ready care thickened lemon water with a label that indicated it was placed in the refrigerator on 6/30/24
Inside the freezer, the following was observed undated: a zip lock bag of no bake cookies, an opened pint of vanilla bean almond milk frozen dessert , and a parfait.
In an interview on 7/9/24 at 4:20 PM, Dining Services Director (DSD) H reported they were not aware of who oversaw maintaining the resident refrigerators.
On 7/9/24 at 4:23 PM, the memory care unit resident refrigerator was observed with DSD H and the following was observed undated: seven bowls of food, opened container of thick and easy, chocolate syrup, two half gallons of chocolate milk, two cups of orange juice, and a mighty shake. One quart of opened med pass fortified nutritional shake was dated 6/26/24. DSD H reported the med pass was good for seven days, the mighty shake was good for 14 days after it was removed from the freezer. DSD H agreed the foods were not labeled and/or expired.
Review of the facility's Dining Services Food Storage Chart that was observed posted on the front of the rehab unit refrigerator revealed expiration dates printed by the manufacturer apply until the product is opened. Once opened, use the limits below unless manufacturer's date is earlier. The date of opening counts as one day. The limits for refrigerated storage were as follows:
- margarine, shell eggs, milk, sour cream, unopened cottage cheese, unopened liquid eggs and yogurt cups maximum storage time was according to the expiration date printed on the carton/case
- left-overs, unused portion of ready to eat food prepared on site, such as recipes that contain meat, milk, eggs, cheese, fresh fruit & vegetables, gravies such as egg salad, and chicken salad had a maximum storage time of 3 days
- cream, commercially prepared salads, deli meats, canned fruits/vegetables/pudding, liquid eggs or hard cooked eggs, and opened raw meat had a maximum storage time of 4 days
- opened thickened beverages had a maximum storage time of 5 days
- fruit juices had a maximum storage time of 7 days
- health shakes (dated as they are removed from the frozen storage) had a maximum storage time of 14 days
- processed meats, bacon, and opened cottage cheese had a maximum storage time of 7 days
- opened cheese, salad dressing, mayonnaise, tartar sauce, and jellies, had a maximum storage time of 30 days
- ketchup, BBQ sauce, mustard, relish, pickles, and sauces had a maximum storage time of 60 days.
The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI00140195 and MI00140198
Based on observation, interview, and record review, the facility failed to ensure the protection of residents from abuse for two (Resident #7 and #8) of 7 reviewed, resulting in the potential for further abuse to occur. Findings Include:
Resident #7 (R7)
Review of the medical record revealed that R7 was admitted to facility [DATE] with diagnoses including unspecified dementia, heart failure, and insomnia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] reflected that R7 was sometimes understood and sometimes able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 3 (Severe Cognitive Impairment). Section G of the same MDS revealed that R7 required one-person extensive assist for bed mobility, transfers, and toilet use.
On [DATE] at 2:43 PM, R7 was observed self-propelling wheelchair off Red River Road Hall toward South Unit Dining Room. R7 stated she was doing good, was just trying to find her mom and kids and would be on her way.
Resident #8 (R8)
Review of the medical record revealed that R8 was admitted to facility [DATE] with diagnoses including moderate vascular dementia, hypothyroidism, and hypertension. Review of the MDS with an ARD of [DATE] reflected that R8 was understood and usually able to understand others with a BIMS score of 8 (moderate cognitive impairment). Review of R8's ADL (Activities of Daily Living) Care Plan with a [DATE] date of revision reflected that R8 was independent with ambulation with use of two wheeled walker.
On [DATE] at 3:43 PM, R8 was observed lying in bed, on back, with head of bed elevated at an approximate 30-degree angle. R8 stated that she was just taking it easy and then was going to do whatever there was to do. R8 confirmed that she had been married, initially stated that her husband had passed away but then stated that she didn't know where he was and that he was out and about keeping busy.
According to the facility reported incident dated [DATE] at 5:45 PM, [R8] was observed kissing [R7] once on mouth and once on her ear. [R8] was insisting that [R7] was her husband. Staff intervened and separated the two, explaining to [R8] that [R7] was a woman and not her husband.
Section 1 of the facility's investigation indicated that both residents remained at the facility and that neither resident was showing any signs of distress because of the incident. The Action Taken section within the facility's investigation indicated, [R8] was referred physician [sic] for a med (medication) review and labs. [R8's] DPOA (durable power of attorney) was contacted to suggest bringing in younger pictures of her husband as resident believes [R7] looks like her husband.
In a telephone interview on [DATE] at 3:48 PM, Licensed Practical Nurse (LPN) U confirmed familiarity with both R7 and R8 as stated that she had frequently when assigned to Golden Pond Hall, the hall where both R7 and R8 resided, during the time that she had worked at the facility. LPN U stated that on [DATE], she thought toward the end of her 12-hour day shift, she was charting at the North Unit Nurses' Station when she was notified by Certified Nurse Aide (CNA) T that she had just witnessed R8 kiss R7 on the lips and had brought R7 to the nurses' station to separate the two. LPN U stated that when she glanced up, she observed R8 approaching R7, who was sitting in her wheelchair in front of the station, from behind and before staff could intervene, observed R8 bend down and kiss R7 on the left ear or left forehead. LPN U stated that as R7 was in a wheelchair, she immediately pulled her behind the nurses' station so that she was beside her and that R8 was instructed to sit on the couch in front of the station. LPN U stated that she informed R8 that R7 was not her husband but as she continued to insist that she was, further redirection was provided to R8 by nearby CNA's.
LPN U denied that she had been notified of or observed R8 pay special attention to R7 prior to the [DATE] occurrence but that on subsequent shifts she made every effort to keep an eye on both R7 and R8. LPN U stated that she tried to keep R7 and R8 separated but that was very difficult as both resided on Golden Pond Hall, R8 seemed to pursue R7, and that she had been informed by a CNA on at least one other occasion after [DATE] of the need to separate the two as R8 was again attempting to kiss R7.
In a telephone interview on [DATE] at 12:37 PM, CNA T confirmed that she had been assigned to Golden Pond Hall, the hall where R7 and R8 resided, frequently and therefore was very familiar with R8 as was frequently her assigned CNA. CNA T stated that R8 was independent with transfer and ambulation with use of walker, wandered independently throughout Golden Pond Hall and in and out of other resident's rooms, showed a special interest in R7 as she believed her to be her husband, would frequently call R7 her husband's name, and would get aggravated with efforts to redirect and reorient her. CNA T stated that staff was directed by management to keep R7 and R8 separated but that was very difficult as both resided on Golden Pond Hall, both dined in North Unit Dining Room, R8 was independently ambulatory and not only wandered on the hall but would seek R7 out.
CNA T stated that on [DATE] as she exited the linen closet on Golden Pond Hall, she observed R8 leaning over and kissing R7 on the lips. CNA T stated that she approached and separated R7 and R8, took R7 to the North Unit Nurses' Station, and advised LPN U as to what she had witnessed. CNA T stated that R8 followed her and R7 to the nurses' station, continued to call R7 her spouses name, and was adamant that R7 was her husband. CNA T stated that after notifying LPN U and providing redirection to R8, that she returned to Golden Pond Hall as she had been in the middle of assisting another resident when she witnessed R8 kiss R7.
In a telephone interview on [DATE] at 3:11 PM, CNA V confirmed familiarity with R7 and R8 as worked on Golden Pond Hall where both resided. Per CNA V, R8 was independent with transfer and ambulation with use of walker, wandered independently both on the hall and in and out of other resident's rooms, and was friendly and liked to converse with other residents. CNA V stated that for approximately one week prior to R8 kissing R7, that R8 had began referring to R7 as her husband, had been wanting to spend more time with her, but had never been observed to touch or attempt to kiss her.
CNA V stated that on the evening of [DATE] she was sitting at the North Unit Nurses' Station, looked up and observed R8 bend down to kiss R7, sitting in her wheelchair in front of the station, on the check. CNA V stated that she informed R8 that R7 was not her husband, that R7 was in fact a woman, but that R8 was persistent, reiterated that R7 was her husband and requested that R7's pants be pulled down so that she could prove that R7 was a man. CNA V stated that as R8 could not be redirected verbally, she had her sit on the couch in front of the nurses' station, distracted her with conversation, and that R8 then seemed to forget about R7.
CNA V stated that staff education was provided by either the Golden Pond Hall nurse or manager following the [DATE] episode regarding watching R8's interactions with R7 to assure that they were appropriate and to try to keep them separated as much as possible but that was difficult as R7's and R8's rooms were both on Golden Pond Hall and they both dined in the North Unit Dining Room, R8 was independently ambulatory and wandered the unit making it difficult to know her exact whereabouts, and R7 self-propelled her wheelchair and moved about the unit as well.
Review of R8's electronic medical record (EMR) completed with the following findings noted:
Unusual Occurrence Note dated [DATE] at 11:28 AM stated, IDT (interdisciplinary team) review of incident .Immediate intervention: activities to contact family and request younger pictures of resident's husband to be brought in and med (medication) review to be completed by the physician .
Behavior Note dated [DATE] at 8:45 AM stated, Staff CNA reported to writer had to intervene resident attempting [sic] to kiss [R7] in the hallway after breakfast. Staff CNA expressed to resident [R7] is not her husband .
Consult Note dated [DATE] at 12:20 PM by R8's physician stated, Chief Complaint: Nurse asked me evaluate the patient about her dementia .History of Present Illness: The patient has recently dementia and behavioral disturbance including mild delusional recent resident incident [sic] .Assessment/Plan: .4. Dementia associated with behavioral disturbance. Continue behavioral modifications .I recommended to followup [sic] with Psych services .
Review of Behavioral Care Solutions psychiatric note dated [DATE] and scanned into R8's medical record stated, .HPI (History of Present Illness): [AGE] year old female admitted to [name of facility] [DATE] for continued care with a primary dx [diagnosis] of Unspecified Dementia .initially referred [DATE] for possible delusions that other residents are her husband with concerns of wandering, going into other resident's rooms . Further review of R8's medical record revealed no psychiatric follow-up completed between [DATE] (when R8's physician recommended psychiatric follow-up due to R8's delusion that R7 was her spouse) and the actual [DATE] date of completion (greater than 2 months after the [DATE] recommended follow-up date).
Behavior Note dated [DATE] at 6:21 PM stated, staff witnessed resident kiss another resident. Staff to encourage and communicate to other staff members to keep residents separated .
According to the facility reported incident dated [DATE] at 3:45 PM, [R8] was observed kissing [R7] on her mouth. [R8] is cognitively impaired and [R7] has characteristics that remind [R8] of her deceased husband. The residents were separated and both remain at their baseline since the incident .
Section 1 of the facility's investigation indicated that both residents remained at the facility and that neither resident was showing any signs of distress because of the incident. The Action Taken section within the facility's investigation indicated, The allegation was verified by staff witnesses. Both residents remain at the facility and continue with their normal routine with no adverse effect from the incident. The attending physician and IDT will continue to support the residents and update their plan of care as needed.
In a telephone interview on [DATE] at 10:24 AM, LPN W confirmed familiarity with both R7 and R8 as had routinely been assigned to Golden Pond Hall, the hall where both resided, during the time that he had worked at the facility. LPN W stated that R8 was confused, protective of certain residents, and clung to R7 as took a liking to her as thought that R7 was her husband. LPN W stated that he was aware of the need to keep the two residents separated, that all of the staff on the unit worked together to keep an eye on R8 but that R8 gravitated toward R7. LPN W further stated that as R8 was independently ambulatory and freely wandered on the unit that staff did not always know her exact whereabouts and that there had been several times during the shifts that he had worked on Golden Pond Hall that either he or the CNAs needed to separate R7 and R8 as R8 would frequently be noted to be approaching R7 or at R7's side.
LPN W stated that on [DATE], although he could not remember the exact time, he had been notified by a female staff member, he believed a Resident Assistant although he could not exactly remember, that R8 had been observed standing next to R7 on Golden Pond Hall, lean down and kiss her on the lips. LPN W stated that he responded immediately, that the residents had already been separated, and that R7 was sitting with staff at a dining room table and R8 was wandering around in the same dining room. LPN W stated that upon notifying Licensed Practical Nurse/Unit Manager (LPN/UM) S, he was instructed that R7 and R8 should be monitored and kept separated but that no further instruction was provided. LPN W stated that close monitoring of R7 and R8 was already routinely completed as that had not been the first time that R8 had kissed R7. LPN W further stated that as R8 was independently ambulatory with her walker and as R7 was able to self-propel her wheelchair and as both residents resided on the same hallway and ate in the same dining room, always monitoring them was not even feasible. LPN W stated that staff had suggested to management that R7 and R8 be separated onto different units as were concerned that R8 would continue to pursue R7 but that did not occur until after the third or more incident between them.
Further review of R8's EMR completed with the following findings noted:
Unusual Occurrence Note dated [DATE] at 12:08 PM stated, IDT review of incident, resident observed kissing another resident she believed was her husband. Immediate intervention: staff to encourage resident to attend scheduled activities between meals .
Behavior Note dated [DATE] at 6:14 PM stated, Resident believes that another resident is her husband. Nursing staff was wheeling the other resident down the hall and [R8] walks up to resident and staff and asked where her husband was going. She stated that she wanted to kiss her husband and than [sic] attempted to go in for a kiss. The staff was able to move resident away before [R8] was able to kiss her. [R8] became very upset and started yelling that no one is to get between her and her husband. Resident than swung and hit a staff member and triedto [sic] follow resident and staff member. Supervisor and family member notified. Resident temporarily moved to another unit immediately for the safety of everyone .
In an interview on [DATE] at 9:30 AM, LPN/UM S stated that she had been the Unit Manager on Golden Pond Hall, the hall where both R7 and R8 resided, until [DATE] when all residents were moved off the unit. LPN/UM S confirmed familiarity with R8, stated that she was independent with ambulation with use of walker, had wandered on Golden Pond Hall, frequently sat at the couches near the North Unit Nurses' Station and managers office, and was generally in a good mood but had episodes of increased confusion where she thought that R7 was her husband.
Upon referencing R8's EMR, LPN/UM S confirmed R8 first kissed R7 on [DATE] and that the immediate intervention included separation of the two residents by the staff. Per LPN/UM S, the IDT reviewed every unusual occurrence report the following working day after an incident and that upon review of the [DATE] occurrence, further interventions included obtaining an updated picture of R8's husband and requesting R8's physician complete an assessment and medication review. LPN/UM S confirmed that a physician assessment had been completed on [DATE], that no medication changes were deemed warranted but that psychiatric follow-up was recommended. Upon further review of R8's record, LPN/UM S confirmed that psychiatric follow-up was not completed until [DATE], a full 2 months after the physician recommendation was made. LPN/UM S stated that she was unsure as to why the psychiatric follow-up had not been completed sooner, would have expected that the follow-up be completed closer to the [DATE] date of recommendation, and stated that due to R8's ongoing delusions that R7 was her spouse would have benefited from prompt psychiatric follow-up.
Upon further review of R8's EMR, LPN/UM S stated that R8 was again observed kissing R7 on [DATE], that she had been notified at the time of the occurrence by LPN W, and that she provided immediate guidance to staff to communicate with other staff members so that they knew both R7's and R8's location in an attempt to keep them separated. LPN/UM S confirmed that all staff were already supposed to be trying to keep R7 and R8 separated but that remained difficult as R8 was so independent and R7 self-propelled her wheelchair on the hall, as well. LPN/UM S confirmed that no other immediate intervention was initiated following the [DATE] occurrence.
LPN/UM S confirmed that the IDT did not review the Tuesday, [DATE], unusual occurrence until Friday, [DATE], could not recall why the review was not completed until 3 days after the occurrence, and stated that the IDT initiated a new intervention on [DATE] to encourage R8 to attend scheduled activities between meals. LPN/UM S stated that the activity staff should have already been encouraging R8 to attend activities but that the newest intervention was also targeted at CNAs to help encourage R8's activity participation so that she was not aimlessly wandering the unit.
LPN/UM S further stated that sometime between the [DATE] occurrence and the [DATE] IDT occurrence review, that she had suggested a room change for R8 at the facility's daily morning IDT meeting. LPN/UM S stated that secondary to R8's advancing dementia with delusional thinking that R7 was her spouse combined with R8's ongoing wandering and the proximity of R7's and R8's rooms on Golden Pond Hall, believed that R8 would be more appropriate on the facility's locked unit. LPN/UM S stated that as the IDT did not see the severity of the situation, no room changes were completed at that time.
LPN/UM S confirmed that on [DATE] R8 was again delusional and believed that R7 was her husband, attempted again to kiss R7, and became frustrated and combative with staff efforts to intervene. LPN/UM S stated that staff were able to separate the two residents and that R8 was temporarily moved to another unit immediately to maintain R7's safety.
LPN/UM S confirmed that only after R8 successfully kissed R7 on two separate occasions ([DATE] and [DATE]) and after staff intervened to prevent the third successful attempt on [DATE], was R8 temporarily moved off of Golden Pond Hall and away from R7. LPN/UM S stated that as R8 was noted to do well in her new room on the locked unit and that as she was less likely to have any contact with R7, the decision was made to make the move permanent.
Review of the facility policy titled Abuse Neglect and exploitation prevention with the most recent effective date of [DATE] stated, Objective: It is the policy of the facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Prevention of Abuse, Neglect and Exploitation .4. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation .is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure the staff assigned have the knowledge of the individual residents' care needs and behavioral symptoms .6. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict .Investigating Alleged Abuse, Neglect and Exploitation .2g. Protecting the resident during and after investigation, may include but not limited to .Increased supervision of the alleged victim and residents .Room and staffing changes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00139667
Based on observation, interview, and record review, the facility failed to immediately report abuse allegations for 1 Resident (Resident #6) of 3 reviewed for abuse resulting in allegations of abuse that were not reported to the Nursing Home Administrator (NHA) and the State Agency timely and the potential for further allegations of abuse to go unreported and not thoroughly investigated.
Findings include:
Resident #6
Review of the medical record revealed Resident #3 (R3) was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, neuromuscular dysfunction of bladder, and complex regional pain syndrome. The Minimum Data Set (MDS) dated [DATE] revealed R6 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS).
On 12/11/23 2:32 PM, R6 was observed in her room nicely groomed and seated in her chair. R6 was easily conversant. R6 recalled that in September she had experienced two separate events with agency staff that she had reported to the staff at the facility via email. R6 stated that for one of the incidents, two agency certified nursing assistants (CNA) came into her room to complete her morning routine which included washing R6 up in her bed and assisting her into her chair. R6 reported that the CNA's were rushing and felt the care was unacceptable because they were rough and didn't follow my routine at all. R6 stated that the bed was soaked, the blue pad was soaked, and her clothing was soaked upon the completion of her morning care. R6 stated the CNA's then proceeded to transfer her to her chair while she was dressed in a wet brief and wet clothing. When R6 expressed the concern of having wet clothing, R6 stated that the CNA's stated that they did not have time to change her because they had other residents that they needed to get up for the day.
In an interview on 12/18/23 1:44 PM, Social Worker (SW) N confirmed that R6 had sent her an email with the concern that the certified nursing assistant was rough with care and left R6 in her chair with wet pants. SW N stated that the email was sent on 9/10/23 and she was not working that day however, SW N saw the email on 9/11/23 and forwarded it to Unit Manager I at 7:17 AM and created a feedback form with the concern as well.
Review of the Feedback Form revealed that R6 reported that she was awakened by two agency certified nursing assistants that were rough, rude and sloppy with care and that R6 was left in her chair with wet pants and told it was just water.
In an interview on 12/18/23 at 8:58 AM, Unit Manager (UM) I stated that any abuse allegations, including rough with care, must be reported no later than two hours. Regarding the concern that R6 expressed via email, UM I stated she believes she was notified via email from the social worker which prompted UM I to gather the feedback form and discuss the concerns with R6. UM I reported that R6 alleged that the certified nursing assistants did not know their own strength and were rough with transferring her that day and had left R6 in her wet clothing, however, offered to changer her to remedy the problem. UM I confirmed that the agency certified nursing assistant was terminated following the allegation.
Review of the Facility Reported Incident submission confirmation email revealed that the abuse allegation was reported to the State Agency on 9/11/23 at 4:57 PM.
In an interview on 12/18/23 at 3:24 PM, Nursing Home Administrator (NHA) A confirmed that there was a delay for reporting the abuse allegation for R6 to the State Agency.
Review of the facility's Abuse and Neglect Procedural Guidelines dated 12/23/22 reflected .Alleged violations will be reported to the designated Abuse Prevention Coordinator who will report allegations to the Administrator. 2. The Initial Report to the state will be made in the following timeframe: a. For alleged violations of abuse or if there is resulting serious bodily injury (defined as an injury involving extreme pain, substantial risk of death, protracted loss or impairment of the function of a bodily member, organ or mental faculty or requiring medical intervention such as surgery/hospitalization or physical rehab, also when injury results from criminal sexual abuse), the facility will report the allegation immediately, but no later than 2 hours after the allegation is made .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed provide Activities of Daily Living (ADL) assistance to 2 sampled resident (Resident #5 and Resident #14), resulting in assistance with ADL and/or bowel/bladder not provided, the potential for skin breakdown, resident's needs to go unmet, discomfort and frustration to a reasonable person.
Findings Include:
Resident #5 (R5)
Review of the medical record revealed R5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included major depressive disorder, unspecified benign prostatic hyperplasia with lower urinary tract symptoms, cognitive communication deficit and anoxic brain damage. The Minimum Data Set (MDS) dated [DATE] revealed R5 scored 9 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS). Review of the Care Plan revealed that R5 required (assistance) by (2) staff for toileting.
On 12/14/23 at 1:16 PM, R5 was observed in his room. R6 was sitting in a specialized high back wheelchair with his legs slightly elevated. Resident was groomed appropriately and was watching television. When greeted, R5 looked in my direction but did not respond to the greeting.
Resident #45 (R14)
Review of the medical record revealed R14 admitted to the facility on [DATE] with diagnosis which included overactive bladder and type two diabetes with diabetic neuropathy. The Minimum Data Set, dated [DATE] revealed R14 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status. Review of the Care Plan revealed R14 required one person extensive assistance for toileting.
In an obervation on 12/14/23 at 1:21 PM, R14 was consuming his lunch in bed watching television. R14 appeared to be preoccupied with the personal belongings of the roommate and a facility social worker quickly intervened.
On 12/11/23, a Facility Reported Incident (FRI) file was reviewed which revealed the following statements:
A staff statement stating that Certified Nursing Assistant (CNA) QQ did not change her pt (patient), pts (patients) were soaked in urine up to upper backs. Pt (patients) were not changed. [CNA QQ] left multiple of her residents soaked in urine, morning employees state it's not the first time, employee does this often.
A staff statement stating that CNA QQ did not check and change her residents during the night.
A staff statement stating that she observed R5 needed to be changed. The staff member asked dayshift CNA to assist CNA QQ with changing and getting the resident up for the day .
A resident stating that the care received from CNA QQ was so-so and that she had a difficult time performing her duties.
A resident statement stating that she fell asleep reading her book in bed and did not see anyone from staff until approximately 1:45 AM when CNA QQ came in to check and change her. The resident was confused as to why the staff had woken her up. The resident stated that the next time that staff came back in was at approximately 5:20 AM to give her a bath. The resident had to inform CNA QQ how to bathe her.
A staff statement stating that observed R5 was wet and approached CNA QQ about changing the resident.
In an interview on 12/13/23 at 12:33 PM, CNA QQ angerly stated that she had eight residents that night and was all alone with no help from other staff members. CNA QQ stated that she stepped down from her position at the facility after her 90-day probationary period.
In an interview on 12/13/23 at 2:15 PM, CNA M stated that she received report from CNA QQ and then went to see her residents. CNA M reported that R5 was soaking wet from urine. CNA M offered to help CNA QQ who initially refused, despite R5 being a 2 person assist with cares. The nurse had to intervene and have a conversation with CNA QQ about accepting the assistance from CNA M.
In a telephone interview on 12/14/23 at 7:51 AM, CNA K reported that she was working with CNA QQ that night. CNA K reported that she observed a lot of neglectful behavior so she called and reported CNA QQ to the abuse hotline. CNA K reported that she witnessed CNA QQ grab the gait belt of a two-assist transfer resident and pulled the resident forward with brute force. CNA K stated that CNA QQ allowed a resident to fall asleep in her recliner and not check on her or provide care for her until 4:00 AM. The resident was upset for the lack of nighttime routine and not transferring her to bed at her preferred bedtime. CNA K stated that she had to cover her own assignment while checking the residents that were assigned to CNA QQ because she knew they were not receiving the necessary care and services. CNA QQ was observed sitting on the couch most of the night. CNA K stated when first shift arrived, the CNAs were shocked with the conditions of CNA QQ's residents, with multiple residents being saturated with urine and noting that R5 was wet up to his neck.
In an interview on 12/14/23 at 10:32 AM, CNA R reported that she worked the morning after the shift with CNA QQ. CNA R observed R5 and R14 being saturated with urine, the blue pad underneath of the residents saturated, and the sheets saturated with urine. CNA R observed the skin of R45 which appeared to have reddened areas from lack of repositioning. When CNA R attempted to bring the concern to the attention of CNA QQ, CNA QQ was dismissive and said that it was not her problem.
In an interview on 12/14/23 at 10:39 AM, CNA P reported that she had worked first shift after CNA QQ. CNA P could recall CNA QQ and coming in to work every time everyone would be saturated and the residents that CNA QQ did get up for the day would be placed in their wheelchairs soaking wet. CNA P had observed reddened areas on the residents from not being repositioned or not having their wedges utilized for offloading.
In a telephone interview on 12/14/23 at 2:16 PM, CNA L worked with CNA QQ a few times and stated that she did not observe CNA QQ performing check and changes on her residents and observed a few residents being saturated in urine. CNA L would offer to help CNA QQ however, CNA QQ would leave the room and attempt to leave the work for CNA L. CNA L stated she reported that CNA QQ was leaving people in bad shape, as in completely soiled and reported the concern to management.
In an interview on 12/18/23 at 2:22 PM, Administrative Director of Nursing (ADON) F confirmed that she was aware of the care concerns regarding CNA QQ. The facility launched an investigation and removed CNA QQ from the schedule. Upon return to the facility, CNA QQ was put on another round of training but was ultimately terminated from the facility for performance and attendance concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adaptive equipment for one (Resident #146) of 19 reviewed, resulting in the potential for decreased independence with drinking.
Findings include:
Review of the medical record revealed R146 admitted to the facility on [DATE] with diagnoses that included dementia, cervical disc disorder, and insomnia. According to the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/23 revealed R146 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and required extensive assistance of one person for eating.
On 8/28/23 at 11:43 AM, R146 was observed arriving to the dining room after staff assisted her to the bathroom. R146 was served two cups of juice in regular cups. R146 spilled half of a cup of juice on the table while trying to drink.
On 8/29/23 at 8:13 AM, R146 was observed in the dining room prior to meal service. R146 was served white milk and apple juice in regular cups. R146's tray ticket revealed two-handled cups were needed.
Review of R146's Nutrition Care Plan revealed daily weight monitoring was initiated on 5/29/23, two-handled cups for beverages was initiated on 5/29/23.
In an interview on 8/30/23 at 11:26 AM, Registered Dietitian (RD) N reported R146 needed supervision at meals. RD N reported interventions included two-handled cups with beverages to promote independence with drinking. RD N reported she had noticed that some staff will provide beverages before meal tickets arrive and that could be how the two-handled cups were not being used.
On 8/30/23 at 2:31 PM, Director of Nursing (DON) B reported it was a combination between nursing and dining for who provided the two-handled cups to residents. DON B reported adaptive equipment should be confirmed with the meal ticket.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when three medication errors were observed from a total of 34 opportunities for three residents (Resident #4, Resident #70, and Resident #103) of six residents reviewed for medication administration, resulting in a medication error rate of 8.82% and the potential for adverse reactions/side effects.
Findings include:
Resident #103 (R103)
Review of the medical record revealed R103 admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease.
On 8/30/23 at 8:00 AM, Licensed Practical Nurse (LPN) Q was observed preparing and administering medications to R103. LPN Q administered Senna 8.6 milligrams (mg), a laxative medication.
Review of the Physician's Order dated 8/15/22 revealed an order for Senna S 8.6-50 mg (sennosides-docusate sodium), a laxative and stool softener medication.
On 8/30/23 at 8:11 AM, LPN Q agreed R103 was ordered to receive Senna S and Senna was administered. LPN Q showed that Senna S was available in the medication cart.
Resident #70 (R70)
Review of the medical record revealed R70 admitted to the facility on [DATE] with diagnoses that included heart disease and diabetes.
On 8/30/23 at 8:27 AM, LPN R was observed preparing and administering medications to R70. LPN R administered aspirin 81 mg EC (enteric coated).
Review of the Physician's Order dated 5/24/23 revealed R70 was ordered to receive Aspirin 81 mg chewable tablet.
Resident #4 (R4)
Review of the medical record revealed R4 admitted to the facility on [DATE] with a diagnosis of multiple sclerosis.
On 8/30/23 at 8:39 AM, LPN S was observed preparing and administering medications to R4. LPN S crushed and administered calcium with vitamin D 500 mg.
Review of the Physician's Order dated 8/1/23 revealed R4 was ordered to receive Calcium 500 mg split calcium in half for easier swallowing.
On 8/30/23 at 2:07 PM, Director of Nursing (DON) B reported the facility only had calcium with vitamin D in stock and did not have plain calcium 500 mg.

Based on interview and record review, the facility failed to administer insulin according to physician orders in one of five residents reviewed for medication administration (Resident #59), resulting in an increased risk of hypoglycemia or hyperglycemia. Findings include:
Resident #59 (R59)
R59's Minimum Data Set (MDS) assessment with an assessment reference date of 7/18/23 introduced a Brief Interview for Mental Status (BIMS), a brief performance-based cognitive screener for nursing home residents, score of 10 (08-12 Moderate Impairment). The same MDS revealed R59 had the diagnoses of diabetes mellitus, non-traumatic brain dysfunction, anemia, dementia, and lung disease.
In review of R59's physician order dated 4/21/23, NovoLog Solution (Insulin Aspart) 100 Units/Milliliter (ml), was to be administered per sliding scale:
if 150 - 200 = 3 units.
201 - 250 = 4 units.
251 - 300 = 5 units.
301 - 350 = 7 units.
351 - 400 = 8 units.
401+ = 9 units,
subcutaneously before meals and at bedtime for type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar).
In review of R59's endocrinologist consult regarding the treatment of diabetes dated 5/08/23, recommended to change Levemir to 20 units in the morning and 15 units in the evening. The same consult recommended to administer Novolog Insulin according to scale at meals, increasing 1 unit from previous scale:
151 - 200 = 4 units.
201 -250 = 5 units.
251 - 300 = 6 units.
301 - 350 = 8 units.
351 - 400 = 9 units.
Over 400: 10 units and call office if persists.
R59's physician orders indicated the scale was active on 5/08/23.
In review of R59's May, June, July and August 2023's Medication Administration Records (MAR), both insulin scales were included on the MAR's; the insulin scale ordered on 4/21/23 was being followed, the order from 5/08/23 was not being followed. R59 received 1 unit less than recommended from 5/08/23 to 8/30/23.
R59's May 2023 MAR indicated NovoLog insulin was administered following the scaled ordered on 4/21/23, in which was 1 unit less than recommended on 5/08/23:
5/10/23 at 7:00 AM- blood sugar (BS) was 248, 4 units was administered, 5 units should have been given.
5/14/23 at 7:00 AM- BS was 159, 3 units was administered, 4 units should have been given.
5/12/23 at 12:00 PM- BS was 167, 3 units was administered, 4 units should have been given.
5/14/23 at 12:00 PM- BS was 167, 3 units was administered, 4 units should have been given.
5/15/23 at 12:00 PM- BS was 174, 3 units was administered, 4 units should have been given.
5/16/23 at 12:00 PM- BS was 203, 4 units was administered, 5 units should have been given.
5/17/23 at 12:00 PM- BS was 258, 5 units was administered, 6 units should have been given.
5/19/23 at 12:00 PM- BS was 221, 4 units was administered, 5 units should have been given.
5/20/23 at 12:00 PM- BS was 187, 3 units was administered, 4 units should have been given.
5/21/23 at 12:00 PM- BS was 186, 3 units was administered, 4 units should have been given.
5/22/23 at 12:00 PM- BS was 173, 3 units was administered, 4 units should have been given.
5/23/23 at 12:00 PM- BS was 151, 3 units was administered, 4 units should have been given.
5/24/23 at 12:00 PM- BS was 152, 3 units was administered, 4 units should have been given.
5/25/23 at 12:00 PM- BS was 211, 4 units was administered, 5 units should have been given.
5/26/23 at 12:00 PM- BS was 156, 3 units was administered, 4 units should have been given.
5/27/23 at 12:00 PM- BS was 162, 3 units was administered, 4 units should have been given.
5/28/23 at 12:00 PM- BS was 151, 3 units was administered, 4 units should have been given.
5/29/23 at 12:00 PM- BS was 242, 4 units was administered, 5 units should have been given.
5/30/23 at 12:00 PM- BS was 177, 3 units was administered, 4 units should have been given.
5/10/23 at 4:00 PM- BS was 179, 3 units was administered, 4 units should have been given.
5/11/23 at 4:00 PM- BS was 251, 5 units was administered, 6 units should have been given.
5/13/23 at 4:00 PM- BS was 219, 4 units was administered, 5 units should have been given.
5/14/23 at 4:00 PM- BS was 213, 4 units was administered, 5 units should have been given.
5/16/23 at 4:00 PM- BS was 151, 3 units was administered, 4 units should have been given.
5/19/23 at 4:00 PM- BS was 179, 3 units was administered, 4 units should have been given.
5/21/23 at 4:00 PM- BS was 227, 4 units was administered, 5 units should have been given.
5/22/23 at 4:00 PM- BS was 251, 5 units was administered, 6 units should have been given.
5/26/23 at 4:00 PM- BS was 206, 4 units was administered, 5 units should have been given.
5/27/23 at 4:00 PM- BS was 153, 3 units was administered, 4 units should have been given.
5/30/23 at 4:00 PM- BS was 160, 3 units was administered, 4 units should have been given.
5/11/23 at 9:00 PM- BS was 215, 4 units was administered, 5 units should have been given.
5/12/23 at 9:00 PM- BS was 219, 4 units was administered, 5 units should have been given.
5/13/23 at 9:00 PM- BS was 228, 4 units was administered, 5 units should have been given.
5/14/23 at 9:00 PM- BS was 256, 5 units was administered, 6 units should have been given.
5/15/23 at 9:00 PM- BS was 200, 3 units was administered, 4 units should have been given.
5/16/23 at 9:00 PM- BS was 156, 3 units was administered, 4 units should have been given.
5/17/23 at 9:00 PM- BS was 216, 4 units was administered, 5 units should have been given.
5/18/23 at 9:00 PM- BS was 171, 3 units was administered, 4 units should have been given.
5/19/23 at 9:00 PM- BS was 194, 3 units was administered, 4 units should have been given.
5/20/23 at 9:00 PM- BS was 176, 3 units was administered, 4 units should have been given.
5/21/23 at 9:00 PM- BS was 194, 3 units was administered, 4 units should have been given.
5/22/23 at 9:00 PM- BS was 175, 3 units was administered, 4 units should have been given.
5/23/23 at 9:00 PM- BS was 173, 3 units was administered, 4 units should have been given.
5/24/23 at 9:00 PM- BS was 263, 5 units was administered, 6 units should have been given.
5/25/23 at 9:00 PM- BS was 175, 3 units was administered, 4 units should have been given.
5/26/23 at 9:00 PM- BS was 164, 3 units was administered, 4 units should have been given.
5/27/23 at 9:00 PM- BS was 230, 4 units was administered, 5 units should have been given.
5/28/23 at 9:00 PM- BS was 180, 3 units was administered, 4 units should have been given.
R59's June 2023 MAR indicated NovoLog insulin was administered following the scaled ordered on 4/21/23, in which was 1 unit less than recommended on 5/08/23:
6/23/23 at 7:00 AM- BS was 199, 3 units was administered, 4 units should have been given.
6/29/23 at 7:00 AM- BS was 158, 3 units was administered, 4 units should have been given.
6/30/23 at 7:00 AM- BS was 189, 3 units was administered, 4 units should have been given.
6/02/23 at 12:00 PM- BS was 222, 4 units was administered, 5 units should have been given.
6/04/23 at 12:00 PM- BS was 218, 4 units was administered, 5 units should have been given.
6/06/23 at 12:00 PM- BS was 165, 3 units was administered, 4 units should have been given.
6/08/23 at 12:00 PM- BS was 219, 4 units was administered, 5 units should have been given.
6/09/23 at 12:00 PM- BS was 151, 3 units was administered, 4 units should have been given.
6/10/23 at 12:00 PM- BS was 238, 4 units was administered, 5 units should have been given.
6/11/23 at 12:00 PM- BS was 173, 3 units was administered, 4 units should have been given.
6/12/23 at 12:00 PM- BS was 251, 5 units was administered, 6 units should have been given.
6/13/23 at 12:00 PM- BS was 262, 5 units was administered, 6 units should have been given.
6/19/23 at 12:00 PM- BS was 210, 4 units was administered, 5 units should have been given.
6/20/23 at 12:00 PM- BS was 187, 3 units was administered, 4 units should have been given.
6/21/23 at 12:00 PM- BS was 210, 4 units was administered, 5 units should have been given.
6/22/23 at 12:00 PM- BS was 211, 4 units was administered, 5 units should have been given.
6/23/23 at 12:00 PM- BS was 259, 5 units was administered, 6 units should have been given.
6/25/23 at 12:00 PM- BS was 227, 4 units was administered, 5 units should have been given.
6/26/23 at 12:00 PM- BS was 204, 4 units was administered, 5 units should have been given.
6/27/23 at 12:00 PM- BS was 257, 5 units was administered, 6 units should have been given.
6/28/23 at 12:00 PM- BS was 222, 4 units was administered, 5 units should have been given.
6/30/23 at 12:00 PM- BS was 231, 4 units was administered, 5 units should have been given.
6/01/23 at 4:00 PM- BS was 200, 3 units was administered, 4 units should have been given.
6/02/23 at 4:00 PM- BS was 180, 3 units was administered, 4 units should have been given.
6/03/23 at 4:00 PM- BS was 150, 3 units was administered, 4 units should have been given.
6/07/23 at 4:00 PM- BS was 218, 4 units was administered, 5 units should have been given.
6/09/23 at 4:00 PM- BS was 150, 3 units was administered, 4 units should have been given.
6/11/23 at 4:00 PM- BS was 152, 3 units was administered, 4 units should have been given.
6/13/23 at 4:00 PM- BS was 162, 3 units was administered, 4 units should have been given.
6/14/23 at 4:00 PM- BS was 173, 3 units was administered, 4 units should have been given.
6/15/23 at 4:00 PM- BS was 151, 3 units was administered, 4 units should have been given.
6/17/23 at 4:00 PM- BS was 179, 3 units was administered, 4 units should have been given.
6/21/23 at 4:00 PM- BS was 238, 4 units was administered, 5 units should have been given.
6/22/23 at 4:00 PM- BS was 172, 3 units was administered, 4 units should have been given.
6/25/23 at 4:00 PM- BS was 173, 3 units was administered, 4 units should have been given.
6/27/23 at 4:00 PM- BS was 202, 4 units was administered, 5 units should have been given.
6/28/23 at 4:00 PM- BS was 198, 3 units was administered, 4 units should have been given.
6/01/23 at 9:00 PM- BS was 278, 5 units was administered, 6 units should have been given.
6/02/23 at 9:00 PM- BS was 181, 3 units was administered, 4 units should have been given.
6/03/23 at 9:00 PM- BS was 180, 3 units was administered, 4 units should have been given.
6/04/23 at 9:00 PM- BS was 267, 5 units was administered, 6 units should have been given.
6/10/23 at 9:00 PM- BS was 220, 4 units was administered, 5 units should have been given.
6/11/23 at 9:00 PM- BS was 383, 8 units was administered, 9 units should have been given.
6/14/23 at 9:00 PM- BS was 181, 3 units was administered, 4 units should have been given.
6/16/23 at 9:00 PM- BS was 169, 3 units was administered, 4 units should have been given.
6/19/23 at 9:00 PM- BS was 227, 4 units was administered, 5 units should have been given.
6/20/23 at 9:00 PM- BS was 250, 4 units was administered, 5 units should have been given.
6/21/23 at 9:00 PM- BS was 156, 3 units was administered, 4 units should have been given.
6/22/23 at 9:00 PM- BS was 210, 4 units was administered, 5 units should have been given.
6/25/23 at 9:00 PM- BS was 215, 4 units was administered, 5 units should have been given.
6/28/23 at 9:00 PM- BS was 219, 4 units was administered, 5 units should have been given.
6/30/23 at 9:00 PM- BS was 200, 3 units was administered, 4 units should have been given.
R59's July 2023 MAR indicated NovoLog insulin was administered following the scaled ordered on 4/21/23, in which was 1 unit less than recommended on 5/08/23:
7/09/23 at 7:00 AM- BS was 219, 4 units was administered, 5 units should have been given.
7/31/23 at 7:00 AM- BS was 200, 3 units was administered, 4 units should have been given.
7/02/23 at 12:00 PM- BS was 246, 4 units was administered, 5 units should have been given.
7/03/23 at 12:00 PM- BS was 280, 5 units was administered, 6 units should have been given.
7/04/23 at 12:00 PM- BS was 274, 5 units was administered, 6 units should have been given.
7/05/23 at 12:00 PM- BS was 197, 3 units was administered, 4 units should have been given.
7/06/23 at 12:00 PM- BS was 232, 4 units was administered, 5 units should have been given.
7/08/23 at 12:00 PM- BS was 241, 4 units was administered, 5 units should have been given.
7/11/23 at 12:00 PM- BS was 227, 4 units was administered, 5 units should have been given.
7/12/23 at 12:00 PM- BS was 193, 3 units was administered, 4 units should have been given.
7/13/23 at 12:00 PM- BS was 238, 4 units was administered, 5 units should have been given.
7/14/23 at 12:00 PM- BS was 151, 3 units was administered, 4 units should have been given.
7/15/23 at 12:00 PM- BS was 195, 3 units was administered, 4 units should have been given.
7/17/23 at 12:00 PM- BS was 179, 3 units was administered, 4 units should have been given.
7/18/23 at 12:00 PM- BS was 187, 3 units was administered, 4 units should have been given.
7/19/23 at 12:00 PM- BS was 251, 5 units was administered, 6 units should have been given.
7/22/23 at 12:00 PM- BS was 250, 4 units was administered, 5 units should have been given.
7/23/23 at 12:00 PM- BS was 195, 3 units was administered, 4 units should have been given.
7/24/23 at 12:00 PM- BS was 160, 3 units was administered, 4 units should have been given.
7/25/23 at 12:00 PM- BS was 223, 4 units was administered, 5 units should have been given.
7/26/23 at 12:00 PM- BS was 208, 4 units was administered, 5 units should have been given.
7/27/23 at 12:00 PM- BS was 337, 8 units was administered, 9 units should have been given.
7/28/23 at 12:00 PM- BS was 264, 5 units was administered, 6 units should have been given.
7/30/23 at 12:00 PM- BS was 303, 7 units was administered, 8 units should have been given.
7/31/23 at 12:00 PM- BS was 176, 3 units was administered, 4 units should have been given.
7/01/23 at 4:00 PM- BS was 237, 4 units was administered, 5 units should have been given.
7/02/23 at 4:00 PM- BS was 184, 3 units was administered, 4 units should have been given.
7/03/23 at 4:00 PM- BS was 164, 3 units was administered, 4 units should have been given.
7/05/23 at 4:00 PM- BS was 223, 4 units was administered, 5 units should have been given.
7/06/23 at 4:00 PM- BS was 154, 3 units was administered, 4 units should have been given.
7/07/23 at 4:00 PM- BS was 187, 3 units was administered, 4 units should have been given.
7/08/23 at 4:00 PM- BS was 151, 3 units was administered, 4 units should have been given.
7/11/23 at 4:00 PM- BS was 178, 3 units was administered, 4 units should have been given.
7/12/23 at 4:00 PM- BS was 168, 3 units was administered, 4 units should have been given.
7/13/23 at 4:00 PM- BS was 194, 3 units was administered, 4 units should have been given.
7/16/23 at 4:00 PM- BS was 184, 3 units was administered, 4 units should have been given.
7/18/23 at 4:00 PM- BS was 253, 5 units was administered, 6 units should have been given.
7/19/23 at 4:00 PM- BS was 182, 3 units was administered, 4 units should have been given.
7/20/23 at 4:00 PM- BS was 220, 4 units was administered, 5 units should have been given.
7/23/23 at 4:00 PM- BS was 243, 4 units was administered, 5 units should have been given.
7/25/23 at 4:00 PM- BS was 197, 3 units was administered, 4 units should have been given.
7/26/23 at 4:00 PM- BS was 177, 3 units was administered, 4 units should have been given.
7/27/23 at 4:00 PM- BS was 188, 3 units was administered, 4 units should have been given.
7/28/23 at 4:00 PM- BS was 152, 3 units was administered, 4 units should have been given.
7/29/23 at 4:00 PM- BS was 243, 4units was administered, 5 units should have been given.
7/30/23 at 4:00 PM- BS was 189, 3 units was administered, 4 units should have been given.
7/31/23 at 4:00 PM- BS was 169, 3 units was administered, 4 units should have been given.
7/02/23 at 9:00 PM- BS was 270, 5 units was administered, 6 units should have been given.
7/04/23 at 9:00 PM- BS was 189, 3 units was administered, 4 units should have been given.
7/05/23 at 9:00 PM- BS was 242, 4 units was administered, 5 units should have been given.
7/06/23 at 9:00 PM- BS was 181, 3 units was administered, 4 units should have been given.
7/07/23 at 9:00 PM- BS was 204, 4 units was administered, 5 units should have been given.
7/08/23 at 9:00 PM- BS was 202, 4 units was administered, 5 units should have been given.
7/09/23 at 9:00 PM- BS was 164, 3 units was administered, 4 units should have been given.
7/12/23 at 9:00 PM- BS was 252, 5 units was administered, 6 units should have been given.
7/14/23 at 9:00 PM- BS was 284, 5 units was administered, 6 units should have been given.
7/15/23 at 9:00 PM- BS was 217, 4 units was administered, 5 units should have been given.
7/16/23 at 9:00 PM- BS was 230, 4 units was administered, 5 units should have been given.
7/17/23 at 9:00 PM- BS was 311, 7 units was administered, 8 units should have been given.
7/18/23 at 9:00 PM- BS was 303, 7 units was administered, 8 units should have been given.
7/21/23 at 9:00 PM- BS was 198, 3 units was administered, 4 units should have been given.
7/23/23 at 9:00 PM- BS was 243, 4 units was administered, 5 units should have been given.
7/24/23 at 9:00 PM- BS was 163, 3 units was administered, 4 units should have been given.
7/25/23 at 9:00 PM- BS was 326, 7 units was administered, 8 units should have been given.
7/26/23 at 9:00 PM- BS was 212, 4 units was administered, 5 units should have been given.
7/28/23 at 9:00 PM- BS was 206, 4 units was administered, 5 units should have been given.
7/29/23 at 9:00 PM- BS was 230, 4 units was administered, 5 units should have been given.
7/30/23 at 9:00 PM- BS was 180, 3 units was administered, 4 units should have been given.
R59's August 2023 MAR from 8/01/23 through 8/29/23, indicated NovoLog insulin was administered following the scaled ordered on 4/21/23, in which was 1 unit less than recommended on 5/08/23:
8/02/23 at 12:00 PM- BS was 233, 4 units was administered, 5 units should have been given.
8/03/23 at 12:00 PM- BS was 293, 5 units was administered, 6 units should have been given.
8/05/23 at 12:00 PM- BS was 152, 3 units was administered, 4 units should have been given.
8/07/23 at 12:00 PM- BS was 214, 4 units was administered, 5 units should have been given.
8/08/23 at 12:00 PM- BS was 194, 3 units was administered, 4 units should have been given.
8/09/23 at 12:00 PM- BS was 176, 3 units was administered, 4 units should have been given.
8/10/23 at 12:00 PM- BS was 204, 4 units was administered, 5 units should have been given.
8/11/23 at 12:00 PM- BS was 179, 3 units was administered, 4 units should have been given.
8/12/23 at 12:00 PM- BS was 158, 3 units was administered, 4 units should have been given.
8/18/23 at 12:00 PM- BS was 202, 4 units was administered, 5 units should have been given.
8/19/23 at 12:00 PM- BS was 176, 3 units was administered, 4 units should have been given.
8/20/23 at 12:00 PM- BS was 242, 4 units was administered, 5 units should have been given.
8/21/23 at 12:00 PM- BS was 194, 3 units was administered, 4 units should have been given.
8/23/23 at 12:00 PM- BS was 214, 4 units was administered, 5 units should have been given.
8/24/23 at 12:00 PM- BS was 229, 4 units was administered, 5 units should have been given.
8/25/23 at 12:00 PM- BS was 209, 4 units was administered, 5 units should have been given.
8/26/23 at 12:00 PM- BS was 197, 3 units was administered, 4 units should have been given.
8/27/23 at 12:00 PM- BS was 277, 5 units was administered, 6 units should have been given.
8/28/23 at 12:00 PM- BS was 184, 3 units was administered, 4 units should have been given.
8/02/23 at 4:00 PM- BS was 156, 3 units was administered, 4 units should have been given.
8/03/23 at 4:00 PM- BS was 239, 4 units was administered, 5 units should have been given.
8/04/23 at 4:00 PM- BS was 168, 3 units was administered, 4 units should have been given.
8/05/23 at 4:00 PM- BS was 181, 3 units was administered, 4 units should have been given.
8/06/23 at 4:00 PM- BS was 196, 3 units was administered, 4 units should have been given.
8/07/23 at 4:00 PM- BS was 189, 3 units was administered, 4 units should have been given.
8/08/23 at 4:00 PM- BS was 180, 3 units was administered, 4 units should have been given.
8/09/23 at 4:00 PM- BS was 260, 5 units was administered, 6 units should have been given.
8/12/23 at 4:00 PM- BS was 179, 3 units was administered, 4 units should have been given.
8/17/23 at 4:00 PM- BS was 215, 4 units was administered, 5 units should have been given.
8/22/23 at 4:00 PM- BS was 302, 7 units was administered, 8 units should have been given.
8/26/23 at 4:00 PM- BS was 185, 3 units was administered, 4 units should have been given.
8/27/23 at 4:00 PM- BS was 157, 3 units was administered, 4 units should have been given.
8/28/23 at 4:00 PM- BS was 199, 3 units was administered, 4 units should have been given.
8/02/23 at 9:00 PM- BS was 249, 4 units was administered, 5 units should have been given.
8/03/23 at 9:00 PM- BS was 173, 3 units was administered, 4 units should have been given.
8/04/23 at 9:00 PM- BS was 213, 4 units was administered, 5 units should have been given.
8/06/23 at 9:00 PM- BS was 199, 3 units was administered, 4 units should have been given.
8/07/23 at 9:00 PM- BS was 242, 4 units was administered, 5 units should have been given.
8/08/23 at 9:00 PM- BS was 174, 3 units was administered, 4 units should have been given.
8/09/23 at 9:00 PM- BS was 200, 3 units was administered, 4 units should have been given.
8/11/23 at 9:00 PM- BS was 214, 4 units was administered, 5 units should have been given.
8/20/23 at 9:00 PM- BS was 318, 7 units was administered, 8 units should have been given.
8/22/23 at 9:00 PM- BS was 215, 4 units was administered, 5 units should have been given.
8/25/23 at 9:00 PM- BS was 162, 3 units was administered, 4 units should have been given.
8/26/23 at 9:00 PM- BS was 189, 3 units was administered, 4 units should have been given.
8/28/23 at 9:00 PM- BS was 315, 7 units was administered, 8 units should have been given.
During an interview with Unit Manager X on 8/30/23 at 10:43 AM, she had no explanation of why R59's Endocrinologist recommendations for Novolog sliding scale insulin from May 2023 were not being followed or why the sliding scale order from 4/21/23 wasn't discontinued. UM X stated she was seeing what this writer was seeing.
During an interview on 8/30/23 at 1:44 PM, Director of Nursing (DON) B stated when a resident returns from a consultation, the nurse would call the physician, put a new order into the system, and the manager should double check the orders were transcribed correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to assess, update, and ensure advance directive information was in place for 1 resident (Resident 109) of two residents reviewed, resulting in the potential for resident's preferences for medical care to not be followed by the facility staff.
Findings Include:
Resident #109 (R109)
A review of the medical record revealed R109 admitted to the facility on [DATE] with diagnoses that included urinary tract infection, type 2 diabetes, aphasia, and adult failure to thrive. R109 had a brief interview for mental status (BIMS), a short performance based cognitive screen for nursing home residents, score of 10 (8-12 moderately impaired) which was completed on 8/26/2023.
On 08/28/23 at 03:06 PM a record review was conducted, and code status wasn't found under physician orders, underneath R109 name, in the progress notes, under miscellaneous or the care plan.
During an interview on 08/29/23 at 07:40 AM, Nursing Department Unit Secretary (NDUS) P stated that everything should be in the electronic medical records.
During an interview on 08/29/23 at 02:08 PM, Social Worker (SW) O stated that the process for getting advance directives recently changed. SW O mentioned that upon admission the code status was verified with the resident or responsible party and the admissions Minimum Data Set (MDS) nurse puts the order in. She stated that if nothing was in the chart for code status then the resident would have to be a full code. SW O mentioned that advance directives aren't put in the care plan for the last month or so. During interview, SW O looked for advance directives on her computer and was unable to locate it in the medical record.
Per the policy titled Resident-Advance Directives with an effective date of 11/1/2017 and last revision date of 03/2021, under procedure and step 2, The Social Worker shall inquire at the time of admission whether or not the Resident/Patient has executed an advance directive, such as a Durable Power of Attorney for Health Care. The Social Worker shall document in the clinical record whether or not the Resident/Patient has done so. If a Resident/Patient has executed an advance directive, the Facility shall review the directive to ensure it aligns with other forms, i.e. the MI-POST (Michigan Physician Orders for Scope of Treatment) and/or DNR (Do not Resuscitate) form. The Advance Directives are then reviewed at each of the Quarterly Care Conferences with the Interdisciplinary Team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident was free from physical restraints in one of one resident reviewed for physical restraints (Resident #59), resulting in the likelihood of injuries, depression, and unmet needs. Findings include:
Resident #59 (R59)
Review of the medical record revealed R59 was admitted to the facility on [DATE] with diagnoses that included hypertension, type two diabetes, major depressive disorder, unspecified dementia, and vascular dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/23 revealed R59 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R59 required extensive assistance of one person for dressing and total dependence for transferring and toileting.
In an observation on 08/28/23 at 1:57 PM, R59 was observed in a wheelchair, holding onto the wheelchair armrest, and repeatedly shaking the armrest of the wheelchair. When interviewed, R59 responded that she does not know what she was watching on television. When asked during the screening process if [R59] had experienced any falls, R59 stated that she had but could not recall the details surrounding the incident.
Review of an Unusual Occurrence note dated 1/22/23 at 11:30 PM revealed Aid (Certified Nursing Assistant) found resident on a floor mat next to the bed with legs straight. Bed was in a lowest position. Call light was on a bed within reach. Nursing assessment done. Resident transferred back to a Medichair (speciality wheelchair), moved in hallway and blocked with overbed tablefor [sic] her safety .
In a telephone interview on 08/30/23 at 11:28 AM, Registered Nurse (RN) Y reported that she was working the night R59 had the fall that occurred on 1/22/23. RN Y stated that after R59 fell from her bed, she was transferred to her wheelchair and placed in the hallway. RN Y reported that while in her wheelchair, R59 was attempting to climb out of her wheelchair so RN Y blocked her from exiting the wheelchair by placing the bedside table in front of R59's wheelchair. RN Y stated that on that night, R59 would have benefited from a one-to-one staff member to maintain her safety but that was not an option, so she utilized the bedside table to block R59 in for her safety.
In an interview on 08/29/23 at 1:55 PM, Registered Nurse (RN) AA reported that she has observed R59 with a bedside table in front of her, but mostly next to her in her room. RN AA reported never observing R59 moving her bedside table. RN AA reported that she tries to do range of motion exercises with R59 but reported that R59's range of motion is not great. She keeps her elbows tucked (to the side) and has some range of motion but cannot extend her arms out.
In an interview on 08/30/23 at 1:34 PM, Director of Nursing (DON) B reported that using a bedside table to block someone into a space is a restraint and that no one should be using any of that stuff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #21 (R21)
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R21 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included anemia, hypertension (high blood pressure), heart failure, heart disease, renal disease, peripheral vascular disease, facility acquired pressure ulcer stage 4, anxiety, and depression. The MDS reflected R21 had a BIM (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required two person physical assist with bed mobility, transfers, dressing, toileting, hygiene, bathing and one person physical assist with eating.
During an observation on 8/28/23 at 9:45 AM, R21 was laying flat on back on air mattress with heels resting directly on mattress. R21 hair appeared un-groomed and greasy and was wearing a hospital gown. Observed a sign by the head of the bed, taped to the wall, with wound care instructions.
Review of the facility Matrix, dated 8/28/23, reflected R21 had a stage 4 pressure ulcer.
During an interview and observation on 8/29/23 at 1:45 PM, PACE(community assistance program) aid AI and R21 family member AJ were in R21 room. R21 was laying flat in bed with heels directly on bed and bilateral compression socks not in place. R21 appeared in pleasant mood and to be able to answer simple questions and appeared well groomed. R21's family AJ reported R21 was having a good day and reported visited R21 almost every day to assist with grooming and feeding during meals and reported PACE staff come three times daily to assist R21 with meals. PACE aid AI verified aid visits 3 times daily to assist with meals and personal care and position changes and reported R21 was compliant with position changes. R21 family AJ reported R21 care started to decline when rehab staff moved from Wing C(R21 hall) back to Wing B and reported several agency staff who were not familiar with R21 needs that included frequent repositioning, incontinence care, two person assist with all care and staff assist with eating. R21's family AJ reported facility staff were not repositioning R21 and R21 developed a large pressure ulcer on her buttock area and staff were not following physician orders and communicating with PACE staff related to treatments. R21's family AJ reported R21 has PACE services that assist with wound care as well and that is why there is a sign on R21 wall with current wound care orders because they were not being completed as ordered. R21's family AJ reported did wash R21 hair since surveyor observation yesterday because it was greasy. R21's family AJ reported had to encourage staff all the time to assist R21 with drinks and frequently offer because R21 could not on own and today observed no beverage at the bedside. PACE aid AI reported after meals facility staff remove the tray including beverages and PACE AI reported she removes drinks from tray to keep in room. R21's family reported has had to ask staff to provide personal care to R21's backside occasionally and change sheets at least weekly after R21 observed soiled and sheets soiled within past 2 months and stated R21 does not like to smell. R21's family AI reported was not aware R21 received antibiotics for pressure wound and reported communication had been an issues for at least 2 months.
Review of R21 Unusual Occurrence Progress Note, dated 6/5/2023 4:00 p.m., reflected, Dependent for all care, does not ambulate, incontinent of stool ,observed with 2 new open areas to coccyx. Tx currently in place. Interventions. Turn / reposition perprotocol, staff to off -load pressure away from coccyx with use positioning device. Currently on low air loss mattress. Care plan and kardex updated.
Review of R21 Physician Progress Note, 6/19/2023 at 12:58 p.m., seen for wound care assessment and treatment, stage 4 coccyx ulcer .coccyx ulcer measures 4.0 x 3.7 w 2cm depth in deepest area and 1.5 cm rest of wound, clean beefy red wound base, almost friable, periwound tissue slightly macerated, intact, no s/s infection .Plan: stage 4 coccyx ulcer VAC dres, change M-W-F.
Review of R21 EMR including the Treatment Administration Record(TAR), dated 6/1/23 through 6/30/23, reflected no evidence of treatment changes noted on 6/5/23 through 6/9/23 when new stage 3 and stage 2 pressure ulcers were identified. The June and July TAR reflected no evidence R21 received stage 4 coccyx wound treatments 6/29/23 through 7/6/23(eight days) and 7/8/23, 7/9/23, 7/24/23, 7/26/23 and 7/29/23.
Review of the TAR, dated 8/1/23 through 8/30/23, reflected R21 did not received Physician ordered dressing changes for the facility acquired stage 4 pressure ulcer to R21's coccyx as evidence by not being documented as complete on the following dates: 8/3, 8/6, 8/9, 8/11, 8/16, 8/18, 8/21, and 8/23/23. (Eight missed dressing changes).
Review of the Skin Care Plans, dated 1/12/23, reflected R21 had potential impairment to skin integrity r/t fragile skin, morbid obesity, impaired mobility. Continued review reflected revisions, dated 6/5/23, that reflected, The resident has impairment to skin integrity, stage 3 pressure injury to the coccyx , and a stage 2 pressure injury laterally r/t fragile skin, morbid obesity, impaired mobility .The resident has Stage 4 pressure ulcer to Lateral Coccyx r/t mechanical destruction of tissue secondary to pressure from refusing to get OOB and/or repositioning, other causative factors: decreased mobility, obesity, CHF w/edema, lymphedema, PVD, loose stools. Date Initiated: 06/13/2023 .Interventions included, BED MOBILITY: The resident requires extensive assist of (2) staff for repositioning and turning in bed routinely and as necessary. Date Initiated: 01/12/2023 .BEDFAST: The resident is bedfast all or most of the time. Date Initiated: 01/12/2023 .Monitor/document/report PRN any s/sx of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Date Initiated: 01/12/2023 .Administer treatments as ordered and monitor for effectiveness.
Date Initiated: 06/15/2023 .Assess/record/monitor wound healing at least every 7 days, Measure length, width and depth where possible, type of tissue, and exudate. Assess and document status
of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD.
Date Initiated: 06/15/2023 .Encourage and assist to a position of comfort at least with every care round as resident will allow/tolerate, more often as needed or requested. Date Initiated: 06/15/2023 .If The resident refuses treatment, confer with the resident , IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 06/15/2023 .Use pillows and such to maintain postural alignments, as resident will allow/tolerate.
Date Initiated: 06/15/2023 .Weekly skin assessment with shower per facility policy. Report any changes in skin condition to MD prn Date Initiated: 06/15/2023 . Continued review of the Care Plans reflected no updates between 5/10/23 and 6/13/23 when pressure ulcer was identified.
Review of the Progress Notes, including behavior notes and tasks, dated 5/1/23 through 8/30/23, reflected no evidence R21 refused position changes every care round.
During an interview on 8/29/23 at 5:03 PM, ADON C reported had worked at the facility since June 2023 and was responsible for wound rounds since 7/21/23. ADON C reported wound rounds are completed weekly for all residents with pressure ulcers or extensive wounds. ADON C reported prior to starting wound rounds 7/21/23 prior Wound Nurse AK was responsible for monitoring facility wounds. ADON C reported found wound monitoring in several locations including assessments, provider notes, Progress Notes without pattern and reported weekly wound rounds were not being completed and things were missed. ADON C reported facility completed skin sweep of entire facility in June 2023 and identified all wounds at that time and was unable to provide date. ADON C reported expected staff to complete weekly skin assessments under assessment tab of EMR. ADON C reported staff expected to complete Unusual Occurrence Note if a new skin irregularity is identified on a non-scheduled day for weekly skin assessment then report to Unit Managers and meet as team. ADON C reported nurse are expected to measure wounds including length, width and depth and describe wound bed and peri wound and include if tunneling present. ADON C reported facility has Nurse Practitioner who often is part of team for weekly wound rounds. ADON C reported had provided documentation to this surveyor related to R21 stage 4 coccyx pressure ulcer and verified was facility acquired and reported was unable to determine the date of onset. ADON C reported did not assess R21 stage 4 pressure ulcer the week of 8/13/23 to 8/19/23 because she was on vacation and was unable to report why weekly wound monitoring was not completed. ADON C reported documentation to be completed same day with occasional next day documentation notes. ADON C reported wound expect physician orders and care plans to be followed and R21 to be repositioned frequently and documentation of refusal.
During an interview on 8/30/23 at 11:13 AM, Certified Nurse Aid (CNA) P reported was familiar with R21 and required full assist with care. CNA P reported rehab staff moved back to B Wing 3/23/23 and reported several agency staff used to work on C Wing(R21 hall) who often can not be dependable.
Resident #309(R309)
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R309 was a [AGE] year-old female admitted to the facility on [DATE] post left hip fracture repair related to fall at home, with diagnoses that included hypertension (high blood pressure), dementia, heart disease, orthostatic hypotension, urinary tract infection and depression. The MDS reflected R309 had a BIM (Brief Interview for Mental status) score of 3 which indicated her ability to make daily decisions was severely impaired, and she required one-person physical assist bed mobility, transfers, walk in room and corridor, locomotion on unit, toileting, dressing, eating, hygiene, and bathing and no mention of behaviors.
Review of the facility Matrix, dated 8/28/23, reflected R309 had a fall with major injury.
During an observation on 8/28/23 at 1:36 PM, R309 was in bed laying on left side with eyes closed.
Review of R309 admission Summary Progress Note, dated 7/31/2023 at 4:30 p.m., reflected, Resident Arrived via wheelchair w/ family present and private transportation. Resident A&ox1 w/ confusion. Resident is able to respond to commands. Resident has unsteady gate and requires one person assist during transfers and toileting. Resident is a high fall risk. Resident admitted for rehab post Left hip surgery. Resident has no c/o pain at the moment. Resident VS WNL. Resident has bruising to Left hip surgical site. Resident skin is intact. Resident has no c/o of pain or discomfort at the moment. Resident has all safety measures in place and call light in reach.
Review of R309 Health Status Note, dated 8/3/2023 at 4:08 p.m., reflected, This nurse received update from [named] hospital, resident has been admitted to the hospital, pending surgery to replace hardware in left hip. Resident scheduled as add on for surgery today. Will continue to monitor.
Review of the Unusual Occurrence Note, dated 8/4/2023 at 2:12 p.m., reflected, IDT review of incidents on 7/31/23; 8/2/23; and 8/3/23. Resident observed on the floor after attempting to self-ambulate to the restroom. This nurse spoke with resident's son [named] who states his mother's memory is not the best. He states that resident can take herself to the bathroom and 2 minutes later, not remember she had already gone. Fall on 8/3/23, resulted in transfer to ER and broken hip. Hip replacement surgery occurred on 8/3/23. Son states mom is doing well; however, does not remember she had surgery. IDT team will discuss possible interventions with family upon re-admission to facility.
Review of R309 fall Care Plans, dated 8/1/23, reflected, The resident is at risk for falls r/t Actual
Fall: causing left hip fracture, family reports Mutiple falls in recent months, , Confusion R/T dementia, Deconditioning, Gait/balance problems, Poor communication/comprehension, Psychoactive drug use, Unaware of safety needs , Unsteady gait, self transfers, impulsive. Date Initiated: 08/01/2023 .The resident will not sustain serious injury through the review date. Date Initiated: 08/02/2023 .Anticipate and meet The resident's needs. Date Initiated: 08/01/2023 .Assist devices as ordered. Date Initiated: 08/01/2023 .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 08/01/2023 .Bed in lowest position when resident is in bed. Date Initiated: 08/09/2023 .Busy board to occupy resident when in hallway. Date Initiated: 08/14/2023 .Encourage rest periods if resident becomes fatigued. Date Initiated: 08/01/2023 .Follow facility fall protocol. Date Initiated: 08/01/2023 .Monitor floor and pick up items, keep free of clutter. Date Initiated: 08/01/2023 .Monitor for medication side effects. Date Initiated: 08/01/2023 .Non-skid footwear when up Date Initiated: 08/01/2023 .Ortho BP and neuro-checks as warranted per unusual occurrence policy. Date Initiated: 08/01/2023 .Place floor mats at bedside when resident is in bed. Date Initiated: 08/09/2023 .Staff to assist resident when rising from chair. Date Initiated: 08/01/2023 .Stay with resident when standing at the table and leave chair behind resident during an activity. Date Initiated: 08/01/2023 . No changes in interventions noted after R309 fall on 8/14/23 or 8/28/23.
Review of the facility fall risk assessment, dated 7/31/23, reflected R309 was at risk for falls.
Received email, dated 8/30/23 at 10:02 a.m., with requested Incident/Accident investigations. The email included five un-witnessed fall Incident/Accident reports for R309, dated 7/31/23, 8/2/23, 8/3/23, 8/14/23 and 8/28/23.
During an interview on 8/30/23 at 10:25 AM, LPN AN reported had worked at the facility for 12 years and reported working as LPN three months ago. LPN AN reported was familiar with R309 and did not recall being present for any falls. LPN AN reported R309 was high risk for falls at time of admission because she was admitted to facility post fall with left hip fracture and repair and fell within one hour after admission. LPN AN reported staff tried to do 1:1(sitting with her) as much as they can along with being responsible for care of at least six other residents, meals, call lights, walk to dine, admissions, discharges, orthostatic blood pressures, vitals, heights, weights, and packing residents for discharge. LPN AN reported times with up to eight new admissions in one day. LPN AN reported R309 was pleasantly confused, forgetful(even forgot about both surgeries) and reported could tell R309 was in pain by holding hip but R309 did not know why. LPN AN reported R309 was constantly moving and needed one on one(1:1) care but staff can't do 1:1 because they do not have the staffing. LPN AN reported encouraged R309 to use call light but re-education was not effective but have to try and reported R309 never used call light. LPN AN reported interventions that were add for R309 to prevent falls were activity blankets, book on tape, crossword, tablet with music(liked Elvis), and mats on floor next to bed. LPN AN reported nurse responsible for resident at the time of a fall was expected to complete Unusual Occurrence Report immediately and implement one to three interventions. LPN AN reported facility fall policy was for nurse to complete full head to toe assessment prior to moving resident off floor, vitals, assess skin for injury including bleeding, complete range of motion of all joints, call physician, transfer resident off the floor with hoyer lift to prevent weight barring, notify DPOA, and manager. LPN AN reported did recall being present for R309 8/2/23 fall and reported R309 was in the hall in a wheelchair while staff were passing dinner trays. LPN AN reported fall was not witnessed and R309 did not have injuries and the Unit Manager assisted with documentation. LPN AN reported B Wing(sub-acute rehab) usually had three to four CNA staff and one to two nurses on days according to census on rehab. LPN AN reported facility had staffing guidelines posted at the Nurse Stations.
Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 3 (Resident #21, #34, and #309) of 32 residents reviewed resulting in the potential for unmet care needs.
Findings include:
Resident #34
Review of the medical record revealed that Resident #34 (R34) was readmitted to facility 4/5/22 with diagnoses including left hand contracture, right hand contracture, rheumatoid arthritis, and chronic ischemic heart disease. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/6/2023 revealed that R34 was rarely/never understood with a staff assessment for mental status reflecting short and long-term memory problems with severely impaired cognitive skills for daily decision making. Section G of the same MDS revealed that R34 required one-person total assist with bed mobility, dressing, and eating; two-person total assist with transfers and toilet use; and had an upper extremity functional limitation in range of motion on both sides.
In an observation on 8/28/23 at 11:05 AM, R34 was observed sitting in room, in high back wheelchair, with upper arms positioned at side, elbows bent, forearms and hands resting on chest, fingers flexed with soft carrot splints (a soft splint shaped like a carrot which positions the fingers away from the palm to protect the skin from moisture, pressure and nail puncture) positioned in both clenched hands. Blue gripper socks were noted on bilateral feet with mild swelling observed to both feet and ankles. Two navy blue hand/wrist splints were noted on the top shelf of the open nightstand which was positioned just to the left of R34's bed. R34's eyes were observed to be open with no verbal response received to questions.
On 8/28/23 at 2:28 PM, R34 was observed lying in bed on right side with arms positioned at sides, bent at elbows with forearms and hands resting on chest with soft carrot splints noted to remain clenched in both hands. Blue hand/wrist splints were observed to remain on top shelf of nightstand. R34's legs were noted to be bent at knees with blue gripper socks on feet. Bilateral feet and ankles remained with swelling with left foot and ankle swelling greater than right.
On 8/29/23 at 8:09 AM, R34 was observed sitting in high back wheelchair in dining room with bilateral arms bent at elbows, forearms and hands resting on chest, soft carrot splint clenched in flexed fingers of right hand with left fingers flexed inward with fingertips touching palm. Blue gripper socks noted to bilateral feet with mild swelling continuing to feet and ankles of both legs.
On 8/29/23 at 1:17 PM, R34 was observed lying in bed positioned on left side with wedge at back. Bilateral arms were noted to be positioned at sides, bent at elbows with forearms and hands resting on chest. A soft carrot splint was observed to remain clenched in right hand with fingers of left hand flexed inward with fingertips touching palm of hand. Bilateral hand splints were noted to remain on top shelf of nightstand. R34's bilateral legs were noted to be bent at knees, blue gripper socks were observed to remain on feet with swelling noted to continue to both feet and ankles.
Review of R34's medical record completed with the following findings noted:
Order dated 4/5/22 stated, BUE (bilateral upper extremity) hand splints to be worn daily 4-6 hours during the day, off at night.
Order dated 4/5/22 stated, BUE hand carrot splints 2 hours on, 2 hours off, all night long.
Order dated 4/5/22 stated, TED hose (thromboembolic deterrent hose--compression socks designed to help prevent blood clots and swelling in legs) BLE (bilateral lower extremities) on in am (morning); off at hs (bedtime).
Review of care plan problem stated, Risk for Impaired skin integrity r/t (related to) Dementia, impaired mobility . and bilateral hand contractures with associated interventions which included BUE hand carrot splints 2 hours on, 2 hours off, all night long. Also has blue hand splints used during the day and TED hose BLE on AM, off HS both with an initiated date of 8/17/23.
Review of R34's Treatment Administration Record (TAR) dated 8/1/2023 - 8/31/2023 reflected orders for BUE hand carrot splints at night and TED hose BLE on in AM; off at HS (bedtime) but was not noted to include order for BUE hand splints. Further review of same TAR reflected that on 8/29/23, Registered Nurse (RN) I had signed the TED hose order out as completed although the hose were not noted to be in place at R34's bilateral lower extremities.
In an interview on 8/28/23 at 11:34 AM, Certified Nurse Aide (CNA) L confirmed familiarity with R34 and stated that she was R34's assigned CNA that date. Per CNA L, R34 was nonverbal but made eye contact when spoken to, was incontinent of both bowel and bladder, and required total assist with bathing, grooming, and dressing. CNA L stated that R34 had carrot splints that she held in her contracted hands but denied that R34 hand any other splints or braces for hands or any specialized socks for legs.
In an interview on 8/29/23 at 1:45 PM, RN I confirmed familiarity with R34 and that she was her assigned nurse that date. RN I stated that R34 had advanced dementia, was essentially nonverbal, and that her positioning was sometimes difficult related to her neck tumor. RN I acknowledged that R34 had bilateral hand contractures, stated that she had carrot splints that she was supposed to have placed in bilateral hands, but stated that R34 did not have nor had she seen hand splints in place for the longest time. RN I further stated that R34 had compression hose but thought that they had been discontinued as R34 received Hospice services. Upon review of R34's medical record, RN I confirmed that R34 had an active order for hand splints during the day, carrot splints at night, as well as TED hose to BLE. RN I confirmed that although she had not placed R34's TED hose that AM, that she had signed the order out as completed for that date and further stated that she had not seen R34's compression socks in place very often anymore.
Review of R34's medical record after completion of the interview with RN I included an Orders-Administration Note dated 8/29/23 at 2:27 PM created by RN I which indicated not worn in relation to R34's TED hose order for 8/29/23.
In an interview on 8/29/23 at 2:04 PM, Agency CNA J confirmed that she was R34's assigned CNA, for the first time, that date. Per Agency CNA J, as she was not familiar with R34, she had referenced the Kardex (tool used by the Certified Nurse Aide to guide them as to the care needs of a specific resident) at the start of the shift for R34's transfer status, continency status, and meal times/locations. Agency CNA J further stated that she was unaware if R34 had braces/splints or TED hose, that R34 was already up in her wheelchair and ready for the day at the start of her shift, and that she would have expected the prior CNA to place these devices, if indicated, when getting her ready for the day.
In a follow-up interview on 8/29/23 at 2:11 PM, RN I confirmed that she had located R34's bilateral hand splints and compression socks in her room and that both the splints and compression socks should have been in place but were not.
In an interview on 8/29/23 at 2:21 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) K confirmed familiarity with R34 as well as overseeing her care as was the manager for the unit where R34 resided. Upon review of R34's orders, LPN/UM confirmed that the orders for both the hand splints and TED hose were active and that both should be in place, per order, and as outlined on both R34's care plan and Kardex. LPN/UM K stated that she would be following up with staff to provide education as stated that each CNA should review the Kardex for each assigned resident daily and that all assigned CNA's should have been aware of R34's hand splints and TED hose application as confirmed both to be indicated on R34's Kardex.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise Care Plans for one (Resident #130) of 32 reviewed for Care Plans, resulting in the potential for unmet care needs.
Findings include:
Resident #130 (R130):
Review of the medical record reflected R130 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia, idiopathic normal pressure hydrocephalus (excessive accumulation of fluid within the brain), major depressive disorder and insomnia. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/15/23, reflected R130 scored twelve out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R130 extensive assistance of one person for most activities of daily living.
On 08/29/23 at 1:26 PM, R130 was observed propelling herself in the hallway in the direction of her room. R130 reported that there had been sexual problems at the facility. R130 reported that she is drugged at night by unknown persons and could not recall much detail about the sexual allegation. R130 reported that staff is aware as well as her son. When asked about details of the allegation, R130 could not recall much about the allegation but reported that the sexual abuse made her feel fed up, frustrated, and terrible. When asked more details regarding the sexual abuse allegation, R130 could not recall any details and talked about a different topic. This allegation was reported, and the facility provided one of the investigation summaries for the previous reported allegations.
Record Review revealed a Behavior Note dated 7/21/2023 at 10:51 AM that R130 reported to fellow resident that she was being touched inappropriately at nighttime and she believes staff is in on it because we know about and aren't doing anything about it. resident care plan addresses these allegations as resident has history of making accusations of being touched at nighttime and these allegations have been previously proven to be false .
In an interview on 08/29/23 at 1:49 PM, Registered Nurse (RN) AA reported that she made the Behavior Note in the electronic medical record on 7/21/23. RN AA stated that she reported the sexual abuse allegation to the unit manager and was told that the allegation was a behavior and that it was care planned. RN AA reported that the unit manager instructed her to make a note in the chart and social work would follow up with R130.
Review of R130's Care Plan revealed resident has impaired cognitive function or impaired thought processes r/t (related to) Dementia. She has a hx (history) of making allegations (investigated and found to be false) that male employee(s) have touched, showered or dressed her. These allegations were proven to be false. When questioned about the incidents she has no recollection of the allegation . No interventions included methods to support her psychosocial well-being and/or methods to ease her frustration and provide a sense of safety for R130.
In an interview on 08/30/23 at 8:23 AM Social Services Supervisor (SW) F reported that the sexual abuse allegations that R130 reports are frequent and had been investigated in the past. SW F stated that the allegations are always treated as it's a real thing, investigated including checking cameras and talking to everyone about strangers in her area. SW F reported that the physician determined that the delusions have something to do with the shunt in her head and fluid buildup which alters her cognition along with the progress of her dementia diagnosis. SW F reported that R130 has an upcoming appointment with the neurologist to investigate the functioning of the shunt in her brain. SW F stated that when R130 reports the sexual abuse, staff is instructed to comfort her and show her empathy. SW F has spoken with R130 regarding the sexual abuse claims and reported that R130 seems annoyed by the sexual abuse. When inquired about proper interventions to address the emotional needs of R130 during times of the delusions of sexual abuse, SW F reported I know her care plan mentions reaching out to family for support but reported that the care plan does not include anything about giving direction how to redirect her, promote her feeling for safety, alleviate her frustration, and to talk to her about her sexual abuse concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received assistance with care according to their personal preferences and care plans for 1 residents(R21) of 3 residents reviewed for hygiene and grooming , resulting in missed grooming, skin breakdown and the increased likelihood for inadequate hygiene and feelings of embarrassment. Findings include:
Resident #21 (R21)
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R21 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included anemia, hypertension (high blood pressure), heart failure, heart disease, renal disease, peripheral vascular disease, facility acquired pressure ulcer stage 4, anxiety, and depression. The MDS reflected R21 had a BIM (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required two person physical assist with bed mobility, transfers, dressing, toileting, hygiene, bathing and one person physical assist with eating.
During an observation on 8/28/23 at 9:45 AM, R21 was laying flat on back on air mattress with heels resting directly on mattress. R21 hair appeared un-groomed and greasy and was wearing a hospital gown. Observed a sign by the head of the bed, taped to the wall, with wound care instructions.
Review of the facility Matrix, dated 8/28/23, reflected R21 had a stage 4 pressure ulcer.
During an interview and observation on 8/29/23 at 1:45 PM, PACE(community assistance program) aid AI and R21 family member AJ were in R21 room. R21 was laying flat in bed with heels directly on bed and bilateral compression socks not in place. R21 family member AJ reported staff forget to put R21 socks on frequently and if they do put them on they forget to remove at night. R21 appeared in pleasant mood and to be able to answer simple questions and appeared well groomed. R21's family AJ reported R21 was having a good day and reported visited R21 almost every day to assist with grooming and feeding during meals and reported PACE staff come three times daily to assist R21 with meals. PACE aid AI verified aid visits 3 times daily to assist with meals and personal care and position changes and reported R21 was compliant with position changes. R21 family AJ reported R21 care started to decline when rehab staff moved from Wing C(R21 hall) back to Wing B and reported several agency staff who were not familiar with R21 needs that included frequent repositioning, incontinence care, two person assist with all care and staff assist with eating. R21's family AJ reported facility staff were not repositioning R21 and R21 developed a large pressure ulcer on her buttock area and staff were not following physician orders and communicating with PACE staff related to treatments. R21's family AJ reported R21 has PACE services that assist with wound care as well and that is why there is a sign on R21 wall with current wound care orders because they were not being completed as ordered. R21's family AJ reported did wash R21 hair since surveyor observation yesterday because it was greasy. R21's family AJ reported had to encourage staff all the time to assist R21 with drinks and frequently offer because R21 could not on own and today observed no beverage at the bedside. PACE aid AI reported after meals facility staff remove the tray including beverages and PACE AI reported she removes drinks from tray to keep in room. R21's family reported has had to ask staff to provide personal care to R21's backside occasionally and change sheets at least weekly after R21 observed soiled and sheets soiled within past 2 months and stated R21 does not like to smell. R21's family AI reported was not aware R21 received antibiotics for pressure wound and reported communication had been an issues for at least 2 months.
Review of R21 Unusual Occurrence Progress Note, dated 6/5/2023 4:00 p.m., reflected, Dependent for all care, does not ambulate, incontinent of stool ,observed with 2 new open areas to coccyx. Tx currently in place. Interventions. Turn / reposition perprotocol, staff to off -load pressure away from coccyx with use positioning device. Currently on low air loss mattress. Care plan and [NAME] updated.
Review of R21 Physician Progress Note, 6/19/2023 at 12:58 p.m., seen for wound care assessment and treatment, stage 4 coccyx ulcer .coccyx ulcer measures 4.0 x 3.7 w 2cm depth in deepest area and 1.5 cm rest of wound, clean beefy red wound base, almost friable, periwound tissue slightly macerated, intact, no s/s infection .Plan: stage 4 coccyx ulcer VAC dres, change M-W-F.
Review of R21 EMR including the Treatment Administration Record(TAR), dated 6/1/23 through 6/30/23, reflected no evidence of treatment changes noted on 6/5/23 through 6/9/23 when new stage 3 and stage 2 pressure ulcers were identified. The June and July TAR reflected no evidence R21 received stage 4 coccyx wound treatments 6/29/23 through 7/6/23(eight days) and 7/8/23, 7/9/23, 7/24/23, 7/26/23 and 7/29/23.
Review of the TAR, dated 8/1/23 through 8/30/23, reflected R21 did not received Physician ordered dressing changes for the facility acquired stage 4 pressure ulcer to R21's coccyx as evidence by not being documented as complete on the following dates: 8/3, 8/6, 8/9, 8/11, 8/16, 8/18, 8/21, and 8/23/23. (Eight missed dressing changes).
Review of the Skin Care Plans, dated 1/12/23, reflected R21 had potential impairment to skin integrity r/t fragile skin, morbid obesity, impaired mobility. Continued review reflected revisions, dated 6/5/23, that reflected, The resident has impairment to skin integrity, stage 3 pressure injury to the coccyx , and a stage 2 pressure injury laterally r/t fragile skin, morbid obesity, impaired mobility .The resident has Stage 4 pressure ulcer to Lateral Coccyx r/t mechanical destruction of tissue secondary to pressure from refusing to get OOB and/or repositioning, other causative factors: decreased mobility, obesity, CHF w/edema, lymphedema, PVD, loose stools. Date Initiated: 06/13/2023 .Interventions included, BED MOBILITY: The resident requires extensive assist of (2) staff for repositioning and turning in bed routinely and as necessary. Date Initiated: 01/12/2023 .BEDFAST: The resident is bedfast all or most of the time. Date Initiated: 01/12/2023 .Monitor/document/report PRN any s/sx of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Date Initiated: 01/12/2023 .Administer treatments as ordered and monitor for effectiveness. Date Initiated: 06/15/2023 .Assess/record/monitor wound healing at least every 7 days, Measure length, width and depth where possible, type of tissue, and exudate. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 06/15/2023 .Encourage and assist to a position of comfort at least with every care round as resident will allow/tolerate, more often as needed or requested. Date Initiated: 06/15/2023 .If The resident refuses treatment, confer with the resident , IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 06/15/2023 .Use pillows and such to maintain postural alignments, as resident will allow/tolerate.
Date Initiated: 06/15/2023 .Weekly skin assessment with shower per facility policy. Report any changes in skin condition to MD prn Date Initiated: 06/15/2023 .Use home compression socks on in the AM and off at HS. Place black socks on, then compression stocking, then follow with white socks. Date Initiated: 01/12/2023 . Continued review of the Care Plans reflected no updates between 5/10/23 and 6/13/23 when pressure ulcer was identified.
Review of the Progress Notes, including behavior notes and tasks, dated 5/1/23 through 8/30/23, reflected no evidence R21 refused position changes every care round.
During an interview on 8/29/23 at 5:03 PM, ADON C reported had worked at the facility since June 2023 and was responsible for wound rounds since 7/21/23. ADON C reported wound rounds are completed weekly for all residents with pressure ulcers or extensive wounds. ADON C reported prior to starting wound rounds 7/21/23 prior Wound Nurse AK was responsible for monitoring facility wounds. ADON C reported found wound monitoring in several locations including assessments, provider notes, Progress Notes without pattern and reported weekly wound rounds were not being completed and things were missed. ADON C reported facility completed skin sweep of entire facility in June 2023 and identified all wounds at that time and was unable to provide date. ADON C reported expected staff to complete weekly skin assessments under assessment tab of EMR. ADON C reported staff expected to complete Unusual Occurrence Note if a new skin irregularity is identified on a non-scheduled day for weekly skin assessment then report to Unit Managers and meet as team. ADON C reported nurse are expected to measure wounds including length, width and depth and describe wound bed and peri wound and include if tunneling present. ADON C reported facility has Nurse Practitioner who often is part of team for weekly wound rounds. ADON C reported had provided documentation to this surveyor related to R21 stage 4 coccyx pressure ulcer and verified was facility acquired and reported was unable to determine the date of onset. ADON C reported did not assess R21 stage 4 pressure ulcer the week of 8/13/23 to 8/19/23 because she was on vacation and was unable to report why weekly wound monitoring was not completed. ADON C reported documentation to be completed same day with occasional next day documentation notes. ADON C reported wound expect physician orders and care plans to be followed and R21 to be repositioned frequently and documentation of refusal.
During an interview on 8/30/23 at 11:13 AM, Certified Nurse Aid (CNA) P reported was familiar with R21 and required full assist with care. CNA P reported rehab staff moved back to B Wing 3/23/23 and reported several agency staff used to work on C Wing(R21 hall) who often can not be dependable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observation, interview, and record review the facility failed to provide failed to provide meaningful, individualized activities for one resident (#59) of two residents reviewed for activities resulting in the potential for depression, boredom, and feelings of lack of self-worth. Findings Include:
Resident #59 (R59)
Review of the medical record revealed R59 was admitted to the facility on [DATE] with diagnoses that included hypertension, type two diabetes, major depressive disorder, unspecified dementia, and vascular dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/23 revealed R59 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R59 required extensive assistance of one person for dressing and total dependence for transferring and toileting.
In an observation on 08/28/23 at 1:57 PM, R59 was observed in a wheelchair, holding onto the wheelchair armrest, and repeatedly shaking the armrest of the wheelchair. When interviewed, R59 responded that she does not know what she was watching on television.
Record Review of the Psychosocial Care Plan initiated on 6/14/21 revealed R59's cognition fluctuated and had memory impairments. R59 struggles with word finding and has difficulty seeing things in a positive way. R59 has made hurtful remarks towards roommates and staff members and may be combative with care. Interventions included daughter requests that staff invite/highly encourage her to go outside everyday and encourage activity participation; loves pets and dogs.
Review of the Kardax (program in the medical record that states care needs) in the Behavior/Mood section revealed take her outside when the weather is nice.
Review of a Minimum Data set (MDS), dated [DATE], revealed R59 was assessed for the importance of certain activities. R59 reported that listening to music she likes, going outside for fresh air, being around animals and pets, and doing her favorite activities were very important to her.
Review of Activity Logs provided by the facility revealed that R59 participated in the following activities:
January 2023; Music therapy on 1/5/23. No documented refusals.
February 2023; Bingo/card [NAME] on 2/27/23. No documented refusals.
April 2023; 4/2/23 Religious, 4/5/23 Religious and Bingo/Card [NAME], 4/15/23 Bingo/Card [NAME] and Movie, 4/21/23 Bingo/Card [NAME] and Movie, 4/26/23 Bingo/Card [NAME]. No outdoor activities reported. No documented refusals.
May 2023; Movie 5/6/23, Movie 5/7/23, 5/25/23 Social/Special Event Outdoors. One only documented outdoor activity in May. No documented refusals
June 2023; 6/5/23 Movie and Outdoors, 6/9/23 Art. Only one outdoor activity documented. No documented refusals.
July and August activity logs were not provided.
In an interview on 08/30/23 at 10:34 AM, Activities Director AE reported that she was not seeing a lot of documentation on R59 being offered activities outside. Activities Director AE stated that staffing had been a recent issue which may have impacted R59's opportunities to participate in preferred activities.
In an interview on 08/30/23 at 12:52 PM, Activities Aide AF reported that she doesn't routinely take R59 outside of the facility to get fresh air.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility failed to: 1) accurately assess, monitor and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for one Resident (R21) of four reviewed for pressure ulcers, resulting in R21 facility acquired stage 4 pressure wound(Full thickness tissue loss with exposed bone, tendon or muscle) that developed infection requiring antibiotic treatment, pain, and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status.
Findings include:
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R21 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included anemia, hypertension (high blood pressure), heart failure, heart disease, renal disease, peripheral vascular disease, facility acquired pressure ulcer stage IV, anxiety, and depression. The MDS reflected R21 had a BIM (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required two person physical assist with bed mobility, transfers, dressing, toileting, hygiene, bathing and one person physical assist with eating.
During an observation on 8/28/23 at 9:45 AM, R21 was laying flat on back on air mattress with heels resting directly on mattress. R21 hair appeared un-groomed and greasy and was wearing a hospital gown. Observed a sign by the head of the bed, taped to the wall, with wound care instructions.
Review of the facility Matrix, dated 8/28/23, reflected R21 had a stage 4 pressure ulcer.
Review of R21 Physician Orders, dated 6/28/23, reflected, Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for Coccyx wound until 07/08/2023 05:59 x 10 days. 20 administrations. LD 07/08/2023 @ 0600. First dose taken 06/28/2023 @ 0600.
During an interview and observation on 8/29/23 at 1:45 PM, PACE(community assistance program) aid AI and R21 family member AJ were in R21 room. R21 was laying flat in bed with heels directly on bed and bilateral compression socks not in place. R21 appeared in pleasant mood and to be able to answer simple questions and appeared well groomed. R21's family AJ reported R21 was having a good day and reported visited R21 almost every day to assist with grooming and feeding during meals and reported PACE staff come three times daily to assist R21 with meals. PACE aid AI verified aid visits 3 times daily to assist with meals and personal care and position changes and reported R21 was compliant with position changes. R21 family AJ reported R21 care started to decline when rehab staff moved from Wing C(R21 hall) back to Wing B and reported several agency staff who were not familiar with R21 needs that included frequent repositioning, incontinence care, two person assist with all care and staff assist with eating. R21's family AJ reported facility staff were not repositioning R21 and R21 developed a large pressure ulcer on her buttock area and staff were not following physician orders and communicating with PACE staff related to treatments. R21's family AJ reported R21 has PACE services that assist with wound care as well and that is why there is a sign on R21 wall with current wound care orders because they were not being completed as ordered. R21's family AJ reported did wash R21 hair since surveyor observation yesterday because it was greasy. R21's family AJ reported had to encourage staff all the time to assist R21 with drinks and frequently offer because R21 could not on own and today observed no beverage at the bedside. PACE aid AI reported after meals facility staff remove the tray including beverages and PACE AI reported she removes drinks from tray to keep in room. R21's family reported has had to ask staff to provide personal care to R21's backside occasionally and change sheets at least weekly after R21 observed soiled and sheets soiled within past 2 months and stated R21 does not like to smell. R21's family AI reported was not aware R21 received antibiotics for pressure wound and reported communication had been an issues for at least 2 months.
During an interview on 8/29/23 at 2:20 PM, Unit Manager(UM) AC reported had worked at the facility for about one month and reported prior wound nurse left in June and Assistant Director of Nursing (ADON) C currently follows resident wounds. UM AC reported ADON C performs weekly wound rounds including wound assessments and documentation can be located on Progress Notes. UM AC reported nursing staff are expected to complete weekly skin assessments. UM AC reported was unsure when R21 pressure ulcer developed. UM AC verified was unable to located R21 wound monitoring between 6/4/23 to 7/6/23 and verified should be weekly.
Review of the facility, Skin Assessment, dated 5/10/23, reflected an area to right buttock described as, suspected pressure injury noted(like open blister). Approximate: 3cmx 4cm. Blanchable redness around area noted. TX initiated: wash with soap a&water, pat dry, apply venelex ointment & cover with (4x4) Silicone DRSG.
Review of the facility, Skin & Wound Evaluation, dated 5/11/23, provided by facility ADON C, reflected R21 had wound measurements of 6.1 cm long by 1.2 cm in width. The document appeared incomplete as evidenced by no other sections of evaluation were answered.
Review of the Provider Progress Note, dated 5/11/2023 at 4:47 PM, for R21, reflected, seen for wound assessment and treatment - perianal/ buttock skin denudation Objective: Assessment: peri anal skin appears denuded from friction and shear, has sm amt of maceration from urine
area measures 2.0x 1.0 w 0 depth, no drainage, skin slightly erythemic, no s/s infection
Plan: d/c the Venalex and use Chamoa zinc oxide base cream will provide better skin protection, apply prn .
Review of R21's Provider consult, dated 5/11/23, reflected plan included, At this point we are going to discontinue the Venelex. I do not feel that is benefiting her wound healing. We will start using Chamo, it is a zinc oxide base cream that will provide a better skin protection and apply that p.r.n. and will need to continue to monitor her clinically as she does have quite a bit of urine sitting on her skin and the skin irritation and denudation is due to some shearing and son maceration and will need to be monitored.
Review of R21 Physician Orders, dated 3/4/22 to 5/11/23, reflected, apply zinc oxide ointment to bilateral buttocks and coccyx every day and evening shift for prevention.
Review of R21 Physician Orders, dated 5/11/23 to 6/8/23, reflected, Use chamo to buttocks for skin
protection for friction and sheer every shift.
Review of the Electronic Medical Record, dated 5/11/23 through 6/4/23, with no evidence of wound monitoring including, progress notes, wound and skin assessments, or provider notes.
Review of R21 Skin and Wound Progress note, dated 6/4/23 at 3:07 p.m., reflected, resident has open area to coccyx approx. 1.0 x 0.5, venelex applied with 3 x 3 dressing placed. will monitor. Review of Physician orders with no evidence of treatment changes.
Review of the facility, Skin Assessment, dated 6/5/23, reflected R21 had a new suspected pressure ulcer on coccyx area with description that included, Stage 3 to coccyx, slough, dark central core, beefy red wound base, no drainage, no s/s of infection, no drainage, 3.5 x1.5, no depth; Lateral stage 2 ulcer 1.0x 0.5, no depth, clean, beefy red wound base, no s/s of infection.
Review of R21 Unusual Occurrence Progress Note, dated 6/5/2023 4:00 p.m., reflected, Dependent for all care, does not ambulate, incontinent of stool ,observed with 2 new open areas to coccyx. Tx currently in place. Interventions. Turn / reposition perprotocol, staff to off -load pressure away from coccyx with use positioning device. Currently on low air loss mattress. Care plan and [NAME] updated.
Review of R21 Physician Progress Note, 6/19/2023 at 12:58 p.m., seen for wound care assessment and treatment, stage 4 coccyx ulcer .coccyx ulcer measures 4.0 x 3.7 w 2cm depth in deepest area and 1.5 cm rest of wound, clean beefy red wound base, almost friable, periwound tissue slightly macerated, intact, no s/s infection .Plan: stage 4 coccyx ulcer VAC dres, change M-W-F.
Review of R21 Progress Note, dated 6/21/2023 at 2:05 p.m., reflected, Wound vac dressing changed to stage 4 coccyx ulcer. Resident medicated for pain prior to procedure. L= 4.5cm x W=4.0cm x D= 1.8cm, tunneling at 7'0 clock 4.5cm. Wound has slough,and some eschar tissue; Peri wound is beefy red, no odor, no s/s of infection .
Review of R21 Progress Note, dated 6/24/2023 at 4:01 a.m., reflected, res temp was 101.5@1953
@2300 temp was 102.3
Review of R21 Health Status Progress Note, dated 6/26/2023 at 4:33 p.m., reflected, Coccyx wound vac dressing changed by nursing; wound measures 6.0cm L X 5.0 CM W X 3.5CM D. Wound bed with yellowish/ greenish slough, peri wound with reddish excoriation, slight drainage, some odor present .
Review of R21 Health Status Progress Note, dated 6/28/2023 at 4:52 p.m., reflected, Wound nurse
from Pace here to evaluate resident's coccyx wound. Physician contacted, treatment changed from wound vac to topical wound treatment with specific directions. Resident started on oral antibiotic for wound infection. Coccyx wound measures 4.5cm L x 6.6cm W X4.6CM D, yellowish/ greenish slough present, periwound with reddish appearance. Note completed by prior wound nurse AK.
Review of R21 Health Status Progress Note, dated 6/29/23, reflected, Late Note .Seen by wound nurse; Coccyx ulcer tx consists of gently packing the wound. Ulcer measures 6cm x 7.0 cmx 6.0cm deepest area. Resident currently on antibiotic for wound infection. Wound has odor, Wound bed presents with greenish/yellow slough. Resident continues on palliative care, due to overall medical decline . Note completed by prior wound nurse AK. (One day between wound measurements with significant difference in measurements noted. No evidence of Physician ordered wound treatments were noted in R21 EMR.)
Review of the Health Status Progress Note, dated 7/2/2023 at 6:32 a.m., reflected, Continues on ABT therapy for wound on coccxy's. Resident remains afebrile, some discomfort to perform the wound care per doctor orders. Continues on scheduled pain medication for pain.
Review of R21 Skin/Wound Progress Note, dated 7/6/2023 at 1:19 p.m., reflected, Seen for Wound assessment and treatment of stage 4 coccyx pressure ulcer. Ulcer measures 5.0 x 6.0 w 3.5cm depth, clean beefy wound base w spotting area of slough, no increase in drainage, no foul odor, peri wound tissue intact. Remains on ATB, also has a foley to divert the urine .
Review of R21 Skin/Wound Progress Note, dated 7/10/23, created 7/19/23, reflected, LATE ENTRY: Assisted with dressing change per orders. PACE NP [named] present with this writer. Wound bed granulated and beefy red. Some slough present on right lateral edge of wound. Measurements are: 4cm tunneling @ 11 O'clock, 4cm tunneling @ 5 O'clock and 2cm tunneling @ 12 O'clock, 5cm deep x 6.25cm wide. Resident tolerated well. Daughter was given an update on progress of wound when visiting.
Review of R21 EMR including the Treatment Administration Record(TAR), dated 6/1/23 through 6/30/23, reflected no evidence of treatment changes noted on 6/5/23 through 6/9/23 when new stage 3 and stage 2 pressure ulcers were identified. Continued review of R21 TAR, dated 6/9/23 through 6/13/23, reflected wound treatment orders, Stage 3 ulcer to coccyx, with lateral open area, NS cleanse, blot dry, apply santyl ointment, cover with large silicone bordered dressing, change daily, and prn, due to incontinence of stool one time a day for wound treatment. Continued review of the TAR reflected no evidence wound treatment was performed on 6/14/23. The TAR reflected treatment order changes on 6/16/23 through 6/19/23 that included, Stage 4 pressure ulcer to coccyx, lateral open area has merged into coccyx wound , NS cleanse, blot dry, apply santyl ointment to wound bed, gently pack with iodaform guaze cover with large silicone bordered dressing, change daily, and prn, due to incontinence of stool one time a day for wound treatment. The TAR reflected negative pressure Wound Vac treatment was started 6/19/23 through 6/28/23. The June and July TAR reflected no evidence R21 received stage 4 coccyx wound treatments 6/29/23 through 7/6/23(eight days) and 7/8/23, 7/9/23, 7/24/23, 7/26/23 and 7/29/23.
Review of R21 Skin/Wound Progress Note, dated 8/9/2023 at 2:10 p.m., reflected, Resident was assessed r/t stage 4 coccyx wound. Wound is 6cmX7cmX1.5cm, 90% granulationtissue to wound bed, 10% slough,wound edges are rolled, pink and surrounding skin is blanchable. Moderate amount of yellow drainage on old bandage.
Review of R21 Skin/Wound Progress Note, dated 8/28/2023 at 9:46 a.m., reflected, Late entry from 8/25/23 Resident was assessed During wound rounds. Coccyx pressure ulcer measures 5.5cmX6.8cmX1.3cm. 95%granulation tissue, 5% slough towound bed. Tolerated treatment well. Surrounding skin is blanchable. Edges are rolled.
Review of the TAR, dated 8/1/23 through 8/30/23, reflected R21 did not received Physician ordered dressing changes for the facility acquired stage 4 pressure ulcer to R21's coccyx as evidence by not being documented as complete on the following dates: 8/3, 8/6, 8/9, 8/11, 8/16, 8/18, 8/21, and 8/23/23. (Eight missed dressing changes).
Review of the Skin Care Plans, dated 1/12/23, reflected R21 had potential impairment to skin integrity r/t fragile skin, morbid obesity, impaired mobility. Continued review reflected revisions, dated 6/5/23, that reflected, The resident has impairment to skin integrity, stage 3 pressure injury to the coccyx , and a stage 2 pressure injury laterally r/t fragile skin, morbid obesity, impaired mobility .The resident has Stage 4 pressure ulcer to Lateral Coccyx r/t mechanical destruction of tissue secondary to pressure from refusing to get OOB and/or repositioning, other causative factors: decreased mobility, obesity, CHF w/edema, lymphedema, PVD, loose stools. Date Initiated: 06/13/2023 .Interventions included, BED MOBILITY: The resident requires extensive assist of (2) staff for repositioning and turning in bed routinely and as necessary. Date Initiated: 01/12/2023 .BEDFAST: The resident is bedfast all or most of the time. Date Initiated: 01/12/2023 .Monitor/document/report PRN any s/sx of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Date Initiated: 01/12/2023 .Administer treatments as ordered and monitor for effectiveness.
Date Initiated: 06/15/2023 .Assess/record/monitor wound healing at least every 7 days, Measure length, width and depth where possible, type of tissue, and exudate. Assess and document status
of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD.
Date Initiated: 06/15/2023 .Encourage and assist to a position of comfort at least with every care round as resident will allow/tolerate, more often as needed or requested. Date Initiated: 06/15/2023 .If The resident refuses treatment, confer with the resident , IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 06/15/2023 .Use pillows and such to maintain postural alignments, as resident will allow/tolerate.
Date Initiated: 06/15/2023 .Weekly skin assessment with shower per facility policy. Report any changes in skin condition to MD prn Date Initiated: 06/15/2023 . Continued review of the Care Plans reflected no updates between 5/10/23 and 6/13/23 when pressure ulcer was identified.
Review of the Progress Notes, including behavior notes and tasks, dated 5/1/23 through 8/30/23, reflected no evidence R21 refused position changes every care round.
During an interview on 8/29/23 at 5:03 PM, ADON C reported had worked at the facility since June 2023 and was responsible for wound rounds since 7/21/23. ADON C reported wound rounds are completed weekly for all residents with pressure ulcers or extensive wounds. The facility also meets for weekly wound meetings that include, MDS coordinators, Unit Managers, Dietary, Therapy, Director of Nursing (DON) B to discuss healing progress, change in treatments, dietary supplements, eating intake, therapy changes, changes in surface changes, showers, skin assessments completed, treatment orders up to date, an needed and scheduled treatments, Care Plans updated and verified was ADON C responsiblility to keeps records. ADON C reported was responsible for weekly wound monitoring including measurements, treatments, communication with provider, description of wound and documents in the Skin/Wound Progress Notes. ADON C reported prior to starting wound rounds 7/21/23 prior Wound Nurse AK was responsible for monitoring facility wounds. ADON C reported found wound monitoring in several locations including assessments, provider notes, Progress Notes without pattern and reported weekly wound rounds were not being completed and things were missed. ADON C reported facility completed skin sweep of entire facility in June 2023 and identified all wounds at that time and was unable to provide date. ADON C reported expected staff to complete weekly skin assessments under assessment tab of EMR. ADON C reported staff expected to complete Unusual Occurrence Note if a new skin irregularity is identified on a non-scheduled day for weekly skin assessment then report to Unit Managers and meet as team. ADON C reported nurse are expected to measure wounds including length, width and depth and describe wound bed and peri wound and include if tunneling present. ADON C reported facility has Nurse Practitioner who often is part of team for weekly wound rounds. ADON C reported had provided documentation to this surveyor related to R21 stage 4 coccyx pressure ulcer and verified was facility acquired and reported was unable to determine the date of onset. ADON C reported did not assess R21 stage 4 pressure ulcer the week of 8/13/23 to 8/19/23 because she was on vacation and was unable to report why weekly wound monitoring was not completed. ADON C reported documentation to be completed same day with occasional next day documentation notes. ADON C reported wound expect physician orders to be followed and R21 to be repositioned frequently and documentation of refusal.
During an interview on 8/30/23 at 11:13 AM, Certified Nurse Aid (CNA) P reported was familiar with R21 and required full assist with care. CNA P reported rehab staff moved back to B Wing 3/23/23 and reported several agency staff used to work on C Wing(R21 hall) who often can not be dependable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate safety measures to ensure resident safety for one resident (R309) of four residents reviewed for accidents and hazards, resulting in R309's repeat falls post surgical repair with re-fracture and increased likelihood for additional accidents and/or injuries.
Findings include:
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R309 was a [AGE] year-old female admitted to the facility on [DATE] post left hip fracture repair related to fall at home, with diagnoses that included hypertension (high blood pressure), dementia, heart disease, orthostatic hypotension, urinary tract infection and depression. The MDS reflected R309 had a BIM (Brief Interview for Mental status) score of 3 which indicated her ability to make daily decisions was severely impaired, and she required one-person physical assist bed mobility, transfers, walk in room and corridor, locomotion on unit, toileting, dressing, eating, hygiene, and bathing and no mention of behaviors.
Review of the facility Matrix, dated 8/28/23, reflected R309 had a fall with major injury.
During an observation on 8/28/23 at 1:36 PM, R309 was in bed laying on left side with eyes closed.
During an observation on 8/28/23 at 1:52 PM, R309 was in bed laying on left side with eyes closed.
Review of R309 admission Summary Progress Note, dated 7/31/2023 at 4:30 p.m., reflected, Resident Arrived via wheelchair w/ family present and private transportation. Resident A&ox1 w/ confusion. Resident is able to respond to commands. Resident has unsteady gate and requires one person assist during transfers and toileting. Resident is a high fall risk. Resident admitted for rehab post Left hip surgery. Resident has no c/o pain at the moment. Resident VS WNL. Resident has bruising to Left hip surgical site. Resident skin is intact. Resident has no c/o of pain or discomfort at the moment. Resident has all safety measures in place and call light in reach.
Review of the Health Status Progress Note, dated 7/31/2023 at 5:49 p.m., reflected, Writer informed by CNA that PT had a fall. upon entering room resident was standing with daughter. Writer assessed PT, VS WNL, Pt has no c/o pain. PT repositioned in bed, w/ family present. Safety measures put in place. Writer will continue to monitor. Note completed by Registered Nurse (RN) AL.
Review of R309 COMMUNICATION with Family/NOK/POA Progress Note, dated 8/1/2023 at 4:07 a.m., reflected, Note Text: @1930, Family members at bedside. [named],dght, [named], dght and son, [named] regarding POC for resident. A/E completed. Reviewed AVS. Education provided to family regarding medication regime s/p DC from hospital. [named daughter] expressed some concern of change in Seroquel dosage from 3 times a day as in the hospital to 2 times a day in rehab. Further expressed her concern of the increased agitation and verbal aggression noted while in the hospital. Provided education of side effects related to post surgery and anesthesia. Informed family the Seroquel has been reduced and the Oxycodone has been increased. [named daughter] suggests the agitation may be related to pain. Reports the resident may be in pain but not vocal. Explained to the family the process used to assess and evaluate for pain with patients who are unable to verbalize. Assured family members, resident will be closely monitored, and frequently assessed for pain, cognition and safety. Residents room is located in very close proximity to nurse's station. CNA's will be seated at the door overnight to monitor resident if she makes any attempts to get out of bed unattended .
Review of the Hospital Discharge notes, dated 7/31/23, reflected R309 was status post open reduction internal fixation for fractured left hip on 7/25/23.
Review of R309 Behavior Note, dated 8/1/2023 at 2:42 p.m., reflected, pt non-compliant with call light and walking assistive device, pt self-transferring, pt educated.
Review of R309 Behavior Note, dated 8/2/2023 at 11:16 a.m., reflected, Pt attempting to self-transfer repeatedly all morning, aide having to sit with pt for safety.
Review of R309 Unusual Occurrence Note, dated 8/2/2023 at 6:22 p.m., reflected, nurse was in a room with another pt, as I was walking out the aide called for nurse stating that pt was laying on the floor, observed pt laying on the floor next to WC on her back, pt has shoes on, pt was unable to describe what happened, stated she didn't know, nurse assessed, pt able to do ROM on all extremities, denies pain, neuro checks and orthos initiated, physician contacted, will continue to monitor, no new orders.
Review of R309 Unusual Occurrence Note, dated 8/3/2023 at 2:53 a.m., reflected, Resident was observed at about 0040hr laying on her right side on the floor toward the foot part of her bed. Upon assessment, inward rotation and shorten of her left foot was observed. And resident yells for pain whenever the left foot was touched. She was unable to move the left foot. She was transferred back to W/C with 2xEA using gait belt. PRN oxycodone 5mg IR was given for pain control and Neuro check initiated, Physician and family notified. 911 called and resident was transferred to [named] hospital ER for further Evaluation at 0207hr. Note was completed by Licensed Practical Nurse(LPN) AM.
Review of R309 Health Status Note, dated 8/3/2023 at 4:08 p.m., reflected, This nurse received update from [named] hospital, resident has been admitted to the hospital, pending surgery to replace hardware in left hip. Resident scheduled as add on for surgery today. Will continue to monitor.
Review of the Unusual Occurrence Note, dated 8/4/2023 at 2:12 p.m., reflected, IDT review of incidents on 7/31/23; 8/2/23; and 8/3/23. Resident observed on the floor after attempting to self-ambulate to the restroom. This nurse spoke with resident's son [named] who states his mother's memory is not the best. He states that resident can take herself to the bathroom and 2 minutes later, not remember she had already gone. Fall on 8/3/23, resulted in transfer to ER and broken hip. Hip replacement surgery occurred on 8/3/23. Son states mom is doing well; however, does not remember she had surgery. IDT team will discuss possible interventions with family upon re-admission to facility.
Review of the Radiology Report, dated 8/3/23, reflected R309 had X-ray of left femur and hip that included, IMPRESSION .Mild deossification with laterally angulated long oblique fracture proximal femoral diaphysis encompassing the distal portion of a proximal femoral intramedullary rod .
Review of R309 Operative Report, dated 8/3/23, reflected, Postoperative diagnosis: HIP PERI PROSTHETIC FRACTURE-femur .Procedure: Open reduction internal fixation of left femur periprosthetic fracture with retention of intramedullary nail .Operative Summary: This is an [AGE] year-old female who had a fall little over a week ago resulting in an IT hip fracture that was treated
through the [named] health care system with a intramedullary nail. She was then transferred to the [named] facility where she had multiple falls resulting in left hip pain. She was found to have a periprosthetic fracture at the tip of the recently placed hip nail. I was consulted by both family and the emergency room physicians for treatment of this complicated problem .
Review of R309 Health Status Note, dated 8/8/2023 at 7:08 p.m., reflected, Patient arrived at 1905 via stretcher and ambulance service, clinical report received from transport driver which included that patient received 1u PRBC today.
Review of the Behavior Note, dated 8/9/2023 at 4:25 p.m., reflected, resident attempting to self transfer multiple times. Offered snack, repositioning, pain medication. resident refused. staff got resident into wheel chair, resident did attempt to hit nurse once, CNA assisted. resident placed in hallway at table as she is a high fall risk. resident calmed down after a few minutes, will continue to monitor.
Review of R309 Physician History and Physical Progress Note, dated 8/9/2023 at 5:40 p.m., reflected, Seen in her room. She had a fall today. unwitnessed. X-ray of left hip was done and report reviewed. It was negative for acute fx. Dementia limits history and ROS Pt was sent to the hospital on 8/3/23 after several falls in the facility. Pt c/o left hip pain. Seen by ortho. Pt to follow up with Ortho in 2-4 weeks. Patient family agreeable to returning to SAR they would like a Fall prevention plan in place .impairment/Multi morbidity and associated functional deficits,Without skilled therapeutic intervention, the patient is at high risk for falls, further decline in function, increase dependency upon caregiver(s), and decrease ability to return to prior living environment. Fall risk, fall assessment done. Pt at high risk of falls d/t multiple risk factors including multiple comorbidities .
Review of the Progress Note, dated 8/11/2023 at 4:23 p.m., reflected, Pt having uncontrolled pain, [named Physician] ordered scheduled oxycodone 5mg BID and 5mg PRN q6h.
Review of R309 Unusual Occurrence Note, dated 8/14/2023 at 5:31 p.m., reflected, Aide reports finding resident on the floor face up in front of her wheelchair. Rt. was sitting near the nurses station for monitoring per care plan. Rt. unable to recall where she fell. Neuros and orthos performed. VS stable. No bruising or abrasions noted after skin assessment. L-hip pain consistent with chronic pain reported. [Named Physician] was notified. STAT L-hip XR ordered.
Review of R309 Unusual Occurrence Note, dated 8/17/2023 at 4:36 p.m., reflected, IDT review of U/O from 8/14/2023 - [named R309] is a [AGE] year old female w a diagnosis of Left Femur Fracture, HTN, CAD, Alzheimer's/Dementia and anxiety. BIMS is 3.0 which indicates severely impaired cognition. On 07/14/2023[8/14/23] resident was observed on the floor near her wheelchair which was in the locked position. Resident could not recall what she was trying to do. Resident was assessed by staff nurse and CENA. Family and physician were informed. Stat XR of Left hip was ordered and completed without any acute process noted. Intervention: activities and busy board implemented when resident in common areas. Fall Huddle performed and environment assessed immediately after occurrence. Environment noted to be free of debris or liquid spills and was well lit. Care plan and [NAME] reviewed and updated accordingly.
Review of the Health Status Note, dated 8/20/2023 at 6:34 a.m., reflected, Urine sample collected, dip test performed with positive results for leukocytes and nitrates. Urine sample to be sent to the lab.
Review of the Infection Note, dated 8/26/2023 at 12:37 p.m., reflected, UA results in, [named physician] notified, new order noted for Cipro 500mg PO BID x7 days.
Review of R309 Progress Note, dated 8/28/2023 at 7:28 p.m., reflected, Resident was unwitnessed, sitting on the floor by the table cleaning up food off the floor with a napkin. No injuries noted. o complaints of pain. VSS. Message left with son [named]. Night nurse to notify physician. Safety measures are in place.
Review of the facility, [NAME] Report, dated 8/2/23(prior to 8/3/23 fall at 12:40 a.m.), reflected R309 had interventions that included, Mobility AMBULATION: 1x EA using 2ww with wheelchair follow in hallway
BED MOBILITY: The resident requires (assistance) by (1) staff to turn and reposition in bed
TRANSFER: 1x EA using 2ww
Safety
Anticipate and meet The resident's needs.
Encourage rest periods if resident becomes fatigued
Encourage the resident to use bell to call for assistance.
Non-skid footwear when up
Staff to assist resident when rising from chair
Stay with resident when standing at the table and leave chair behind resident during an activity .
Review of R309 fall Care Plans, dated 8/1/23, reflected, The resident is at risk for falls r/t Actual
Fall: causing left hip fracture, family reports Mutiple falls in recent months, , Confusion R/T dementia, Deconditioning, Gait/balance problems, Poor communication/comprehension, Psychoactive drug use, Unaware of safety needs , Unsteady gait, self transfers, impulsive. Date Initiated: 08/01/2023 .The resident will not sustain serious injury through the review date. Date Initiated: 08/02/2023 .Anticipate and meet The resident's needs. Date Initiated: 08/01/2023 .Assist devices as ordered. Date Initiated: 08/01/2023 .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 08/01/2023 .Bed in lowest position when resident is in bed. Date Initiated: 08/09/2023 .Busy board to occupy resident when in hallway. Date Initiated: 08/14/2023 .Encourage rest periods if resident becomes fatigued. Date Initiated: 08/01/2023 .Follow facility fall protocol.
Date Initiated: 08/01/2023 .Monitor floor and pick up items, keep free of clutter. Date Initiated: 08/01/2023 .Monitor for medication side effects. Date Initiated: 08/01/2023 .Non-skid footwear when up Date Initiated: 08/01/2023 .Ortho BP and neuro-checks as warranted per unusual occurrence policy. Date Initiated: 08/01/2023 .Place floor mats at bedside when resident is in bed
Date Initiated: 08/09/2023 .Staff to assist resident when rising from chair. Date Initiated: 08/01/2023 .Stay with resident when standing at the table and leave chair behind resident during an activity. Date Initiated: 08/01/2023 . No changes in interventions noted after R309 fall on 8/14/23 or 8/28/23.
Review of the facility fall risk assessment, dated 7/31/23, reflected R309 was at risk for falls.
Requested all Incident/accident reports for R309 with complete investigations if applicable for past four months via email on 8/29/23 at 4:39 p.m. to Chief Operating Officer(COO) AB.
Second request for all Incident/accident reports for R309 with complete investigations if applicable for past four months via email on 8/30/23 at 9:42 a.m. to Chief Operating Officer(COO) AB related to no documents had been provided for review at that time.
Received email, dated 8/30/23 at 10:02 a.m., with requested Incident/Accident investigations. The email included five un-witnessed fall Incident/Accident reports for R309, dated 7/31/23, 8/2/23, 8/3/23, 8/14/23 and 8/28/23.
During an interview on 8/30/23 at 10:25 AM, LPN AN reported had worked at the facility for 12 years and reported working as LPN three months ago. LPN AN reported was familiar with R309 and did not recall being present for any falls. LPN AN reported R309 was high risk for falls at time of admission because she was admitted to facility post fall with left hip fracture and repair and fell within one hour after admission. LPN AN reported staff tried to do 1:1(sitting with her) as much as they can along with being responsible for care of at least six other residents, meals, call lights, walk to dine, admissions, discharges, orthostatic blood pressures, vitals, heights, weights, and packing residents for discharge. LPN AN reported times with up to eight new admissions in one day. LPN AN reported R309 was pleasantly confused, forgetful(even forgot about both surgeries) and reported could tell R309 was in pain by holding hip but R309 did not know why. LPN AN reported R309 was constantly moving and needed one on one(1:1) care but staff can't do 1:1 because they do not have the staffing. LPN AN reported encouraged R309 to use call light but re-education was not effective but have to try and reported R309 never used call light. LPN AN reported interventions that were add for R309 to prevent falls were activity blankets, book on tape, crossword, tablet with music(liked Elvis), and mats on floor next to bed. LPN AN reported nurse responsible for resident at the time of a fall was expected to complete Unusual Occurrence Report immediately and implement one to three interventions. LPN AN reported facility fall policy was for nurse to complete full head to toe assessment prior to moving resident off floor, vitals, assess skin for injury including bleeding, complete range of motion of all joints, call physician, transfer resident off the floor with hoyer lift to prevent weight barring, notify DPOA, and manager. LPN AN reported did recall being present for R309 8/2/23 fall and reported R309 was in the hall in a wheelchair while staff were passing dinner trays. LPN AN reported fall was not witnessed and R309 did not have injuries and the Unit Manager assisted with documentation. LPN AN reported B Wing(sub-acute rehab) usually had three to four CNA staff and one to two nurses on days according to census on rehab. LPN AN reported facility had staffing guidelines posted at the Nurse Stations.
During an interview and record review on 8/30/23 at 10:45 AM, RN AO reported had worked at the facility for four years. RN AO reported staffing guidelines are at nurse stations and provided copy for review. Review of facility, New Staffing Guidelines All Units, dated 1/14/22, revealed B Wing(rehab) should have minimum of 4 aids for 19-24 residents and 1 nurse for every 16 residents of staffing crisis otherwise 1 for every 12 residents on days. RN AO reported worked 8/28/23 on B Wing as only nurse with 3 aids and no Unit Manager on days with census of 24. RN AO reported on 8/28/23 the second nurse on the schedule had been terminated 7/3/23 so facility staff were aware prior to shift that second nurse was not planning to be there and schedule originally had 4 cna staff but one was pulled to Long Term Care which left rehab short a nurse and a CNA. RN AO reported they had two falls(including R309), and two admissions on 8/28/23 prior to second nurse arriving at 2:00 p.m. RN AO reported R309 was a very high risk for falls and required constant supervision and redirection. RN AO reported R309 had been sitting in hall and had an unwitnessed fall with no known injuries on 8/28/23 when staffing was low. RN AO reported CNA staff had been pulled from Rehab unit on 17 occasions since 8/23/23.
During an interview on 8/30/23 at 11:00 a.m., Unit Secretary(US) P reported was also a CNA and reported R309 was very spontaneous and was okay if someone was by R309 but as soon as staff walked away R309 attempted to self transfer.
During an interview and observation on 8/30/23 at 11:54 AM, Systems and Strategic Project Manager(SSPM) AP reported could assist with video review from facility camera system. Review of the B wing(rehab) nurse station area with view of R309 room from 8/3/23 at 12:30 a.m. to 2:05 a.m. with SSPM AP present. Observed several staff enter R309 room at 12:38 a.m.(no noted staff sitting outside room prior). At 12:51 a.m. CNA staff pushed R309 out of room in wheel chair and parked in the hall with left leg elevated on foot rest and R309 foot observed rotated inward and gait belt around R309(no hoyer sling noted under R309). CNA staff attempted to reposition R309 left lower leg and R309 appeared to be restless. Continued review of the video reflected LPN AM approach R309 at 1:28 a.m.(nurse not observed near R309 from 12:51 a.m. to 1:28 a.m.) Emergency Medical Services arrived at 2:02 a.m.
During a telephone interview on 8/30/23 at 1:45 PM, LPN AM reported was nurse when R309 had an unwitnessed fall in room and re-fractured left hip on 8/3/23. LPN AM reported R309 was a high risk for fall and staff tried to keep an eye on R309 but did not witness R309 fall from bed and was located at around 12:40a.m. LPN AM reported R309 did not have a fall mat in place at the time of the fall and staff did not hear any noise from the room. LPN AM reported R309 had frequent attempts to self transfer. LPN AM reported R309 was assessed after the fall and was observed to have left leg internal rotation with pain. LPN AM reported three to four staff assisted resident from floor to wheel chair with use of gait belt and physician, and EMS were called.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00138710.
Based on observation, interview, and record review, the facility failed to provide treatment and services to restore as much normal bowel and bladder function as possible in one of two residents reviewed for bowel and bladder incontinence (Resident 149#), resulting in continued or worsened incontinence. Findings include:
Resident #149 (R149)
On 8/28/23 at 10:44 AM, R149 was observed sitting in her room in a wheelchair. R149's family member was interviewed at the same date and time and stated R149 was admitted to the facility for short-term rehabilitation following a stroke, and the plan was for her to return home with services. R149's family member voiced a concern that the facility had refused to work on bowel and bladder training for R149's incontinence.
R149's Minimum Data Set (MDS) dated [DATE], revealed she was admitted to the facility on [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 03 (00-07 Severe Impairment). R149's same MDS assessment revealed she required extensive assistance (staff provide weight-bearing support) for toilet use (how resident transfers on and off toilet, cleanses self after elimination, adjusted clothes). The same assessment revealed R149 was frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) of bladder and frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement) of bowel. The same MDS assessment indicated R149 never had a trial toileting program (scheduled toileting, prompted voiding, or bladder training) attempted since urinary and bowel incontinence was noted in the facility.
The Centers for Medicare and Medicaid Service's, Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.17.1, October 2019; revealed an individualized, resident-centered toileting program may decrease or prevent urinary and bowel incontinence. The same source revealed many incontinent residents (including those with dementia) respond to a toileting program, especially during the day. According to the same RAI manual, each incontinent or resident found at risk for incontinence should be identified, assessed, and provided with individualized treatment and services to achieve or maintain as normal elimination as possible. The same source advised a toileting trial should include observations of at least 3 days of toileting patterns with prompting to toilet and of recording results in a bladder record or voiding diary. The same source advised a bowel toileting program should be based on an assessment of the resident's unique bowel pattern and the provider may want to consider assessing the resident for adequate fluid intake, adequate fiber in the diet, exercise, and scheduled times to attempt bowel movement.
R149's Urinary Incontinence Care Area Assessment, with assessment reference date of 8/08/23, revealed she had moisture associated skin damage (MASD) due to urinary incontinence. The same document indicated R149 received assistance of one staff person for check and change with rounding. The same assessment did not indicate the type of R149's incontinence (stress, urge, mixed, overflow, transient, or functional). The same assessment indicated the overall objective for R149's urinary incontinence included improvement of continence. The same assessment did not indicate a toileting trial of at least 3 days of toileting patterns with prompting to toilet and of recording results in a bladder record or voiding diary were completed. The same assessment instructed to provide input from resident and/or family/representative regarding incontinence, questions/comments/Concerns/preferences/suggestions was left blank.
R149's bowel and bladder incontinence care plan dated 8/19/23 revealed her goal was to remain free from skin breakdown due to incontinence and brief use and the intervention was to check and change in conjunction with assisted toileting.
Unit Manager AC was interviewed on 8/29/23 at 3:19 PM and stated she did not know if the facility had a bowel and bladder program for incontinence and stated the nurse assistants checked and change residents every 2 hours.
During an interview with Certified Nurse Assistant (CNA) AD on 8/30/23 at 10:06 AM, she stated R149 was incontinent, and toilet her whenever she had the urge or when getting in or out of bed.
Director of Nursing (DON) B was interviewed on 8/30/23 at 1:51 PM and stated she had not seen any bowel and bladder monitoring for patterns completed at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform nutritional assessments and implement nutrition interventions for two (Resident #109 and Resident #146) of six reviewed, resulting in the potential for continued weight loss and a decline in nutritional status.
Findings include:
Resident #146 (R146)
Review of the medical record revealed R146 admitted to the facility on [DATE] with diagnoses that included dementia, cervical disc disorder, and insomnia. According to the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/23 revealed R146 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), required extensive assistance of one person for eating, weighed 125 pounds (#), sustained a significant weight loss of 5% or more in the last month or 10% or more in the last six months and was not on a prescribed weight loss regimen.
Review of Mini Nutritional assessment dated [DATE] and 7/3/23 revealed R146 scored 2 which reflected R146 was malnourished.
Review of R146's weights revealed the following:
5/25/23 149.4#
6/5/23 141#
6/6/23 137#
6/8/23 136#
6/9/23 134#
6/12/23 128#
6/26/23 124#
8/1/23 124.2#
R146 had not been weighed since 8/1/23.
Review of the Weight Change Note dated 6/1/23 revealed weight down 8# x 3 days, previously stable. BMI 22. Intakes continue 50-75%. Whole milk w/meals and ice cream added to meet kcal needs. Some flux anticipated r/t [related to] diuretic tx [treatment]. Will continue to monitor.
Review of the Weight Change Note dated 6/8/23 revealed R146 had 12.4# weight loss which was a 8.3% loss. The note revealed Meal intakes not meeting estimated needs likely r/t severe Dementia. Dines in hall with supervision/encouragement. Added order for healthshakes w/meals to help meet nutritional needs.
Will continue to monitor.
Review of the Weight Change Note dated 6/13/23 revealed R146 had a 21.4# weight loss which was a 14.3% loss. The note further explained that R146 lost 9# in one week and intakes were improved to 75% due to family coming in to assist with feeding R146. R146 continued to receive health shakes with meals and prostat for wound healing.
Review of the Significant Change Nutrition assessment dated [DATE] revealed intakes increased to avg 75% with increased assistance, meeting nutritional needs. The prostat was discontinued due to a healed wound. The assessment revealed R146 enjoyed ice cream, used two handled cups, required partial assistance with eating.
Review of the Weight Change Note dated 7/14/23 revealed R146 was flagging for ongoing weight loss. Recommend moving resident to 1:1 [one on one] assist table for assistance. Removed Healthshakes from meal trays, added standing orders to offer whole or chocolate milk and juice to maintain calorie intake of meals. Added order to offer Boost Plus as AM/MD snacks to increase overall intake. Can hold drinks by herself.
On 8/28/23 at 11:43 AM, R146 was observed arriving to the dining room after staff assisted her to the bathroom. R146 was served two cups of juice in regular cups. Milk was not offered or served. R146 spilled half of a cup of juice on the table while trying to drink. At 11:56 AM, R146's pureed texture meal was served. R146 began feeding herself. Milk was not served. R146 ate approximately 60% of her meal before she required staff assistance to eat the remainder.
On 8/29/23 at 8:13 AM, R146 was observed in the dining room prior to meal service. R146 was served white milk and apple juice in regular cups. At 8:20 AM, R146 began using her knife to scoop her food and feed herself. Once staff arrived to the table, R146 was assisted with placing a spoon in her food so she could feed herself.
On 8/30/23 at 7:53 AM, R146 was observed in the dining room with water and juice in cups with sippy lids and two handles. R146 was not served milk. R146 was observed feeding herself.
Review of R146's Nutrition Care Plan revealed daily weight monitoring was initiated on 5/29/23, two-handled cups for beverages was initiated on 5/29/23, I require 1:1 assistance at meals was initiated 6/8/23, and offer whole or chocolate milk with meals to increase protein-calorie intake was added 5/29/23.
In an interview on 8/30/23 at 11:26 AM, Registered Dietitian (RD) N reported R146 needed supervision at meals. RD N reported interventions included offering assistance with meals, two-handled cups with beverages, and milk with meals to increase protein and calorie intake. RD N reported she had noticed that some staff will provide beverages before meal tickets arrive and that could be how the milk and two-handled cups were not being used.
Resident #109 (R109)
A review of the medical record revealed R109 admitted to the facility on [DATE] with diagnoses that included urinary tract infection, type 2 diabetes, aphasia (a language order that affects a person's ability to communicate), and adult failure to thrive. R109 had a brief interview for mental status (BIMS), a short performance based cognitive screen for nursing home residents, score of 10 (8-12 moderately impaired) which was completed on 8/26/2023.
During an interview on 08/28/23 at 11:18 AM, R109 was lying in bed and mentioned that he had weight loss before which was why he was on a tube feeding previously. R109 said that he didn't need it anymore. R109 wasn't sure if he had weight loss currently after coming back to the facility on 8/21/2023.
Review of R109's weights on 08/28/23 at 01:54 PM:
8/26/2023: 178
8/25/2023: 180
8/21/2023: 184.2
8/3/2023: 191
8/2/2023: 190
8/1/2023: 193
7/31/2023: 192
7/30/2023: 192
7/29/2023: 190
7/28/2023: 191
7/27/2023: 192
Weights from 7/27/2023 to 8/26/2023 indicated a -7.29 (%) loss which was a significant weight loss.
Review of August 2023 order summary indicated that daily weights one time per day during the day would start 8/22/2023. Weights were not obtained on 8/22, 8/23 and 8/24.
Review of progress notes on 8/29/2023 at 11:05AM after R109 was admitted back to the facility on 8/21/2023, indicated there were no nutrition notes regarding R109's weight loss. There also wasn't a nutrition assessment completed since coming back to the facility on 8/21/2023.
During an interview on 08/29/23 at 01:25 PM, Registered Dietitian (RD) U mentioned that the baseline care plan meeting was supposed to be completed within 72 hours and after the RD meets with the resident.
Review of the baseline care plan under nutrition revealed new weight loss wasn't mentioned from discharge weight on 8/3/2023 to R109 coming back to the facility on 8/21/2023. The baseline care plan intervention mentioned Routine weight monitoring per policy and as clinically indicated.
Review of progress notes on 8/29/2023 at 04:55PM, noted RD N created a late entry progress note on 8/29/2023 which was dated for 8/21/2023. This progress note discussed R109's weight decrease and tube feeding. Also noted RD N completed and locked R109's nutrition assessment on 8/29/2023 with a late entry note. The nutrition assessment indicated significant weight loss.
Upon review of orders again on 8/30/2023, it was noted the boost supplement order was put in on 8/29/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation on 8/29/2023 at 8:20 AM, the call light for room [ROOM NUMBER], that was visible outside of the room door, was on. At 8:25 AM, five staff members were observed to walk past room and did not stop to address the resident's need.
On 8/29/2023 at 8:44 AM, the call light was on for room [ROOM NUMBER] two staff members walked past and did not address the call light or resident needs, and at 8:48 AM, two other staff members walked by and did not address the call light or the resident's needs. At 8:49 AM, four other staff members were observed to walk by room [ROOM NUMBER] and did not stop and address the call light or the resident's needs.
In an observation on 8/30/2023 at 9:44 AM, room [ROOM NUMBER]'s call light was on. Two staff members walked by room [ROOM NUMBER] and did not address the call light or the resident's needs. A nurse was observed standing at the medication cart in the hall, but did not address the call light or resident's needs.
In an observation on 8/30/2023 at 9:55 AM, a call light on the 200 hall was on, and a housekeeper walked past the call light but did not stop and address the resident's concerns.
On 8/30/2023 at 9:58 AM, the call light on the 200 hall remained on. A staff member walked by the call light, but did not stop and address the resident's needs.
On 8/30/2023 at 10:00 AM, room [ROOM NUMBER]'s call light was on. A nurse was standing at the medication cart that was directly across from room [ROOM NUMBER], but did not address the call light or the resident's needs, and at 10:03 AM was observed to push the medication cart down the hall without acknowledging room [ROOM NUMBER]'s call light. At 10:04 AM four staff members were observed at the nurse's station, where the call light was visible, but never answered room [ROOM NUMBER]'s call light.
In an interview on 8/30/2023 at 10:07 AM, Certified Nurse Aid (CNA) V stated that all employees of the facility were to answer call lights, and if that person could not assist with the resident's needs then the call light was to be left on, and the staff member was to bring the need to the appropriate staff members attention. CNA V stated that no other staff members other than the CNAs answer call lights. CNA V stated that it was very frustrating that staff just leave the call lights on for the CNAs to address.
In an interview on 8/30/2023 at 10:13 AM, CNA W stated that the CNAs were not able to do two hours checks and turns for the residents. CNA W said it was difficult to get resident's up for meals, and a lot of residents required a two person mechanical light to get up on the 200 hall. CNA W said that no staff outside of CNAs ever assist on the hall.
In an interview on 8/30/2023 at 12:51, Director of Nursing (DON) B stated that she expected that call lights be answered timely, and stated that all staff in all departments were expected and responsible to answered call lights.
Record review of the facility's policy and procedure titled, POLICY: CALL LIGHTS dated 3/2/2022, revealed under #8, Staff members who see an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified and the call light shall be left on until the residents need is met.
Resident #149 (R149)
On 8/28/23 at 10:44 AM, R149 was observed sitting in her room in a wheelchair. R149's family member was interviewed at the same date and time and stated R149 was admitted to the facility for short-term rehabilitation following a stroke, and the plan was for her to return home with services.
On 8/29/23 at 9:16 AM, R149's family reported R149 preference was to go to bed a 7:00 PM, but it was not possible due to shift change, and the amount of call lights on at that time.
R149's Minimum Data Set (MDS) dated [DATE], revealed she was admitted to the facility on [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 03 (00-07 Severe Impairment). R149's same MDS assessment revealed she required extensive assistance (staff provide weight-bearing support) of two plus persons for transfers.
A confidential Resident Council Meeting commenced on 8/29/23 at 11:30 AM. Three of seven residents that were actively participating in the meeting reported concerns with staffing. One resident stated they waited a over an hour for assist when there was only one nurse assistant scheduled on her unit. Another resident stated she had to eat breakfast in bed sometimes because they did not get her up in the morning in time and had waited over an hour for assistance. One resident stated he had to eat dinner in his room sometimes due to staffing.
This citation pertains to intake MI00138710.
Based on observation, interview, and record review the facility failed to ensure sufficient nursing staff for four residents (R114, R125 and R149 and R309) and the confidential residents attending Resident Council resulting in the potential of all 171 residents residing at the facility being unable attain or maintain their heights practicable physical, mental, and psychosocial well-being related to complaints of missed or late medications and treatments, safety and unmet care needs.
Finding Included:
Review of the facility's CMS-672 Resident Census and Conditions of Residents dated 8/28/23 revealed the facility's census was 171, of which 111 required assistance of one or two staff for bathing, 158 required assistance of one or two staff for dressing, 107 required assistance of one or two staff for transferring, 154 required assistance of one or two staff for toilet use, and 51 required assistance of one or two staff for eating. The CMS-672 also revealed 60 residents were dependent on staff for bathing, 7 were dependent on staff for dressing, 44 were depending on staff for transferring, 9 were dependent on staff for toilet use, and 30 were dependent on staff for eating.
Resident #309(R309)
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R309 was a [AGE] year-old female admitted to the facility on [DATE] post left hip fracture repair related to fall at home, with diagnoses that included hypertension (high blood pressure), dementia, heart disease, orthostatic hypotension, urinary tract infection and depression. The MDS reflected R309 had a BIM (Brief Interview for Mental status) score of 3 which indicated her ability to make daily decisions was severely impaired, and she required one-person physical assist bed mobility, transfers, walk in room and corridor, locomotion on unit, toileting, dressing, eating, hygiene, and bathing and no mention of behaviors.
Review of R309 Operative Report, dated 8/3/23, reflected, Postoperative diagnosis: HIP PERI PROSTHETIC FRACTURE-femur .Procedure: Open reduction internal fixation of left femur periprosthetic fracture with retention of intramedullary nail .Operative Summary: This is an [AGE] year-old female who had a fall little over a week ago resulting in an IT hip fracture that was treated
through the [named] health care system with a intramedullary nail. She was then transferred to the [named] facility where she had multiple falls resulting in left hip pain. She was found to have a periprosthetic fracture at the tip of the recently placed hip nail. I was consulted by both family and the emergency room physicians for treatment of this complicated problem .
Received email, dated 8/30/23 at 10:02 a.m., with requested Incident/Accident investigations. The email included five un-witnessed fall Incident/Accident reports for R309, dated 7/31/23, 8/2/23, 8/3/23, 8/14/23 and 8/28/23.
During an interview on 8/30/23 at 10:25 AM, LPN AN reported had worked at the facility for 12 years and reported working as LPN three months ago. LPN AN reported was familiar with R309 and did not recall being present for any falls. LPN AN reported R309 was high risk for falls at time of admission because she was admitted to facility post fall with left hip fracture and repair and fell within one hour after admission. LPN AN reported staff tried to do 1:1(sitting with her) as much as they can along with being responsible for care of at least six other residents, meals, call lights, walk to dine, admissions, discharges, orthostatic blood pressures, vitals, heights, weights, and packing residents for discharge. LPN AN reported times with up to eight new admissions in one day. LPN AN reported R309 was pleasantly confused, forgetful(even forgot about both surgeries) and reported could tell R309 was in pain by holding hip but R309 did not know why. LPN AN reported R309 was constantly moving and needed one on one(1:1) care but staff can't do 1:1 because they do not have the staffing. LPN AN reported encouraged R309 to use call light but re-education was not effective but have to try and reported R309 never used call light. LPN AN reported interventions that were add for R309 to prevent falls were activity blankets, book on tape, crossword, tablet with music(liked Elvis), and mats on floor next to bed. LPN AN reported nurse responsible for resident at the time of a fall was expected to complete Unusual Occurrence Report immediately and implement one to three interventions. LPN AN reported facility fall policy was for nurse to complete full head to toe assessment prior to moving resident off floor, vitals, assess skin for injury including bleeding, complete range of motion of all joints, call physician, transfer resident off the floor with hoyer lift to prevent weight barring, notify DPOA, and manager. LPN AN reported did recall being present for R309 8/2/23 fall and reported R309 was in the hall in a wheelchair while staff were passing dinner trays. LPN AN reported fall was not witnessed and R309 did not have injuries and the Unit Manager assisted with documentation. LPN AN reported B Wing(sub-acute rehab) usually had three to four CNA staff and one to two nurses on days according to census on rehab. LPN AN reported facility had staffing guidelines posted at the Nurse Stations.
During an interview and record review on 8/30/23 at 10:45 AM, RN AO reported had worked at the facility for four years. RN AO reported staffing guidelines are at nurse stations and provided copy for review. Review of facility, New Staffing Guidelines All Units, dated 1/14/22, revealed B Wing(rehab) should have minimum of 4 aids for 19-24 residents and 1 nurse for every 16 residents of staffing crisis otherwise 1 for every 12 residents on days. RN AO reported worked 8/28/23 on B Wing as only nurse with 3 aids and no Unit Manager on days with census of 24. RN AO reported on 8/28/23 the second nurse on the schedule had been terminated 7/3/23 so facility staff were aware prior to shift that second nurse was not planning to be there and schedule originally had 4 cna staff but one was pulled to Long Term Care which left rehab short a nurse and a CNA. RN AO reported they had two falls(including R309), and two admissions on 8/28/23 prior to second nurse arriving at 2:00 p.m. RN AO reported R309 was a very high risk for falls and required constant supervision and redirection. RN AO reported R309 had been sitting in hall and had an unwitnessed fall with no known injuries on 8/28/23 when staffing was low. RN AO reported CNA staff had been pulled from Rehab unit on 17 occasions since 8/23/23.
During an interview on 8/30/23 at 11:00 a.m., Unit Secretary(US) P reported was also a CNA and reported R309 was very spontaneous and was okay if someone was by R309 but as soon as staff walked away R309 attempted to self transfer.
Resident #125 (R125)and Resident #114 (R114)
In an interview on 08/29/23 at 7:59 AM, R125 reported that the previous Saturday and Sunday waited an hour and a half, maybe two (hours) for her call light to be answered so she could receive help getting into bed for the night. R125 reported that waiting for call light response at night happens lot lately.
In an interview on 08/29/23 at 09:00 AM, R114 reported that she would like to be up and out of bed more but staff tell me they will when they get time but they never come and get me up. R114 stated that the problem of not being able to obtain the help to get out of the bed is a constant issue but is worse on the weekends.
In an interview during the week of the survey, a confidential staff member reported that staffing on the weekends is awful. Agency staff members call in, come in late, or choose to leave when they do not like their assignment. The confidential staff member reported coming in on mornings and seeing red hips from the residents not being repositioned and residents in soiled briefs.
In an interview on 08/30/23 at 6:54 AM, Certified Nursing Assistant (CNA) AH stated that agency staff had been hired to assist with the staffing but it appears to be a process that is failing. CNA AH reports that agency fail to report to their scheduled shift, call in, come in late, and or leave early. CNA AH stated that there are times when she has 24 residents assigned to her.
In an interview on 08/30/23 at 7:18 AM, Certified Nursing Assistant (CNA) AG reported that working understaffed happens quite often. CNA AG stated that agency staff show up late, call in, or leave the facility entirely if they do not agree with their assignment for the day. CNA AG reported that often she has to skip doing things such as oral care and basic grooming because she does not have the time.

Based on interview and record review the facility failed to ensure three out of six Certified Nurse Aids (CNA) have completed a yearly competency/skills check list resulting in the potential for compromised resident care and unmet needs.
Findings Included:
In an interview on 8/30/2023 at 10:13 AM, CNA W stated that she had been telling Director of Nursing (DON) B, and even wrote a letter that she needed to get her skills competency checklist completed. CNA W stated she also told Unit Manager X, and she had been telling them for three months that her skills check list was due at the end of the month.
In an interview on 8/30/2023 at 2:18 PM, [NAME] President of Human Resources (VP/HR) D stated that the CNA skills competency checklist was to be completed yearly. VP/HR D said it must be done in person. VP/HR D stated that CNA W was registered, but must have missed the group in person training, and said that the group in-person skills/competency checklist were held maybe in May and December. VP/HR D said management sets up the group training. VP/HR D said CNA W's skills competency checklist was due on 8/29/2023 so it was past due.
On 8/29/23 at 2:53 PM, Director of Nursing (DON) B provided personnel information for requested employees but stated that annual competency skills evaluations were not included but would be provided.
On 8/29/23 at 5:30 PM, DON B stated that she was still looking for the annual competency skills evaluations for the requested employees.
On 8/30/23 at 11:17 AM, DON B stated that Human Resources was continuing to search for the requested annual competency skills evaluations. DON B further stated that she was unaware if they had been completed as she had just started mid-May and that a Human Resources staff person may be a better resource.
In an interview on 8/30/23 at 11:28 AM, [NAME] President of Human Resources (VP/HR) D stated that for each employee there was a medical file and a personnel file but that the Nursing Department currently kept the records pertaining to the Nurses and Certified Nurse Aide (CNA) competency skills evaluations. Per VP/HR D each CNA had a competency skills evaluation completed upon completion of the first portion of the employee training (within the first 30 days of employment), at 90 days, and then annually. VP/HR D further stated that the annual competency skills evaluations were completed in person and tracked online through the facilities online training system. VP/HR D stated that the management team, including the Nurse Educator, coordinated and completed the group skills competency evaluations that were currently held twice yearly in May and December.
VP/HR D stated that CNA H was hired on 4/21/2015 and upon review of the online tracking system stated that CNA H last completed an annual in person skills competency evaluation on 5/13/2022 with pending registration for the 5/2023 training which was now past due as should have been completed in May of 2023.
VP/HR D stated that CNA G was hired on 3/31/2020 and upon review of the online tracking system stated that CNA G last completed an annual in person skills competency evaluation on 5/11/22 with pending registration for 2023. VP/HR D stated that CNA G's annual competency skills evaluation was past due as should have been completed in May of 2023.

Based upon interview and record review, the facility failed to ensure that the nurse staffing data was posted daily resulting in the potential for all 171 residents as well as visitors to be uninformed of the facility's staffing information.
Findings include:
On 8/30/23 at 12:34 PM, approached Director of Nursing (DON) B to inquire regarding the facility's daily posting of nurse staffing information as unable to locate the posting at/around main entrance, north or south unit nurses' station or at/around building entrance on rehabilitation unit. DON B stated that she was unaware of where posting was located, questioned [NAME] President of Human Resources (VP/HR) D, and proceeded to south unit nurses' station as per VP/HR D that was where the posting was located. As posting unable to be located at/around south unit nurses' station, DON B relayed that after contacting the facility's scheduling coordinator, that the posting was located at the facility's rehabilitation entrance. Upon approach of entrance, DON B stated that the posting should be located on the board just outside Talent Acquisition and Development Manager's (TA/DM) E's office but upon review, confirmed that the current dates posting was not available nor was the 8/29/23 posting from the previous day present. DON B stated that the facility's scheduler was responsible for completing and posting the nurse staffing information daily but as the scheduler had been out of the building since 8/29/23, TA/DM E would be her back up and should have completed the posting in the scheduler's absence.
In an interview on 8/30/23 at 12:42 PM, TA/DM E stated that her job role included recruitment, payroll, and supporting the current scheduler but that she did not have a role in the completion or posting of the daily staffing information as was completed by the scheduler and nursing department, not the human resources department. TA/DM E further stated that she was unaware that she was supposed to complete the posting in the schedulers absence but was familiar with the process and would complete and post.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor the use of an antipsychotic for one (Resident #144) and attempt non-pharmacological interventions prior to the use of a PRN (as needed) antianxiety medication for one (Resident #68) of five reviewed, resulting in the potential for adverse reactions and unnecessary medications.
Findings include:
Resident #68 (R68)
Review of the medical record revealed R68 admitted to the facility on [DATE] with diagnoses that included vascular dementia with behavioral disturbance, mixed receptive expressive language disorder, major depressive disorder, and anxiety. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/1/23 revealed R68 had moderate cognitive impairment, too antipsychotic, antianxiety, and antidepressant medications.
Review of the Physician's Progress Note dated 11/1/22 revealed Restart Ativan 0.5 mg (milligrams) every 6 hours PRN indefinitely. Do not want to schedule Ativan as she does not require this every day. She is at risk for falling and do not want her to receive this medication more than needed.
Review of the Physician's Order dated 11/1/22 revealed an order for Ativan 0.5 mg every 6 hours as needed for anxiety.
Review of the Kardex (care guide) revealed the following behavior/mood interventions:
* If angry, allow her time to calm herself. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.
* When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.
* When upset/tearful, offer reassurance and brushing residents hair helps to calm her down.
On 8/29/23 at 12:44 PM, R68 was observed in bed yelling out. R68 seemed to be in distress. Staff entered her room and was able to hold her hand and calm her down.
Review of the medical record revealed PRN Ativan was administered during the last month on the following dates and times without any documented non-pharmacological interventions attempted:
8/1/23 at 11:33 AM for resident agitated
8/6/23 at 8:55 AM for anxious
8/7/23 at 12:25 PM
8/8/23 at 12:25 AM for pt [patient] anxious
8/10/23 at 10:22 AM for severely anxious
8/11/23 at 8:54 PM for pt anxious
8/12/23 at 10:32 AM
8/19/23 at 4:37 AM
8/20/23 at 8:21 AM for anxious, crying, and screaming
8/20/23 at 4:56 PM for anxious
8/21/23 at 2:00 PM for upset yelling
8/24/23 at 8:13 AM for anxious
8/24/23 at 3:30 PM for severely anxious, crying and screaming
8/25/23 at 1:22 PM for very anxious. This dose was later documented as ineffective.
8/26/23 at 9:02 PM for pt anxious
8/27/23 at 7:00 PM for agitation and combativeness
8/29/23 at 7:35 PM for crying out
8/30/23 at 12:13 PM at 12:13 pm for anxiety. This dose was later documented as ineffective.
In an interview on 8/30/23 at 1:32 PM, Director of Nursing (DON) B reported staff should attempt non-pharmacological interventions prior to the administration of a PRN antianxiety medication. DON B reported the attempted interventions should be documented in a nurse's note.
Resident #144
Review of the medical record revealed that Resident #144 (R144) was readmitted to facility 8/1/23 with diagnoses including other drug induced secondary parkinsonism, schizoaffective disorder, post-traumatic stress disorder, and neurocognitve disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/7/2023 revealed a Staff Assessment for Mental Status which reflected that R144 had both short and long-term memory problems with moderately impaired cognitive skills for daily decision making. Section N of the same MDS revealed that R144 received antipsychotic medications 6 days, antianxiety medications 2 days, and antidepressant medications 6 days since the 8/1/23 readmission date.
In an observation and interview on 8/28/23 at 10:43 AM, R144 was observed lying in bed, on back, dressed in jeans and a black sweatshirt with a wander alert device noted at right wrist. R144 was noted to be calm and talkative, stated that things are pretty good but they have the building locked down because of me. R144 expressed frustration over being in lockdown but admitted that I really have nowhere else to go. R144 discussed other topics for short periods of time before circling back around to I'm in lockdown.
Review of R144's medical record completed with the following findings noted:
Psychiatry Inpatient Discharge Summary with a 6/29/23 date of admission and 8/1/23 date of discharge indicated diagnoses including Parkinsonism due to drug with benztropine ordered for Extrapyramidal Symptom/Reaction (EPS--group of symptoms that can occur in people taking antipsychotic medications including involuntary muscle movements, tremors, stiff muscles, and involuntary facial movements) caused by Medications.
Review of R144's active orders included Ativan (an antianxiety agent) 0.5mg (milligram) tablet every 12 hours for anxiety, Risperdal (an antipsychotic agent) 2mg tablet daily for delusions, Sertraline (an antidepressant) 50mg tablet daily for depression, Trazadone (an antidepressant) 50mg tablet daily for insomnia, and Benztropine 1mg tablet twice daily for Extrapyramidal reaction.
Review of R144's Comprehensive Care Plans included separate Care Plan Problems, Goals, and Interventions for antianxiety, antidepressant, and antipsychotic medication.
R144's antianxiety care plan problem stated, The resident uses anti-anxiety medications r/t (related to) Anxiety disorder, a goal which indicated The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy ., and Interventions which included Administer Anti-Anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q-shift (every shift).
R144's antidepressant care plan problem stated, The resident uses antidepressant medication r/t Depression, a goal which indicated The resident will be free from discomfort or adverse reactions related to antidepressant therapy ., and interventions which included Administer Antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q-shift.
R144's antipsychotic care plan problem stated, The resident uses an antipsychotic r/t Disease process delusions, a goal which indicated The resident will be/remain free of psychotropic drug related complications ., and interventions which included Administer Psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q-Shift.
Further review of R144's orders and active care plan interventions included no indication of the side effects that should be monitored for with each individual medication category (antianxiety, antidepressant, antipsychotic) even though R144's hospital discharge summary reflected identification of mediation side effects and initiation of treatment for side effects during hospitalization, as well as ongoing treatment upon R144's 8/1/23 facility readmission, and continued treatment at this time.
In an interview on 8/30/23 at 8:22 AM, Social Service Supervisor (SSS) F stated that upon admission or with implementation of a psychotropic medication (including an antianxiety, antidepressant, and/or an antipsychotic), the medications risks/benefits was reviewed with the resident/responsible party, consent was obtained, behavior tracking was initiated, and a care plan problem was formulated to reflect the specific type of medication (such as antianxiety, antidepressant, antipsychotic) with an intervention that included specific side effects of the medication that should be monitored for. SSS F confirmed familiarity with R144, acknowledged that he was on multiple psychotropic medications, and stated that the facility was provided guidance from the hospital that R144 was very sensitive to medications, with Benztropine (Cogentin) recommended as R144 was noted with EPS (Extrapyramidal symptoms) during hospitalization that was thought to be associated with the psychotropic medications that he received.
Upon review of R144's medical record, SSS F confirmed active orders for Risperdal, Sertraline, Trazodone, and Ativan and stated that she would expect the assigned nurse to monitor for potential side effects, as listed within the specific care plan intervention, for each of these medications. Upon review of R144's antianxiety, antidepressant, and antipsychotic medication care plan and associated interventions, SSS F confirmed an active intervention within each care plan to monitor for side effects but confirmed no intervention which listed the associated side effects for each medication. Per SSS F, the care plan intervention which listed the associated side effects had been recently discontinued (further review indicated a resolved date of 8/12/23) as had been inappropriately triggered to be monitored on the Certified Nurse Aide (CNA) Kardex which, per SSS F, was out of a CNA's scope of practice. SSS F stated that she would be updating the care plan intervention within the antianxiety, antidepressant, and antipsychotic care plan to include the specific side effects associated with the individual medication so that the nurse had a reference for monitoring purposes.
Review of the facility policy titled Medication Management with an 5/2/19 effective date stated, To unsure each Resident/Patient's medication regimen is free from unnecessary drugs; to prevent excessive dosage and excessive duration of medications; to ensure there is adequate monitoring .and to reduce or discontinue the usage of medications that present adverse consequences .Monitoring of Medication Side Effects .1. All medications will be monitored for side effects daily and documented in the clinical record and on the 24-hour report sheet if noted .2. Antipsychotics and other psychotropic medications will be monitored for significant side effects of therapy with emphasis on .a. Tardive dyskinesia b. Postural (orthostatic) hypotension c. Cognitive impairment d. Akathisia e. Parkinsonism f. Anticholinergic effects g. Neuroleptic malignant syndrome h. Cardiac arrhythmias i. Death secondary to heart related events j. Falls k. Lethargy l. Blood sugar elevations m. Cerebrovascular events n. Excessive sedation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biological's stored in a medication cart were securely locked while the cart was unattended, resulting in the potential for residents to access medications.
Findings Included:
In an observation on the 200 hall on 8/29/2023 at 11:16 AM, Licensed Practical Nurse (LPN) S was observed in the hall administering medications to a resident. The medication cart was was observed to be located by room [ROOM NUMBER], and LPN S was located by rooms 209-213. The medication cart was observed to be left unlocked while LPN S was down the hall administering medications to a resident. The time the cart was unattended was approximately 4 minutes.
In an interview on 8/29/2023 at 2:19 PM, LPN S stated that the facility's policy was to lock the medication carts when the cart in not be attended to and before walking away from the cart. LPN S said did realize that she had left the cart unlocked until she returned to the cart.
Review of the facility's policy and procedure, not dated, revealed under, Procedures the policy revealed, #3 When not attended by a person permitted access, all medication storage areas must be kept locked.
In an interview on 8/30/2023 at 12:51 PM, Director of Nursing (DON) stated that it was her expectation that the medication carts be locked when not in attendance by the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00138710.
Based on observation, interview, and record review, the facility failed to provide food and drink per assessment and individualized care plan, in 2 of 19 reviewed for dining (Resident #51 & #149), resulting in the potential for choking, decreased food acceptance, protein deficiency, and burns (Resident #51). Findings include:
Resident #51 (R51)
On 8/28/23 at 12:30 PM, R51 was observed sitting in a wheelchair in the dining room at a table alone with no other residents. R51's lunch meal ticket was on the table next to her lunch and instructed to cut meats into bite sized pieces; and to serve hot liquids with a lid. R51 at the same date and time indicated she was finished, her plate was observed with a serving of chicken breast untouched, and not cut into bite-sized pieces. R51 had a coffee in a cup without a lid. There we no extra napkins on the table and her meal was not served a bowl.
On 8/29/23 at 12:49 PM, R51 had just finished her lunch. R51's plate was observed with a piece of chicken that was untouched and not cut into bite-sized pieces. R51's lunch was served on a plate with the exception of the dessert. R51 ate couple of bites of peas and dessert for lunch on this same day.
R51's Minimum Data Set (MDS) with assessment reference date of 7/18/23, revealed she was admitted to the facility on [DATE], had the diagnoses of stroke, anemia, heart failure, dementia, anxiety and depression. R51's same MDS revealed a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 06 (00-07 severe impairment) and required set up with supervision assistance for meals.
R51's Activities of daily living care plan dated 1/25/23 revealed her left hand had contractures and she wore a splint. R51's Nutrition at risk care plan dated 7/27/23 indicated to provide resident with lids for hot liquids, extra napkins and serve food in bowls.
During an interview on 8/29/23 at 1:23 PM, Registered Dietician (RD) U stated cutting meat into bite-sized pieces could be done in the kitchen or by the nurse assistant. RD U stated R51 required staff assistance and that the facility needed more assistance in the dining room.
Resident #149 (R149)
On 8/28/23 at 10:44 AM, R149 was observed sitting in her room in a wheelchair. R149's family member was interviewed at the same date and time and stated R149 was admitted to the facility for short-term rehabilitation following a stroke, and the plan was for her to return home with services.
R149's Minimum Data Set (MDS) dated [DATE], revealed she was admitted to the facility on [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 03 (00-07 Severe Impairment). The same MDS revealed R149 required extensive assistance for eating and had signs and symptoms of possible swallowing disorder including holding food in mouth/cheeks or residual in mouth after meals, coughing or choking during meals or when swallowing medications, and complaint of difficulty or pain with swallowing.
During an interview on 8/29/23 at 9:16 AM with R149's family, they stated R149's supplement that was delivered with her meals was not thickened appropriately.
In review of R149's Nutritional care plan dated 8/07/23, R149 was ordered a regular diet with mechanical soft texture, honey thickened liquids, and a supplement drink was to be provided with breakfast and lunch.
On 8/29/23 at 1:57 PM, Registered Dietitian (RD) U stated nursing staff were to thicken R149's nutritional supplements.
On 8/30/23 at 9:47 AM, Certified Nurse Assistant (CNA) AD was interviewed and stated R149 was supposed to have honey thickened liquids, but they had run out of honey thickened packets; she used a nectar thickened packet to thicken R149's nutritional supplement during breakfast on the same day of the interview. When asked if R149 had any coughing with her liquids during breakfast, she stated the family assisted her with her breakfast meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to meet resident individualized food preferences in one (Resident #208) of 19 residents reviewed, resulting in the potential for weight loss, decreased meal enjoyment and/or frustration.
Findings Include:
Resident #208 (R208)
According to the facility's admission record, R208 admitted to the facility on [DATE] with diagnoses that included cirrhosis of the liver disease/excess abdominal fluid, chronic obstructive pulmonary disease (COPD, lung disease), type 2 diabetes, and hyperlipidemia (high cholesterol).
A review of the MDS (Minimum Data Set) dated 08/28/2023 reflected R208 had a brief interview for mental status (BIMS), a short performance based cognitive screen for nursing home residents, score of 14 (13-15, cognitively intact).
During an interview on 08/29/23 at 10:00 AM, R208 indicated she didn't get to choose what she wanted to eat. She said they bring out food without choices. R208 stated that there weren't any alternates to choose from and mentioned that the night before she didn't eat her dinner because she didn't like the meal served but they were able to make her a grilled cheese sandwich.
During another interview conducted on 08/30/23 at 09:07 AM, R208 was sitting up in a chair in her room eating breakfast. It was noted that cream of wheat and breakfast burrito were untouched. R208 stated that she only had cereal for breakfast because she didn't like the cream of wheat or breakfast burrito which was served since she couldn't pick what she wanted to eat.
During an interview on 08/29/23 at 01:25 PM, Registered Dietitian (RD) U stated residents were assessed upon admission for food preferences, usual body weight, allergies, gastrointestinal symptoms, chewing or swallowing concerns. RD U mentioned that R208 admitted at the facility on 8/22/2023, so meeting with the resident was long overdue. RD U said that in rehab only 1 entree for every meal was served. RD U stated that they were not asked what they want to eat and were served the main meal unless a dislike was indicated on the meal card. RD U also mentioned that there was an alternate list that was on channel 51 and they could order from there ahead of time. RD U said that the baseline care plan meeting was supposed to be completed within 72 hours and occurs after the RD meets with the resident.
During an interview on 08/30/23 at 11:19 AM, RD N who covered the rehabilitation halls discussed that residents are interviewed for food preferences ideally within the first 72 hours. Sometimes other staff lets her know if resident has likes and dislikes. RD N mentioned that she received a notification and doesn't remember whether it was a phone call or email that R208 wanted to speak to her. RD N said that she didn't get a chance to talk to R208 during her visit. R208 discharged from the facility on 8/30/2023 on the day of the interview. RD N mentioned that only the RD obtains food preferences and there isn't a backup for when the RD isn't there. RD N said that the back of the meal ticket had information on alternates on it and Channel 51 did too. When asked if R208 would know this information without a RD visit, RD U indicated that she probably would not know this information.

Based on observation, interview, and record review the facility failed to ensure cleanliness of kitchen equipment, food storage temperatures were documented, and food products were dated, resulting in the potential for food borne illness to occur in a current facility census of 171 residents.
Findings Included:
In an observation on 8/28/2023 at 9:14 AM, during the initial kitchen tour, revealed the juice machine had thick sticky debris on the pour spouts of the apple and cranberry juice, and the front of the juice machine observed to have sticky thick debris on it.
During observation of the walk in cooler an opened bag of shredded cheese, which was not tied close, was observed to not have any date on the package of when the cheese package was opened, nor did it have a use by date on the bag. A container of stir fry sauce was observed to have an opened date of 7/10/2023 and an expiration date of 8/9/2023, a container of teriyaki sauce had an opened date of 7/3/2023 and an expiration date of 8/2/2023, and a container of barbeque sauce had a use by date of 8/16/2023.
Observation inside the walk in freezer revealed a bag of opened broccoli that had a manufacture's use by date of 8/13/2023. There was no date the bag of broccoli was opened on the bag. A bag of lettuce was observed to have a use by date of 8/28/2023 and there was no date on the bag that the lettuce was opened.
Record review of temperature logs for the months of June, July, and August 2023 regarding the walk in refrigerator and the walk-in freezer revealed a total of 33 times temperatures were not documented on the P.M. shift.
On 8/29/2023 at 11:10 AM, observation of the bag of lettuce observed on 8/28/2023 during initial kitchen tour, revealed that the bag of lettuce remained unchanged from the 8/28/2023 observation, and the the juice dispenser also was observed to have no change from the 8/28/2023 observation.
In an interview on 8/29/2023 at 1:05 PM, Dietary Manager (DM) M stated that it was her expectation that the food packages were dated with the date the package was opened and the use by date be clear on the package also. DM M said all packages were to be sealed/tied close after opened, and said the staff member who opened the food package were to put the date that the package was opened on the package, and also the use by date. DM M further stated that the walk-in refrigerator and freezer temperature logs were to be checked twice a day and documented on the logs.
Record review of the facility's policy and procedure titled, PRODUCTION, PURCHASING, STORAGE Policy #B004 dated 5/1995 revealed, Subject: COLD STORAGE TEMPERATURES POLICIES: Temperatures of food storage areas and cold food vendors are monitored and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies .Supervisor At the beginning of each month place a new temperature log form on clipboard .Each morning at opening and evening at closing, record temperatures of each storage unit; initial each entry. Circle any deviant readings .
Review of the facility's policy and procedure titled, PRODUCTION, PURCHASING, STORAGE Policy #B003 dated 5/1995 revealed, POLICIES: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. PROCEDURES: Most, but not all, products contain an expiration date. The words sell-by , best-by , enjoy-by or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use by , sell-by , best-by , or enjoy by date should be discarded. Cover, label and date unused portions and open packages .

Based on observation and interview, the facility failed to ensure appropriate hand hygiene and infection control practices during lunch time meal pass, resulting in missed opportunities for hand hygiene, improper hand hygiene techniques, and the potential for the spread of infection.
Findings Include:
In an observation on 08/28/23 at 12:11 PM, an observation was made of a staff member grabbing a plate containing a resident's lunch and delivering the plate to the resident. The staff member returned to the kitchen and grabbed another resident's plate containing their lunch and proceeded to deliver to a different resident without performing hand hygiene in between residents. The same staff member returned to the kitchen, grabbed another plate containing food and passed to a third resident without performing hand hygiene The same staff member assisted a resident with repositioning in a wheelchair, and proceeded to continue to the kitchen area. The same staff member obtained another plate containing food and passed it to a fourth resident. The staff member opened silverware and began assisted with feeding a resident. Hand hygiene was not performed for the entire observation.
In an observation on 08/28/23 at 12:16 PM, a staff member passed two plates containing food to separate residents without performing hand hygiene in between passing plates. During meal pass, the same staff member was observed scratching her face with an ungloved hand and reaching into the clean silverware to obtain requested silverware for a resident. Hand hygiene was not performed during the observation.
In an observation on 08/28/23 at 12:22 PM, an observation was made of a staff member delivering a small bowl of soup to a resident, returning to the kitchen and obtaining a plate of food to deliver to a different resident. The staff member proceeded to pass two more plates to two separate residents without performing hand hygiene in between meal passes.
In an interview 08/30/23 at 2:47 PM, Infection Prevention Registered Nurse (IP RN) T stated that the expectation would be for staff to perform hand hygiene in between passing plates from one resident to the next. IP RN T reported that she performs hand hygiene audits and that hand hygiene during meal pass had been an identified problem in the past and she had planned on performing a hand hygiene audit in the dining room in the near future.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer a pneumococcal immunization timely to one (Resident #146) of five reviewed for immunizations, resulting in the potential to contract a pneumococcal infection, and/or experience serious illness or complications.
Findings include:
Review of the medical record revealed R146 admitted to the facility on [DATE] with diagnoses that included dementia, cervical disc disorder, and insomnia. According to the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/23 revealed R146 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool)
Review of R146's immunization history revealed no documentation for a pneumococcal immunization history.
Review of the Pneumococcal Vaccine Informed Consent/Declination revealed on 7/10/23, consent was given for R146 to receive a pneumococcal immunization. The medical record revealed R146 had not yet received the immunization.
In an interview on 8/30/23 at 3:05 Infection Preventionist (IP) T reported she tracked resident immunization status. IP T showed her tracking tool which did not have a date of a pneumococcal immunization for R146. IP T reported she knew R146 needed the pneumococcal immunization and planned on giving it when the influenza vaccines arrived during flu season. IP T reported she did have the ability to order pneumococcal immunizations separately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00137052
Based on observation, interview, and record review, the facility failed to assure non medication therapeutic interventions were performed per care plan using ice packs for pain management every two hours for one resident (R14) of one resident reviewed for unnecessary medications use, resulting in the need for unnecessary medication to be utilized.
Findings include:
Resident #14 (R14)
Review of the medical record revealed Resident #14 (R14) was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (stroke), Hemiplegia (paralysis on one side of the body) and Hemiparesis left side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), non-dominate, Osteoporosis, pain in right hip, Chronic Kidney Disease, Radiculopathy (pinched nerve, weakness, altered sensation, difficulty controlling specific muscles) of the Lumbar Region, Depression and Anxiety.
According to Resident #14 (R14)'s Minimum Data Set (MDS) dated [DATE], revealed R14 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R14 requires two people to provide all care.
During an interview on 07/18/23 at 1:26 PM, R14 stated that she had file several complaints about staffing. R14 added, one night shift, they only had only one Certified Nursing Assistant (CNA) and one nurse for all of residents on the rehab. R14 went on to explain that part of her nightly routine is to make and place ice packs on/off every two hours for pain management. R14 stated she told the CNA about her nightly routine, and the CNA told R14 she didn't have time. R14 stated she had this task posted on her wall but would still have to tell all CNA's how to make an ice pack. R14 added that on another night, R14 had another agency CNA, who stated she knew how to make the ice pack, but it broke open in the night, and the bed and clothing was wet. Due to the lack of staff and skill making these ice packs as instructed and having them break open, it did nothing for pain management. The ineffective therapeutic method increased R14's pain. R14 stated that other CNAs reported not being trained to do that, or not having time to make them. Due to the interruption in R14's pain management intervention, she required an as needed ordered pain medication. R14 also stated, due to the lack of consistency in care is affecting your wellbeing. R14 may have not needed this as needed pain medication had the interventions on the care plan be followed and her ice pack changed every two hours with repositioning every two hours.
Record review of care plan and task sheets revealed R14 had care planned to use ice pack of her choice, knowing the risk versus benefits of potential skin burns. R14 was of sound body and mind and was able to make choices for herself. Care plan did not give specific instructions on preparing the ice packs. Observation of instructions hanging on the wall instructing staff how to prepare these ice packs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 19 (R19)
According to the clinical record Resident #19 (R19) was a [AGE] year old female with multiple medical comorbidities, according to the Minimum Data Set (MDS) dated [DATE], R19 scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review of the clinical record reflected R#19 had a Durable Power of Attorney (DPOA).
During phone interviews with R19's DPOA N on 7/18/23 at 9:40am. and 7/19/23 9:45 it was reported DPOA N had made numerous complaints regarding R19's care, including but not limited to staffing levels, call light response time.
Resident #4 (R4)
According to the clinical record, Resident #4 (R4) was an [AGE] year old female admitted to the facility on [DATE] with a diagnosis of dementia-, review of the MDS dated [DATE] R4 scored 1 (severe cognitive impairment) on the BIMS. On 7/19/23 at 1:35pm during a phone interview with family member of R4 (family member R) she reported visiting the facility several times a week and verbalized many concerns pertaining to low staffing levels and missing showers.
Resident #10 (R10)
According to the clinical record, including the Minimum Data Set, resident 10 (R10) scored 15 out of 15 (cognitively intact) on Brief Interview for mental Status (BIMS) . On 7/24/23 at 1:45 pm during an interview with R10 she reported having concerns with staffing levels and call light response times, R 10 elaborated that it frequently took 30 minutes or longer to have her call light answered by staff. R10 further stated staff are often agency and were not trained on how to take care of her or what her needs are, I always have to tell them how I transfer , what I need etc
On 07/18/23 at 12:00 during an interview with Certified Nursing Assistant (CNA) O she reported staffing levels were challenging and that the facility uses a lot of agency staff and they do not provide care as they should, there is a lack of accountability just as long as someone shows up.
On 7/18/23 at 12:20 Interview with CNA P she reported after 15 minutes of a call light being turned on the light will turn red. CNA P stated she has around 10 resident which sounds manageable but they are all total care and require 2 person assistance, which is very time consuming.
On 7/20/23 at 1:15 pm during a phone interview with CNA U she reported she was not always able to complete tasks do to lack of staffing and keeping so many behavioral residents supervised and safe was a top priority.
Phone interview with CNA GG on 7/20/23 at 1:30, reported the inability to consistently provide showers, incontinence care lacking or shaving not being done for the men, things like that get missed. CNA GG stated it was not the best care, but it was the best she could do with the acuity of care she was assigned.
On 7/24/23 at 2:45 pm during an interview with form facility Registered Nurse (RN) T reported staffing levels were unsafe, there were numerous residents with severe behavioral residents that could not be adequately supervised resulting in many preventable falls. RN T stated the lack of support from upper management, stating there was no one to ask questions to , get guidance from, the unit in which RN T was somewhat isolated and between the lack of staff and support from upper management RN T stated she had no choice but to resign. I cant afford to risk my license there.
Review of the facility's FACILITY ASSESSMENT last updated on 7/17/2023, revealed the facility was licensed to provide care for 236 residents, and had a daily average census of 48 residents who resided on the long-term care north unit, 99 on the long-term care south unit, and 24 on the rehab unit.
The assessment under #1, Resident support/care needs revealed, a. Our facility provides the following care to our resident population. Additional care or services may be provided as unique diagnoses and/or conditions present. This list is not an all-inclusive list, but rather identifies common care needs provided.
Table 5, General Care, Activities of Daily Living, Specific Care of Practices, Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairments, supporting resident independence in doing as much of these activities by himself/herself.
Under #4. Acuity revealed, .a. describe your residents' overall acuity levels .We identify each unit and hallway to have unique resident acuities, care needs, staff requirements, and resource allocation needs based on the resident population.
Under #6. Other revealed, a. Other pertinent facts or descriptions of the resident population that must be considered when determining staffing and resource needs include evaluation of residents' preferences such as with regard to daily schedules, waking, bathing, activities, naps, food, and going to bed. These are highly individualized factors and fluctuate often. Residents, families, and direct care staff provide continuous feedback to ensure we continue to align with these factors as able.
Further review of the assessment revealed under, 2. Individual staff assignment, Describe how you determine and review individual staff assignments for coordination and continuity of care for residents within and across these staff assignments., i. Direct Care staffing is initially determined by the facility defined LTC (Long-Term Care) and Rehab Units minimum staffing requirements. These requirements are aligned to exceed the state minimums as well as the facility's determination of its own minimums to achieve the highest level of resident safety and person-centered care approaches ., ii. Staffing is then based on unit specific care needs. The facility further defines staffing ratios for each unit and hall based on identified care needs. The facility strives to provide consistent assignments to promote increased resident wellbeing, person-centered care, and build relationships. The facility cares for individuals with varying stages of dementia and at times present with challenging behaviors. Additional support staff are utilized for these cases on an as needed basis.
Continued review of the assessment revealed the facility had a 79% of residents who required feeding assistance, 99% of residents who required assistance with ADLS (activities of daily living), 97% needed assistance with toileting, 95% needed assistance with mobility and 14% required the use of a mechanical lift for transfers, 6% required catheter care, 78% required bladder incontinence care, and 50% required bowel incontinence care.
Further review of the facility's assessment revealed on Table 4: Assistance with Activities of Daily Living/Mobility that the only percentages listed for Independent, Assist of 1 Staff, Assist of 2 Staff, and Dependent was regarding Dressing. Bathing, transfers, eating, toileting, and ambulation did not contain any percentages regarding the resident's required assistance or own ability in the four areas.
Linked to intake numbers MI00137052, MI00136671, MI00137567, MI00135578, MI00135655, MI00136421, MI00135578, MI00135925
Based on observation, interview and record review the facility failed to provide sufficient staffing to ensure resident needs were met timely for 6 (#13, 14, 24, 19, 4, and 10 ) of 8 residents from a total sample of 24 residents, resulting in unmet care needs and frustration.
Findings include:
Resident #13 (R13)
Review of the medical record revealed Resident #13 (R13) was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes, Lymphedema (localized swelling caused by a compromised lymphatic system), Venous Insufficiency (blood doesn't flow efficiently through the veins), Chronic Venous Hypertension (abnormalities in the capillaries in the leg), Peripheral Vascular Disease (disease of the circulatory system), Depression and Anxiety.
According to Resident #13 (R13)'s Minimum Data Set (MDS) dated [DATE], revealed R13 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R13 requires one to two people to assist with all care.
During an interview and observation on 07/18/23 at 1157AM, R13 stated the care was horrible, they were still using agency people. Added that she did not get her morning medications on the Tuesday mornings she went to the wound clinic until 4:00 PM on June 20, 2023. R13 also stated she did not get her insulin, gabapentin, or blood pressure medication due at 0900 AM in the morning before leaving at 0945 AM for the wound clinic. R13 stated that she reported to the occupational therapist that she did not get her meds, who went to talk to nurse. The medications were signed that patient was not there, and were not given on June 27, 2023, until 2:45 PM. R13 stated this was the second Tuesday morning that she had not received her medications before going to the wound care clinic. R13 also stated that all the nurses on her unit are agency nurses, and nobody knows what is going on. R13 stated that she has more pain on those days due to not getting her gabapentin for nerve pain. R13 also added, they keep rotating staff, and nobody gets to know them. R13 then stated I don't even get my showers like I am supposed to get, no wonder the wound clinic doesn't want them doing these dressing changes. Nobody does skin checks like they are supposed to be doing either.
Record review revealed R13 did not receive her 0900 AM medications on Tuesday mornings prior to her scheduled appointment at the wound clinic. Medication administration record reveals that on June 27,2023, nurse marked R13 with a number 1, meaning she was not there. R13 did not receive it until after she approached the nurse as a reminder, well after lunch time.
Record review of the care plan task sheet revealed that R13 had only received two bathes in the last 30 days due to staffing. Care plan reflects bathes are scheduled weekly. Care plan task sheet did not reflect that R13 refused any bathes during this 30-day period.
During an interview and observation on 07/19/23 at 10:25 AM, Unit Manager (UM) G stated she would have administered the medications due prior to a scheduled appointment. UM G added, you don't want to be getting morning medications in the afternoon that could be contraindicated to her afternoon medications. UM G stated that nurses have the option to mark that the resident was not available, then added they had a calendar at the nurse's station of her upcoming appointments. Observation of a calendar hanging at the nurse's station with resident's name on it and what day and time they would be leaving for their appointments. UM G stated that R13 had regular appointments are every two weeks and should get her medications before she left. UM G added that nurses were in-serviced, shown where the calendar was, so she could have got her medications prior to appointment.
During an interview and observation on 07/20/23 at 11:27 AM, Social Worker (SW) Y stated that she followed up on the complaints. R13 reported to her that she didn't think there was enough staff on night shift. The rehab hall/unit had a higher level of needs and care than other areas of the facility.
During an interview and observation on 07/20/23 at 1:30 PM, Director of Nursing (DON) B stated the staff did not know how to use PCC (electronic medical record), they started training, and it was a work in progress. DON B added that CNAs didn't use Kardex (Care Plan specific's) anymore, she didn't think paper was efficient and too hard to keep up with. DON B also stated she was aware not all staff use computers and acknowledged lots of agency staff who didn't check the computer for transfer status, feeding assistance, days they got showers, or personal care preferences. DON B stated she realizes staff can't remember all the specifics of each resident needs for an entire shift, but states CNAs are expected to meet there needs. The shower sheets/ skin assessments were on paper, and they would not document them on PCC, so we are training them to do so. Same with weekly skin assessments, if the nurses lock them late, DON B must go in and adjust the schedule to be a week out from the date they were locked. DOB B also added they were working on getting another agency to work with that is more accountable and would provide the care and document it.
Resident #14 (R14)
Review of the medical record revealed Resident #14 (R14) was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (stroke), Hemiplegia (paralysis on one side of the body) and Hemiparesis left side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), non-dominate, Osteoporosis, pain in right hip, Chronic Kidney Disease, Radiculopathy (pinched nerve, weakness, altered sensation, difficulty controlling specific muscles) of the Lumbar Region, Depression and Anxiety.
According to Resident #14 (R14)'s Minimum Data Set (MDS) dated [DATE], revealed R14 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R14 requires two people to provide all care.
During an interview on 07/18/23 at 1:26 PM, R14 stated that she had file several complaints about staffing. R14 added, one night shift, they only had only one Certified Nursing Assistant (CNA) and one nurse for all of residents on the rehab. R14 went on to explain that part of her nightly routine is to make and place ice packs on/off every two hours for pain management. R14 stated she told the CNA about her nightly routine, and the CNA told R14 she didn't have time. R14 stated she had this task posted on her wall but would still have to tell all CNA's how to make an ice pack. R14 added that on another night, R14 had another agency CNA, who stated she knew how to make the ice pack, but it broke open in the night, and the bed and clothing was wet. Due to the lack of staff and skill making these ice packs as instructed and having them break open, it did nothing for pain management. The ineffective therapeutic method increased R14's pain. R14 stated that other CNAs reported not being trained to do that, or not having time to make them. Due to the interruption in R14's pain management intervention, she required an as needed ordered pain medication. R14 also stated, due to the lack of consistency in care is affecting your wellbeing.
Record review of care plan and task sheets revealed R14 had care planned to use ice packs of her choice, knowing the risk versus benefits of potential skin burns. R14 was of sound body and mind and was able to make choices for herself. Care plan did not give specific instructions on preparing the ice packs. Observation of instructions hanging on the wall instructing staff how to prepare these ice packs.
During an interview and observation on 07/20/23 at 1:30 PM, Director of Nursing (DON) B stated that some staff did not know how to use PCC (electronic medical record), they started training, and it was a work in progress. The shower sheets/ skin assessments were on paper, and staff would not document them on PCC, so we are training them to do so. Same with weekly skin assessments, if the nurses lock them late, DON B must go in and adjust the schedule to be a week out from the date they were locked. DOB B also added they were working on getting another agency to work with that is more accountable and would provide the care and document it.
Resident #24 (R24)
Review of the medical record revealed Resident #24 (R24) was admitted to the facility on [DATE] with diagnoses that include Seizures, encephalopathy (disease that can affect the functioning of the brain), Duchenne or [NAME] Muscular Dystrophy (muscular dystrophy), Dysphagia (difficulty swallowing), Cardiomyopathy (disease that affects the heart muscle), Hypo-Osmolality and Hyponatremia (retention of water by loss of sodium) and contractures of both left and right knee.
According to Resident #24 (R24)'s Minimum Data Set (MDS) dated [DATE], revealed R24 scored 15 out of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R24 is dependent of all transfers and care provided by two people at a time.
During an interview on 07/24/23 at 1:38 PM, R24 stated he had had an accident yesterday. He put on his call light because he needed to have a bowel movement, due to staffing, nobody came in time to assist him, so he had a bowel movement in his pants and needed to get cleaned up and get his clothes changed. R24 stated the real issue was his medication administration time. Also added nurses don't have the time to read his chart related to his medical diagnosis. R24 stated that with his seizures, he needs his medications administered at the time due, not an hour before or an hour after. R24 shared he went to his doctor this morning and had an order to receive those medications within 10 minutes of the time its was due. Added this was due to consistency of receiving medications on time to reduce the likelihood of seizure activity. R24 also added that on his floor residents need two people to provide care, so if there is only two CNA's working, he must wait a long time for help.
During an interview and observation on 07/19/23 at 10:25 AM, UM G stated when agency staff get to the floor/unit with orientation completed, badges, and were ready to work. Also added the rehab unit is staffed with 100% agency nurses. UM G also stated the CNAs are staffed half agency and half facility. UM G stated she had received a couple of complaints come from residents, stated agency staff needed more training, facility staff knows the resident's needs. UM G also stated she identified a seizure medication that wasn't getting passed at the correct time. UM G reported they were trying to staff the best they can. May not always be ideal, may have to wait longer to receive care. UM G stated she takes those concerns to management.
During an interview and observation on 07/19/23 at 12:55 PM, CNA BB stated that when agency staff were scheduled to work, you don't know if they were familiar to the hall/unit they were working until they got there, if they showed up.
During an interview and observation on 07/19/23 at 1:00 PM, agency CNA CC stated she had computer access because she used to work here. CNA CC also stated she knew some of the residents so it's easier for her to provide the care they need. Then added some agency CNA's are not at lucky.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision for one (Resident #17) of one resident reviewed for inappropriate behaviors, hitting, sitting on residents and going into other residents rooms from a total sample of 15 residents, resulting in the potential for injury to others.
Findings Include;
Resident #17 (R17)
Review of the medical record revealed Resident #17 (R17) was admitted to the facility on [DATE] with diagnoses that included Progressive Neurological Condition, Alzheimer's, Parkinson's Disease, anxiety and receiving hospice services for end-of-life care.
According to Resident #17 (R17)'s Minimum Data Set (MDS) dated [DATE], revealed R17 scored 07 out of 15 (severely impaired) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R17 is independent of ambulation.
Record review of 05/02/23 03:43 AM progress note, revealed R17 had been very combative when being redirected throughout the night. R17 had been grabbing and hitting staff. R17 had been entering other patient's rooms while sleeping. When staff tries to enter residents' room, he forced staff out and closed his door.
Record review of 05/04/23 07:06 AM progress note, revealed .when R17 got out of bed in the morning, he was combative toward the staff, trying to sock them with his fist. R17 entered several of the resident's rooms and started to sit on their beds with the residents asleep in the bed. When they tried to direct him out of the room, he became combative and tried to slam the door shut with him inside the room. One resident's room he entered; he sat down on top of the resident in the bed. R17 was impossible to redirect and entering several residents' rooms, was unsafe for the resident. When staff tried to close the doors to keep the residents in the hallway, he was able to open the doors himself. Resident is very strong and unsafe to be close to residents in their bed sleeping .
Record review of 05/04/23 13:03 AM progress note, revealed R17 had been very combative with staff and other residents, has Multiple superficial skin tears on bilat forearm and what appears to be some bruising around the skin tears on bilat arms .when he was hitting staff and other residents, as the staff had to try to contain him from his combativeness .
Record review of 05/12/23 19:17 PM progress note, revealed R17 was wandering and exit seeking throughout shift. In the morning, resident was severely agitated, trying to put on another resident's bra, and refused to go out of the resident's room. R17 tried to push this nurse when trying to redirect .
Record review of 05/15/23 3:35 PM progress note, revealed R17 grabbed and hit staff this afternoon during bingo group. R17 was attempting to take another resident out of the bingo group. Staff attempted to re-direct the other resident back into the group .
Record review of 05/19/23 4:00 PM progress note, revealed R17 was wandering the halls and other resident's rooms looking for an exit out. When nurse tried to redirect R17, he became agitated .
Record review of 05/28/23 11:08 AM progress note revealed, R17 continue to wander into other resident's rooms not able to redirect .
Record review of 05/31/23 0900 AM progress note revealed nurse was on the hall and heard a CNA attempting to redirect the resident out of a female resident's room. Nurse and CNA intervened when the resident attempted to hit the other resident. R17 then grabbed the CNA' s hand/thumb and would not let go. Nurse was able to help direct the resident to the door, where R17 continued to attempt to enter the room . R17 was hitting/punching nurse on the right side of body. R17 grabbed this writer's wrist and would not let go . Female resident was very upset regarding the situation .
Record review of 06/01/23 4:16 PM progress note revealed R17 was combative this am and broke the wrist of the nurse. He punched another resident. Pt was aggressive and combative with staff and residents. Had altercation with roommate. His room was changed .
Record review of R17's care plan, Social Worker (SW) C made an initial intervention on 05/01/2023 to intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternative location as needed. Care plan did not reveal any revisions related to R17 entering other resident's rooms and getting into their clothes, R17 sitting on top of residents while they were sleeping in their own beds, after 05/01/2023. The care plan task sheet did not reveal updates related to his behavioral changes, entering other resident's rooms, getting into other resident's personal belongings, hitting others and grabbing others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Linked to intakes: MI00137567, MI00137052, MI00136671
Based on observation, interview and record review, the facility failed to provide necessary care and services to ensure a resident's abilities in activities of daily living (ADL) did not diminish in 3 (Resident #13,#14, #24 ) of 3 residents reviewed for comprehensive care planning, resulting in increased levels of assistance provided by staff with ADL care.
Findings include;
R13
Review of the medical record revealed Resident #13 (R13) was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes, Lymphedema (localized swelling caused by a compromised lymphatic system), Venous Insufficiency (blood doesn't flow efficiently through the veins), Chronic Venous Hypertension (abnormalities in the capillaries in the leg), Peripheral Vascular Disease (disease of the circulatory system), Depression and Anxiety.
According to Resident #13 (R13)'s Minimum Data Set (MDS) dated [DATE], revealed R13 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R13 requires one to two people to assist with all care.
During an interview and observation on 07/20/23 at 11:27 AM, R13 stated she filed a complaint because she is not getting the care she needs. R13 also mentioned the staff are in a hurry to get in and out of resident's room, trying to keep up. R13 stated with her Lymphedema, her skin is tender, and staff need to go slow and be gentle. R13 mentioned she may not see staff for hours during the day. R13 stated she puts on her call light and had to wait forever for someone to come in and help her. R13 then stated the staff will tell her the call light was not even on, that she never had the call light on. R13 stated she was not stupid; she knows how to use a call light. They just don't answer them.
Record review of care plan for R13 revealed she was to receive bathes on Monday and Thursday evenings. During bathes or showers, to pat R13's skin to clean, rather than rub, which causes her pain. Check nail length and trim and clean on bath days and as needed. Provide a sponge bath when a full bath or shower cannot be tolerated. R13 requires skin inspections with Shower on Monday evening. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse.
Record review of the care plan [NAME] showing personal care that R13 received. Documentation revealed R13 received two showers in the last 30-day period. Showers were on 06/27/23 and 07/11/23. R13 should have received eight showers in the last 30-day period.
During an interview and observation on 7/19/23 at 200 PM, Senior Director of Business Services. (SDBS) E stated that R13 voiced concern about her care. Concerns were mainly about agency staff, one agency CNA. SDBS E also stated that R13 wounds were addressed at the wound clinic, skin concerns have improved. SDBS E also stated resident had used her call light when it didn't really go on, so she had to wait longer. R13 could not identify one CNA. Only expressed the call light, not skin issues. When asked if there was any further follow up on getting personal care needs met, SDBS E stated no.
R14
Review of the medical record revealed Resident #14 (R14) was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (stroke), Hemiplegia (paralysis on one side of the body) and Hemiparesis left side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), non-dominate, Osteoporosis, pain in right hip, Chronic Kidney Disease, Radiculopathy (pinched nerve, weakness, altered sensation, difficulty controlling specific muscles) of the Lumbar Region, Depression and Anxiety.
According to Resident #14 (R14)'s Minimum Data Set (MDS) dated [DATE], revealed R14 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R14 requires two people to provide all care.
During an interview on 07/18/23 at 1:26 PM, R14 stated that she had file several complaints about staffing. R14 added, one night shift, they only had only one Certified Nursing Assistant (CNA) and one nurse for all of residents on the rehab. R14 went on to explain that part of her nightly routine is to make and place ice packs on/off every two hours for pain management. R14 stated she told the CNA about her nightly routine, and the CNA told R14 she didn't have time. R14 stated she had this task posted on her wall but would still have to tell all CNA's how to make an ice pack. R14 added that on another night, R14 had another agency CNA, who stated she knew how to make the ice pack, but it broke open in the night, and the bed and clothing was wet. Due to the lack of staff and skill making these ice packs as instructed and having them break open, it did nothing for pain management. The ineffective therapeutic method increased R14's pain. R14 stated that other CNAs reported not being trained to do that, or not having time to make them. Due to the interruption in R14's pain management intervention, she required an as needed ordered pain medication. R14 also stated, due to the lack of consistency in care is affecting your wellbeing.
Record review of care plan and task sheets revealed R14 had care planned to use ice pack of her choice, knowing the risk versus benefits of potential skin burns. R14 was of sound body and mind and was able to make choices for herself. Care plan did not give specific instructions on preparing the ice packs. Observation of instructions hanging on the wall instructing staff how to prepare these ice packs.
During an interview and observation on 07/20/23 at 1:30 PM, Director of Nursing (DON) B stated the staff did not know how to use PCC (electronic medical record), they started training, and it was a work in progress. DON B added that CNAs didn't use [NAME] (Care Plan specific's) anymore, she didn't think paper was efficient and too hard to keep up with. DON B also stated she was aware not all staff use computers and acknowledged lots of agency staff who didn't check the computer for transfer status, feeding assistance, days they got showers, or personal care preferences. DON B stated she realizes staff can't remember all the specifics of each resident needs for an entire shift, but states CNAs are expected to meet there needs. The shower sheets/ skin assessments were on paper, and they would not document them on PCC, so we are training them to do so. Same with weekly skin assessments, if the nurses lock them late, DON B must go in and adjust the schedule to be a week out from the date they were locked. DOB B also added they were working on getting another agency to work with that is more accountable and would provide the care and document it.
R24
Review of the medical record revealed Resident #24 (R24) was admitted to the facility on [DATE] with diagnoses that include Seizures, encephalopathy (disease that can affect the functioning of the brain), Duchenne or [NAME] Muscular Dystrophy (muscular dystrophy), Dysphagia (difficulty swallowing), Cardiomyopathy (disease that affects the heart muscle), Hypo-Osmolality and Hyponatremia (retention of water by loss of sodium) and contractures of both left and right knee.
According to Resident #24 (R24)'s Minimum Data Set (MDS) dated [DATE], revealed R24 scored 15 out of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R24 is dependent of all transfers and care provided by two people at a time.
During an interview and observation on 07/24/23 at 3:00 PM, R24 stated he only gets one shower a week. When asked if that was often enough, R24 stated he would if more frequently than once a week. When asked if he had asked to increase his shower frequency, R24 stated he didn't know he could. Observation made on R24's long fingernails with a couple nails that needed filed due to rough edges. R24 took his fingernail and was itching inside his ear and reported he gets wax build up and using his nail is the only way he knows how to get the wax out. Then R24 laughed and stated he needed to be careful doing that because he had scratched the inside of his ear before, and it would bleed. When asked if he had the caregivers trim his nails, he stated he didn't know they would do that.
Record review of R24's care plan interventions, he was to get a shower, vital signs and skin check on Wednesday during day shift. Also under skin impairment, intervention included avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Keep skin clean and dry. Use lotion on dry skin. Moisture prevention ointment to areas on his coccyx.
Continued interview and observation, R24 stated he didn't realize the CNAs were supposed to be doing his nails, as he looked down at his long uneven nails. R24 also stated he would make sure they got cut and filed.
During an interview and observation on 07/20/23 at 1:30 PM, Director of Nursing (DON) B stated the staff did not know how to use PCC (electronic medical record), they started training, and it was a work in progress. The shower sheets and [NAME] were on paper, and they would not mark them on PCC, so we are training them. Also stated they haven't used paper [NAME] in about 2 years. DOB B also added they were working on getting another agency to work with that is more accountable and would provide the care and document it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains To Intake # MI00137928
Based on interview and record review the facility failed to ensure medical and physical needs would be met upon discharging/transitioning home for one resident (resident #18) of three residents reviewed for discharge planning, resulting in unmet medical needs and hospitalization.
Findings include:
According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident 18 (R18) was a [AGE] year old male admitted to the facility with diagnoses that included peripheral arterial disease with Stage 4 ulcer of the Right calf with exposed tendon, an unstageable left heel, healing coccyx. Osteomylits, bacterial infection. R18's MDS reflected R18 was discharged home on 6/24/23 and scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and required extensive assistance from 2 staff for bed mobility, total assist with two staff for transfers, and extensive assistance from two staff persons for dressing and toileting. Review of R18's June 2023 monthly physician orders reflected R18 was ordered an antibiotic administered every 8 hours with a stop date of 07/07/23, of note the antibiotic was administered via peripherally inserted central catheter (picc line) in addition to the antibiotic being administered thru the picc line hepaerain (blood thinner ) was also administered into the picc line. Wound care orders consisted of cleanse left heel with wound cleanser, apply Santyl, cover with 4x4 silicone border dressing then small (army battle dressing) ABD pad, wrap with Kerlex. Cleanse right calf with wound cleanser, apply Santyl, cover with ABD and wrap with kerlix every evening shift.
On 7/18/23 at 10:30 am during a phone interview with hospital employee HH it was reported that R18 was unsafely discharged home with multiple medical co-morbidities on 6/24, per hospital employee HH R18 was home less that 1 hour before calling 911 and returned to the hospital due to the unsafe discharge.
Progress notes dated 5/31/22 reflected a meeting was held and in attendance was R18's caregiver, wife, Nurse Practitioner, Social Work , Nursing and daughter via phone. The progress notes addressed R18's multiple medical issues, fear of falling and the inability to safely return home. The progress note further reflected the caregiver was to contact the Veteran Administration (VA) regarding placement, and Social Work (SW) would follow up on 06/02/23, there was no explanation as to why R18 was not present at the meeting. The next progress note from SW was 6/12/23, there was no mention of VA placement but instead that R18's wife and caregiver (not R18) were agreeable to R18 returning home.
Progress notes 6/13/23 reflected SW inquired about antibiotics being changed to oral which was not an option per the provider, shelter offset (reducing the out of pocket cost to the facility) the SW progress note reflected two options 1. provide paper work needed to apply for shelter offset if R18 chooses to stay to complete IV antibiotic therapy thru 7/07 or Option 2. Caregiver training on IV's and R 18 would need to discharge home. The SW progress note reflected the options were presented to R18's wife and R18's caregiver, not R18. The progress note ended with SW to follow up with caregiver and wife on 6/14/23 for their decision and confirmation of discharge plan. There was not SW progress note 6/14, the next SW progress note was dated 6/20/23 and reflected SW met with R18 in which a discharge planning meeting was held, R18 was present and it was explained that R18's Medicare benefits were exhausted as of 6/16/23 and that R18's wife needed to complete the paper work for shelter in place (in which she refused to do so) or discharge home with caregiver who would need to be trained on how to do IV's or discharge home with private duty (out of pocket) care. The same progress note reflected that R18 stated he could not afford private duty care, his caregiver could not adequately be trained to manage a picc line with IV antibiotic 3 times a day so reluctantly R18 agreed to hospice referral but does not want IV antibiotics discontinued. The 6/21 SW progress notes reflected a referral was made to hospice on R18's behalf.
The next progress notes that pertained to R18's discharge plan was dated 6/22/23 which referred to R18 to a hospice Long term acute care hospital for the remainder of IV', which denied to accept R18 and an Infusion company which were not able to provide PICC line care 3 times a day. According to the progress note SW met with wife and caregiver, R18 not agreeable to be trained on how to manage IV's, wife angry and did not want R18 to return home in present state , caregiver declined to be trained on PICC line, SW not reflected R18 and SW agreed discharge would be 6/24/23.
Nursing progress notes 6/23/23 reflected the nurse showed R18 how to care for IV and R18 replied It seems too difficult and I have no idea what you just did. I cant learn things as easy as I used to. When the nurse asked if there was someone at home who could learn how to administer the IV antibiotics R18 stated no, they did not want to get involved with medical side of things.
Nursing progress notes dated 6/24/23 reflected they received a phone call from R18's caregiver asking to be trained on managing IV's , the nursing progress note reflected training could not be done as R18 was discharged earlier that morning.
On 07/22/23 at 12:25 pm during an interview with SW X she reported that R18 had to be discharged from the facility because his Medicare days had exhausted and due to his wife's noncompliance with filling out necessary paperwork for Medicaid, the facility may not get paid. SW X stated there was no caregiver training on how to manage the PICC line, or wound care, and that home care or any other outside agency agreed they could/would not be able to meet the PICC line/antibiotic use of every 8 hours. When queried if R18 was discharged homely safely, SW X replied no. When queried why R18 wasn't given the opportunity to stay and be provided a bill and finish his Physician ordered antibiotics with the facility having the option of 30 day involuntary discharge for non-payment as option if necessary, SW X stated she didn't know.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes: MI00137052, MI00137567
Based on observation, interview, and record review the facility failed to implement care plans for 3 of 4 residents (Resident #13, #14 and #24) reviewed for Care Plans, from a total of 26 sampled residents, resulting in unmet care or the potential for inadequate/inappropriate care.
Findings Include:
Resident #13 (R13)
Review of the medical record revealed Resident #13 (R13) was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes, Lymphedema (localized swelling caused by a compromised lymphatic system), Venous Insufficiency (blood doesn't flow efficiently through the veins), Chronic Venous Hypertension (abnormalities in the capillaries in the leg), Peripheral Vascular Disease (disease of the circulatory system), Depression and Anxiety.
According to Resident #13 (R13)'s Minimum Data Set (MDS) dated [DATE], revealed R13 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R13 requires one to two people to assist with all care.
During an interview and observation on 07/20/23 at 11:27 AM, R13 stated she filed a complaint because she is not getting the care she needs. R13 also mentioned the staff are in a hurry to get in and out of resident's room, trying to keep up. R13 stated with her Lymphedema, her skin is tender, and staff need to go slow and be gentle. R13 mentioned she may not see staff for hours during the day.
Record review of care plan for R13 revealed she was to receive bathes on Monday and Thursday evenings. During bathes or showers, to pat R13's skin to clean, rather than rub, which causes her pain. Check nail length and trim and clean on bath days and as needed. Provide a sponge bath when a full bath or shower cannot be tolerated. R13 requires skin inspections with Shower on Monday evening. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse.
Record review of the care plan [NAME] showing personal care that R13 received. Documentation revealed R13 received two showers in the last 30-day period. Showers were on 06/27/23 and 07/11/23. R13 should have received eight showers in the last 30-day period.
Resident #14 (R14)
Review of the medical record revealed Resident #14 (R14) was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (stroke), Hemiplegia (paralysis on one side of the body) and Hemiparesis left side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), non-dominate, Osteoporosis, pain in right hip, Chronic Kidney Disease, Radiculopathy (pinched nerve, weakness, altered sensation, difficulty controlling specific muscles) of the Lumbar Region, Depression and Anxiety.
According to Resident #14 (R14)'s Minimum Data Set (MDS) dated [DATE], revealed R14 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R14 requires two people to provide all care.
During an interview on 07/18/23 at 1:26 PM, R14 stated that she had file several complaints about staffing. R14 added, one night shift, they only had only one Certified Nursing Assistant (CNA) and one nurse for all of residents on the rehab. R14 went on to explain that part of her nightly routine is to make and place ice packs on/off every two hours for pain management. R14 stated she told the CNA about her nightly routine, and the CNA told R14 she didn't have time. R14 stated she had this task posted on her wall but would still have to tell all CNA's how to make an ice pack. R14 added that on another night, R14 had another agency CNA, who stated she knew how to make the ice pack, but it broke open in the night, and the bed and clothing was wet. Due to the lack of staff and skill making these ice packs as instructed and having them break open, it did nothing for pain management. The ineffective therapeutic method increased R14's pain. R14 stated that other CNAs reported not being trained to do that, or not having time to make them. R14 also stated, due to the lack of consistency in care is affecting your wellbeing.
Record review of care plan and task sheets revealed R14 had care planned to use ice pack of her choice, knowing the risk versus benefits of potential skin burns. R14 was of sound body and mind and was able to make choices for herself. Care plan did not give specific instructions on preparing the ice packs. Observation of instructions hanging on the wall instructing staff how to prepare these ice packs.
During an interview and observation on 07/20/23 at 1:30 PM, Director of Nursing (DON) B stated the staff did not know how to use PCC (electronic medical record), they started training, and it was a work in progress. DON B added that CNAs didn't use [NAME] (Care Plan specific's) anymore, she didn't think paper was efficient and too hard to keep up with. DON B also stated she was aware not all staff use computers and acknowledged lots of agency staff who didn't check the computer for transfer status, feeding assistance, days they got showers, or personal care preferences. DON B stated she realizes staff can't remember all the specifics of each resident needs for an entire shift, but states CNAs are expected to meet there needs. The shower sheets/ skin assessments were on paper, and they would not document them on PCC, so we are training them to do so. Same with weekly skin assessments, if the nurses lock them late, DON B must go in and adjust the schedule to be a week out from the date they were locked. DOB B also added they were working on getting another agency to work with that is more accountable and would provide the care and document it.
Resident #24 (R24)
Review of the medical record revealed Resident #24 (R24) was admitted to the facility on [DATE] with diagnoses that include Seizures, encephalopathy (disease that can affect the functioning of the brain), Duchenne or [NAME] Muscular Dystrophy (muscular dystrophy), Dysphagia (difficulty swallowing), Cardiomyopathy (disease that affects the heart muscle), Hypo-Osmolality and Hyponatremia (retention of water by loss of sodium) and contractures of both left and right knee.
According to Resident #24 (R24)'s Minimum Data Set (MDS) dated [DATE], revealed R24 scored 15 out of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R24 is dependent of all transfers and care provided by two people at a time.
During an interview and observation on 07/24/23 at 3:00 PM, R24 stated he only gets one shower a week. When asked if that was often enough, R24 stated he would if more frequently than once a week. When asked if he had asked to increase his shower frequency, R24 stated he didn't know he could. Observation made on R24's long fingernails with a couple nails that needed filed due to rough edges. R24 took his fingernail and was itching inside his ear and reported he gets wax build up and using his nail is the only way he knows how to get the wax out. Then R24 laughed and stated he needed to be careful doing that because he had scratched the inside of his ear before, and it would bleed. When asked if he had the caregivers trim his nails, he stated he didn't know they would do that.
Record review of R24's care plan interventions, he was to get a shower, vital signs and skin check on Wednesday during day shift. Also under skin impairment, intervention included avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Keep skin clean and dry. Use lotion on dry skin. Moisture prevention ointment to areas on his coccyx.
Continued interview and observation, R24 stated he didn't realize the CNAs were supposed to be doing his nails, as he looked down at his long uneven nails. R24 also stated he would make sure they got cut and filed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect residents on the same hall from one resident (R17) during an investigation of alleged abuse toward other residents on his hall and failed to report and investigate an allegation of abuse to residents on his hall, reviewed for abuse and a total sample of 15 residents, resulting in the potential for further abuse. Findings include:
Resident #17 (R17)
Review of the medical record revealed Resident #17 (R17) was admitted to the facility on [DATE] with diagnoses that included Progressive Neurological Condition, Alzheimer's, Parkinson's Disease, anxiety and receiving hospice services for end-of-life care.
According to Resident #17 (R17)'s Minimum Data Set (MDS) dated [DATE], revealed R17 scored 07 out of 15 (severely impaired) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R17 is independent of ambulation.
Record review of 05/02/23 03:43 AM progress note, revealed R17 had been very combative when being redirected throughout the night. R17 had been grabbing and hitting staff. R17 had been entering other patient's rooms while sleeping. When staff tries to enter residents' room, he forced staff out and closed his door.
Record review of 05/04/23 07:06 AM progress note, revealed .when R17 got out of bed in the morning, he was combative toward the staff, trying to sock them with his fist. R17 entered several of the resident's rooms and started to sit on their beds with the residents asleep in the bed. When they tried to direct him out of the room, he became combative and tried to slam the door shut with him inside the room. One resident's room he entered; he sat down on top of the resident in the bed. R17 was impossible to redirect and entering several residents' rooms, was unsafe for the resident. When staff tried to close the doors to keep the residents in the hallway, he was able to open the doors himself. Resident is very strong and unsafe to be close to residents in their bed sleeping .
Record review of 05/04/23 13:03 AM progress note, revealed R17 had been very combative with staff and other residents .when he was hitting staff and other residents, as the staff had to try to contain him from his combativeness .
Record review of 05/12/23 19:17 PM progress note, revealed R17 was wandering and exit seeking throughout shift. In the morning, resident was severely agitated, trying to put on another resident's bra, and refused to go out of the resident's room. R17 tried to push this nurse when trying to redirect .
Record review of 05/15/23 3:35 PM progress note, revealed R17 grabbed and hit staff this afternoon during bingo group. R17 was attempting to take another resident out of the bingo group. Staff attempted to re-direct the other resident back into the group .
Record review of 05/19/23 4:00 PM progress note, revealed R17 was wandering the halls and other resident's rooms looking for an exit out. When nurse tried to redirect R17, he became agitated .
Record review of 05/28/23 11:08 AM progress note revealed, R17 continue to wander into other resident's rooms not able to redirect .
Record review of 05/31/23 0900 AM progress note revealed nurse was on the hall and heard a CNA attempting to redirect the resident out of a female resident's room. Nurse and CNA intervened when the resident attempted to hit the other resident. R17 then grabbed the CNA' s hand/thumb and would not let go. Nurse was able to help direct the resident to the door, where R17 continued to attempt to enter the room . R17 was hitting/punching nurse on the right side of body. R17 grabbed this writer's wrist and would not let go . Female resident was very upset regarding the situation .
Record review of 06/01/23 4:16 PM progress note revealed R17 was combative this am and broke the wrist of the nurse. He punched another resident. Pt was aggressive and combative with staff and residents. Had altercation with roommate. His room was changed .
Record review of care plan and [NAME] for R17 did not reveal interventions to keep other residents safe from R17 entering their rooms, getting into there personal belongings, and being combative and aggressive towards them. R17 had trialed medications for behaviors that were ineffective. Care plan and [NAME] did not residents safe from R17.
During an interview on 07/20/23 at 10:20 AM, Quality Life Enrichment Manager (QLEM) C stated she was the one that investigated incidents, there was no other incident reports, concern forms or facility reported incidents other than the one already submitted.
During the onsite survey, it was found that the facility identified and corrected their deficient practice prior to the survey team entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains To Intake #'s MI00138136
Based on observation, interview and record review the facility failed to ensure that residents and family members were made aware of their right to file a written grievance against the facility for Resident/Families ( R#4, 10, 13, 14 and R24) and failed to promptly and accurately document, investigate, track and resolve grievances for Resident #19 , and failed to provide written responses to grievances upon request for R19, resulting in anger, frustration and unresolved complaints.
Findings include:
According to the clinical record Resident #19 (R19) was a [AGE] year old female with multiple medical comorbidities, according to the Minimum Data Set (MDS) dated [DATE], R19 scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review of the clinical record reflected R#19 had a Durable Power of Attorney (DPOA).
During phone interviews with R19's DPOA N on 7/18/23 at 9:40am. and 7/19/23 9:45 it was reported DPOA N had made numerous complaints regarding R19's care, including but not limited to activities, call light response time, call light not being within reach, hydration, assistance level provided at meals, denture use, environment, care plans and Kardex not being provided to certified nursing assistants (CNA's) . DPOA N further stated she had reached out to the Ombudsman as her complaints/concerns do not get addressed or corrected, and fell on deaf ears by the Nursing Home Administrator (NHA) A and or other Management staff. DPOA N further stated the bulk of her complaints had been verbally reported to various nurses and management staff and out of desperation she recently started to attend County Board meetings in effort to have her concerns taken seriously and be addressed. Review of email chain dated 07/05/23 between DPOA N and NHA A in which Social Worker X, Unit Manager G and the Ombudsman were cc'd, the email chain revealed DPOA N requested her complaints be logged in writing and a written response was requested.
Review of R19/ DPOA N 's feedback forms from April thru July 2023 were requested and revealed the 4/03/23 feedback form reflected a concerns related R19's glasses not being cleaned, her pajama bottoms not being put on at night, and 2 sets of missing pajamas. The 5/10/23 feedback form reflected concerns about R19 not being transported to the dining room for meals, water not being kept in reach and wearing the same cloths two days in a row.
Review of the monthly facility grievance log from April 2023 thru July reflected for
April 2023
Meal Time
Medication timing
C.N.A recognition
Meals as ordered/timing & application of socks
DC of medication
Food quality per resident preference
Resident self management of alcohol
Room move adjustments to new unit
Meal texture & adaptive equipment
May 2023
Variety-treatment plan, linen changes and staffing
Treatment orders
Cleanliness of dishes/glasses
Quality of food
LOA concerns
Room cleanliness/items going through laundry/virtual visits
Concerns about limitations/ and weights
Personal appearance
Missing clothing
Lost hangers
Preference to evening routine
Invites to care conferences
Follow up for ADL support
Pet Visitation
Positioning & Braces
June 2023
Shower concern
POA-regarding LOA for resident
Communication w/son re:x-ray
[NAME] calls
Safety(MSU event) & HiPAA letter
Quality of Food
The log does not reflect the date of the concern, the individual that identified the concern, if the concern was resolved or not, what resident was involved the date of a resolution etc . On 7/18/23 at 2:48 PM during an interview with the facility Chief Operating Officer (COO) M she reported she was in charge of grievances. When queried the facility utilized the grievance log, COO M reported the log was taken to the facility Quality Assurance meetings. When queried how information from the log was ascertained to track, identify patterns, trends that pertained to residents, staff, shifts etc COO M stated she could pull the actual feedback forms if as needed.
Review of the monthly facility feedback ( grievance) log did not reflect DPOA N's concerns that were identified on the feedback form dated 5/10/23 from DPOA N that pertained to R19 not being transported to the dining room for meals, or wearing the same clothes two days in a row. Further review of the feedback log, did not capture concerns from the 4/3/23 feedback form that pertained to R19, which complained about pajama bottoms not being put on and eye glasses needing to be cleaned more regularly. During the same 7/18/23 2:48 pm , interview with COO M she reported all facility staff has had so much communication with DPOA N and on such a regular basis they don't always document the complaints because they are so frequent and repetitive that the facility fixes the issues and she continues to complain about things that were already been fixed. When queried how it was determined DPOA N'/ R19's issues was actually fixed opposed to resurfaced if the complaints aren ' t being logged/tracked , COO M did not respond to the question.
On 7/25/23 at approximately 1:00 pm during an interview with COO M a request to view DPOA N's feedback form along the written response as requested from DPOA N's email chain dated 7/05/23, COO M reported the feedback form including the written response were not filled out.
Resident #4
According to the clinical record, Resident #4 (R4) was an [AGE] year old female admitted to the facility on [DATE] with a diagnosis of dementia-, review of the MDS dated [DATE] R4 scored 1 (severe cognitive impairment) on the BIMS. On 7/19/23 at 1:35pm during a phone interview with family member of R4 (family member R) she reported visiting the facility several times a week and verbalized many concerns pertaining to low staffing levels, missing showers and other care concerns. Family member R stated she verbally reports her concerns to nursing staff which she described as mostly agency and management who does not address concerns, Family member R further stated she started to attend the County board meetings to get her concerns addressed. When queried if she had filled out feedback (grievance) forms, family member R reported she did not know of such forms or that was an option to have her concerns addressed.
Resident #10
According to the clinical record, including the Minimum Data Set, resident 10 (R10) scored 15 out of 15 (cognitvely intact) on Brief Interview for mental Status (BIMS) . On 7/24/23 at 1:45 pm during an interview with R10 she reported having concerns with staffing levels and call light response times, R 10 elaborated that it frequently took 30 minutes or longer to have her call light answered by staff. R10 further stated staff are often agency and were not trained on how to take care of her or what her needs are, I always have to tell them how I transfer , what I need etc when quiried if she had filed a grievance or a feedback form, R10 stated she had no idea there was such a thing, and further stated she complained to the actual Nurses which are from the agency and never had any follow through.
According to the facility policy :
POLICY: Resident Feedback Policy
REFERENCY: Administration
EFFECTIVE: 7/21/21
OBJECTIVE: Residents, patients, their representatives/other family member/advocates may file a Resident Feedback From. This form will provide the facility with feedback including but not limited to: suggestions/compliments/issues/grievances for individuals/groups/overall.
PROCEDURE:
1. Any residents, patients, their representatives/other family member/advocates may file a Resident Feedback form for any suggestions/compliments/issues of any type without fear of threat or reprisal of any form.
2. Upon admission, residents are provided with written information on how to file a Resident Feedback Form.
3. Resident Feedback Forms will be placed in areas of the facility for easy access by those wishing to complete one as well as how to file Feedback orally.
4. Resident Feedback Forms can be filed anonymously.
5. Resident Feedback Forms may be submitted in writing or orally. The Administrator may delegate the responsibility of Resident Feedback follow up to the appropriate department leader/designee.
6. Upon receipt of a written/oral Resident Feedback Form/request, the department leader/designee will determine next steps and follow up with the Administrator.
7. Resident Feedback Forms should be resolved timely. Most Feedback Forms should be resolved within 24-72 hours. There may be situations where more time is necessary.
8. The COO is delegated by the Administrator for overseeing the grievance/feedback process, receiving, and tracking through their conclusion.
9. Resident Feedback Forms that are considered reportable as required by state law will be managed according to reporting criteria.
10. The resident/or person filing the Resident Feedback Form, will be provided feedback from the Resident Feedback form.
11. Resident Feedback forms are to be retained for no less than 3 years
(F 585- Rev.173,Issued: 11-22-17,Effective:11-28-17).
Updated: 5/
Resident #13 (R13)
Review of the medical record revealed Resident #13 (R13) was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes, Lymphedema (localized swelling caused by a compromised lymphatic system), Venous Insufficiency (blood doesn't flow efficiently through the veins), Chronic Venous Hypertension (abnormalities in the capillaries in the leg), Peripheral Vascular Disease (disease of the circulatory system), Depression and Anxiety.
According to Resident #13 (R13)'s Minimum Data Set (MDS) dated [DATE], revealed R13 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R13 requires one to two people to assist with all care.
During an interview and observation on 07/20/23 at 11:07 AM, R13 stated she filed a complaint because she is not getting the care she needs. R13 also mentioned the staff are in a hurry to get in and out of resident's room, trying to keep up. R13 stated with her Lymphedema, her skin is tender, and staff need to go slow and be gentle. R13 mentioned she may not see staff for hours during the day. R13 stated she puts on her call light and had to wait forever for someone to come in and help her. R13 then stated the staff will tell her the call light was not even on, that she never had the call light on. R13 stated she was not stupid; she knows how to use a call light. They just don't answer them.
During an interview and observation on 07/20/23 at 11:25 PM, SW Y stated she follows up on complaints/concerns/feedback forms. SW Y also stated that R13 stated she didn't feel there was enough staff during the night to take care of all the residents on their floor due to the higher care needs. R13 also complained about a CNA that was ruff with the care provided. Also stated that R13 told her she was in fear related to the higher care needs and that staffing was based off numbers, not needs of the residents. SW Y stated they completed an audit on staffing for April and May, was not sure of the outcome of the audit.
During an interview and observation on 07/20/23 at 12:10 PM, SW X stated she had completed two concern forms/feedback forms with R13. Stated it then goes to Clinical Operations Officer (COO) M. SW X stated that R13 told her that the CNA that came in to help her had red hair, very ruff with her, was rude to her and she was an agency CNA. SW X also stated that the UM G was going to follow up on it. SW X added that UM G was going to look in the employee directory for this caregiver with red hair that fit this description. SW X stated it was the facility policy to follow up with three wellness visits after a concern is identified. SW X stated that R13 did not mention the nurse that did not give her the medications prior to the wound clinic appointment, nor did she mention that she was not getting her bathes. When asked if the R13 was informed of the outcome of her complaint, SW X stated she didn't know.
During an interview and observation on 07/20/23 at 2:00 PM, R13 stated that nobody has reported back to her the finding out her complaints. Added, they write is down, but what happens to the information, who knows.
During an interview and record review of complaints/concern forms/feedback forms on 07/24/23 at 2:30 PM, COO M stated that she does not return the form in original or copy form back to the residents. COO M then stated she logs the complaints to look for patterns. The log sheet does not show if the complaint/feedback form/concern was addressed or not, does not reveal if it was to the resident's satisfaction, or within the timeframe per the Feedback Policy.
POLICY: Resident Feedback Policy
REFERENCY: Administration
EFFECTIVE: 7/21/21
OBJECTIVE: Residents, patients, their representatives/other family member/advocates may file a Resident Feedback From. This form will provide the facility with feedback including but not limited to: suggestions/compliments/issues/grievances for individuals/groups/overall.
PROCEDURE:
1. Any residents, patients, their representatives/other family member/advocates may file a Resident Feedback form for any suggestions/compliments/issues of any type without fear of threat or reprisal of any form.
2. Upon admission, residents are provided with written information on how to file a Resident Feedback Form.
3. Resident Feedback Forms will be placed in areas of the facility for easy access by those wishing to complete one as well as how to file Feedback orally.
4. Resident Feedback Forms can be filed anonymously.
5. Resident Feedback Forms may be submitted in writing or orally. The Administrator may delegate the responsibility of Resident Feedback follow up to the appropriate department leader/designee.
6. Upon receipt of a written/oral Resident Feedback Form/request, the department leader/designee will determine next steps and follow up with the Administrator.
7. Resident Feedback Forms should be resolved timely. Most Feedback Forms should be resolved within 24-72 hours. There may be situations where more time is necessary.
8. The COO is delegated by the Administrator for overseeing the grievance/feedback process, receiving, and tracking through their conclusion.
9. Resident Feedback Forms that are considered reportable as required by state law will be managed according to reporting criteria.
10. The resident/or person filing the Resident Feedback Form, will be provided feedback from the Resident Feedback form.
11. Resident Feedback forms are to be retained for no less than 3 years
(F 585- Rev.173,Issued: 11-22-17,Effective:11-28-17).
Updated: 5/22;1/23
Resident #14 (R14)
Review of the medical record revealed Resident #14 (R14) was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (stroke), Hemiplegia (paralysis on one side of the body) and Hemiparesis left side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), non-dominate, Osteoporosis, pain in right hip, Chronic Kidney Disease, Radiculopathy (pinched nerve, weakness, altered sensation, difficulty controlling specific muscles) of the Lumbar Region, Depression and Anxiety.
According to Resident #14 (R14)'s Minimum Data Set (MDS) dated [DATE], revealed R14 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R14 requires two people to provide all care.
During an interview and observation on 07/19/23 at 11:00 AM, R14 stated she had brought up more than once her issues with CNA's not knowing how to make an ice pack at resident council. R14 then stated she requested to talk to the NHA A regarding this issue. R14 stated that NHA A what kind of training they are getting. CNAs are not shadowing other CNA's. Agency staff are telling residents that are not getting trained. R14 stated she voiced consistency, because it means a lot to residents and staff. Facility rotates them around all the floors instead of training them for a certain floor. R14 stated she has some blank feedback forms because they are not out on the floor. Added, she can fill it out and have a staff member sign it. R14 stated she had asked COO M for copy of grievance/feedback form after submitted it and she told them no. R14 than stated that the form states, they will respond within 24 hours, not a month or more. R14 stated that grievance forms are not located by the rehab endurance door either.