Every finding on record at Adira Nursing and Rehabilitation

This citation pertains to Intake Number 2976205. Based on interview and record review the facility to implement a process for receipt of and reconciliation of home medications for one resident (Resident #701) of two residents reviewed for pharmacy services. Findings Include:On [DATE] at 10:00 AM, Complainant K shared his father (Resident #701) admitted to the facility for short term rehabilitation after an extended hospital stay. Upon admission he provided the facility with his father's anti-rejection (immunosuppressant) medications to cover the duration of his stay. He gave the facility the following:Tacrolimus 1 mg (milligram)- 2 bottles (30 capsules in each bottle)Tacrolimus 4 mg - 2 bottles (30 capsules in each bottle)Complainant K started he was supposed to receive 5 mg per day (1 mg tablet and 4 mg tablet). At discharge the medication order was for 5-1 mg Tacrolimus capsules which was confusing to him given he provided two bottles of 4 mg capsules. They received back one box of 4 mg (20 capsules) and an empty box of 1 mg Tacrolimus. The medication provided did not match the ordered dosage in their administration record and it had the appearance the medication was administered incorrectly to his father. On [DATE] at approximately 10:15 AM, a review was conducted of Resident #701's medical records and it revealed he was at the facility from [DATE] to [DATE] with diagnoses that included Atrial Fibrillation, Kidney Transplant, Heart Failure, Cardiomyopathy, and Immunodeficiency. Further review of the records yielded the following:Acute Care Medication Discharge List dated [DATE]: .Tacrolimus ER 1 MG- take 5 tabs by mouth daily. Handwritten note next to order Family supply bottle.admission Check List & Audit Form dated [DATE]: .Tacrolimus 1 mg fam (family) supplied) .Nursing admission assessment dated [DATE]:No mention of home medications provided to the facility for Resident #701.Inventory of Personal Effects:No mention of home medications provided to the facility for Resident #701. MAR (Medication Administration Record)Tacrolimus Oral Capsule 1 mg - give 5 capsules by mouth one time a day for kidneys.Based on the home medication provided by Complainant K if the facility only administered 1 mg capsules of Tacrolimus (60 capsules provided) throughout Resident #701's stay (20 days) they would have ran out of medications in approximately 12 days. Per the complainant he did not receive a phone call requesting additional medications. There is not a physician's order for a 4mg dosage of Tacrolimus. On [DATE] at 11:12 AM, an interview was conducted with Nurse E regarding Resident #701's home medications administered at the facility and his discharge. The nurse reported upon his discharge his son was upset because she could not find the remaining medications they provided at admission and how they were administering the medication to his father (5-1 mg capsule vs 1- 1 mg & 1-4 mg capsule). Nurse E stated she did locate the medication in the bottom drawer and contacted the family who picked them up. She recalled it being 1- bottle of 1 mg Tacrolimus and 1- bottle of another dosage. Nurse E stated she did count the medications but did not document the count in his medical record.Nurse E continued from what she can remember there were two bottles of Resident #701's home medications in the top drawer and she administered from both bottles as there were two different dosages- with one being 1 mg and she could not recall the other dosage. She stated when residents provide their home medications it should be documented in the chart what they bring in, but they do not count the medications like they would do for narcotics. There is no actual reconciliation process for residents' home medications. On [DATE] at 11:47 AM, an interview was conducted with Nurse D regarding Resident #701's admission to the facility. Nurse D stated the resident did have home medication in the top drawer of the medication cart but she was not the nurse whom the family provided them too. She stated Resident #701 had a few bottles (of Tacrolimus) and there were two different dosages. Nurse D would take one capsule out of the 1 mg bottle and one capsule out of the higher dosage bottle. During Resident #701's stay they switched medication carts and she is not certain if this medication was moved around during the process.Nurse D stated there is no process in place to write down the number of home medications they come in with, the dosages or the number of medications in the bottle upon admission. On [DATE] at 1:50 PM, Infection Control Nurse I was queried regarding their admission process for residents with home medications and reconciliation of those medications. Nurse I stated it would be listed in their order set and on their personal inventory form. She stated the inventory sheet would only list the medication name and quantity of bottles provided. Nurse I was queried if staff would list the dosage of the medication or a count of how many pills were received and she stated they would not, as they do not count home medications and give the bottles back upon discharge.Nurse I stated the admission checklist did indicate Resident #701's family provided 1 mg tacrolimus bottle (did not state the quantity of bottles provided) but she was not able to locate any other documentation related to his home medications. Based on what was written on the form Resident #701 would have ran out of tacrolimus in about five days (Nurse I agreed). From Nurse I review of Resident #701's records it was unable to be ascertained what dosages, quantity of home medications were provided to the facility upon admission and what was given back to Resident #701 at discharge.Nurse I continued with the medications they receive from pharmacy they can reconcile non-narcotic medications and request the shipping manifest. She was asked was there a current process/procedure to receipt/reconcile home medications and she stated there was not. Review was conducted of the facility policy entitled, Medications Brought in the Facility by Physicians or Resident/Family Members, revised 08/2020. The policy stated, .Medications from Home.the medication has not expired, and the medication has been positively identified by the physician or pharmacist prior to use. The facility will have documentation that the identification has been made. Delivery and receipt must be documented as with any other medication, ion a common receipt log or in the individual resident's record. Review was conducted of the facility policy entitled, Reconciliation of Medications on Admission, reviewed 7/25. The policy stated, .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility.Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route.

Based on interview and record review the facility failed to initiate timely pain interventions for two residents (Resident #13 & Resident #81) of two residents reviewed for pain, resulting in both Resident #13 and Resident #81 experiencing documented increased pain after falls (which resulted in femur fractures requiring surgical repair), without any pharmacological or non-pharmacological interventions provided and a12 + hour delay in transferring both residents to the hospital for proper evaluation and treatment.Findings Include:Resident #13:Review was conducted of Resident #13's chart and it revealed she admitted to the facility on [DATE] with diagnoses that included, Alzheimer's Disease, Diabetes, Asthma, Dementia, Heart Failure and Hypertension. Resident #13 required assistance of facility staff for daily care. Further review of her chart yielded the following:Progress Notes: 10/3/2025 at 14:43: CNA informed nurse that was resident was on the floor. Nurse went into room to assess and resident was observed on the right side of the bed. ROM (range of motion) complete and able to move all extremities without difficulty. No new injuries or bruising noted. Resident two person transferred with mechanical lift back into bed. Physician, family, and nurse manager notified of fall. Neuro check and fall charting initiated. 10/3/2025 at 21:13: Resident indicated her right foot and ankle area were hurting her post fall. Notified the physician and an x-ray of foot and ankle ordered. 10/4/2025 at 01:14: Received a critical result for the x-ray of her foot and ankle, the 5th metatarsal has a hairline, no displaced fracture. Notified the OnCall manager and the physician. 10/4/2025 at 05:06: During morning care resident noted to be grimacing and crying out stated her hip hurt. At that time it was noted that the right leg is bent at knee and is externally rotated. order received for xray to hip and knee (right). 10/4/2025 at 13:45: Phone call placed to.x-ray due to status of technician for STAT x-ray that has been ordered. Message sent to technician and tech to call back. 10/4/2025 at 20:12: Left hip/leg x-ray results received w/ right femur intertrochanteric fracture with mild upward displacement of the distal segment. (physician) notified Resident to be sent to the ER. On call notified. 10/4/2025 at 20:56: (EMS) arrived at approximately 8:50pm to transfer resident via stretcher to (hospital). Diagnostic Orders: 10/3/2025 at 19:36: Right ankle, complete,, 3+ view, right foot, complete, 3+ views. Stat order.10/4/2025 at 04:33: Right hip, unilateral w/ pelvis when performed, 2-3 views, right knee, 1/2 view. Stat order. Pain Assessment:10/3/2025 at 08:36: 610/4/2025 at 14:23: 5 MAR (Medication Administration Record):Resident #13's October 2025 MAR was reviewed and there were no entries that indicated the resident was offered or administered any pain medications after her fall and indications of pain. It reasonable to ascertain Resident #81 was experiencing pain. There were no medications administered or nonpharmacological interventions provided to manage her pain prior to be transferred to the hospital approximately 31 hours later. X-Ray Results:10/3/2025: Right Foot-2 views .Post fall complaints of foot pain, acute pain due to trauma .hairline non-displaced fracture of distal fifth metatarsal. Hospital Records: .Closed right intertrochanteric femoral fracture, nondisplaced hairline fracture of right 5th metatarsal.X-Ray and CT of the right hip, pelvis, femur personally reviewed. There is a comminuted intertrochanteric hip fracture in the setting of pre-existing osteoarthritis.Per report she had an unwitnessed fall at her nursing home. She had immediate right hip pain. We were also told the x-rays were obtained at the nursing home that revealed a right 5th metatarsal fracture.Plan for right hip cephalomedullary nail.She does endorse pain over palpation of the right hip.pain to palpation elicited on light palpation of the right hip. Review was conducted of incontinence care and turning/repositioning of the resident post fall:Bladder Continence and Toilet Use:10/3/2025 at 19:2410/3/2025 at 08:4010/4/2025 at 16:43Turning and Repositioning in bed/chair resident lays/sits in every two hours ass resident will tolerate:On 10/3/2025 Resident #13 was turned and repositioned at 19:12On 10/4/2025 Resident #13 was turned and repositioned at 12:03 and 16:45. On 01/20/2026 at 2:06 PM, an interview was conducted with Nurse I regarding Resident #13's fall and subsequent fracture. Nurse I stated the resident required a mechanical lift for transfers as she could not get in/out the bed alone. She was dependent on facility staff for most of her daily cares. Nurse 'I recalled the CNA (Certified Nursing Assistant) observed her on the floor to the right of her bed. Resident #13 was flat on her back with her head toward the top of the bed and upon going into the room, the bed was at knee height to the nurse (the nurse is 5'9). The resident was unable to verbalize what occurred but the last time Nurse I saw the resident she was in the center of the bed. It was assumed from her position on the floor she rolled out of bed. Nurse I continued Resident #13 was assessed prior to being placed back in bed and there were no outward expressions of pain with range of motion and transferring her back into bed. There was no redness, swelling and nothing appeared to be externally rotated at this time. Nurse J worked the night shift on 10/3/2025 and that is when Resident #13 began to express signs of pain. On 1/20/2026 at 2:17 PM, an interview was conducted with Nurse J regarding Resident #13's pain and fracture discovery. The nurse said she was not as familiar with the resident, but it appeared she was in pain. Upon assessment Resident #13 would grimace with touching of her ankle/foot area. The 1st set of X-rays for her foot/ankle were ordered afte4r this initial assessment and conducted during her shift. Later in the shift the CNA went in to change her, and Nurse J was able to assess her hip area, and it appeared to be externally rotated. As the resident was being changed, she was grimacing and crying out. The CNA was quite familiar with her and stated while her being vocal during care is normal this was different type of crying out. Nurse J was asked if she recalled administering pain medications to Resident #13 during her shift for her outward expressions of pain, the nurse stated to refer to the MAR given the amount of time that had lapsed. The MAR showed that no pain medications were administered to the resident during Nurse J s shift. The nurse stated if they did not move the resident, she did not have any expressions of pain and check, and changes were every two-three hours. After the assessment of Resident #13's hip is when she contacted the physician and requested the 2nd set of x-rays. The x-ray of the resident's hip did not occur prior to the conclusion of her shift, but the initial x-ray resulted which indicated a metatarsal hairline fracture. On 01/22/2026 at 1:00 PM, the DON (Director of Nursing) was interviewed regarding the lack of pain interventions, delay in onsite imaging and transfer to the hospital. The DON reported from the fall investigation they found Resident #13 leaned to the right to watch television and fell out of bed. The CNA observed the resident on the floor and promptly reported it Nurse I. During the next shift, pain in the resident's ankle/foot was reported and the 1st set of x-rays ordered and indicated a hairline 5th metatarsal fracture. She was downgraded to hoyer transfer and was to avoid activity that would place pressure on her foot.The DON reported the 2nd set of X-rays were ordered about 5:00 AM but were not completed for an extended period of time. The x-ray company was contacted at approximately 1:45 PM on 10/4/25 for an update (8 hours after the stat order was placed). The DON was queried if the resident was administered any pain medications or if other non-pharmacological interventions were provided for Resident #13 prior to being transferred to the hospital. The DON stated from the review she does not see that any pain medications were administered to the resident nor other non-pharmacological interventions. The DON further stated the resident only cried out in pain when she was changed or repositioned. The DON was unable to provide an explanation as to why they waited 9+ hours for a stat x-ray to be completed,16 hours to transfer a resident with evident pain and externally rotated leg without any pain interventions indicated. On 1/22/2026 at 2:34 PM, an interview was conducted with CNA K regarding Resident #13. CNA K reported the resident was a two person assist prior her fall in October 2025 and did not like to be touched. The resident required assistance with daily care as she could not roll and did not utilize her call light. CNA K stated they were aware she had fallen earlier in the day and as they began to roll the resident from side to side during the check and change it was evident her side was causing her a great deal of pain. The resident was acting differently from her baseline. When they were getting into position to change her CNA K barely placed her hand on the resident and she was saying ouch-ouch, and yelling out as they were completing her incontinence care. Resident #13 was a heavy wetter and was always changed about every two -three hours, they would have to also change her sheets as well as those were urine saturated. During each encounter that night for check and changes the resident was crying out in pain. It can be noted that Resident #13 was discovered on the floor next to her bed at approximately 1:45 PM on 10/3/2025. She indicated right foot and ankle pain post-fall and an x-ray was ordered around 7:36 PM. X-ray results received indicated non-displaced fracture of the 5th metatarsal. Durning morning care on 10/4/2025, the resident was grimacing, and crying out stated her hip hurt. It was noted her right leg was bent at the knee and externally rotated. Stat x-rays were ordered at 4:33 AM. X-ray results were received at 8:12 PM on 10/4/2025 that showed right femur intertrochanteric fracture. The resident was transferred to the hospital at 8:50 PM. Resident #13 remained in the facility for about 31 hours post fall and approximately 20 hours after documentation of increased pain. During those 20 hours facility staff provided incontinence care which required turning and repositioning who was noticeably in pain with light touching, yet there was no pain interventions documented. Resident #81: On 1/20/20/2026 at approximately 11:00 AM, Resident #81 was observed in bed with the covers pulled over his head. He appeared to be resting and did not answer this writer when his name was called multiple times. On 1/20/2026 at approximately 1:30 PM, a review was conducted of Resident #81's records and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Dementia, Alcohol Cirrhosis of the Liver, Alcohol induced Dementia, Anxiety, Major Depressive Disorder and Mood Disorder. Resident #81 required some assistance with his daily care but was able to transfer between his bed/wheelchair and toilet independently. Further review was conducted of his chart, and it yielded the following: Care Plan: .Ambulation: I require assist of 1 with use of RW.Wheelchair: Standard wheelchair with auto locking brakes independent with wheelchair mobility.Toilet use: I am independent; Transfer: Independent between bed and wheelchair with use of assist rail. Independent with toilet transfers. 1 assist showers chair no device.I am at risk for falls r/t impaired cognition incontinence, hx UTI's, hypotension, hx fall with fracture, anxiety. I have poor safety awareness with impulsive but I have a strong attempt to remain as independent as possible. I will continue to attempt to self- transfer.Have commonly used articles within easy reach. I have a lightweight dresser in my room.Wheelchair to be left at bedside. I have left femoral neck fracture r/t Fall 9/26/25 surgical percutaneous screw fixation of left femoral neck fracture. Kardex: .Frequent check while resident in on bed; keep room well lit; Maintain bed at transfer height as I tolerate with wheelchair next to bed with brakes locked.Brief use: disposable briefs. Change prn (as needed). Progress Notes: 9/24/2025 at 19:05: Was alerted by CNA (Certified Nursing Assistant) that resident placed his call light on to report that he fell and has left hip pain. Resident stated he was by his dresser and fell on his left side, states his left hip hurts and can hardly move it. When asked when he fell he stated about an hour or so ago. Assessment completed and revealed a skin abrasion to the left knee. ROM (range of motion) appropriate in all extremities except the left lower leg, ROM is limited and resident reports having increased pain with movement. Provider notified new order received for STAT x-ray of the left hip and knee, orders placed. On call notified. 9/25/2025 at 01:23: X-ray results available and faxed to (physician) for review. Impression: Faint linear lucency in the neck region of the left femur, which is suspicious for fracture. Awaiting response from provider.9/25/2025 at 07:06: Physician notified of recent x-ray results and wants resident sent to (Hospital) for evaluation. (EMS) notified and awaiting transfer. Pain Assessment: 9/24/2025 at 19:17: 8 - pain level entered by Nurse G X-Ray Findings:Date of Service: 9/24/2025: Left hip, unilateral w/pelvis when performed, 1 view: .Faint linear lucency in the neck region of the left femur, which is suspicious for fracture. Recommended clinical correlation and further evaluation with MRI left hip. MAR (Medication Administration Record):Resident #81s' September 2025 MAR was reviewed and there were no entries that indicated the resident was offered or administered any pain medications after his fall. The resident pain was assessed at an 8 and it's reasonable to ascertain Resident #81 was experiencing pain. There were no medications administered or nonpharmacological interventions provided to manager his pain prior to be transferred to the hospital where he underwent repair of his femur. Hospital Records: admission Date 9/25/2025: .The patient is a [AGE] year-old make who presented to the ED after a fall.He rolled out of bed last night.Diagnostic Studies: Acute nondisplaced fracture left femoral neck. He reports he was attempting to exit his bed and fell. He is complaining of pain to the left hip that is worse with any movement and better with rest and medication. On exam he reports left hip and knee pain.underwent percutaneous screw fixation of the fracture on 9/26. Resident #81 remained in the facility for approximately 12 hours with any documented pain interventions from facility staff. Fall Incident and Accident Report:Statement from CNA H: Resident was moving the [NAME] drawer to barricade the door.I unbarricaded the door and ask if he needed help. Rounded on the patient more frequently. Statement from Nurse G: Lost balance and fell while by dresser. orthostatic to be done on falls in proper order: sitting- not done r/t hip pain. On 1/22/2025 at approximately 12:55 PM, a phone call was attempted with Nurse G there was no answer and voicemail was left requesting return phone call. On 01/22/2026 at 1:30 PM, an interview was conducted with the DON (Director of Nursing) regarding Resident #81's fall. The DON reported he is the same level of care he is now that he was prior to his fall. He was on a different unit when the fall occurred and had barricaded himself in the room. The CNA was able to enter the room and move the dresser back into the correct location. About 45 minutes later he pressed his call light and reported he had fallen but was lying in bed. The nurse completed an assessment, and he complained of left hip and knee pain; the nurse received ordered for an X-ray which were completed and showed a fracture. The nurse contacted the physician about 1 AM but did not receive a response until 6 AM with orders to transfer to the hospital for further evaluation. While at the hospital he did undergo surgery to repair his hip. The DON was asked what the timeframe for Stat X-rays and she is reported it's 3-4 hours depending on the company and they will call the facility with any findings. A review was conducted of Resident #81's MAR and the DON was queried if pain medications were administered at any point from discovery of the fall with verbalization of pain to his transfer. The DON reported there was no documentation located that he was provided pain medications. It can be noted Resident #81 alerted staff to his fall at approximately 7:00 PM, he was assessed as an 8 for pain and stated his left hip hurt and he could barely move it. He remained in the facility for an additional twelve hours without any pain intervention implemented for his hip fracture. Review was conducted of the facility policy entitled, Pain Assessment and Management, revised April 2025. The policy stated, .Observe the resident (during rest and movement) for behavioral signs of pain. Possible behavioral signs of pain include: negative verbalizations and vocalizations such as groaning, crying, screaming.facial expressions such as grimacing, frowning, clenching of the jaw, etc. behavior such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities. Establish a treatment regimen that is specific to the resident based on consideration of the following. Non-pharmacological interventions may be appropriate alone or in conjunction with medications.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include: On 01/20/2026 at 11:40am-12:20pm during lunch observation, observed [NAME] B remove and don gloves without washing hands before taking temperatures and prepping food during lunch observation in the kitchen. On 01/20/2026 at 11:40am-12:20pm observed [NAME] B don gloves without washing hands before taking temperatures of food on the steam table in the kitchen. On 01/20/2026 at 11:40am-12:20pm observed [NAME] B touch her face with her finger then open trays at the steam table and proceeded to don gloves without washing hands in the kitchen. On 01/20/2026 at 11:40am-12:20pm observed [NAME] B don gloves without washing hands before prepping food trays in the kitchen. On 01/20/2026 at 12:20pm interviewed Dietary Manager C on when kitchen staff should be washing their hands, and he stated that kitchen staff should wash their hands any time their hands can be contaminated. He also acknowledged that he witnessed [NAME] B not washing her hands during lunch preparation. According to the 2022 Food Code, 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms.immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and.Before donning gloves to initiate a task that involves working with food.

Based on observation, interview and record review, the facility failed to provide appropriate care of an indwelling catheter for one resident (R2) of one resident reviewed for indwelling catheters. Findings include: Resident #2 (R2): R2 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include infection and inflammatory reaction due to indwelling urethral catheter, obstructive and reflexive uropathy, chronic kidney disease and retention of urine. R2 has a brief interview for mental status (BIMS) score of 15, indicating they are cognitively intact. On 01/20/2026 at 11:33AM, while conducting an interview with R2, it was observed that the urine collection bag for the catheter was hanging on the left arm rest of the wheelchair, it was observed to be hanging above the level of the bladder. On 01/21/2026 at 9:43AM, R2 was watching tv in his room, the urine collection was observed below the wheelchair and touching the floor. On 01/21/2026 at1:49PM, R2 was observed in the therapy gym, the urine collection bag is below the wheelchair and on the floor. On 01/21/2026 at 2:12PM, an interview was conducted with Unit Manager (UM) A. Unit Manager A was made aware that R2's urine collection bag was observed hanging on the armrest of the wheelchair. UM A stated that R2 will do that himself from time to time, but that it shouldn't be up there. UM A was asked if the urine collection bag for R2 should be resting on the floor under the wheelchair. UM A stated, no and I will take care of that right now. Record review of the policy titled, Catheter Care, Urinary, revealed, Maintaining Unobstructed Urine Flow3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Infection Control2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag.b. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview and record review, the facility failed to ensure safe narcotic storage, narcotic reconciliation and the discarding of expired medications for two medication carts of three medication carts reviewed, resulting in unreconciled narcotic medications with key exchange and expired medications. Findings include. On 1/22/2026 at 8:07 AM, Harbor Medication Cart was observed in the presence of Nurse M. The following medications were found to expired or improperly stored: 2 -bottles of Brimonidine Tartrate Ophthalmic Solution with no open or use by date Rocklatan Ophthalmic Solution Opened on 8/25/2025 and per the label may store up to 6 weeks. Vial of Tuberculin (stored with the eye drops) no open/use by date and stored improperly. 1 Timolol Maleate Ophthalmic Solution with no open or use by date Nitroglycerin expired on 9/2025 Atropine Sulfate 1% sublingual oral drops that expired on 11/2025 but was opened 1/1/2026 Lantus Insulin Pen with open date of 12/18 and no use by date. Nurse M attempted to contact the facility pharmacy for guidelines for duration of use for the eye drops but they were unable to provide the requested information. Nurse M reported the nitroglycerin, atropine, rocklatan eye drops should have been discarded as they were expired. She stated the vial of tuberculin is not supposed to be stored in the refrigerator not their medication cart. On 1/22/2026 at 9:02 AM, Unit Manager N was interviewed regarding the Harbor medication cart. Manager N shared night shift nurses are supposed to go through the cart. She continued the immunization vial should not have been in the cart and the Lantus is good for 28 days (with the open date of 12/18 it was expired). According to the package insert for Lantus, it stated, .once you take your SoloStar out of cool storage, for use or as a spare, you can use it for up to 28 days . According to the package insert for Tuberculin, .Store at 35 degrees to 46 degrees F. Do not freeze.a vial of Tubersol which has been entered and in use for 30 days should be discarded. According to the package insert Rocklatan,.after opening, the product may be kept.for up to 6 weeks. Per The International Pharmacopeia- Thirteenth Edition, 2025, stated, Multidose ophthalmic drop preparations may be used for up to 4 weeks after the container is initially opened. Review was conducted of the facility policy entitled, Storage of Medications, revised 5/25Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. On 1/22/2026, at 1:06 PM, Nurse F was observed asking Nurse E for their keys. Nurse E pulled a set of keys out of their bag and handed the keys to Nurse F. Nurse F was asked if they normally do that and Nurse F stated, I go home for lunch and leave my keys here just in case someone needs something. Nurse F walked down the hallway passing by their medication cart. On 1/22/2026, at 1:16 PM, Nurse F was asked if Nurse E was available. Another staff member stated they thought Nurse E was on break. Nurse F stated, she must not have left because she didn't give me her keys. On 1/22/2026, at 2:24 PM, the Director of Nursing (DON) was alerted of the observation of Nurse E and Nurse F passing medication cart keys with no narcotic reconciliation and the DON stated, you don't share narc (narcotic) keys. The DON was asked for a narcotic reconciliation observation. On 1/22/2026, at 2:37 PM, Nurse E and Nurse F began reconciling narcotic medications along with Unit Manager A. When they were counting the narcotic (ABH gel) for Resident #75 Nurse E stated, (four) for Resident #75 and Nurse F set out 3 packets of ABH gel and quickly began to write the number 3 in the AMOUNT REMAINING column on the CONTROL SUBSTANCE RECORD. Nurse F stated, I gave him one. Unit ManagerA gathered the document to obtain a copy. Nurse E stated, we've worked together for fifteen years and I would only do this with this nurse. A review of the facility provided CONTROL SUBSTANCE RECORD for Resident #75 revealed 1/23/26 . AMOUNT USED 1 ADMINSTERED BY . AMOUNT REMAINING 3 The administered by column was signed by Nurse F. A review of the facility policy Storage of Medications revealed The facility stores all drugs and biologicals in a safe, secure, and orderly manner . Access to controlled medications is limited to authorized personnel. Personnel access to controlled medications is recorded .

This citation pertains to Intake Number 2607357.Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers for one resident (Resident #1) of three residents reviewed for skin alterations, resulting in Resident #1 developing three facility-acquired pressures ulcers- one Stage 3 pressure ulcer ( full- thickness skin loss with exposure of the subcutaneous tissue layer beneath) to his coccyx: unstageable wound (full- thickness loss where the depth of the wound is obscured by necrotic tissue or eschar) to his left heel and a deep tissue injury (pressure related injury to subcutaneous tissues that appears as deep bruise under intact skin) to his left lateral malleolus and inconsistencies in classification of the wounds. Findings Include Resident #1:On 9/16/2025 at approximately 12:15 PM, Resident #1 was observed resting in bed watching television. He was well dressed in a knitted shirt and black slacks. His left lower leg was observed to be bandaged above his socks with the date of 9/11. When Resident #1 was asked if he had any other open areas on his body he pointed to coccyx area. CNA (Certified Nursing Assistant) G entered the room and when asked about the resident's wounds she expressed, he has three (pressures ulcers) - left ankle, left heel and coccyx and all were facility acquired. It can be noted Resident #1 did not have soft heel boots on and his bilateral heels were resting on the bed.On 9/16/2025 at 1:30 PM, Wound Nurse F was interviewed regarding Resident 1's three wounds. He stated they were all facility acquired but two they believe are vascular and they are awaiting testing. The three wounds were reviewed:Resident #1's left malleolus was discovered on 7/29/2025 with classification as stage 2 pressure ulcer; on 7/31/2025 it was classified as unstageable. Wound Nurse F expressed he was unsure what the true classification was currently as they are awaiting testing. Left heel opened on 8/7/2025 and was initially classified as pressure DTI (deep tissue injury) but around 8/28/25 is when it was changed to other as it appeared more vascular in nature. He reported the wound was worsening and now it appears to be healing.Coccyx was discovered on 8/7/2025 and the current treatment is triad cream. It is classified at MASD (moisture associated skin damage) which is due to incontinence related moisture. Nurse F stated the wound is associated from Resident #1 sweating or being urine.On 9/16/2025 at approximately 2:00 PM, a review was conducted of Resident #1's medical record and it revealed he was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, diabetes, dementia, hypertension, kidney disease and heart disease. Resident #1 was deemed incompetent but can express his needs to facility staff. Further review revealed the following:admission Skin Assessment 5/26/25:- No skin issues present on admissionCare Plan: .I have an ADL (Activities of daily Living) self-performance.ambulation. I am non ambulatory.Transfer: I require assistance by (1) staff to move between surfaces with use of sliding board. Bed Mobility: I require 1 assistance to turn and reposition in bed.Use of incontinence products-brief.daily skin inspections. Report abnormalities to the nurse.Kardex: Off-loading heels boots as I will tolerate.Bladder Continence and Toilet Use 30-day look back: Most of the lookback, Resident #1 was incontinent and changed about once on each shift, with 8+ hours between episodes and the resident being incontinent 95% of the time.MDS (Minimum Data Set Assessment) dated 8/27/2025 check MDS date for accuracyNumber of Stage 3 pressure ulcers: 1Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar: 1Number of unstageable pressure injuries presenting as deep tissue injury:1Progress Notes:7/15/2025 04:39: Resident was observed expressing discomfort during check and change. Resident verbally complained of pain in both legs and refused to be touched during care.7/29/2025 10:45: Upon entering the patient's room this morning, stage 2 pressure ulcer was noted to left lateral malleolus, along with a DTI to left heel.8/1/2025 at 14:46:. Resident noted to have stage 3 coccyx, unstageable left lateral malleolus, DTI left heel.8/12/2025: 14:11: .Ulcer of sacral region, stage 3 Sacrum. Frequent incontinence checks. Pressure injury of deep tissue of left heel Left heel: Offload left heel Recommend NWB ( none weight bearing) to the left foot doppler ordered for left lower leg. Decubitus ulcer, ankle, left, unstageable Left lateral malleolus. Pt (patient) is bowel incontinent yes. Pt is urinary incontinent yes. Stage 3 pressure injury - Sacrum Wound Length x Width x Depth: 2.4cm x 1.8cm x 0.1cm. Deep Tissue Injury - Left HeelWound Length x Width x Depth: 2.4cm x 1.5cm x 0.1cm. Unstageable Pressure Injury - Left Lateral Malleolus Wound Length x Width x Depth: 1.4cm x 1.1cm x 0.1cm.9/9/25 at 10:48: .Recommend ordering CT angiogram to further evaluate vascular status given non-healing.foot ulcer.The wound service is consulted for evaluation and treatment of:- Moisture associated skin damage (MASD) to the sacrum, previously coded at Stage 3 Pressure injury. Surface area has decreased.- A diabetic ulcer to the left heel, previously coded as deep tissue injury. Surface area has decreased.- A diabetic ulcer to the left lateral malleolus, previously coded as unstageable pressure injury.Arterial doppler BLE 9/1/25: The common femoral arteries, superficial arteries, and popliteal arteries are well visualized bilaterally. They appear patent without evidence of obstruction to flow. There is no evidence of significance stenosis or atherosclerotic disease.Review was conducted of Resident #1 wound notes for all three wounds and the following was reviewed:Coccyx Wound:Facility acquired- opening on 7/26/2025:Stage 2 on 7/28/2025; MASD IAD Incontinence Associated Dermatitis on 7/31/2025; Stage 3 on 8/7/2025; MASD- IAD Incontinence Associated Dermatitis on 8/28/2025.7/28/2025: 2.13 cm x 2.61 cmx 1.16 cm, 60% slough and 40% epithelial and edges are fragile.7/31/2025: 1.71 cm x 3.09 cm x 0.91 width.light serosanguineous drainage, edges attached and surrounding tissue fragile .8/7/2025: No measurements were indicated on this wound evaluation. Light serous drainage and intermittent pain during care.8/15/2025: 2.73 cm x 2.41 cm x 1.84 cm, light serosanguineous drainage, attached edges ad fragile surrounding tissue with slight pain at dressing change.8/21/2025: 0.88 cm x 1.75 cm x 1.03 cm, islands of epithelium pink or red, light serosanguineous drainage.8/28/2025: 0.51 cm x 2.11. cm x 0.74 cm, sanguineous/bloody drainage, moderate pain at dressing change.There was inconsistency in the classification of the coccyx wound as the facility reclassified it multiple times.Left Heel Wound:7/31/2025: DTI.3.24 cm x 2.51 cm x 1.71 cm, surrounding tissue is fragile, slight pain at dressing change, wound bed is pink or red.8/7/2025:DTI.No measurements included on this assessment, resident reports pain during movement.8/15/2025: DTI.2.76 cm x 2.39 cm x 1.48 cm, edges attached and surrounding tissue is fragile.8/21/2025: DTI.7.17 cm x 4.24 cm x 2.22 cm, surrounding tissue is dry/flakey and fragile, slow to heel.8/28/2025: Consistent with vascular complicated by diabetes.1.78 cm x 2.03 cm x 1.34 cm.dry, flakey, fragile.9/4/2025: 4.01 cm x 3.44 cm x 1.62 cm, type- consistent with vascular complicated by diabetes, 80% slough, light serosanguineous drainage, fragile edges and moderate pain at dressing changes. progress: stalled.9/11/2025: 3.07 cm x 2.9 cm x 1.39 cm. consistent with vascular complicated by diabetes .80% slough, light serosanguineous drainage, moderate pain at dressing changing.It can be noted on 08/28/2025, Resident #1's wound was changed to reflect the facility's current impressions regarding the wound- they stated the wound was consistent with vascular complicated diabetes Left Lateral Malleolus- in house acquired Stage 2 - Unstageable (slough and/or eschar)7/29/2025: Pressure- Stage 2.1.47 cm x 1.63 cmx 1.3 cm, no drainage and intermittent pain.7/31/2025: Pressure- Unstageable (slough and/or eschar).1.3 cm x 1.62 cm x 1.17 cm, 100% slough, light serosanguineous drainage. 8/7/2025: Pressure- Unstageable (slough and/or eschar) .1.85 cm x 1.73 cm x1.39 cm.light serous drainage, edges intact, pain at dressing change.8/15/2025: Pressure- Unstageable (slough and/or eschar) .1.11 cm x 1.36 cm x 1.13 cm.50% slough, no drainage.8/21/2025:Pressure- Unstageable (slough and/or eschar).2.38 cm x 2.25 cm x 1.67cm, 100% slough, light serosanguineous drainage, moderate pain at dressing change.9/4/2025: Consistent with vascular complicated diabetes.6.87 cm x 5.44 cm x 2.45 cm.10% granulation, 90% eschar, light sanguineous/bloody drainage, moderate pain at dressing change.It can be noted on 9/4/2025, Resident #1 wounds were changed to reflect the facility's current impressions regarding the wound- they stated the wound was :consistent with vascular complicated diabetes.: On 9/1/2025 Resident #1's doppler of his bilateral extremities revealed the following, .The common femoral arteries, superficial femoral arteries, and popliteal arteries are well visualized bilaterally. They appear patent without evidence of obstruction to flow. There is no evidence of significant stenosis or atherosclerotic disease. Color doppler analysis reveals normal direction of flow. Doppler spectral analysis reveals normal arterial wave patterns without evidence of spectral broadening. There is no evidence of thrombosis. Overlying soft tissue tissues appear grossly normal.On 9/16/2025 at 12:25 PM, observation was made of Resident 1's left heel and lateral malleolus wound in the presence of CNA G and Nurse I.His heel was observed to be 90%-100% covered with eschar. Nurse I stated the left malleolus had eschar in the center, slough at the base, small amount of maceration with beefy redness surrounding the eschar center. A few inches down from the lateral malleolus wound was an approximately a dime size open area. The center was black/brown, and the surrounding area was red/pink. There was no documentation found related to this new skin alteration for Resident #1.On 9/16/2025 at 10:20 AM, the DON (Director of Nursing) reported Resident #1's three wounds were all discovered around the same time. The DON was asked why the coccyx wound was reclassified multiple times. The DON reported during their wound meeting they discussed what they thought the best course of treatment would be and that is when they decided the wound was MASD and not pressure. The results from the doppler were reviewed which indicated no arterial insufficiencies and the DON was asked as to why the wounds were reclassified at diabetic ulcers when the imaging refutes their stance. The DON stated she would research and provide further clarity. On 09/16/2025 at 11:15 AM, CNA G reported Resident #1 was unable to reposition himself with assistance and he favors laying on his back even when they change his position. The CNA added the residents left foot flares to the left when he is in bed. On 9/16/2025 at 2:06 PM, the DON and Clinical Support Nurse K were interviewed regarding Resident #1's wound. They explained his wounds were inconsistent with pressure and they were not healing. Once they looked deeper into the wounds they found the malleolus and coccyx appeared to have a vascular component to it, they completed the doppler which showed no issues. It was explained this was basic level imaging and after it resulted, they still wanted to image further to rule out vascular issues. They assert his wounds are consistent with vascular complicated diabetes and they are still in the rule out process.It can be noted the wound Nurse Practitioner notes recoded the sacrum wound from a Stage 3 Pressure Injury to MASD, left heel DTI was recoded to diabetic ulcer and left malleolus unstageable pressure injury was recoded to diabetic ulcer on 9/2/25 but during the interview process the facility reported they have not officially recoded the heel and malleolus yet as they wait or further testing. There are inconsistences from the inception of Resident 1's wounds with classification and subsequent diagnosis of the wounds. On 9/16/2025 at 3:15 PM, an interview was conducted with MDS (Minimum Data Set) Coordinator J. She reported she recently completed a significant change for Resident #1 based on his wounds. While she does not complete a physical assessment of the wound she does review the documentation, and the team discusses the wounds in their meetings. When coding the wounds for the MDS she goes off the ARD (Assessment Reference Date), and recent documentation closet to her seven day look back period. Review was completed of the CAA (Care Area Assessment) Worksheet dated 8/25/2025 and it stated the following, (Resident #1) is a long term care resident here at the facility. He requires assist with all adls (activities of daily living). He has three facility acquired pressure ulcers.he is incontinent of bowel and bladder and requires assist with incontinence care and toileting.He has a stage 3 pressure ulcer to his coccyx, a DTI to his left heel and an unstageable pressure ulcer to his left lateral malleolus. According to the National Pressure Injury Advisory Panel, dated 9/11/2025 . The heel is one of the most common anatomical sites for PI (pressure injuries.Review was conducted of the facility policy entitled, Skin Management Guidelines Prevention of Pressure Ulcers/Injuries, reviewed 11/2024. The policy stated, .Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. Identify any signs of developing pressure injuries (i.e., nonblanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); Wash the skin after any episodes of incontinence, using pH balanced skin cleanser.

This Citation Pertains to Intake# MI00150592. Based on observation, interview and record review, the facility failed to ensure 1). Call light notifications were readily available to staff and 2). Call lights were responded to in a timely manner to meet residents' needs including Resident (#6), from a facility census of 82 residents. Findings Include: On 3/6/2025 at 11:45 AM, Nurse G was asked how the staff knew if there was a call light on and said there was a screen at the nurse's desk that showed which lights were on. The 200 unit had 2 halls, with one shorter and one much longer. The call light screen was not visible from either hall. Nurse G said the staff would need to walk to the nurse's desk to see if a call light was on. The nurse said there were no lights or sounds in the halls to indicate if a resident had their call light on. On 3/6/2025 at 12:15 PM, during an observation on the locked dementia unit, 2 staff were observed assisting residents to eat in the dining room. A call light screen was around the corner from the dining room and not visible to the staff as they assisted the residents with the meal. The staff were asked who the nurse was on the dementia unit and they said it was Nurse F and she was at lunch. The 2 staff in the dining room were the only staff on the unit. On 3/6/2025 at 4:15 PM, Nurse F was interviewed about the call light system in the dementia unit; she was sitting at a table on the other side of the dining room. She was facing towards the other hall where the call light screen was located, but the words on the screen were not readable from that far away. Nurse F said to read the screen, you had to walk over to it. She was asked if she would know if a resident's call light was on in a room near where she was sitting and she said not unless you walked over to the screen on the other hall and looked. The nurse showed a walkie talkie in her pocket, and she said if she saw a light was on, she could contact another staff member to answer it. On 3/6/2025 at 5:00 PM, the Administrator and Director of Nursing/DON were interviewed related to the call light system and the one screen on each unit that listed the call lights that were on. They said there were no lights in the halls or call light alarms to notify staff when the resident turned the call light on. They said this was something they were looking at. A review of the facility policy titled, Call light, Use of, reviewed 3/25 revealed the following, Procedure Purpose: To respond promptly to resident's call for assistance Facility personnel must be aware of call lights. Answer call lights in a prompt, calm, courteous manner . 22927 An interview on 3/6/2025 at 11:25AM with Resident #6 revealed he did not fall here, but was trying to walk, because no one comes to help him here. Resident #6 stated They say i fell here in my room, but he was trying to crawl to the bathroom, because no one comes to answer the call light. Yes, they came to help him up after he was on the floor for a while. Resident #6 was asked if there was enough Staffing? Resident #6 stated that was a good question; it takes them more than a while to come help him, resident stated he was talking 20-30 minutes or more. Resident #6 stated that when he needs to ask for something they leave the room and sometimes don't come back or come back in a half hour or more. Record review of Resident #6's Accident/Incident reports were reviewed: -On 2/3/2025 at 3:30PM resident #6 was observed on the floor on the right side of bed. Resident was noted stating he was looking for his urinal. -On 2/13/2025 at 7:20PM resident was observed laying on the floor in his room. Resident was noted stating he was trying to go to the bathroom. - On 2/18/2025 at 00:005AM resident was observed laying on the floor next to bed. Resident was noted stating he was trying to crawl to the bathroom. - On 3/3/2025 at 1:00AM resident was observed laying on the floor next to his bed. Resident was noted stating he was trying to go to the bathroom. In an observation on 3/6/2025 at 11:47AM the State Surveyor pressed the call light for Resident in room [ROOM NUMBER]-1, a small red dot light behind the bed came on, the surveyor walked out into the hallway. There was no over the room light noted and walked to the nursing station to observe a flat screen that showed that room [ROOM NUMBER] call light was on. In an interview on 3/6/2025 at 11:55AM with Registered Nurse/Unit Manager (RN) A was walking through the Coast Unit when the state surveyor stopped to ask about the resident call light system. RN A stated that there were no call light above resident rooms and that those were removed in the last remodel. RN A stated that the staff use walkie/talkies, and each Certified Nurse Assistant (CNA) is assigned a walkie talkie and are to bring with them to work. RN A also stated that CNAs/nurses can come to the nursing station on the unit and look at the flat screen. Observation and interview on 3/6/2025 at 11:58 of Certified Nurse Assistant (CNA) B who was walking down the Coast Hall when the state surveyor stopped the CNA and asked if she had a walkie talkie and why was it silent when a call light was on? The CNA B took the walkie talkie from her pocket and was noted to be turning the walkie talkie on or sound up. Once CNA B had turned up the volume on the walkie talkie static could be heard. The CNA B stated that she just looks at the screen at the nursing station. Observation on 3/6/2025 at 12:02PM on the Harbor dementia unit clean utility room revealed 137 white/blue or brown wash clothes, towels, sheets, blankets and other items. The state surveyor stopped on the unit to listen to the sounds of the unit and there was no walkie talkies heard. In an observation and interview on 3/6/2025 at 1:15 PM in room [ROOM NUMBER]-1 with Resident #6, the call light was pushed, a small red light came on at the wall behind the bed. Resident #6 just wanted his right leg foot repositioned. Resident #6 stated that he hates living at the facility. He stated that first of all, no one comes when he presses the call light. Resident #6 stated that he has waited up to 20-30 minutes to get help, even when he pushes the red button repeatedly. Resident #6 stated that they are all rude and don't listen to him and They don't care about the people that need the care. The state surveyor walked to the room doorway and listened for walkie talkies to be going off related to the call light being activated, nothing was heard. At 1:23PM Staff member Licensed Practical Nurse (LPN) D walked to room [ROOM NUMBER] across the hall from the resident's room. There was no noise if the LPN had a walkie talkie and then she walked back up the hall. At 1:25PM maintenance Director C went into the room [ROOM NUMBER] across the hall. Resident #6 started to yell out to get help. Maintenance Director C did hear the resident and came into the room to ask what the resident needed. Then told the resident he would have to wait for a CNA to lift his leg up into the bed. At 1:27PM Licensed Practical Nurse (LPN) D walked past the room. At 1:28 PM Certified Nurse Assistant E came into the room to ask the resident what he needed. CNA E did not have a walkie talkie and stated that she left it at the nursing station.

This Citation Pertains to Intake# MI00150592 This Citation has 2 DPS's Based on observation, interview and record review the facility failed to ensure appropriate interventions were in place to manage skin breakdown for Resident #2 and pressure ulcer treatment to aid in healing for one resident (Resident #3), of 4 residents reviewed for skin breakdown and pressure ulcers, resulting in Resident #2 developing a large, red, excoriated area on his bilateral buttocks and Resident #3 developing an unstageable pressure ulcer on the left lateral malleolus (ankle). Findings Include: Skin conditions Resident #2 A record review of the face sheet and Minimum Data Set/MDS assessment, revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: COPD, respiratory failure, stomach bleeding, history of a stroke, right sided weakness, urinary tract infection, hypertension, arthritis, history of falls and intervertebral disc degeneration. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care including bed mobility. Section H of the MDS assessment indicated the resident was always incontinent of bowel and bladder. Section M of the MDS assessment said the resident did not have a pressure ulcer or other type of skin condition. On 3/6/2025 at 11:40 AM, Resident #2 was observed during lying in bed watching TV. Wound Nurse J and Nurse G assessed the resident for skin breakdown. Wound Nurse J said Resident #2 was not on his list to be seen. He said the facility provided him names of residents to see once a week. He assessed their wounds, evaluated the treatments for healing and applied new dressings; he said he usually saw residents with pressure ulcers. During the skin observation of Resident #2 with Nurses J and G, it was identified that the resident had a large, excoriated area on both left and right buttocks (approximately 10 cm x 10 cm). The area was very dark red, thick, raised and peeling, with many small open areas. Wound Nurse J said it wasn't a pressure ulcer, probably caused from wetness and he would identify a treatment for it. The Wound Nurse was asked if the wound just happened that day and he stated, No. A record review of the physician orders for Resident #2 on 3/6/2025 revealed there was no wound treatment ordered for the red, open area on his buttocks. There was an order dated 2/20/2025 for Weekly Skin Assessment . A record review of Resident #2's Medication Administration Record/Treatment Administration Record (MAR/TAR) for March 2025, revealed there was no treatment to his buttocks documented. There was one entry for the Weekly Skin assessment dated [DATE] and it said the resident had 0 skin breakdown. A record review of the February 2025 TAR's for Resident #2 identified 3 skin observations February 5th, February 12th, and February 19th, 2025. Each entry had a 1 documented for Previously identified wound/breakdown. In addition, there was a Skin observation on 2/26/2025 that listed 0 for No skin breakdown. A review of the Wound Evaluation dated 3/6/2025 for Resident #2, by Nurse J identified the resident's buttock wound as In-house acquired MASD (Moisture Associated Dermatitis)-IAD Incontinence Associated Dermatitis of the sacrum. A review of the Care Plans for Resident #2 identified the following: (Resident #2) has high risk to impaired skin integrity related to excoriation to buttocks due to B&B (bowel and bladder) incontinence and history of Stage 4 pressure ulcer to the right trochanter . dated initiated 6/14/2022 and revised 1/21/2025 with Interventions including: Follow facility protocol for treatment of injury; Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to MD. Dated 6/14/2022 and revised 12/15/2024. Another Care Plan titled, (Resident #2) is at risk for further pressure ulcer development and impaired skin integrity related to history of pressure ulcers and MASD, hemiplegia, hemiparesis affecting the right side . date initiated 6/29/2022 and revised 1/21/2024 with Interventions including: Daily wound assessments, dated initiated 10/29/2023d and revised 8/16/2024; and Treatments as ordered, date initiated 7/27/2022 and revised 5/2/2023. An additional Care Plan titled, I have impaired skin integrity related to excoriation to buttocks, date initiated and revised 1/14/2025 with Interventions including: Daily skin assessments, date initiated 7/16/2024 and revised 7/16/2024. The resident had no documented daily wound assessments and there was no treatment ordered for his skin breakdown. Resident #3 A record review of the Face sheet and MDS assessment indicated Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, muscle wasting and atrophy, obsessive compulsive disorder, bipolar disorder, generalized anxiety, depression, and arthritis. The MDS assessment dated [DATE] indicated the resident had a memory problem and needed assistance with care. Section M of the MDS assessment revealed the resident had an unhealed, unstageable pressure ulcer and was at risk for pressure ulcers. The resident's prior MDS assessment dated [DATE] indicated the resident did not have any pressure ulcers, but was at risk for pressure ulcers. On 3/6/2025 at 12:35 PM, Resident #3's wound care was observed with Wound Nurse J and Hospice Nurse I. The resident was observed to have an undated/timed or initialed dressing on her left lateral ankle area. The wound nurse was asked if it was the appropriate dressing, and he said it was not; there was no calcium alginate on the wound bed- only a foam dressing. He said it was supposed to have calcium alginate in the wound bed and a foam dressing over top. When asked about it, he said he was told that someone had placed the dressing earlier that day, but it was unclear when. During the wound observation for Resident #3, on 3/6/2025 at 12:35 PM, Wound Nurse J said the wound bed had yellow slough (stringy dead tissue) and was unstageable. The wound was approximately 2 cm x 2 cm in size and had a large amount of serosanguinous (bloody) drainage under the foot on a pad. It had leaked through the dressing. Hospice Nurse I said the wound was not improving. The nurses said the wound was facility acquired. A record review of the physician orders revealed the following: Left malleolus unstageable pressure ulcer (Wound #1) Cleanse with (normal saline) and pat dry. Skin prep peri wound, place calcium alginate AG into wound bed. (Cut to fit). Cover with foam dressing. Change every day and PRN (as needed), revision date 2/27/2025 and start date 2/27/2025. A review of Resident #3's MAR/TAR for March 2025 revealed the following: Left malleolus unstageable pressure ulcer (Wound #1): Cleanse with ns (normal saline) and pat dry. Skin prep peri wound, place calcium alginate AG into wound bed. (Cut to fit). Cover with foam dressing Change every day and PRN, every day for wound care, Start date 02/28/2025. Each entry was marked Days. The 3/6/2025 wound treatment was initialed by Nurse F as being completed. On 3/6/2025 at 4:20 PM, during an interview with Nurse F she was asked if she had completed the wound dressing for Resident #3 that day. She stated, No, I didn't. Nurse F was asked if she signed the TAR that she did do the dressing and she stated, Yes, I signed it for the Wound Nurse at 11:55 AM. When asked if that was what she was supposed to do, she said she didn't know. Reviewed the Wound Nurse had changed the dressing at 12:35 PM; this was after Nurse F had documented she completed the dressing change. Further review of Resident #3's TAR for March 2025, identified an as needed entry for wound care to the resident's left malleolus. No one had documented additional dressing changes. A review of the facility policy titled Skin Management Guidelines: Prevention of Pressure Ulcers/Injuries, origination date 7/2017 and revised 11/2024 provided, The purpose of this procedure is 1) to identify residents at risk for developing alterations in skin including pressure ulcer/injury risk factors, and 2) to identify specific interventions to assist with prevention and management of skin alterations . Skin is assessed on admission to the facility and at least weekly to identify alterations in skin, and any wound assessments should be documented in the medical record . Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable . DPS #2 Based on observation, interview and record review, the facility failed to ensure a change of condition was assessed and monitored for one Resident #7, of one resident reviewed for a change of condition, resulting in Resident #7 developing a large, red, inflamed testicle that was causing discomfort. Findings Include: Resident #7 A record review of the Face sheet and MDS assessment indicated Resident #7 was admitted to the facility on [DATE] with diagnoses: Dementia, diabetes, liver cirrhosis, hypertension, heart disease, gout and hepatic [NAME]-occlusive disease. The MDS assessment dated [DATE] revealed the resident had poor memory with a BIMS of 0/15 and needed some assist with all care. A record review of the progress notes identified the following: 1/15/2025 at 1:45 PM, a nursing note Resident scrotum is observed to be red, warm/hard to the touch. No drainage is observed. Physician is notified with orders received for Keflex 500 mg every 8 hours x 7 days and Diflucan 100 mg daily for 7 days . 1/22/2025 at 5:39 PM, a nurses note Resident continues on antibiotics tolerated well. No adverse reactions noted. Will continue to monitor. A review of a physician note dated 2/5/2025 does not mention if the resident's testicular infection resolved. There was no additional documentation if the testicular redness and infection was resolved. On 3/6/2025 at 4:29 PM, Nurse F was interviewed about Resident #7 and asked if his testicular infection with redness had resolved. Nurse F reviewed the resident's orders and said his antibiotic had been completed and she assumed the infection was resolved. The nurse was asked if anyone had assessed the resident to determine if it was effective. Nurse F reviewed the resident's charting and said there was no note to indicate the resident's infection had healed. She said another nurse had asked about it and said she would assess the resident. On 3/6/2025 at 4:35 PM, a skin assessment was observed for Resident #7 with Nurse F and his Nurse Aide. The resident's left testicle was observed to be enlarged, bright red and swollen. The resident was asked about the testicle, and he stated, If I could show my family I would. He said it bothered him. Nurse F said she would contact the physician. A review of the physician orders did not identify any treatment or order for monitoring of Resident #7's testicle. A review of the Care Plans for Resident #7 identified the following: I have impaired skin integrity related to red, swollen and painful scrotum, dated and initiated and revised 1/16/2025 with Interventions including: Treatments as ordered; Float my heels while in bed; Weekly skin assessments . There were no treatments or monitoring after the antibiotic was completed. The weekly skin assessments did not mention the residents red, enlarged, painful scrotum. On 3/6/2025 at 4:15 PM, reviewed with Director of Nursing and Administrator wound care observations for Residents #2 and #3 and the lack of monitoring and treatment for Resident #7's reddened, enlarged, painful testicle and Resident #2's assessment, monitoring of the resident's buttock and sacral wounds and Resident #3's treatment and documentation issues. The Administrator said the Wound Nurse was new and the facility would look into the issues. A review of the facility policy titled, Change in a Resident's Condition or Status, date revised May 2017 and reviewed 12/24 provided, Our facility shall promptly notify the resident, his or her attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and or status .The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): . significant change in a resident's physical/emotional/mental condition . The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

This Citation Pertains to Intake: MI00150592 . Based on interview and record review, the facility failed to prevent repeat falls for one resident (Resident #1) of 3 sampled residents, resulting in Resident #1 sustaining unwitnessed repeated falls with inconsistent neurological monitoring. Findings include: Record review of the facility 'Falls Program' policy review date 12/2024 revealed the purpose was to provide a safe environment for residents, modify risk factors and reduce risk of all-related injuries. Procedure: Implement and indicate individualized interventions on care plan/Kardex to minimize fall risk. If fall occurs: Charge nurse to complete the following: (f.) Neurological Assessment- completed when unwitnessed or if resident hits head, (h.) Document the complete incident in (electronic medical record). Resident #1: Record review of Resident #1's Minimum Data Set (MDS) 1/21/2025 revealed an elderly female with Brief Interview of Mental status (BIMs) score of 3 out of 15, severe cognitive impairment. Medical diagnoses included: Debility, anemia, hypertension, arthritis, dementia, malnutrition, and anxiety. Record review and interview of Resident #1's falls with the Director of Nursing (DON) from the beginning of the year 1/1/2025 revealed: -On 1/25/2025 at 5:35AM Resident #1 was observed on floor in resident's room (unwitnessed fall). Complaints of pain to forehead and a quarter size bump to forehead with bruising observed. Record review with the DON of Resident #1's progress notes dated from 1/24/2025 through 1/27/2025 revealed there were no nursing progress note of the residents fall with head injury, discomfort/pain date 1/25/2025 through 1/27/2025. On 1/27/2025 at 10:17AM the interdisciplinary team noted: Nursing description of event: Observed resident on the floor next to her bed. She was sitting on top of all her blankets. Complaints of pain to forehead. A quarter size bump on forehead with bruising observed. No other visible injuries observed. Current condition: Resident is at baseline with signs of latent injury. Root cause: Resident was recently placed on APM to promote skin integrity and rolled off the bed. Plan: Hospice contact to request perimeter APM mattress. Record review of Resident #1's fall report dated 1/29/2025 at 6:23 PM revealed: Resident #1 was observed on the floor (unwitnessed fall) in the dining room in front of her wheelchair. Record review with the DON of Resident #1's document folder in the electronic medical record revealed there were no neurological checks/monitoring documented for the unwitnessed fall. The DON stated that there should have been a 72-hour neurological monitoring post unwitnessed fall. Record review of the facility 'Falls and Fall Risk, managing' policy revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. (5.) If falling reoccurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. (6.) If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable Record review of resident #1's fall report dated 1/31/2025 at 3:36 AM revealed: Resident (#1) fell , possibly hitting her head, next to the bed by the bedside table. Record review with the DON of Resident #1's document folder in the electronic medical record revealed there were no neurological checks/monitoring documented for the unwitnessed fall. The DON stated that there should have been a 72-hour neurological monitoring post unwitnessed fall. - Record review of resident #1's fall report dated 2/2/2025 at 3:35 PM revealed: Resident (#1) observed on floor (unwitnessed fall) in resident's room. Skin tears noted to left arm. Record review and interview on 3/6/2025 at 4:05PM with the Director of Nursing (DON) of Resident #1's interdisciplinary team note dated 2/3/2025 at 11:10AM did not mention the fall or skin tear injury. Record review of facility 'Change in a Resident's Condition or Status' policy revision date 12/2024 revealed (2.) A significant change of condition is a major decline or improvement in the resident's status that: (c.) Requires interdisciplinary review and/or revision to the care plan ., (8.) The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

Based on interview and record review, the facility failed to ensure that a Registered Nurse was on duty for eight consecutive hours a day, seven days a week. Findings Include: On 3/6/2025 at 11:30 AM, posted nurse staffing sheets (a document listing all nurse staff by discipline (RN, LPN or Nurse aide working in the building on each shift- posted per federal guidelines) for the year 2025 was requested. A review of the Daily posted staffing sheets from 1/1/2025- 3/6/2025 identified a blank form, as well as a lack of 8 hour daily Registered Nurse (RN) coverage. There were several days in January 2025 that did not have an RN working for at least 8 consecutive hours: 1/1/2025 (0 RN hours), 1/9/2025 (4 RN hours) and 1/24/2025 (0 RN hours). There were several days in February 2025 that did not have an RN working for at least 8 consecutive hours: 2/5/2025 (0 RN hours) and 2/20/2025 was blank- the document identified the facility census and date, but the remainder was blank. On 3/6/2025 at 5:10 PM, the Daily Staff Postings binder was reviewed with the Administrator and Director of Nursing/DON. Discussed that there were several days indicated on the Posted staffing sheets that there was not an Registered Nurse/RN for at least 8 consecutive hours in a day. Reviewed there was LPN coverage, but not the required 12 RN hours/ per day. 1/1/2025 and 1/9/2025 were reviewed as examples; also reviewed 2/20/2025 was blank. The DON and Administrator said they were not sure what happened.

This Citation Pertains to Intake Numbers MI00147625, MI00147548, and MI00147423 Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures to ensure pressure ulcer prevention and management for five residents (#5, #56, #58, #60, and #76) of eight residents reviewed. This deficient practice resulted in a lack of implementation of meaningful, appropriate, and planned interventions for pressure ulcer prevention, multiple residents developing pressure ulcers, unnecessary pain, and the likelihood for a decline in overall health status. Findings include: Resident #56: On 10/28/24 at 11:10 AM, Resident #56's room door was observed to be closed. Upon knocking and entering the room, a pungent, foul odor with overwhelming putrid qualities was immediately noted. The smell grew stronger closer to the Resident. The Resident was lying in bed on their back with their knees bent and heels/feet directly against the mattress. Resident #56 was wearing a hospital style gown. When queried if they had any wounds or open areas on their skin, Resident #56 revealed they have an open area on their back. With further inquiry, Resident #56 revealed the wound developed at home. When queried regarding wound care provided at the facility, Resident #56 revealed dressing change times are not consistent due to staffing but indicated staff usually change the dressing. When queried if staff remind and/or assist them to turn and reposition in bed every two hours, Resident #56 responded they do not and revealed they do not always see a staff member that frequently. At 11:18 AM, Certified Nursing Assistant (CNA) U entered Resident #56's room. CNA U assisted the Resident to roll to their right side to provide care. After rolling onto their side, a wound on the Resident's upper left back was visualized. An undated was dressing was in place but did not cover the entire wound bed. Dark colored wound drainage was present on the bedding where the Resident had been laying. Record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), diabetes mellitus, pressure ulcer (wound caused by pressure), and lower extremity contractures. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision/touching assistance for rolling and moderate to total assistance for transferring, bathing, and toileting. The MDS further detailed the Resident had a stage three (full thickness tissue loss pressure ulcer). Review of Resident #56's Electronic Medical Record (EMR) revealed a care plan entitled, I have impaired skin integrity related to admitted with . Stage III pressure ulcer to back . (Initiated: 8/3/24; Revised: 10/22/24). The care plan included the interventions: - Daily skin assessments (Initiated: 8/28/24) - Float my heels while in bed (Initiated: 8/3/24) - Treatments as ordered . (Initiated: 8/4/24) - Turn and reposition q (every) 2 h (hours) (Initiated: 8/3/24) - Weekly wound measurement and evaluation (Initiated: 8/3/24) On 10/30/24 at 5:17 AM, 7:39 AM, and 8:14 AM, Resident #56 was observed in their room in bed. For all three observations the Resident was positioned on their back with the heels and feet positioned directly against the mattress. An observation of wound care for Resident #56's left upper back pressure ulcer was completed on 10/30/24 at 11:49 AM with Licensed Practical Nurse (LPN) G. LPN G removed the dressing from the wound bed and a small amount of dark reddish colored drainage was observed. The wound bed was red in color and irregularly shaped. Resident #60: On 10/28/24 at 12:14 PM, Resident #60 was observed lying in bed in their room with their eyes open wearing a hospital style gown. The Resident was laying on their back and slightly on their right side with their lower legs and heels positioned directly against the mattress. The room lights were off, the blinds were closed, and there was no visual and/or audio sensory stimulation. When queried regarding the care they receive at the facility, Resident #60 stated, I got a sore spot on my butt it ain't going away. Resident #60 then stated, Been waiting to talk to nurse about my butt. When asked if the area hurt, Resident #60 responded that it did. An observation of the Resident's room revealed no positioning devices and/or additional pillows for pressure relief. When queried if staff assist them to turn and reposition in bed, Resident #60 shook their head to indicate no. When asked if they are able to turn themselves in bed, Resident #60 repeated that there was a sore spot on their buttocks but did not provide a response to the question. When queried regarding getting out of bed and staff assistance, Resident #60 replied that they cannot walk and do not get up. Record review revealed Resident #60 was admitted to the facility on [DATE] with diagnoses which included dementia, malnutrition, arthritis, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required substantial to total assistance to complete all ADL's with the exception of eating. The MDS further detailed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers. Upon request for a list of Residents with wounds and pressure ulcers, the facility provided a list entitled, Wound Report for 10/23/24. The report detailed Resident #60 had Shearing to right and left buttock that was present upon admission. Review of Resident #60's Healthcare Provider (HCP) orders and Treatment Administration Record (TAR) revealed the Resident had the following active wound care order in place, Cleanse open areas to BL (bilateral) buttocks with wound cleanser. Pat dry. Apply calcium alginate (wound dressing indicated to treat moderate to heavily draining partial to full thickness draining wounds including full thickness tissue loss pressure ulcers, tunneling wounds, and some burns) to wound beds. Cover with a foam dressing. Change every 3 days and PRN (as needed) every night shift every 3 day(s) for wound care (Start Date: 10/9/24). A second active PRN order for the same treatment was present for if dressing missing or soiled Review of Resident #60's Completed, Discontinued, On hold, Pending Clinical Review, Pending Confirmation, and Struck out HCP orders revealed the following: - Cleanse open area to left buttock with wound cleanser. Pat dry. Apply Selan cream to open cleanser. Pat dry. Apply Selan cream to open area. Cover with a foam dressing. Change daily and PRN (as needed) . if dressing soiled or missing (Ordered: 9/19/24; Discontinued: 10/9/24) - Cleanse open area to left buttock with wound cleanser. Pat dry. Apply Selan cream to open cleanser. Pat dry. Apply Selan cream to open area. Cover with a foam dressing. Change daily and PRN every night shift . Review of Resident #60's EMR revealed the following Wound Evaluation assessment documentation: - 9/19/24 - 4:07 PM . Coccyx . Present on Admission . Length: 13.21 cm (centimeters). Width: 6.41 cm. Deepest Point: 0.1 cm . Describe: Type Other . Shearing (a contributing factor in pressure ulcers, a wound caused solely by sufficient pressure and force to keep the body moving in one direction - friction) . Wound Age Unknown . Staged by In-house nursing . Wound Bed . Granulation . 100% . Exudate . None . Treatment . Primary Dressing . Selan (zinc oxide barrier cream) Secondary Dressing: Foam . Additional Care: Incontinence management, Mattress with pump, Moisture barrier . Turning/repositioning program . Education Educated resident on the importance of turning and repositioning every 2 hours as tolerated . The wound picture included with the assessment and used to measure the wound showed a large open wound on the right buttocks with irregular borders and a pink/red colored wound bed with areas of black tissue within the wound bed. Two separate, smaller wounds were proximal to the larger wound on the right buttocks. A separate wound was present on the coccyx and left buttocks. The wound bed was irregularly shaped and approximately 45% of the wound bed being composed of dark black and purple tissue, approximately 5% of the wound bed being visible deeper and deep red in color and the other areas of the wound bed pink in color. - 9/24/24 - 1:25 PM . Coccyx . Length: 9.26 cm .Width: 4.46 cm . Deepest Point: 0.1 cm . Describe . Shearing . Granulation . 100% . Exudate . None . Treatment . Primary Dressing . Selan . Secondary Dressing: Foam . Additional Care: Incontinence management . Moisture barrier . Nutrition/dietary supplementation . Turning/repositioning program . Educated resident on the importance of turning and repositioning every 2 hours as tolerated . The wound picture included was taken from a different angle and the wound on the right buttocks was not entirely captured in the picture/measurement. The picture showed the wound on the right buttocks and the coccyx/left buttocks to be completely separate areas not connected by a skin bridge. The two separate, smaller wounds proximal to the wound on the right buttocks were not visible in the image. A white colored substance was present around the coccyx/left buttocks wound edges in the picture. The wound bed was a milky white/pink color with darker area of tissue present at approximately the 7 to 8 o'clock position of the wound bed. - 10/22/24 - 11:23 AM . Coccyx Length: 7.5 cm . Width 1.93 cm . Shearing . Wound Bed . Epithelial 50% . Granulation 50% . Exudate: Light . Serous . Treatment . Dressing Appearance: (Prior) Missing . Primary Dressing: Calcium alginate Secondary Dressing: Foam . Additional Care: Cushion, Heel suspension/protection device, Incontinence management, Moisture barrier, Moisture control. Nutrition/dietary supplementation, Turning/repositioning program . Notes resident noted to be lying on right side most of the day and does not like to reposition off the right side; attempts to float heels off bed declined. Education attempted; resident not able to retain information . The attached wound picture included in the assessment was from a different angle than previous pictures. The entire coccyx/left buttocks was not included in the image. The open wound on the right buttocks appeared to have a skin bridge but the wound bed was unable to be completely seen for description due to the angle of the image. The Resident was visibly soiled, and bowel movement was present in the image. - 10/29/24 - 9:22 AM . Coccyx . Length: 7.02 cm . Width: 2.18 cm . Describe . Shearing . Granulation . 100% . Scab . Exudate . Light . Serosanguineous . Treatment . (Prior) Dressing . Missing . Primary Dressing: Calcium alginate Secondary Dressing: Foam . Additional Care: Cushion, Heel Suspension/protection device, Incontinence management, Mattress with pump . Repositioning device(s), Turning/repositioning program . Notes Shearing has improved. One small, superficial scab to left buttock and superficial excoriation to right buttock remains . Education: Attempted but resident cognition is poor . The attached wound picture included in the assessment was from a different angle than previous images and the entire coccyx/left buttocks was not included. The coccyx/left buttocks wound visible in the image was pink in color with an oblong area on dark yellow/light brown colored tissue in the center. The open wound on the right buttocks was unable to be completely visualized due to the angle but appeared to have a skin bridge but the wound bed was unable to be completely seen for description due to the angle of the image. Review of Resident #60's EMR revealed a care plan entitled, I have impaired skin integrity skin impairments to bilateral buttocks r/t mobility and incontinence of bladder and bowel . HX (history) of PI (Pressure Injury) with scar tissue . Risk for friction and shearing . (Initiated: 9/19/24; Revised: 10/15/24). The care plan included the interventions: - Weekly wound measurement and evaluation (Initiated: 9/19/24) - Remind me as needed to move feet and legs to offload pressure (Initiated: 9/19/24; Revised: 10/15/24) - APM mattress (Initiated: 9/19/24; Revised: 10/15/24) - I prefer to not offload pressure as recommended (Initiated: 9/19/24) - Daily skin assessments (Initiated: 9/19/24) - Encourage and assist me to turn and reposition as I tolerate, If I decline attempt small shifts of body. If I decline both reapproach at later time (Initiated: 9/19/24; Revised: 10/15/24) Review of Resident #60's care plans revealed the Resident did not have a care plan and/or intervention in place On 10/30/24 at 5:13 AM, Resident #60 was observed in their room from the hallway of the facility. They were uncovered and their brief was visible. The Resident was laying on their back and slightly on their right side with their lower legs and heels positioned directly against the mattress. Upon entering the room, there were no additional pillows and/or positioning devices in place on the bed, floor, or in the room. The Resident did not have heel suspension/protection devices in place nor were there any observed in the room. An interview was completed with Licensed Practical Nurse (LPN) G on 10/30/24 at 7:34 AM. When queried regarding Resident #60's wounds and treatments, LPN G reviewed the Resident's EMR and stated the only treatment they had for the Resident was skin prep to heels. When queried regarding the wound on the Resident's coccyx/buttocks, LPN G reviewed the Resident's EMR again and verbalized they were unaware of the area because the treatment is completed on the night shift. LPN G revealed the wound care treatment on the Resident's coccyx/buttocks was not due to be completed. At 7:36 AM on 10/30/24, Resident #60 was observed in their room. The Resident was laying on their back and slightly on their right side with their lower legs and heels positioned directly against the mattress. On 10/30/24 at 8:27 AM, Resident #60 was observed in their room in bed. The Resident was laying on their back and slightly on their right side with their lower legs and heels positioned directly against the mattress. An interview was completed with RN CC on 10/30/24 at 8:29 AM. When queried regarding observation of Resident #60 being in the same position, lack of positioning devices, and lack of heel boots (suspension/protection devices), RN CC revealed they would need to review the Resident's EMR. No further explanation was provided. Resident #76 On 10/28/24 at 12:19 PM, Resident #76 was observed laying on their back in bed in their room. Their legs and heels were positioned directly against the mattress and both of their feet were pressed against the footboard of the bed. The knee section of the bed was observed to be elevated positioning their feet lower than their knees. Resident #76 was taller than average height for a male and their bed did not have a length extension in place. The Resident's left hand was in a fist and their left arm was visibly edematous and positioned flaccidly by their side directly on the mattress. When queried, Resident #76 revealed they had a stroke which effected their left side and had minimal movement in their left arm and hand. When queried if they were able to turn and reposition themselves in bed, Resident #76 verbalized they could not. When queried if the staff assist them to turn and reposition them in bed, Resident #76 verbalized they do not. When queried regarding the care they receive, Resident #76 stated, This place is terrible. When asked why, Resident #76 replied, The aides have attitude. Resident #76 was asked how the aides have attitude and replied, They tell me it's not their job when ask for help. Resident #76 further revealed there are rarely staff present on the unit and it takes an hour or two for staff to answer their call light when they do need assistance. Resident #76 specified there are two Certified Nursing Assistants (CNA) who check on them, but the rest do not. When queried if they had any open areas and/or wounds, Resident #76 relayed they had something on their buttocks but did not think it was open. On 10/29/24 at 8:16 AM and 10:57 AM, Resident#76 was observed laying in bed positioned directly on their back with their legs and heels positioned directly against the mattress. The knee area of the Resident's bed remained bent, and their feet lower than their knees and pressed against the footboard. Record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses which included left sided hemiplegia and hemiparalysis (one sided paralysis) following cerebral infarct (stroke), heart failure, diabetes mellitus, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required maximum/substantial assistance for rolling/turning, bathing, and hygiene and total assistance for transferring. The MDS further revealed the Resident was at risk for, but did not have any pressure ulcers. Review of Resident #76's EMR revealed a care plan entitled, I have impaired skin integrity related to admission with shearing of the sacrum area (Initiated and Revised: 9/6/24). The care plan included the interventions: - Float my heels while in bed (Initiated: 6/22/24) - Turn and reposition q2h (Initiated: 6/22/24) - Weekly skin assessments (Initiated: 6/22/24) - Weekly wound measurement and evaluation (Initiated: 6/22/24) A second care plan entitled, I am at risk for altered skin integrity related to decreased mobility (Initiated: 9/6/24) was noted in Resident #76's EMR. The care plan included the intervention, Apply house stock barrier cream to skin prn to protect from moisture (Initiated: 9/6/24). On 10/30/24 at 5:10 AM, 8:35 AM, and 10:14 AM, Resident #76 was observed in their room in bed. The Resident was positioned on their back with their legs and heels positioned directly against the mattress. The knee area of the bed remained elevated causing the Resident's feet to be lower than then their knees. There were no additional pillows for positioning on the Resident's bed. An interview was completed with CNA C on 10/30/24 at 10:36 AM. When queried, CNA C confirmed they were assigned to care for Resident #76. CNA C was then asked if Resident #76 is able to turn and reposition themselves in bed and revealed they could not. When queried if the Resident was supposed to be turned and repositioned by staff, CNA C replied, Yeah. CNA C was asked when Resident #76 had last been turned and repositioned, CNA C stated, Well, I ain't done (Resident #76) yet this morning. It was last night. When asked what time, CNA C was unable to recall. When queried what time they started work, CNA C replied that they were doing a double. When asked what they meant, CNA C stated they worked days yesterday then came back for night (shift) and were now working day shift. When asked how they reposition Resident #76, CNA C replied, Turn and put a pillow under (Resident #76) if they ask for it otherwise (Resident #76) just lay on their back and raises the head of the bed. When asked if they were saying they only repositioned and offloaded pressure with a pillow if Resident #76 asked, CNA C confirmed and reiterated Resident #76 is able to raise the head of their bed with the bed controls. An observation of care and Resident #76's skin was completed with CNA C and Registered Nurse (RN) CC on 10/30/24 at 10:39 AM. On the ball area of Resident #76's left foot, under the great toe, a darkened and discolored area of skin, circular in shape and approximately the size of a nickel was noted. When asked if the area was blanchable, RN CC pressed on the area and blanching was not observed. When asked, RN CC confirmed the tissue was non-blanching. On Resident #76's distal left heel, a dark black colored area of tissue was observed. The area was circular, slightly smaller than a dime, and located directly over a bony prominence. RN CC was asked if the area was blanchable and applied pressure. The area directly over the darkened black area was observed to be non-blanchable. When queried, RN CC confirmed the area was non-blanchable. When queried, Resident #76 stated their left heel had been hurting. A follow up interview was completed with RN CC and Unit Manager Licensed Practical Nurse (LPN) P on 10/30/24 11:07 AM. When queried regarding observations of the Resident on their back in bed with their lower extremities positioned directly against the mattress and feet pressed against the foot board of the bed as well as staff statement related to repositioning, both RN CC and LPN P confirmed Resident #76 should be turned and repositioned every 2 hours. When queried regarding observations of Resident #76's heels not being elevated and/or floated in bed as indicted on their care plan, RN CC and LPN PP verbalized understanding but did not provide further explanation. When asked if the Resident had heel boots in place due to their lack of mobility and pressure ulcer risk, RN CC and LPN P revealed they did not. When queried if the area identified on the ball area of Resident #76's left foot under the great toe may have been caused from where the Resident's foot was pressing against the footboard, both staff revealed that may be the cause. When queried if the area was a pressure injury, RN CC affirmed it was. When queried if the area identified on the Resident's heel was also caused from pressure, the staff indicated it was. RN CC and LPN C were then asked what the areas would be classified as and revealed a Deep Tissue Injury (DTI- pressure ulcer with unknown depth due to intact skin and underlying tissue damage) or a suspected Deep Tissue Injury (sDTI- localized area of discolored intact skin with underlying tissue damage of unknown depth caused by pressure). On 10/30/24 at 11:30 AM, an interview was completed with the facility Administrator. When queried, the Administrator verified the Resident was unable to turn/reposition themselves and that their heels were supposed to be elevated off the mattress. The Administrator revealed they were surprised the Resident did not have heel boots in place. An observation of Resident #76 and their room was completed with the facility Administrator at this time. The Resident was observed lying in bed, positioned on their back upon entering the room. When queried regarding Resident #76's feet being pressed against the footboard of their bed, the Administrator confirmed Resident #76 is tall and the bed is short for them. When queried regarding the knee section of Resident #76's bed being elevated, causing their feet to be lower than their knees and the controller not working, the Administrator asked Resident #76 what happened, and the Resident confirmed the bed was stuck. The Administrator verbalized they would get a longer and functioning bed for them. The Administrator asked Resident #76 if they had heel boots in their room and Resident #76 informed them that they did not. On 10/31/24 at 12:03 PM, Resident #76 was observed laying in in bed on their back with their legs and heels positioned directly against the mattress. An interview was completed with RN HH on 10/30/24 at 2:00 PM. RN HH indicated wound images were obtained of Resident #76's feet and verbalized they did not see the areas identified with RN CC. A review of the images obtained by the facility revealed the areas identified were not included. A second skin observation of Resident #76's left foot was completed on 10/31/24 at 11:00 AM with RN CC. The darkened and discolored areas were present the Resident's left heel and the ball area under great toe. The ball area under the great toe was less pronounced. When queried, RN CC confirmed the areas remained but indicated the area on the ball area of the great toe had improved. When asked, RN CC applied pressure to the ball area under the great toe and blanching was noted. The area on the left heel remained discolored, dark and non-blanchable. When queried, RN CC confirmed the heel area was present. When asked, RN CC stated, Could be a sDTI and indicated it may have been caught early enough to prevent worsening. 22927 Resident #5: Observation on 10/28/24 at 12:00 PM of Resident #5 was seated up in a Broda style wheelchair in the resident's room. The state surveyor observed a dressing to left heel/foot while seated up in wheelchair. An interview on 10/28/24 at 12:14 PM with Resident #5 revealed that she did have wounds to her legs feet and went to the wound clinic for treatment. Resident #5 stated that she also had a wound to her tail bone that started about 2 weeks ago. In an interview on 10/30/24 at 02:00 PM, Licensed Practical Nurse (LPN) M the unit manager and wound care nurse revealed that Resident #5's Coccyx wound started on 10/24/2024 and that she wrote a progress note. Resident #5's coccyx pressure injury was facility-acquired. In an interview on 10/30/24 at 2:13 PM, Registered Nurse (RN) F stated that Resident #5's coccyx wound was worse than the picture taken on 10/25/2024. RN F stated that Resident #5 had just returned from the wound clinic with new orders. Record review of wound clinic orders dated 10/30/2024 revealed a Stage II Pressure injury to the Sacrum with ordered treatment of Santyl to wound bed, cover with border dressing, skin prep, change dressing daily & PRN if soiled/saturated. Clean with wound cleanser each dressing change. An interview on 10/31/24 at 08:07 AM with Resident #5 revealed her tailbone wound was getting bigger, and she feels it, it hurts to get up and sit the chair. The sore hurts and its uncomfortable. Blood sugar was 159 this morning. I'm a brittle diabetic. The meals don't come at the same time daily, and I don't get my insulin before my meals, the international diabetes center told me that I needed insulin prior to my meals and that does not happen a lot of time. Observation and interview was conducted on 10/31/24 at 11:11 AM with Registered Nurse (RN) T and Certified Nurse Assistant (CNA) C of Resident #5's sacrum/coccyx wound dressing change. Observation of resident's old sacrum/coccyx dressing was not dated. RN T applied Derma cleanse spray applied to wound and wiped with gauze. Wound measurements obtained by nurse: coccyx 8cm length x 1.5cm width, no depth measurement taken, palpation of wound edges noted left side tenderness of outside of wound. Resident #5 rated pain at 8 on the pain scale when area is touched, and a 3 on pain scale when not touched. Santyl applied with tongue depressor stick, 4 x 4 gauze applied and covered with foam border dressing, tape applied to edge of dressing to occlude edges. new brief placed. 38471 Resident #58: During initial tour on 10/28/2024, Resident #58 was observed resting in bed laying on her back, with only a pillow under her head. Resident #58 was asked if she had any open wounds on her body and she shared she has a sore on her bottom. On 10/28/2024 at approximately 7:30 AM, a review was completed of Resident #58's medical record and it revealed she initially admitted to the facility on [DATE] with diagnoses that included, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Pressure Ulcer of Sacral region, muscle wasting and atrophy and Acute Kidney Failure. Further review of Resident #58's records yielded the following: Progress Notes: 7/17/2024 at 15:17: When doing a skin assessment on this resident it was noted she has a new pressure wound to her coccyx .ordered an air mattress for the resident . 7/18/2024 at 12:38: .Wound #1 is an unstageable pressure to her coccyx . 8/7/2024 at 10:09: Assessed residents coccyx wound today, wound is draining purulent drainage. Wound bed 25% slough . 8/15/2024 at 12:42: Resident sent to the hospital . for further evaluation due to pressure on the coccyx and risk for infection . Care Plan: (Resident #58) has actual impairment to skin integrity r/t (related to) abrasions Stage 2 right buttocks .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 .The resident needs assistance to turn/reposition at least every 2 hours, more often as needed as she will allow .I have impaired cognitive function or impaired thought processes r/t mild cognitive impairment .Bed mobility: 1 require extensive assist of 1. Dressing: I require extensive assist of 1 .Transfers: mechanical lift 2PA (person assist) . July 2024 TAR (Treatment Administration Record): Review was completed of the TAR, and it indicated on 7/2/2024, 7/9/2024 and 7/16/2024 (one day before the pressure injury was discovered) a body audit was documented as completed on Resident #58, that stated no new skin breakdown. On 7/17/2024 an unstageable pressure injury to Resident #58's coccyx was discovered. August 2024 TAR: Resident #58 did not receive scheduled wound treatments on the following days: 8/10/24 8/13/24 8/23/24 8/24/24 8/26/24 Furthermore, Resident #58 was sent to the hospital on 8/15/2024, but nursing staff did not indicate that on the TAR so it appeared the resident missed multiple wound treatments. Cleanse coccyx wound with wound cleanser, pat dry apply calcium alginate with silver, cover foam dressing, change daily and prn. Started on 7/25/2024 and discontinued on 8/19/2024. Cleanse coccyx wound with wound cleanser, pat dry apply calcium alginate with silver, cover foam dressing, change daily and prn. Started and discontinued on 8/23/2024. Resident #58 never received this treatment to her wound. September TAR 2024: Resident #58 did not receive scheduled wound treatments on 9/8/2024, 9/17/2024 and 9/25/2024. October TAR 2024: Resident #58 did not receive scheduled wound treatments on 10/2/24 and 10/7/24. On 10/30/2024 at 2:10 PM, an interview was conducted with Unit Manager/Wound Care Nurse M regarding Resident #58's facility acquired coccyx wound. Nurse M expressed the resident will not turn and reposition and prior to development of the wound she refused the specialty mattress. Nurse M was queried on what the facility has trialed to offload the resident from her back. When asked about a wedge pillow or body pillow or other unique way to offload her. Nurse M reported they had not tried anything of that nature to her knowledge. Nurse M was asked when the last time the resident has been out of bed, and she reported it had been a while. Nurse M expressed once she was alerted to the wound it was already progressing and its highly unlikely the wound was not present the day prior when the body audit was completed. Nurse M explained given the presentation of the wound there would have been the presence of skin impairment in this area prior to facility staff alerting her to the wound. The wound developed due to the resident positioning in bed. Nurse M was asked to provide any evidence that showed facility staff were attempting other methods to offload the resident and/or get her out of bed since wound inception. On 10/29/2024 at approximately 8:00 AM, Resident #58 was observed laying in bed on her back. Further review was conducted of Resident #58's wound documentation from inception on 7/17/2024: 7/17/2024: 0.87 cm (centimeter) x 2.13 x 0.52cm: Unstageable pressure, 100% slough, periwound is non-attached. 7/24/2024: 1 cm x 1.92cm x 0.76cm; Unstageable pressure, 100% slough, moderate serous exudate . 7/31/2024: 1.21cm x 1.91xm x 0.78; Unstageable pressure, 100% slough, non- attached edges, progress -deteriorating . 8/7/2024: 8.84cm x 4.36cm x 2.94cm; Unstageable pressure, 30 [TRUNCATED]

This Citation Pertains to Intake Numbers MI00147548 and MI00147625. Based on observation, interview and record review, the facility failed to ensure dignified, respectful, and professional care and treatment for 12 residents (# 5, #11, #21, #24, #29, #36, #39, #40, #60, #64, #76, and #81) of 12 residents reviewed and 12 of 12 residents from the confidential Resident Group meeting, resulting in a lack of the provision of care, timely response to care needs, extended wait times for assistance, incontinence, and residents' verbalizations of discourteous staff, feelings of being a burden, frustration, and sadness. Findings include: Resident #11: Record review revealed Resident #11 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included left leg fracture, diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required substantial to total assistance to complete all Activities of Daily Living (ADL) with the exception of eating. On 10/28/24 at 11:57 AM, Resident #11 was observed sitting in a wheelchair in their room. An interview was completed at this time. When queried regarding staffing levels at the facility, Resident #11 replied, Night shift is the worst. When asked what they meant, Resident #11 stated, It took over two hours last night for staff to answer their call light. Resident #11 revealed they have to call the facility on their phone to get help. Resident #11 was asked how frequently that occurs and indicated it is a nightly occurrence. Resident #11 then stated, If something was really wrong, I would be dead. When asked how that makes them feel, Resident #11 stated, Horrible, (staff) don't care. When asked if staff treat them with dignity and respect when they are in the room, Resident #11 verbalized they do not. Resident #11 was asked to provide an example. Resident #11 revealed they are able to eat independently but need assistance to prepare their food such as opening containers and cutting up items due to their tremors. Resident #11 then stated, (Staff) wont even prepare my meal for me anymore like I need. Just runs off without talking. When asked, Resident #11 reiterated the staff don't care and it makes them feel horrible. Resident #29: On 10/28/24 at 12:06 PM, Resident # 29 was observed in their room. The Resident was lying in bed, positioned on their back. An interview was completed at this time. Resident #29 was female and noted to have long, thick, dark colored hair on their chin. When queried regarding their stay at the facility, Resident #29 revealed they came to the facility approximately one month prior from the hospital. Resident #29 stated they had a stroke and needed therapy. When asked how therapy was going, Resident #29 indicated they were doing well in therapy and relayed do Not get therapy every day. When queried if they need staff assistance to get out of bed, Resident #29 stated, Not get therapy then no get out of bed. When asked why, Resident #29 did not provide a response. When asked how they transfer and get out of bed, Resident #29 replied, One or two staff have to help them. When queried regarding how they use the bathroom, Resident #29 stated, They (staff) put diapers on. Resident #29 was asked if they know when they need to use the bathroom and stated, Yeah but it takes them an hour to answer the call light. When asked if they put the call light on when they needed to use the restroom, Resident #29 nodded their head to indicate they did and reiterated that it takes over an hour for the staff to respond. With further inquiry, Resident #29 revealed facility staff tell them to go in their brief because they do not have time or staff to help them to the bathroom. Resident #29 indicated it is easier for the staff to change their brief than it is for them to assist them to use the toilet. A bedside commode was not observed in the Resident's room. When queried if staff had attempted to assist them to use a bedside commode, Resident #29 revealed staff had never offered/provided a bedside commode. When queried how it makes them feel to urinate and/or have a bowel movement in their brief, Resident #29 replied, Bad and verbalized it makes them feel like they are a baby. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses which included right sided hemiplegia and hemiparalysis (one sided paralysis) following cerebral infarction (stroke), osteoarthritis, depression, and falls. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required partial to total assistance to complete ADL. Review of Resident #29's Electronic Medical Record (EMR) revealed a care plan entitled, I have an ADL self-care performance deficit related to CVA (Cerebrovascular Accident - stroke) with right side weakness . (Initiated: 10/6/24; Revised: 10/15/24). The care plan included the interventions: - Toilet USE: I require assistance by (2) staff for toileting (Initiated: 10/6/24; Revised: 10/21/24) - Transfer: I require assistance by (2) staff to move between surfaces (Initiated: 10/22/24) A follow up interview was completed with Resident #29 and Family Member Witness FF on 10/31/24 at 11:11 AM in the Resident's room. Resident #29 was observed laying in bed on their back. When queried the average length of time it takes for staff to answer their call light, Resident #29 reiterated it is typically over an hour. Witness FF then stated, It $400.00 a day and they (staff) give me attitude when ask for help and say they don't have enough staff, but they can't wait for their money. When asked to explain, Witness FF revealed they have to go and find staff to assist Resident #29 when they are visiting because they do not answer their call light. When asked what they meant when they said attitude, Witness FF revealed the staff are rude and act as though you are bothering them when you need something. When queried if staff tell them to go to the bathroom room in their brief because they do not have time to help them, Resident #29 replied, Yes. Witness FF added, The perception in there is no urgency to assist the residents. Resident #29 was then queried regarding the visible hair on their chin and stated, No, don't want. They (chin hairs) bother me. When queried if staff had offered to assist them to remove the hair, Resident #29 revealed they had not. At 11:28 AM on 10/31/24, an interview was conducted with Registered Nurse (RN) CC. When queried if staff are expected to assist residents to remove unwanted facial hair, RN CC indicated they assume that would be included in daily ADL care. An observation of Resident #29 was completed with RN CC at this time. When queried regarding the Resident's facial hair, RN C stated they would get rid of the whiskers. No further explanation was provided. Resident #60: Record review revealed Resident #60 was admitted to the facility on [DATE] with diagnoses which included dementia, malnutrition, arthritis, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required substantial to total assistance to complete all ADL with the exception of eating. On 10/28/24 at 12:14 PM, Resident #60 was observed laying in bed in their room with their eyes open wearing a hospital style gown. The room lights were off, the blinds were closed, and there was no visual and/or audio sensory stimulation. A fall mat was noted on the floor on the left side of the Resident's bed. Resident #60's call light was not within reach. The call light cord was hanging over the head of the bed with the button on the floor under the headboard. When queried regarding the care they receive at the facility, Resident #60 replied, I got a sore spot on my butt it ain't going away. Resident #60 then stated, Been waiting to talk to nurse about my butt. When queried regarding staff responsiveness when they put on their call light, Resident #60 did not provide a direct response and indicated they just have to wait. Resident #60 was asked how they get assistance if they need it and revealed they did not know where their call light was. On 10/30/24 at 5:13 AM, Resident #60 was observed in their room from the hallway of the facility. The Resident was uncovered with their brief exposed and visible from the hallway. There were no staff present in the hallway or general area. Upon entering the room, Resident #60 was observed to be awake. The Resident's call light was not within the Resident's reach and was wrapped around the headboard of the bed. When queried how they were doing, Resident #60 indicated they were cold and asked for a blanket to cover up with. A blanket was not observed on the floor and/or area surrounding the Resident's bed. When asked what happened to their blanket, Resident #60 did not provide an answer. An interview was completed with RN CC on 10/30/24 at 8:29 AM. When queried regarding observation of Resident #60 being exposed and visible from the hallway and not having a blanket, RN CC responded that Resident #60 removes their blankets. When asked why there where no blankets in or around the bed if the Resident had removed it, RN CC was unable to provide an explanation. When queried regarding observations of the Resident's call light not being in reach, RN CC verbalized resident call lights should be positioned where they can reach them. No further explanation was provided. Resident #76: On 10/28/24 at 12:19 PM, Resident #76 was observed laying on their back in bed in their room. The Resident was wearing a visibly soiled blue long sleeve shirt with significant amounts of chunks of unknown substances on it. The Resident was unshaven and had an unkept appearance. Resident #76 was tall, and both of their feet were noted to be pressed against the footboard of the bed. The Resident did not have a bed extension in place. Resident #76's left upper arm was positioned by their side in bed. Their arm was discernibly edematous, and their hand was positioned in a fist. When queried, Resident #76 revealed they had a stroke which effected their left side. When queried if they were able to move their left arm and hand, Resident #76 indicated they could not. The Resident's fingernails were observed to be long and unkept with sharp edges and had a build up of dark colored unknown substances under the nail. When queried regarding the care they receive at the facility, Resident #76 stated, This place is terrible. When asked why, Resident #76 replied, The aides have attitude. Resident #76 was asked how the aides have attitude and replied, They tell me its not their job when ask for help. With further inquiry, Resident #76 stated, The one lady wouldn't give me a bed bath - she told me that wasn't her job. When asked if another staff member assisted them to wash up/gave them a bed bath, Resident #76 revealed they did not. Resident #76 revealed they returned to the facility from the hospital a few weeks prior and when they asked for something the aide (Certified Nursing Assistant [CNA]) told me, I don't give a damn about you. When asked if they had any other examples, Resident #76 stated, My urinal was half full on my (overbed) table and I ask them (staff) to empty it. (Staff) said I'm tired of emptying your piss. Resident #76 stated, They (staff) mistreating me. Resident #76 verbalized staff also do not respond to their call light timely. When asked how long it takes for staff to answer their call light on average, Resident #76 responded that it is usually an hour or two. Resident #76 then stated, There was a lady on the floor. I had my call light on for an hour and nobody came so I called my wife (on the phone). Resident #76 revealed their wife proceeded to call the facility and staff responded. When asked where the lady was at on the floor, Resident #76 indicated they were in the hallway by the doors to the unit. Resident #76 then stated, (Another Resident) lay on the floor all night yelling out. When asked if staff responded, Resident #76 revealed it was hours later and stated, (Staff) were cussing at (other resident) because they were hollering out when they did respond. Resident #76 then stated, You should come in between 1:00 AM and 6:00 AM to see what going on in here. When queried regarding ADL care including bathing, Resident #76 revealed the facility staff tell them they do not have enough staff to assist when they request bathing. When queried regarding their shirt, Resident #76 verbalized they have been wearing the same shirt for the past two days. Resident #76 stated, I asked them (staff) to change it and revealed facility staff had ignored their request. When asked how tall they are, Resident #76 replied, 6 (foot) 4 (inches). Resident #76 was queried regarding their feet being directly against the footboard and revealed their feet have always been against the footboard since they were admitted to the facility. Resident #76 further revealed there are night shifts when there is only one CNA working. When asked how they know there is only one CNA working, Resident #76 replied that staff tell them and explained that is why they cannot assist them. At the conclusion of the interview, Resident #76 stated, They (staff) will pick on me because I talk to you. Resident #76 was asked to explain and revealed staff do not like it when you tell the truth. Resident #76 indicated facility staff will try to discredit what them but verbalized they just wanted people to be treated right. Record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses which included left sided hemiplegia and hemiparalysis (one sided paralysis) following cerebral infarct (stroke), heart failure, diabetes mellitus, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to total assistance to complete all ADL. On 10/31/24 at 12:03 PM, Resident #76 was observed laying in their bed from the hallway of the facility only wearing a shirt and a brief. The Resident was uncovered, and their brief was exposed and visible from the hallway of the facility. Upon entering the room, a blanket was not observed on the bed. When queried why they were uncovered and not wearing any pants, Resident #76 stated, Been waiting for (CNA C) to bring a blanket. When queried how long they had been waiting, Resident #76 revealed it had been around an hour. Resident #81: Record review revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, dementia, depression, heart disease, and left leg below the knee amputation. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required partial to total assistance to complete all ADL with the exception of eating. On 10/31/24 at 11:09 AM, Resident #81 was observed laying in bed, uncovered with their brief exposed from the hallway room entrance. There were no facility staff in the unit and/or general area of the Resident's room. An interview was completed with the facility Administrator on 10/31/24 at 10:46 AM. The DON was informed of statements made by residents during interviews as well as observations. The Administrator verified concerns and revealed the facility had work to do. 38471 During a confidential Resident Council meeting held on 10/29/2024 at 11:30 AM, the twelve residents in attendance were queried regarding the care provided to them at the facility. They reported the following concerns with their provisions of care: -Water pass is not consistently being completed and many times they will not receive waters on third shift. -Facility staff take 30-45 minutes to answer call light and upon them responding, they report they were doing something else. Call light response times are most extended on 1st and 3rd shift. -Members reported their families have entered the building and observed staff sitting at the nursing station playing on their phone or chatting with one another as call lights are alarming. -When aides answer their call lights they are snappy, abrupt and have poor attitudes. They further expressed they will ask what do you want, upon entering the room and it makes them feel as they are a burden. -At shift change there is no consideration that residents are sleeping, and staff are talking and laughing loudly. -Aides will come in their rooms and use their cellphones when they are supposed to be providing care. On 10/31/2024 at approximately 8:15 AM, a review was conducted of the last 6 months of resident council notes, and it revealed the following regarding resident complaints regarding call lights and hydration: October 1, 2024: .See concern form about residents not getting water on all sifts and when it does come its warm. See concern from about call light response times it depends on the staff and the shift who are slow to respond . September 3, 2024: See concern form about residents not getting water on all sifts and when it does come its warm. See concern from about call light response times it depends on the staff and the shift who are slow to respond . August 6, 2024: .The following residents (four residents) did express concern with call light response times, doors being slammed and people talking loud at night and early morning . July 2, 2024: . (two residents) do have concerns with doors being slammer and staff talking loud/high pitch giggling usually first thing in the morning and late at night . stated we don't always get fresh water, something its first shift that don't it out and other times its second shift that forgets to give us water . June 4, 2024: .stated we don't always get fresh water, something its first shift that don't it out and other times its second shift that forgets to give us water . 22927 Resident #5: In an interview on 10/28/24 at 10:40 AM with Resident #5 complained of being put to be at 7:00 PM and does not like it. The Resident #5 would like to stay up and do activities, and visitors come in the evenings. Resident #5 stated that there is a Certified Nurse Assistant (CNA) that comes into the room and just states 'what do you want, now' Resident stated that she tries not to use the call light because of the staff. Record review of the Resident #5' care plans medical record revealed the resident was a mechanical lift for transfers. Record review of Resident #5's Kardex care guide revealed that there was no bedtime identified for the resident. Resident #40: In an interview on 10/28/24 at 09:46 AM with Resident #40 revealed that she feels that the staff are not nice and don't do the work. Her catheter care does not get done and the staff are rude, and it take a long time to get call lights answered, but she can hear the staff in the hallway laughing and loud at night. Record review of Resident #40's care plans for activities of daily living (ADL) revealed that the resident required physical assist of two staff members with repositioning, toileting, mechanical transfers, dressing, and bathing/showers. In an interview on 10/28/24 at 03:40 PM with Resident #40 revealed that the Resident feels that there are not enough staff to help her as a quadriplegic mechanical lift person and that she has to wait long periods of time to get assistants. 49944 Resident #21 (R21): R21 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include difficulty walking, muscle weakness, major depressive disorder and obstructive uropathy. R21 has a BIMS (brief interview for mental status) score of 15, indicating they are cognitively intact. On 10/30/24 at 11:24 AM, R21 was observed sitting in their wheelchair, their head was down on the bedside table and they were sleeping. There was a large puddle of urine on the floor under the wheelchair, some of the puddle had started to dry and the room had a strong odor of urine that was noticeable from the hallway. This surveyor approached R21 and woke them up. R21 was asked how long she has been like this. R21 stated they have been like this since breakfast. R21 turned on their call light at 11:26 AM. R21 was asked if it takes a long time to get their call light answered and if being incontinent has ever happened before as a result of the long answer time. R21 stated it takes a long time to get the call light answered and this has happened before. Staff was observed responding to R21 at 11:48 AM. Staff told R21 they would be right back and left the room, staff entered the room again at 11:50 AM, staff then left the room again without providing care. Staff entered the room again at 11:53 AM to provide care. Resident #24 (R24): R24 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic respiratory failure, chronic obstructive pulmonary disease, anxiety disorder and hypertension. R24 has a BIMS score of 14, indicating they are cognitively intact. On 10/28/24 at 11:22 AM, an interview was conducted with R24. R24 was asked how the staff treats them. R24 stated the nurse aides have attitudes, and they give them a hard time about taking a shower. R24 stated that they use supplemental oxygen, and the nurse aides give them a hard time about refilling the portable oxygen tank. R24 was asked if they have any issues getting the call light answered timely. R24 stated, sometimes the call light can be on a couple of hours and it's on so long I will forget how long its been on. Resident #36 (R36): R36 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include adult failure to thrive, anxiety disorder, dysphagia and muscle weakness. R36 has a BIMS of 14, indicating they are cognitively intact. On 10/28/24 at 03:57 PM, an interview was conducted with R36. R36 was asked how the staff treats them. R36 stated some of the staff can be mean, one specific person (R36 doesn't know the name of this person), tells her that if she continues to turn her call light on she will just put her in her wheelchair and put her out by the nurses station. R36 stated they asked the aide their name, but the aide wouldn't tell R36 their name. R36 stated they are afraid to ask this aide for anything because of how mean they can be. Resident #39 (R39): R39 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include type two diabetes, difficulty in walking, dysphagia and urine retention. R39 has a BIMS score of 9, indicating they have mild cognitive impairment. R39 is alert and able to answer questions. On 10/28/24 at 02:10 PM, an interview was conducted with R39. R39 was asked how the staff treats her. R39 stated the staff are rude and they cuss while providing care, the cussing can be in general or directed at them. R39 stated they just want the staff to be nice. R39 was asked if it is any specific shift or staff member. R39 stated it is all shifts and no one specific. R39 is concerned that staff treat them badly, even though they feel they are obedient and does what the staff ask. Resident #64 (R64): R64 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, hypertension and muscle wasting. R64 has a BIMS score of 15, indicating they are cognitively intact. On 10/28/24 at 10:57 AM, an interview was conducted with R64. R64 was asked how the staff treats them. R64 stated that some of the staff is very nice, however, others make you feel like you are a problem to them. R64 was asked if it was any specific staff or shift. R64 stated that they though it was second or third shift staff that were the problem. R64 was asked if they get their call light answered in a timely fashion. R64 said it usually takes around 20 minutes or more to get assistance with the call light and it has been worse since their room change to the current room.

This Citation pertains to Intake Numbers MI00147548 and MI00147625. Based on observation, interview and record review the facility failed to document and provide routine showers and hygiene care for 12 residents (#5, #9, #24, #40, #50, #56, #57, #64, #72, #76, #78, #80) of 12 residents reviewed and 7 of 12 residents from confidential Resident Group meeting, resulting in residents' feelings of embarrassment from poor hygiene, and frustration. Findings Include: During a confidential Resident Council meeting held on 10/29/2024 at 11:30 AM, the twelve residents in attendance were queried regarding the care provided to them at the facility. Seven residents stated they were not consistently receiving their showers. Residents stated they had not received showers in two weeks and were not provided with a reason as to why. They expressed frustration as they felt disregarded. Resident #57: During initial tour on 10/28/2024, Resident #57 was observed resting in bed while. Review was completed of her medical record, and it revealed she initially admitted to the facility on [DATE] with diagnoses that included, Bipolar Disorder, Alcohol Abuse, Major Depression, Generalized Anxiety and Diverticulosis. Review was completed of Resident #57's showers over the last 30 days and it indicated the resident received one shower on 10/8/2024. Resident #72: During initial tour on 10/28/2024, Resident #72 was observed in the common area with consistent movement of standing up then back down. She was not able to be interviewed due to her disease process. On 10/29/2024 at 4:50 PM, a review was conducted of Resident #72's medical record and indicated the resident admitted to the facility on [DATE] with diagnoses the included. Dementia, Schizoaffective, Major Depressive Disorder and traumatic brain injury. Further review of Resident #72's chart yielded the following: Care Plan: .I have an ADL self-care performance deficit related to impaired cognition and mobility . BATHING/SHOWERING: I require extensive assistance by (1) staff with bathing/showering . Review was completed of Resident #57's showers over the last 30 days and it indicated the resident received two showers (10/3/24 and 10/6/2024) during the lookback period. On 10/31/24 at 08:23 AM, The administrator was questioned regarding resident showers being completed as scheduled. The administrator reported she believed facility staff are showering residents but there is an issue with documentation. She explained they have discussed with nurses their responsibility to hold aides accountable for ensuring resident cares are completed and subsequent documentation. They have found the nurses are apprehensive to directly address the aides when oversights occur. 37668 Resident #56: On 10/28/24 at 11:10 AM, Resident #56's room door was observed to be closed. Upon knocking and entering the room, a pungent, foul odor with overwhelming putrid qualities was immediately noted. The smell grew stronger closer to the Resident. The Resident was laying in bed with their knees bent wearing a hospital style gown. Their hair was uncombed with a greasy appearance. A large amount of personal food items, including nutritional shakes and candy, as well as condiments packets were present in various areas throughout the room. When queried regarding the food items present, Resident #56 revealed their family brings it to them. Resident #56 verbalized that the facility kitchen always sends tea and they do not like tea without sugar so that keep packets in their room. Resident #56 was asked how they transfer and get out of bed and revealed they are unable to walk, and staff have to transfer them with the Hoyer lift (mechanical lift used for transferring from surface to surface). When queried regarding bathing and showering, Resident #56 replied, Only shower once a week. When queried regarding other bathing assistance, Resident #56 indicated the staff provide incontinence care when they ask them. Resident #56 was then asked if they are satisfied with having one shower a week, Resident #56 revealed they did not want to want to bother the staff. When asked what they meant, Resident #56 indicated the staff are busy and it is harder for them to get them out of bed because of the lift so they do not complain. Resident #56 was asked if they would like to shower more and revealed they would it they need it. At 11:18 AM, Certified Nursing Assistant (CNA) U entered Resident #56's room. CNA U assisted the Resident to roll to their right side to provide care. After rolling onto their side, a wound on the Resident's upper left back was visualized. An undated was dressing was in place but did not cover the entire wound bed. Dark colored wound drainage was present on the bedding where the Resident had been laying. Record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), diabetes mellitus, open wound, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to total assistance to completed Activities of Daily Living (ADL) with the exception of oral hygiene and eating. Review of Resident #56's Electronic Medical Record (EMR) revealed a care plan entitled, have an ADL self-care performance deficit related to altered mobility . I choose to keep a multitude of items on my bedside table, combining edible and non-food items (Initiated: 8/3/24; Revised: 10/29/24). The care plan included the intervention, Bathing/Showering: require assistance by (2) staff for bathing/showering. Use a lift to transfer to shower chair (Initiated: 8/3/24; Revised: 9/23/24). On 10/31/24 at 11:50 AM, Resident #56 was observed sitting in their wheelchair. The Resident's hair was uncombed with a greasy, dirty appearance. Resident #76: On 10/28/24 at 12:19 PM, Resident #76 was observed laying on their back in bed in their room. The Resident was wearing a visibly soiled blue long sleeve shirt with significant amounts of chunks of unknown substances on it. The Resident was unshaven and had an unkept appearance. Resident #76 was tall, and both of their feet were noted to be pressed against the footboard of the bed. The Resident did not have a bed extension in place. Resident #76's left upper arm was positioned by their side in bed. Their arm was discernibly edematous, and their hand was positioned in a fist. When queried, Resident #76 revealed they had a stroke which effected their left side. When queried if they were able to move their left arm and hand, Resident #76 indicated they could not. The Resident's fingernails were observed to be long and unkept with sharp edges and had a buildup of dark colored unknown substances under the nails. When queried how they get out of bed, Resident #76 revealed staff transfer them using the Hoyer (mechanical) lift. Resident #76 was asked how often they get out of bed and revealed they do not get up often. When queried regarding the care they receive at the facility, Resident #76 stated, This place is terrible. When asked why, Resident #76 replied, The aides have attitude. Resident #76 was asked how the aides have attitude and replied, They tell me it's not their job when they ask for help. When queried regarding bathing and showers, Resident #76 revealed staff have told them that it is to difficulty to get them up and that they do not have enough staff, so they usually end up just getting a bed bath. Resident #76 revealed they do not always get bed baths and stated, The one lady wouldn't give me a bed bath - she told me that wasn't her job. When asked if another staff member assisted them to wash up/gave them a bed bath, Resident #76 revealed they did not. Resident #76 was asked how often they would like a shower and revealed more often than they receive. When queried how often they showered prior to coming to the facility, Resident #76 revealed they showered daily. Resident #76 then disclosed their career and the importance of good hygiene and cleanliness. When queried regarding their fingernails, Resident #76 revealed staff do not assist and/or provide fingernail care routinely. Record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses which included left sided hemiplegia and hemiparalysis (one sided paralysis) following cerebral infarct (stroke), heart failure, diabetes mellitus, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to total assistance to complete all ADL'S. On 10/30/24 at 10:39 AM, an observation of care for Resident #76 was completed with Certified Nursing Assistant C. An observation of Resident #76's feet revealed the Resident's toenails were thick, discolored, and overgrown. The toenails on both of the Resident's feet were curved around the end of their toes. When queried when they last had their toenails addressed and/or were seen by podiatry services, Resident #76 revealed they were not sure and had not been seen by a podiatrist. An interview and observation of Resident #76's toenails was completed with Unit Manager Registered Nurse (RN) CC on 10/30/24 at 11:00 AM. When queried regarding the condition of the Resident's toenails, RN CC verbalized the Resident's toenails needed to be addressed and they would see about getting them seen by a podiatrist. Review of Resident #76's EMR revealed a care plan entitled, I have an ADL self-care performance deficit elated to . and generalized weakness (Initiated: 6/20/24; Revised: 7/2/24). The care plan included the interventions: - Bathing/Showering: I require assistance by (2) staff with bathing/showering (Initiated: 6/20/24; Revised: 6/21/24) Resident #76 did not have a care plan in place related to finger and/or toenail care. Review of task documentation in Resident #76's EMR revealed the task, Shower/Bed Bath Monday and Thursday 1st shift but did not distinguish Resident preference nor did it reflect that the Resident received showers twice a week. 49944 Resident #24 (R24): R24 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic respiratory failure, chronic obstructive pulmonary disease, anxiety disorder and hypertension. R24 has a BIMS score of 14, indicating they are cognitively intact. On 10/29/24 at 04:00 PM, R24 stated that the nursing staff give her a hard time about taking a shower. R24 was asked if this happens all the time. R24 stated that they gave the staff one day off from giving her a shower because they were busy and now, they have taken liberty with it. R24 stated they believe the nursing staff will hide out and not shower her, the staff always says they are busy. On 10/30/24 at 11:05 AM, record review of the EMR (electronic medical record) for R24 revealed they have had three baths/showers completed in the last 30 days. Record review further revealed that R24 has three shower refusals, and three times staff has not documented/offered a shower on 9/30, 10/7 or 10/14. On 10/30/24 at 11:07 AM, record review of the ADL (activities of daily living) care plan, dated 01/21/2023, revealed R24 requires assistance with one staff for shower/bathing. Resident #50 (R50): R50 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include left tibia and left fibula fracture, muscle weakness, anxiety disorder and a history of falling. R50 has a BIMS score of 11, indicating moderate cognitive impairment. On 10/29/24 at 10:31 AM, observation revealed R50 was well dressed, groomed, the scent of urine is noted while sitting beside the resident. On 10/29/24 at 11:16 AM, record review revealed that R50 has only had four showers in the last 30 days. Documentation revealed that one shower was refused. Nothing was documented on 10/6, 10/20 or 10/27. On 10/30/24 at 11:17 AM, record review of the ADL care plan, dated 07/05/2024, revealed R50 is a one staff assist for showers. On 10/30/24 at 12:57 PM, R50 was asked if it was accurate that they had only received four showers in the last 30 days. R50 said that is probably true. R50 was asked about the other potential dates for the month that they didn't receive a shower. R50 stated they just didn't give them to me, I will never refuse a shower. Resident #64 (R64): R64 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, hypertension and muscle wasting. R64 has a BIMS score of 15, indicating they are cognitively intact. On 10/30/24 at 01:00 PM, an interview was conducted with R64. R64 was asked if they ever refuse showers. R64 stated they have refused showers due to the COVID outbreak a while back, stating they were afraid to leave the room. R64 stated they received a bed bath during COVID. R64 was asked if it was accurate they had only received 4 showers in the last 30 days. R64 stated the staff never offered showers for the other days of the month that were missed. R64 stated they don't want a shower from someone that doesn't want to give it anyhow, I will not beg them. R64 stated the staff know my schedule and if they wanted to do it then they would've. R64 stated in the previous room there was a shower and no need to leave it to get a shower completed. On 10/30/24 at 01:10 PM, record review revealed that R64 has only had 4 showers in the last 30 days. Four showers were documented as given, one was refused, and no documentation was noted on 9/30, 10/3, 10/7 and 10/14. On 10/30/24 at 01:15 PM, record review of the ADL care plan, dated 05/01/2024, revealed that R64 requires assistance of one staff for shower/bathing. 22927 Resident #5: Activities of Daily Living: In an interview on 10/28/24 at 10:40 AM with Resident #5 stated that she does have missed her showers. The Resident #5 stated that she requested showers 3 days a week, like she would if she was at home. But the staff will miss her shower day and if she does not remind them and then [NAME] the aides, they will not do it. Record review of Resident #5's Activity of Daily Living (ADL) care plan dated 7/18/2024 noted bathing with 2 assists, prefers to have showers Monday-Wednesday-Fridays. Record review of Resident #5's shower task question #3: Shower, bed bath or tub, 30-day look back revealed that Resident #5 only received seven (7) showers in 30 days. Record review of Resident Kardex care guide used by Certified Nurse Assistants (CNA) noted: Shower/bed bath Monday, Wednesday, Fridays on 1st shift and PRN (as needed). Resident #9: Activities of Daily Living: In an interview on 10/29/24 at 02:22 PM with Resident #9 revealed that he was not getting showers, and that they just wash him up in bed. Resident #9 stated he would rather have a shower with warm water and a good scrubbing. Record review of Resident #9's care plans for activities of daily living (ADL) revealed that the resident required physical assist of two staff members with repositioning, toileting, mechanical transfers, dressing, and bathing/showers. Record review of Resident #9's shower/bathing on Wednesday and Saturdays task form 30-day look back from 10/1/2024 through 10/27/2024 revealed only two (2) showers/bathes were given to a totally dependent upon staff resident. Resident #40: Activities of Daily Living: In an interview on 10/28/24 at 09:46 AM with Resident #40 revealed that the shower chairs do not fit the resident, the facility has a blue reclining shower chair. There is no shower bed, and staff tell (the resident) that the tub is broken, so she gets a bed bath or only half a shower because the shower chair does not fit in the shower. Record review of Resident #40's care plans for activities of daily living (ADL) revealed that the resident required physical assist of two staff members with repositioning, toileting, mechanical transfers, dressing, and bathing/showers. Record review of Resident #40's shower/bathing task form 30-day look back from 10/1/2024 through 10/27/2024 revealed only three (3) showers/bathes were given to a totally dependent upon staff resident. Resident #78: Activities of Daily Living: In an interview on 10/29/24 at 02:25 PM with Resident #78 revealed that he did not know how often he gets a shower/bath stating not very often, and he did not know why. Resident #78 stated that They just give him a washcloth and to wash up in the room. Record review of Resident #78's Activity of Daily Living (ADL) care plan dated 7/8/2024 revealed the resident needed assistance with one staff. Record review of Resident #78's shower/bathing Monday and Thursday task form 30-day look back 9/30/2024 through 10/30/2024 revealed only three (3) showers/bathes given on 10/3/24, 10/7/24 and 10/14/24. Resident #80: Activities of Daily Living: Observation on 10/29/24 at 09:04 AM of Resident #80 Appeared un-shaven and scruffy in appearance and thin. In an attempted interview on 10/29/24 at 02:27 PM with Resident #80 made eye contact and shook his head to surveyor questions. Resident #80 responded with slow speech that they just wash me up in bed, its cold. Record review of Resident #80's Activity of Daily Living (ADL) care plan intervention dated 3/17/2024 revealed Resident #80 required assistance of 2 staff with shower/bathing. Record review of Resident #80's shower/bathing every Tuesday and Sunday on 2nd shift, 30-day look back 9/30/24 through 10/30/24 revealed only 3 showers/bathes: On 9/30/24, 10/10/24 and 10/20/24.

Based on observation, interview and record review, the facility 1) Failed to ensure proper labeling of medications in 5 of 5 medication carts, and 2 of 2 treatment carts, 2) Failed to properly secure/lock 2 of 2 treatment carts with medical supplies and prescription creams/ointments, 3) Failed to clean up loose medication tablets and debris, and 4) Failed to ensure proper completion of 2 temperature logs for medication refrigerators, resulting in the opened and undated medications, creams/ointments, with the potential for a resident to received medications/treatments with altered/decreased efficacy and potency, drug diversion or ingestion of unlocked medication/treatment carts, cross contamination and inappropriate temperatures. Findings include: Record review of the facility 'Storage of Medications' policy dated ,d+[DATE] revealed that medications and biological's are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized or administer medications. Temperature: all medications are maintained within the temperature ranges noticed in the United Stares Pharmacopeia and by the Centers for Disease Control (CDC). (c.) Refrigerated- 36 degrees Fahrenheit to 46 degrees Fahrenheit. (4.) Medications requiring refrigeration are kept in a refrigerator at temperatures between 36-degree Fahrenheit and 46-degree Fahrenheit with a thermometer to allow temperature monitoring Expiration dating (Beyond-use dating): (5.) When the manufacturer has specified a usable duration after opening the nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacture recommends another date or regulations/guidelines require different dating. Ensure proper labeling of medications and loose medications: Observation on [DATE] at 11:32 AM with Licensed Practical Nurse B of the short hall Coast unit medication cart revealed: Resident # 48 Humalog insulin pen open/used not dated on pen or package. Resident # 30 had Trelegy Ellipta inhaler ,d+[DATE].5 ,d+[DATE]mcg opened/used not dated on the inhaler or on the box. A single white tablet found in bottom of third drawer of the medication cart. Observation on [DATE] at 11:43 AM with Licensed Practical Nurse B of the long hall Coast unit medication cart revealed: Resident # 50 - Fluticasone 50mcg/ACT nasal spray was opened/used with no dates on box or bottle. Loose tablets were found in the medication drawers of large potassium tablet oblong shaped with a small white tablet found in the second drawer of the med cart loose. Observation on [DATE] at 11:44 AM with Licensed Practical Nurse (LPN) Z of the secure dementia unit medication cart was found unlocked by that state surveyor. LPN Z was seated across the room at a laptop computer seated at a table. Observation of the dementia unit revealed there to be self-ambulating residents to ambulate the hallways. Observation of the medication cart second drawer of dementia unit medication cart revealed 3 loose white tablets. Observation of multi-dose medications for residents: Resident # 67 - Treglegy Ellipta inhaler ,d+[DATE].5 ,d+[DATE]mcg opened/used not dated on the inhaler or on the box. Resident # 58 Albuterol sulfate 90mcg/ACT inhaler opened/used not dated on the inhaler or on the box. Properly secure/lock 2 of 2 treatment carts: Observation with Registered Nurse (RN) P on [DATE] at 09:26 AM of the Bay treatment cart was found to be open with prescription medication creams/ointments noted in second drawer of the cart. Observations of the hallway noted Resident #73 and Resident #78 to self-ambulate the hallways. The state surveyor was able to open the drawers of the treatment cart and revealed: Resident # 15 - Clobetasol propionate 0.05% two tubes are open/used and there were no dates open dates on box or tubes. Resident # 80 -Mupirocin 2% ointment tube open and used with no open date on tube or box noted. Resident # 56 - Nystatin 100,000-unit bottle open and used no dates on box or on bottle. Resident # 27 - Gentamicin sulfate cream 0.1% tube is well used with no dates on tube or box. Resident # 141 - discharged on [DATE]- Lidocaine 3% Hydrocortisone 0.5% is used and open with no dates on tube or box noted. Resident # 46 -Betamethasone Valerate 0.1% cream opened and used with no open dates noted on tube or box. 2 tubes noted in cart with no dates. Registered Nurse P stated that the Bay one unit was a short-term rehab unit and had a wound care nurse on Tuesdays and Wednesday, and the wound care staff come around and use the treatment cart and the floor nurse do the dressing between visits. The treatment cart should be locked, and RN P locked the cart. Observation on [DATE] at 07:36 AM of the dementia unit medication cart located in the hallway with the computer screen open to Resident # 44 medication sheet. There was no nurse at the cart but was heard in a resident room. Observation on [DATE] at 07:46 AM with Licensed Practical Nurse (LPN) N of the harbor dementia unit treatment cart was found unlocked in dementia unit with prescription treatment ointments and creams noted: Resident # 25 - Triamcinolone 0.1% cream opened well used and no date on tube or box. Two boxes found undated for the resident. Resident # 58- Mupirocin 2% ointment tube open and box not dated when opened. Resident # 63- Santyl 250 units ointment opened with no dates on tube or box. Record review of the facility 'Medication Administration' policy dated ,d+[DATE] revealed medications are administered in a safe and timely manner, and as prescribed. (19.) During administration of medications, the medication cart is kept closed and locked Failed to ensure proper completion of 2 temperature logs for medication refrigerators: Observation on [DATE] at 07:37 AM with Licensed Practical Nurse (LPN) N of the harbor dementia unit/Coast unit medication room refrigerator temperature log found clipped on the front of the refrigerator was noted to have missing days of monitoring. Record review of the Harbor/Coast unit medication refrigerator log dated [DATE] revealed multiple blank shifts of no temperatures documented. Record review of the Bay medication refrigerator log dated [DATE] revealed multiple shifts of low temperatures not in recommended range for medications. On [DATE] the temperature log noted 28 degrees Fahrenheit and a note that the temperature was turned up. On [DATE] documented temperature of 30 degrees Fahrenheit. [DATE] documented temperature of 32 degrees Fahrenheit. [DATE] documented temperature of 32 degrees Fahrenheit. Review of the [DATE] temperature log revealed 17 multiple shifts of low refrigerator temperatures documented. Record review of the facility 'Temperature Log' instructions: (3.) Refrigerator temperature must be between 36 degrees and 46 degrees Fahrenheit. Observation on [DATE] 09:44 AM with Licensed Practical Nurse (LPN) M of the Bay medication refrigerator revealed there to be Tuberculin B solution, RSV Arexvy 120mcg solution, multiple boxes of flu vaccine, multiple insulin pens on the middle shelf and Shingrix 50mcq and 4 boxes of influenza vaccine noted to the bottom of the fridge. Record review of the temp log clipped to the front of the refrigerator revealed the Temperature of the refrigerator was increased. In an interview on [DATE] at 09:49 AM with Registered Nurse (RN) F revealed that he had increased the medication refrigerators temperature on [DATE], stating it was his writing and that he noticed the refrigerator temp was too cold and turned up the refrigerator temp on that date [DATE] and reported it to the infection control nurse P. In an interview on [DATE] 10:20 AM with the corporate clinical specialist Registered Nurse A related to the Medication refrigerator temperature logs revealed that she had spoken to the pharmacy about the low temp and high temps of the refrigerator, that as long as immunizations are not crystallized the medications are good. State surveyor identified that the facility was not aware of the medication refrigerator lack of temperature monitoring for the Coast/Harbor unit, nor the inconsistent documented temps for Bay I & II units. Record review of the consultant pharmacist summary dated [DATE], located in the pharmacy medication monthly review recommendation binders provided by the facility revealed: Both carts at Coast (unit) reviewed. Cart ,d+[DATE] undated insulin pens/vials. One expired insulin vial. Pink medication residue spilled on cart and dripped onto inhaler section of cart. Two undated inhalers. Undated applesauce. Cart 2 had two undated insulin pens. One expired vial. Two undated inhalers Medication storage room between Coast/Harbor reviewed. Refrigerator temperature log missing three dates.

Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection/documentation/analysis and failed to ensure appropriate hand hygiene and disposal of soiled linens/waste products, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis. and the likelihood for spread of microorganisms and illness to all 84 facility residents. Findings include: Facility line listing documentation since the last annual survey were requested from the facility Administrator and Infection Control (IC) Registered Nurse (RN) P on 10/29/24 at 12:07 PM and 12:10 PM respectively. On 10/29/24 at 12:44 PM, IC RN P provided the line listing documentation for June and July 2024. On 10/29/24 at 2:55 PM, the only requested line listing documentation received was for June and July 2024 and an interview was completed was completed with IC RN P. When queried regarding the status of the line listings, IC RN P revealed they took over (IC) in June (2024) and were unable to locate all the requested line listings. IC RN P revealed the Acting Director of Nursing (DON) and Administrator were assisting them to look but they had also been unable to locate the information. When asked why they did not send August, September, and October 2024 as that was after they took over as the IC nurse, IC RN P revealed they were still working on October but did not provide further explanation. IC RN P was asked to provide what line listing documentation they had for review. A review of facility provided Infection Control line listing documentation from December 2023 to October 2024 revealed the facility did not provide line listing documentation for January, February, May, and September 2024. At 5:20 AM on 10/30/24, an observation of the locked dementia unit of the facility was completed. The treatment cart was observed in the middle of the hallway, between rooms [ROOM NUMBERS]. The cart was unlocked and unattended by staff and there were unfolded and rumpled towels, unfolded briefs, and water cups sitting on top of the cart. Multiple open garbage bags, containing soiled items and linens were sitting on the floor in the hallway between rooms [ROOM NUMBERS]. Licensed Practical Nurse (LPN) KK was observed by the medication cart and an interview was completed. When queried regarding the treatment cart being in the middle of the hallway, LPN KK replied that the Certified Nursing Assistants (CNA) were using the cart. When queried if the rumpled towels on top of the cart were dirty, LPN KK replied, They are now. I will have them get rid of them. When asked if all the items on the top of the cart were contaminated, LPN KK did not provide a response but indicated the CNA should not be using the cart and they would address it. LPN K was then asked what the open garbage bags were on the floor and revealed the CNA leave the bags there on night shift and put their garbage in them when they do their check and changes and then take the bags to the soiled utility all at once. When queried if they were saying the bags were full of soiled incontinence products and linens, LPN KK confirmed. LPN KK was then asked if it was sanitary and good IC to place multiple residents soiled items together on the floor and said it was not. LPN KK revealed the CNA were in rooms but verbalized they would speak to them. At 6:05 AM on 10/30/24, the open garbage bags containing soiled incontinence products and linens remained in the same place on the floor. At this time, CNA MM was observed walking down the hall with soiled (inside out/removed) gloves in their hands. CNA MM walked past the garbage bags and approached the room CNA LL was in. CNA LL was then observed exiting the room they were in after providing care. CNA LL was observed removing their gloves, touching items in the room, and not performing hand hygiene before entering another room to assist a different resident. An interview was conducted with the facility Administrator on 10/30/24 at 6:58 AM. The provided IC line listing documentation was reviewed with the Administrator at this time, and they confirmed Jan January, February, May, and September 2024 were not included. When asked why, the Administrator revealed they were unable to locate documentation maintained by the prior IC nurse. The facility IC monthly summaries since the last annual survey were requested at this time. An interview was completed with IC RN P on 10/30/24 at 11:16 AM. When queried regarding process surveillance and IC audits completed on night shift, IC RN P revealed they frequently work night shift due to staff call ins/staffing needs and they are able to observe what occurs even if they do not complete audits. When queried if they observed any concerns with staff placing garbage bags on the floor in the hall containing multiple residents soiled items, IC RN P stated, I know some do that. When queried regarding the risk of microorganism transmission from an IC point of view, IC RN P verbalized understanding and stated Staff were educated a couple weeks ago related to the bags on the floor. IC RN P verbalized staff would need to be educated again. An interview and review of facility IC data was completed with IC RN P on 10/31/24 at 8:08 AM. When queried regarding process surveillance and IC audits completed on night shift, IC RN P revealed they frequently work night shift due to staff call ins/staffing needs and they are able to observe what occurs even if they do not complete audits. IC RN P then stated, Two nurses called in last night and I worked all day yesterday until midnight. IC RN P was asked when they came back to work and replied, I got here about 7:30 AM. When queried if they observed any concerns with staff placing garbage bags on the floor in the hall containing multiple residents soiled items, IC RN P stated, I know some do that. When queried regarding the risk of microorganism transmission from an IC point of view, IC RN P verbalized understanding and stated Staff were educated a couple weeks ago related to the bags on the floor. IC RN P indicated they would need to educate staff again. When queried regarding observations of staff not performing hand hygiene including not using Alcohol Based Hand Sanitizer, IC RN P replied, I have observed instances where not performing (hand hygiene) during audits. When queried if they noticed a trend in infections and lack of hand hygiene, IC RN P verbalized they had not. When queried regarding the number of Urinary Tract Infections (UTI) at the facility, IC RN P stated, Yeah, we go in spurts. Maybe in august we had a group of women who all had e-coli (bacteria commonly found in the intestines). When asked if they were able to identify a cause/trend for the infection in the group of women, IC RN P revealed they did not. IC RN P was then informed of multiple observations of Resident #81 and Resident #11's indwelling urinary catheter drainage bags being on the floor. When queried, IC RN P revealed both Resident's were recently treated for UTI. When asked if the bags and tubing being on the floor may be contributing to the infection, IC RN P verified it could be. When queried regarding the months that the line listings were not provided for, IC RN P confirmed they were unable to locate the documentation. When asked, IC RN P verbalized understanding of the importance of maintaining the documentation for review. The facility line listings contained sections titled, Covid-19, Influenza, Antibiotics, Antifungals/Antivirals, Carry Over, and Prophylactic with correlating resident infections included under each section. The July 2024 IC Line listing was reviewed with RN P at this time. The line listing document included three Residents who tested positive for Covid-19. The room number of the residents and/or any room changes were not included on the line list form. When queried how they were able to easily see and track potential spread without the room numbers, IC RN P verbalized they could not and would add the room numbers to their line list. When asked what the date on the line list indicated, IC RN P replied, Date they tested positive. When queried if the residents had any signs/symptoms of infection prior to testing positive, IC RN P stated, We had an employee test positive and then tested residents. The line listing revealed five facility staff tested positive for Covid-19. All residents including on the line listing, with the exception of the those who tested positive for Covid-19, were listed as receiving Antimicrobial treatment. When queried how they track residents who may have a potential infection and/or an infection that does not require Antimicrobial treatment, IC RN P stated, We don't have a section for that. With further inquiry, IC RN P revealed they were not tracking and monitoring potential infections. When asked what the date on the line listing signified, IC RN P revealed it was the date which treatment was initiated. When asked why the symptom onset date was not included, IC RN P replied, Because of the charting. With further inquiry, IC RN P revealed the facility staff do not consistently chart and do not consistently chart in the same areas so they are often not aware an Antimicrobial has been started until after it is ordered and treatment had been initiated. When asked how they were able to accurately identify possible transmission and trends if they are not looking at the date when symptoms began, IC RN P verbalized understanding and revealed they had not considered that as they were completing the line listing form as they were instructed to do. A review of the monthly summary for July 2024 revealed the total number of infections did not match the total number of infections included on the line listing. When asked why the numbers did not correlate, IC RN P stated, I was not to include residents on the summary that I couldn't guarantee were a true infection. IC RN P was then asked how they determined which residents to exclude from the monthly IC data reporting summary and stated, So if I didn't have a wound culture or actual C&S (Culture and Sensitivity) and only symptoms I didn't count them. When queried if the residents who were not counted were still receiving Antimicrobial medications, IC RN P confirmed they were. When asked what criteria they utilized for determining if an infection meets criteria, IC RN P replied, McGeer. When queried why the McGeer section on the line list was not completed for all residents listed, an explanation was not provided. When asked if they were tracking infections or antibiotics/Antimicrobial treatments, IC RN P verbalized the IC tracking completed on the line listing is reactive rather than proactive to identify potential infections early and prevent potential spread. Review of facility provided policy/procedure entitled, Surveillance for Infections (Reviewed 4/24) revealed, The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAI) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions 3. Infections that will be included in routine surveillance include those with: a Evidence of transmissibility in a healthcare environment; b. Available processes and procedures that prevent or reduce the spread of infection; c. Clinically significant morbidity or mortality associated with infection (e.g., pneumonia, UTI, C. difficile); and d. Pathogens associated with serious outbreaks . 4. Infections that may be considered in surveillance include those with limited transmissibility in a healthcare environment; and/or limited prevention strategies. 5. Nursing Staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the Charge Nurse as soon as possible . 8. The Charge Nurse will notify the Attending Physician and the Infection Preventionist of suspected infections . Data Collection and Recording: 1. For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: a. Identifying information (i.e., resident's name, age, room number, unit, and Attending Physician); b. Diagnoses; c. admitted , date of onset of infection (may list onset of symptoms, if known, or date of positive diagnostic test); d. Infection site . e. Pathogens; f. Invasive procedures or risk factors; g. Pertinent remarks . h. Treatment measures and precautions . 22927 Dressing changes cross contamination: Observation and interview on 10/30/24 at 09:48 AM with Licensed Practical Nurse (LPN) M and LPN G with Resident #9's lower leg dressing change revealed a barrier was placed on over bed table, all dressing items fell from the plastic bag on to the floor and were picked up and placed back on the barrier. Observation on 10/30/24 at 09:50 AM of Resident #9's urinary catheter site. Observed right lateral foot/leg, LPN G reached into her uniform pocket and took scissors from her pocket and gave to LPN M. Licensed Practical Nurse (LPN) M used the scissors to cut through the old gauze dressing that was bloody with serosanguinous drainage. LPN M stated that the wounds were from poor circulation and that the resident was admitted with the wounds. Observation of open area to lateral leg, lateral ankle, and lateral right heel and toes are black. LPN M applied wound cleaner derma cleanse, sprayed each wound and wiped with gauze, resident winced with pain. LPN M continued with cleaning other wounds. Wound treatment of calcium alginate was placed into the wounds. LPN M stated the dressing was changed yesterday for all wounds. ABD dressings to cover wounds, wrapped with gauze wrap, taped, dated and initialed. In an interview on 10/31/24 at 11:02 AM with the Infection Preventionist (IP) P was asked about cross contamination from scissors during dressing change was explained. IP P stated that the scissors should have been wiped down with alcohol swabs, or we have the sterile suture remover kits with the scissor in the kit, that's what they should have used. Medication Administration: Observation and interview on 10/29/24 at 07:15 AM with Licensed Practical Nurse (LPN) B observation of the coast Medication room medication on fridge temp log was not consistently filled out/documented temp checks. On 10/29/24 at 07:20 AM with LPN B of the supply room between the Coast and Bay units revealed tube feeding supplies. LPN B retrieved an instant ice bag and walked back to Resident #50 room and applied to the residents left knee. LPN B walked back to the cart, and began medication pass with no hand hygiene. Observation 10/29/24 at 07:32 AM with LPN B did not do hand hygiene prior to medication administration after going to med room and supply room and back to the medication cart. Observation on 10/29/24 at 07:35 AM with LPN B of top drawer on Coast medication cart noted two clear plastic medication cups with crushed medications. LPN B stated the medications were for Resident # 21Fluoxetine, second cup with whole tablets of Coreg and clozapine in cups in top drawer there were no identification or resident name on the cups.

Based on interview and record review the facility failed to complete advance directives for seven residents (R19, R24, R29, R30, R36, R39, R50) of seven residents reviewed for advance directives, resulting in missing or incomplete advance directive forms. Findings include: Resident #19 (R19): R19 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include cerebral palsy, dysphagia, anxiety disorder and need for assistance with personal care. R19 has a Brief Interview for Mental Status (BIMS) score of 13, indicating they are cognitively intact. R19 has a guardian due to the inability to make their own medical decisions. On [DATE] at 10:53 AM, record review of the EMR (electronic medical record) for R19 revealed a physician's order for CPR (cardiopulmonary resuscitation), there is an advance directive care plan in place, no signed documents indicating code status were able to be located. Resident #24 (R24): R24 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic respiratory failure, chronic obstructive pulmonary disease, anxiety disorder and hypertension. R24 has a BIMS score of 14, indicating they are cognitively intact. On [DATE] at 01:52 PM, record review of the EMR for R24 revealed a physician's order for CPR, there is an advance directive care plan in place, no signed documents indicating code status were able to be located. Resident #29 (R29): R29 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, major depressive disorder, hypertension and hemiplegia and hemiparesis following a cerebral infarction. On [DATE] record review of the EMR for R29 revealed a physician's order for CPR, a care plan for advanced directive. An advance directive form dated [DATE] was located in the EMR, it contained one signature from a staff member and none of the boxes were checked indicating the code status R29 wished to receive. Resident #30 (R30): R30 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include heart failure, history of pulmonary embolism, dependence on oxygen and obstructive sleep apnea. R30 has a BIMS of 14 indicating they are cognitively intact. On [DATE] at 10:02 AM, record review of the EMR for R30 revealed a physician's order for full code by default (the code status given when an advance directive hasn't been chosen) dated [DATE], there is an advance directive care plan in place, no signed documents indicating code status were able to be located. Resident #36 (R36): R36 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include adult failure to thrive, anxiety disorder, dysphagia and muscle weakness. R36 has a BIMS of 14, indicating they are cognitively intact. On [DATE] at 10:46 AM, record review of the EMR for R36 revealed a physician's order for CPR, and advance directive care plan was in place, no signed documents were located indicating code status. Resident #39 (R39): R39 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include type two diabetes, difficulty in walking, dysphagia and urine retention. R39 has a BIMS score of 9, indicating they have moderate cognitive impairment. R39 is alert and able to answer questions. On [DATE] at 10:26 AM, record review of the EMR for R39 revealed a physician's order for CPR, an advance directive care plan is in place, no signed documents indicating code status could be located. Resident #50 (R50): R50 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include left tibia and left fibula fracture, muscle weakness, anxiety disorder and a history of falling. R50 has a BIMS score of 11, indicating moderate cognitive impairment. On [DATE] at 10:37 AM, record review of the EMR for R50 revealed a physician's order for full code by default, an advance directive care plan was present, unable to locate signed documents indicating the code status chosen. On [DATE] at 02:24 PM, an interview was conducted with SW (social worker) J. SW J indicated they are responsible for discharge planning at the facility. SW J was asked if the facility has a form that is signed by the guardian, responsible party or resident that is uploaded to the EMR to indicate advance directives. SW J stated yes, there is supposed to be a form that is uploaded with the code status decision on it. SW J was asked to locate a form in the EMR and was unable to do so. On [DATE] at 02:30 PM an interview was conducted with SW S. SW S was asked if there is a form that is uploaded into the EMR and signed for code status on admission. SW S indicated that on admission residents fill out a form that is supposed to be completed and uploaded to the EMR to indicate advance directives. SW S was asked how long after admission is a reasonable timeframe to get the code status form completed. SW S stated the process occurs on admission, nursing fills out the advance directive form with the resident, responsible party or guardian. SW S stated they would have to check with nursing to see how long that takes to complete that process. On [DATE] at 10:43 AM: SW S indicated they are still trying to locate the signed advance directive forms for the residents that were requested. Review of the policy titled, Advance Directives/Advance Care Planning reviewed ,d+[DATE], revealed: Policy Interpretation and Implementation 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law. 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 4. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information. 5. Each resident will also be informed that the facility's policies do not condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advance directive. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision.

Based on observation, interview and record review, the facility failed to ensure that reviews and revisions of residents' care plans were made to ensure interventions necessary for care and services were provided for 5 residents (#5, #9, #40, #78, #80), resulting in a lack of showers/bathing, weight loss and/or catheter care, consistently resulting in the potential for unmet care needs. Findings include: Resident #5: Activities of Daily Living: In an interview on 10/28/24 at 10:40 AM with Resident #5 stated that she does have missed her showers. The Resident #5 stated that she requested showers 3 days a week, like she would if she was at home. But the staff will miss her shower day and if she does not remind them and then [NAME] the aides, they will not do it. Record review of Resident #5's Activity of Daily Living (ADL) care plan dated 7/18/2024 noted bathing with 2 assists, prefers to have showers Monday-Wednesday-Fridays. Record review of Resident #5's shower task question #3: Shower, bed bath or tub, 30-day look back revealed that Resident #5 only received seven (7) showers in 30 days. Record review of Resident Kardex care guide used by Certified Nurse Assistants (CNA's) noted: Shower/bed bath Monday, Wednesday, Fridays on 1st shift and PRN (as needed). Urinary Catheter: In an interview on 10/28/24 at 12:20 PM with Resident #5 revealed that her Supra pubic urinary catheter doesn't get changed as it should, and she has to tell staff to change the catheter. Resident #5 stated that the suprapubic catheter is supposed to come up on the computer, but it doesn't. It didn't get changed as it should. Resident #5 stated that the suprapubic catheter care doesn't get done regularly. Record review of Resident #5's Kardex care guide dated 10/28/2024 revealed Certified Nurse Assistant to provide catheter care each shift and as needed, record urine output each shift. Record review of Resident #5's Catheter care/output/kink each shift (3 times daily) checks task form 30 day look back revealed catheter care was given: No documented catheter care or output on: October 6th, 7th, 8th, 10th, 12th, 13th, 15th, 17th, 18th, 19th and 23rd. Catheter care given one time a day: 2nd, 3rd, 11th, 16th, 20th, 21st, 22nd, 24th and 30th. Catheter care two times daily: 1st, 4th, 27th, and 29th. Catheter care given 3 times daily: 9th, 14th, 25th, 26, and 28th. Resident #9: Nutrition: In an interview on 10/28/24 at 10:27 AM with Resident #9 revealed that he had lost weight, and he doesn't know why. Resident #9 stated that he does have a peg tube that they feed him with. Record review of Resident #9's weight log noted a weight on 10/2/24 of 147.2 pounds and on weight on 10/18/24 of 130.1 pounds, that is a 17.1-pound weight loss or 11.62% weight loss. Record review of Resident #9's tube feeding care plan dated 8/15/2024 revealed tube feeding as ordered by registered dietitian. No rate was documented on the care plan. There were no added interventions noted after the 10/18/2024 weight loss. Resident #40: Activities of Daily Living: In an interview on 10/28/24 at 09:46 AM with Resident #40 revealed that the shower chairs do not fit the resident, the facility has a blue reclining shower chair. There is no shower bed, and staff tell (the resident) that the tub is broken, so she gets a bed bath or only half a shower because the shower chair does not fit in the shower. Record review of Resident #40's care plans for activities of daily living (ADL) revealed that the resident required physical assist of two staff members with repositioning, toileting, mechanical transfers, dressing, and bathing/showers. Record review of Resident #40's shower/bathing task form 30-day look back from 10/1/2024 through 10/27/2024 revealed only three (3) showers/bathes were given to a totally dependent upon staff resident. Resident #78: Activities of Daily Living: In an interview on 10/29/24 at 02:25 PM with Resident #78 revealed that he did not know how often he gets a shower/bath stating not very often, and he did not know why. Resident #78 stated that They just give him a washcloth and to wash up in the room. Record review of Resident #78's Activity of Daily Living (ADL) care plan dated 7/8/2024 revealed the resident needed assistance with one staff. Record review of Resident #78's shower/bathing Monday and Thursday task form 30-day look back 9/30/2024 through 10/30/2024 revealed only three (3) showers/bathes given on 10/3/24, 10/7/24 and 10/14/24. Resident #80: Activities of Daily Living: Observation on 10/29/24 at 09:04 AM of Resident #80 Appeared un-shaven and scruffy in appearance and thin. In an attempted interview on 10/29/24 at 02:27 PM with Resident #80 made eye contact and shook his head to surveyor questions. Resident #80 responded with slow speech that they just wash me up in bed, its cold. Record review of Resident #80's Activity of Daily Living (ADL) care plan intervention dated 3/17/2024 revealed Resident #80 required assistance of 2 staff with shower/bathing. Record review of Resident #80's shower/bathing every Tuesday and Sunday on 2nd shift, 30-day look back 9/30/24 through 10/30/24 revealed only 3 showers/bathes: On 9/30/24, 10/10/24 and 10/20/24. Record review of the facility 'Care Plan, Comprehensive Person-Centered' policy dated 3/2023 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. (11.) Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change. (12.) The interdisciplinary team reviews and updates the care plan: (a.) when there has been a significant change in the resident's condition. (b.) When the desired outcome is not met. (c.) When the resident has been readmitted to the facility from a hospital stay; and (d.) at least quarterly, in conjunction with the required quarterly MDS assessment. Record review of facility 'Bath-Shower' policy dated 2/2024 revealed care plan guidelines to list the amount of assistance the resident needs with bathing and any resident preferences, precautions, special soap or lotion to be used, etc.

Based on observation, interview and record review the facility failed to conduct and maintain timely activity assessments for eleven residents (#4, #5, #26, #28, #32, #37, #42, #45,#75,#77, #79) of 11 residents reviewed for assessments and ensure that one resident (#4) was able exercise their right to vote of 1 resident reviewed for voting preferences. Findings Include: During Resident Council meeting held on 10/29/2024 at 11:30 AM, Resident #4 shared she would like to vote in the upcoming Presidential election and does not recall this being addressed with her. On 10/29/2024 at 2:35 PM, Activities Director R was queried regarding the process for residents voting in the upcoming election. Director R explained upon admission each resident is asked about their preference regarding voting. When asked about Resident #4, the Director stated during their voting preference audit in September 2024, she declined to vote and recently informed her that her mother would assist with her voting. Director R was asked if there was any follow up that was completed to ensure this was completed and she stated it was not. There was no documentation related to steps taken to ensure the resident was able to carry out her interest in voting. Activities Director R specified within the assessment where voter preferences were located. Resident #4 assessment was reviewed, and it indicated upon admission her desire to vote. During review of her assessments, it was noticed their only Activity Assessment from was admission in May 2024. Director R was asked regarding this and explained activity assessments are only completed upon admission, with significant change and annually; quarterly assessments are not completed. On 10/29/2024 at approximately 2:55 PM, the administrator was asked what the frequency of activity assessments are. The administrator stated they were quarterly but will provide the policy. On 10/30/2024 at approximately 8:00 AM, a review was completed of Resident #4's medical record and it indicated the resident was admitted to the facility on [DATE] with diagnoses that included, Multiple Sclerosis, Protein Calorie Malnutrition, Depression, Paraplegia and Anxiety. Resident #4 can make her needs known and is her own person. Further review yielded the following: Activity Assessments: Admission assessment in 5/2024 completed- there were no other assessments. The assessment indicated Resident #4 is registered and interested in voting On 10/30/2024 at 3:40 PM, Activities Director R explained she was not aware that quarterly activity assessments were a requirement or she would have been completing them. A subset of residents were reviewed for frequency of Activity Assessments and it showed quarterly assessments were not being completed for facility residents as follows: Resident #5 had no activity assessments completed since admission in 9/2021 that were documented under assessments tab. Resident #26 had one assessment completed on 6/13/2024 with readmitted [DATE]. Resident #28 had on assessment completed on 10/26/2024 with readmitted [DATE]. Resident #32 had one assessment completed in 3/2024. Resident #37 had assessments completed on 9/12/2024, 10/18/2023 and 10/16/2024. Resident #42 had one assessment completed on 6/5/2024. Resident #45 had one assessment completed on 5/29/2024. Resident #75 had one assessment completed on 12/12/2023 with initial admission to the facility. Resident #77 assessment was completed on 1/18/2024 upon admission. Resident #79 assessment was completed on 2/22/2024 upon admission. Review was completed of the facility policy entitled, Voting Rights, reviewed 1/24. The policy stated, Residents are encouraged to exercise their right to vote in local, state and national elections. The facility will help residents expressing a desire to exercise their right to vote achieve that right . Review was completed of the facility policy entitled, Activity Evaluation, reviewed 1/24. The policy stated, .an activity evaluation is conducted and maintained for each resident as least quarterly and with any significant change of condition that could affect his/her participation in planned activities .The activities director is responsible for completing, directing and/or delegating the completion of the activities component .

Based on observation, interview and record review, the facility 1) Failed to ensure quality of care to meet residents' needs for diabetic and behavioral care and 2) Failure of facility staff to retrieve medications from the backup source for 11 Residents (#5, #9, #41, #46, #50, #56 #72, #76, #81, #137, #147), resulting in the lack of identification and assessment of changes in condition and delays in treatment. Findings include: Record review of the facility 'Medication Administration' policy dated 11/2023 revealed medications are administered in a safe and timely manner, and as prescribed. (7.) Medications are administered within one (1) hour of their prescribed time, unless otherwise specified Record review of the facility 'Insulin Administration' policy dated 1/2024 revealed characteristics and types of insulin noted three key characteristics of insulin are: Onset of action- (a.) how quickly the insulin reaches the bloodstream and begins to lower blood glucose. (b.) Peak effects- the time when the insulin is at its maximum effectiveness. (c.) Duration of effects the length of time during which the insulin id effective. Resident #5: Observation on 10/28/2024 at 10:30 AM of Registered Nurse/Infection Preventionist P was observed to draw up insulin and enter Resident #5's room. In an interview on 10/28/24 at 10:40 AM with Resident #5 stated that she just received her morning insulin which was to be given before breakfast just now at 10:30 AM. Resident #5 stated that her medications are late a lot of the time. Record review of Resident #5's October 2024 Medication Administration Record (MAR) for the date of 10/28/2024 revealed: Lispro insulin subcutaneous solution pen-injector 100 units/ml, inject 9 units subcutaneously three times a day related to type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema. Administration times: 8:00 AM, 12:00 PM and 5:00 PM. Record review of Resident #5's October 2024 Medication Administration Record (MAR) for the date of 10/28/2024 revealed: Lantus insulin subcutaneous solution pen-injector 100 units/ml, inject 14 units subcutaneously two times a day related to type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema. Administration times: 8:30 AM and 8:30 PM. Record review of Resident #5's diabetes mellitus type 1 with diabetic neuropathy and polyneuropathy care plan revealed nursing interventions of accu-check and insulin as ordered, staff to administer dated 5/2/2023, may use resident's personal Dexcom blood glucose monitor for blood glucose monitoring dated 2/23/2024 were some of the interventions listed. In an interview on 10/29/24 at 02:59 PM with Registered Nurse/Infection Preventionist P RN/IP was working the Bay unit medication cart on 10/28/24. RN P was asked about Resident #5's Insulin administration was at 10:30 AM but supposed to be given at 8:00 AM. RN/IP P found out that she was working the medication cart at 6:20 AM from a text at home and had to come into work. RN/IP P usually worked at 8 AM. RN/IP P stated that she had just put in 12 days on call, here every day, so in the morning she did not think about checking the text messages. There are a lot of call-ins, RN/IP P was the only unit manager. Licensed Practical Nurse (LPN) M was working the floor only, but when the state people came in LPN M showed up as a manager. RN/IP P stated that she did pass medications late because she did not know the residents and the facility let her know last minute that she was working. RN/IP P would work the night shift to pick-up for staffing call-ins. The Director of Nursing (DON) does work, the corporate consultant is a nurse but does not pick-up floor hours and the Minimum Data Set (MDS) assessment nurse does not work the floor either. All the meds were late, by hours late. In an interview on 10/29/24 at 03:17 PM with the corporate registered dietitian (RD) AA revealed that residents with diagnosis of diabetes should get their insulin consistently, based on when they eat, we give insulin to what the order states. Record review of Resident #5's 'Medication Admin Audit Report' pages 1-72, dated from 10/1/2024 through 10/30/2024 revealed multiple days of late insulin medication administration. Record review of date of 10/28/2024 revealed that Lantus insulin was to be given at 8:30 AM and was administered at 10:30 AM by Registered Nurse P. Record review of Resident #5's 'Medication Admin Audit Report' pages 1-72 revealed multiple days of late insulin administration. Resident #9: In an interview on 10/28/24 at 10:27 AM with Resident #9 in his room revealed that he had lost weight and that he did not know why. Resident #9 stated that he did have a peg tube that that staff used for his formula stuff feed. Resident #9 acknowledged that he was also diabetic and dependent on insulin for blood sugar control. Record review of Resident #9's October 2024 Medication Administration Record (MAR) revealed: Lispro insulin subcutaneous solution per sliding scale subcutaneously every six hours related to type 1 diabetes mellitus. Administration times: 00:00 AM, 06:00 AM, 12:00 PM and 6:00 PM. Record review of Resident #9's weight log revealed weight on 10/2/24 of 147.2 pounds, and on 10/18/24 a weight of 130.1 pounds. That was a 17.1-pound loss in 16 days. Weight loss percentage of 11.62% loss. Record review of Resident #9's diabetes mellitus care plan revealed care plan revision date of 8/29/2024 with latest intervention dated 7/2/2024 of diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness. Record review of Resident #9's 'Medication Admin Audit Report' for the month of October 2024 revealed late insulin documented administration times: 10/2/2024 administer Lispro insulin at 6:00 PM, documented administration time was 10/3/2024 at 00:03 AM. 10/3/2024 administer Lispro insulin at 00:00 AM, documented administration time was 05:34 AM. 10/4/2024 administer Lispro insulin at 00:00 AM, documented administration time was 04:43 AM. 10/4/2024 administer Lispro insulin at 12:00 PM, documented administration time was 3:12 PM. 10/6/2024 administer Lispro insulin at 6:00 PM, documented administration time was 09:02 PM. 10/10/2024 administer Lispro insulin at 6:00 PM, documented administration time was 08:37 PM. 10/13/2024 administer Lispro insulin at 12:00 PM, documented administration time was 2:19 PM . Multiple days with late insulin. Resident #41: Record review of Resident #41's October 2024 Medication Administration Record (MAR) revealed: Lispro insulin subcutaneous solution per sliding scale subcutaneously three times a day related to diabetes. Administration times: 07:30 AM, 11:30 AM and 4:30 PM. Record review of Resident #41's 'Medication Admin Audit Report' for the month of October 2024 revealed late insulin documented administration times: 10/1/2024 administer Lispro insulin at 07:30 AM subcutaneously before meal, documented administration time was 10:45 AM. 10/2/2024 administer Lispro insulin at 07:30 AM subcutaneously before meal, documented administration time was 10:04 AM. 10/2/2024 administer Lispro insulin at 11:30 AM subcutaneously before meal, documented administration time was 1:55 PM. 10/3/2024 administer Lispro insulin at 11:30 AM subcutaneously before meal, documented administration time was 12:34 PM. 10/4/2024 administer Lispro insulin at 11:30 AM subcutaneously before meal, documented administration time was 2:15 PM. 10/5/2024 administer Lispro insulin at 7:30 AM subcutaneously before meal, documented administration time was 8:36 AM. 10/6/2024 administer Lispro insulin at 07:30 AM subcutaneously before meal, documented administration time was 8:32 AM. 10/6/2024 administer Lispro insulin at 11:30 AM subcutaneously before meal, documented administration time was 1:24 PM. 10/7/2024 administer Lispro insulin at 07:30 AM subcutaneously before meal, documented administration time was 9:59 AM. 10/11/2024 administer Lispro insulin at 07:30 AM subcutaneously before meal, documented administration time was 9:52 AM. 10/13/2024 administer Lispro insulin at 11:30 AM subcutaneously before meal, documented administration time was 1:28 PM. 10/14/2024 administer Lispro insulin at 07:30 AM subcutaneously before meal, documented administration time was 10:23 AM . Multiple days with late insulin. Resident #46: Record review of Resident #46's October 2024 Medication Administration Record (MAR) revealed: Humalog insulin subcutaneous solution per sliding scale subcutaneously three times a day related to diabetes. Administration times: 08:00 AM, 12:00 PM and 5:00 PM. Record review of Resident #46's 'Medication Admin Audit Report' for the month of October 2024 revealed late insulin documented administration times: 10/1/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 9:28 AM. 10/1/2024 administer Humalog insulin at 11:30 AM subcutaneously before meal, documented administration time was 1:06 PM. 10/3/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 9:57 AM. 10/3/2024 administer Humalog insulin at 11:30 AM subcutaneously before meal, documented administration time was 12:49 PM. 10/4/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 10:55 AM. 10/4/2024 administer Humalog insulin at 11:30 AM subcutaneously before meal, documented administration time was 2:27 PM. 10/5/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 12:36 PM. 10/5/2024 administer Humalog insulin at 11:30 AM subcutaneously before meal, documented administration time was 12:36 PM. 10/7/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 8:31 AM. 10/13/2024 administer Humalog insulin at 07:00 AM subcutaneously before meal, documented administration time was 11:06 AM. 10/13/2024 administer Humalog insulin at 11:00 AM subcutaneously before meal, documented administration time was 1:45 PM. 10/15/2024 administer Humalog insulin at 07:00 AM subcutaneously before meal, documented administration time was 8:42 AM. 10/17/2024 administer Humalog insulin at 08:00 AM subcutaneously before meal, documented administration time was 4:49 PM. 10/17/2024 administer Humalog insulin at 12:00 PM subcutaneously before meal, documented administration time was 4:49 PM . Multiple days with late insulin. Resident #50: Record review of Resident #50's October 2024 Medication Administration Record (MAR) revealed: Humalog insulin subcutaneous solution per sliding scale subcutaneously three times a day related to diabetes. Administration times: 07:30 AM, 11:30 AM and 4:30 PM. Record review of Resident #50's 'Medication Admin Audit Report' for the month of October 2024 revealed late insulin documented administration times: 10/10/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 10:31 AM. 10/10/2024 administer Humalog insulin at 11:30 AM subcutaneously before meal, documented administration time was 12:42 PM. 10/11/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 11:06 AM. 10/12/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 8:39 AM. 10/13/2024 administer Humalog insulin at 11:30 AM subcutaneously before meal, documented administration time was 2:14 PM. 10/14/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 9:10 AM. 10/14/2024 administer Humalog insulin at 011:30 AM subcutaneously before meal, documented administration time was 1:36 PM. 10/17/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 9:41 AM. 10/20/2024 administer Humalog insulin at 11:30 AM subcutaneously before meal, documented administration time was 1:19 PM. 10/21/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 11:28 AM. 10/22/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 9:05 AM. 10/24/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 9:13 AM . Multiple days with late insulin. Resident #56: Record review of Resident #56's October 2024 Medication Administration Record (MAR) revealed: Lantus insulin subcutaneous solution subcutaneously two times a day related to diabetes. Administration times: 08:00 AM and 8:00 PM. Record review of Resident #56's 'Medication Admin Audit Report' for the month of October 2024 revealed late insulin documented administration times: 10/1/2024 administer Lantus insulin at 08:00 AM subcutaneously before meal, documented administration time was 9:47 AM. 10/2/2024 administer Lantus insulin at 08:00 AM subcutaneously before meal, documented administration on 10/4/2024 time was 9:16 AM. 10/3/2024 administer Lantus insulin at 08:00 PM subcutaneously before meal, documented administration on 10/4/2024 time was 1:17 AM. 10/5/2024 administer Lantus insulin at 08:00 PM subcutaneously before meal, documented administration on 10/6/2024 time was 1:41 AM. 10/6/2024 administer Lantus insulin at 08:00 AM subcutaneously before meal, documented administration time was 11:09 AM. 10/7/2024 administer Lantus insulin at 08:00 AM subcutaneously before meal, documented administration time was 9:17 AM. 10/9/2024 administer Lantus insulin at 08:00 AM subcutaneously before meal, documented administration time was 10:24 AM. 10/10/2024 administer Lantus insulin at 08:00 AM subcutaneously before meal, documented administration time was 9:36 AM. 10/15/2024 administer Lantus insulin at 08:00 PM subcutaneously before meal, documented administration time was 9:1 PM. 10/16/2024 administer Lantus insulin at 08:00 AM subcutaneously before meal, documented administration time was 10:35 AM. 10/17/2024 administer Lantus insulin at 08:00 PM subcutaneously before meal, documented administration on 10/18/2024 time was 1:15 AM. 10/20/2024 administer Lantus insulin at 08:00 AM subcutaneously before meal, documented administration time was 11:18 AM . Multiple days with late insulin. Resident #81: Record review of Resident #81's October 2024 Medication Administration Record (MAR) revealed: Lispro insulin subcutaneous solution subcutaneously three times a day related to diabetes. Administration times: 08:00 AM, 12:00 PM and 6:00 PM. Record review of Resident #81's 'Medication Admin Audit Report' for the month of October 2024 revealed late insulin documented administration times: 10/5/2024 administer Lispro insulin at 07:00 AM subcutaneously before meal, documented administration time was 10:22 AM. 10/6/2024 administer Lispro insulin at 07:00 AM subcutaneously before meal, documented administration time was 8:21 AM. 10/16/2024 administer Lispro insulin at 08:00 AM subcutaneously before meal, documented administration time was 10:19 AM. 10/16/2024 administer Lispro insulin at 12:00 PM subcutaneously before meal, documented administration time was 2:23 PM . Multiple days with late insulin. Record review of Resident #81's October 2024 Medication Administration Record (MAR) revealed: Humalog insulin subcutaneous solution subcutaneously to scale related to diabetes. Administration times: 07:30 AM, 11:30 and 4:30 PM. Record review of Resident #81's 'Medication Admin Audit Report' for the month of October 2024 revealed late insulin documented administration times: 10/7/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 10:13 AM. 10/7/2024 administer Humalog insulin at 11:30 AM subcutaneously before meal, documented administration time was 2:39 PM. 10/9/2024 administer Humalog insulin at 07:30 AM subcutaneously before meal, documented administration time was 9:50 AM. 10/9/2024 administer Humalog insulin at 11:30 AM subcutaneously before meal, documented administration time was 1:41 PM . Multiple days with late insulin. Resident #137: Record review of Resident #137's October 2024 Medication Administration Record (MAR) revealed: Humalog insulin subcutaneous solution subcutaneously to scale related to diabetes. Administration times: 078:30 AM, 12:00 PM, 5:00 PM and 8:00 PM. Record review of Resident #137's 'Medication Admin Audit Report' for the month of October 2024 revealed late insulin documented administration times: 10/18/2024 administer Humalog insulin at 08:00 PM subcutaneously before meal, documented administration on 10/19/2024 time was 1:50 AM. 10/20/2024 administer Humalog insulin at 08:00 AM subcutaneously before meal, documented administration time was 9:52 AM. 10/21/2024 administer Humalog insulin at 08:00 PM subcutaneously before meal, documented administration time was 9:51 PM. 10/27/2024 administer Humalog insulin at 08:00 AM subcutaneously before meal, documented administration time was 9:52 PM. 10/28/2024 administer Humalog insulin at 08:00 AM subcutaneously before meal, documented administration time was 10:04 AM. 10/28/2024 administer Humalog insulin at 12:00 PM subcutaneously before meal, documented administration time was 1:49 PM . Multiple days with late insulin. Record review of facility 'Diabetes-Clinical Protocol' policy dated 4/2024 revealed as part of the initial assessment, the physician will help identify individuals with elevated blood sugar, impaired glucose tolerance, or confirmed diabetes, as well as factors that may influence glucose tolerance. Record review of 'Nursing 2017 Drug Handbook' page 779 Insulin (fixed combinations) noted that to improve glycemic control in patients with diabetes mellitus noted subcutaneous doses within 15 minutes before a meal or 15 minutes after the start of a meal. 37668 Resident #76: Record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses which included left sided hemiplegia and hemiparalysis (one sided paralysis) following cerebral infarct (stroke), heart failure, diabetes mellitus, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required maximum/substantial assistance for rolling/turning, bathing, and hygiene and total assistance for transferring. The MDS further revealed the Resident was at risk for but did not have any pressure ulcers. A review of Resident #76's Medication Admin Audit Report for 10/1/24 to 10/29/24 revealed the Resident's medications were administered late (greater than one hour before or after scheduled administration time) 199 times. Resident #81: Record review revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, dementia, depression, heart disease, and left leg below the knee amputation. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required partial to total assistance to complete all ADL with the exception of eating. An interview was completed with Social Services Director S on 10/29/24 at 4:14 PM. When queried regarding Resident #81's psychotropic medications including dosage changes, Director S revealed the Resident's Seroquel (antipsychotic) medication dosage and administration times were changed due to the Resident's behaviors increasing throughout the day. When queried if the Resident had been receiving the medications as ordered and timely prior to the reevaluation and change, Director S indicated they would assume they were but do not administer medications. A review of Resident #81's Medication Admin Audit Report for 10/1/24 to 10/29/24 revealed the Resident's medications, including psychotropic, cardiac, antibiotics, and insulin, were administered late (greater than one hour before or after scheduled administration time) 188 times. 38471 Resident #72: During initial tour on 10/28/2024, Resident #72 was observed in the common area with consistent movement of standing up, then back down. She was not able to be interviewed due to her disease process. On 10/29/2024 at 4:50 PM, a review was conducted of Resident #72's medical record and indicated the resident admitted to the facility on [DATE] with diagnoses the included. Dementia, Schizoaffective, Major Depressive Disorder and traumatic brain injury. Further review of Resident #72's chart yielded the following: Physician Orders: Trazadone HCI Oral Tablet 50 MG (milligram)- Give one tablet by mouth at bedtime for depression. Lorazepam Oral Tablet 0.5 MG- Give one tablet by mouth three times a day related to Schizoaffective disorder, Bipolar type. Progress Notes: Trazadone (antidepressant medication): 10/25/2024 19:13: Orders - Administration Note trazodone HCl Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for depression waiting on delivery from pharmacy. 10/24/2024 20:12: Orders - Administration Note trazodone HCl Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for depression. Waiting to receive from pharmacy. 10/23/2024 19:32: Orders - Administration Note trazodone HCl Oral Tablet 50 Give 1 tablet by mouth at bedtime for depression. Waiting to receive from pharmacy. 10/20/2024 22:38: Orders - Administration Note Text: trazodone HCl Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for depression. not avail (not available). 10/18/2024 22:19: Orders - Administration Note trazodone HCl Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for depression pharmacy won't fill due to soon. 10/12/2024 18:56: Orders - Administration Note Text: trazodone HCl Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for depression pharmacy wont fill. 10/11/2024 18:42: Orders - Administration Note Text: trazodone HCl Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for depression. Pharmacy states reorder too soon In October 2024 Resident #72 was not administered their trazadone on seven occasions based on nursing progress notes. When compared when the MAR (Medication Administration Record) the medication was not administered eight times during the month due to alleged unavailability. When the medication was available in the backup box. Lorazepam (Anti-Anxiety Medication): 10/22/2024 1829: Orders- Administration Note Text: Lorazepam Oral Tablet 0.5 MG-Give 1 tablet by mouth three times a day. duplicate order not given. 10/10/2024 22:09: Orders - Administration Note Text: Lorazepam Oral Tablet 0.5 waiting for pharmacy to send medication. 10/10/2024 15:07: Orders - Administration Note Text: Lorazepam Oral Tablet 0.5 MG awaiting c2. 10/10/2024 10:11: Orders - Administration Note Text: Lorazepam Oral Tablet 0.5 MG on order awaiting c2. 10/9/2024 22:08: Orders - Administration Note Text: Lorazepam Oral Tablet 0.5 MG. waiting for pharmacy to send medication. 10/9/2024 16:34: Orders - Administration Note Text: Lorazepam Oral Tablet 0.5 MG. Medication hasn't arrived from pharmacy. No access for back up. Sending c2 doctor will administer once medication arrives. 10/9/2024: 10:53: Orders - Administration Note Text: Lorazepam Oral Tablet 0.5 MG. Medication hasn't arrived from pharmacy. No access for back up. Sending c2 to doctor will administer once medication arrives. 10/8/2024 20:06: Orders - Administration Note Text: Lorazepam Oral Tablet 0.5 MG. Med not given. 10/8/2024 08:03: Orders - Administration Note Text: Lorazepam Oral Tablet 0.5 MG. not available, waiting on pharmacy delivery. In October 2024 Resident #72's was not administered their Lorazepam on nine occasions based on nursing progress notes, when the medication was available in the backup box. On 10/30/2024 at approximately 10:30 AM, a review was conducted of the medications available in their back up box. The following was available: 8-0.5 MG Lorazepam 10-50 MG Trazadone

Based on observation, interview and record review, the facility failed provide care and services prevent urinary tract infections for 5 residents (#5, #11, #40, #81, #83), resulting in the potential for recurrent urinary tract infections, and cross contamination with the potential for prolonged illness, antibiotic therapy and/or hospitalization s. Findings include: Record review of facility 'Catheter Care, Urinary' policy dated 5/2024 revealed the purpose of the procedure was to prevent catheter-associated urinary tract infections. Resident #5: In an interview on 10/28/24 at 12:20 PM with Resident #5 revealed that her urinary Suprapubic catheter did not get changed as it should. The resident has to tell staff to change the catheter. Resident #5 stated that the catheter is to be changed monthly and that it is supposed to come up on the computer, but it doesn't get changed. It didn't get changed as it should and that she worries about getting infections. Resident #5 stated that her suprapubic catheter care does not get done regularly. Record review of Resident #5's Kardex care guide dated 10/28/2024 revealed Certified Nurse Assistant to provide catheter care each shift and as needed, record urine output each shift. Record review of Resident #5's Catheter care/output/kink each shift (3 times daily) checks task form 30 day look back revealed catheter care was given: No documented catheter care or output on: October 6th, 7th, 8th, 10th, 12th, 13th, 15th, 17th, 18th, 19th and 23rd. Catheter care given one time a day: 2nd, 3rd, 11th, 16th, 20th, 21st, 22nd, 24th and 30th. Catheter care two times daily: 1st, 4th, 27th, and 29th. Catheter care given 3 times daily: 9th, 14th, 25th, 26, and 28th. Record review of Resident #5's care plans pages 1-46 revealed Resident #5 was at risk for Multidrug Resistant Organism related to suprapubic catheter and wounds. Interventions dated 11/9/2023 included: Educate on hand hygiene, enhanced barrier precautions. Record review of Resident #5's Activity of Daily Living (ADL) care plan revision dated 10/18/2023 revealed that Resident #5 had self-care deficit related to weakness, unsteady gait, pain and diagnosis of multiple sclerosis. Interventions included: two persons assist with bathing, mechanical transfers, dressing, bed mobility and toileting. Record review of Resident #5's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2024 revealed order on 2/29/2024 to replace old catheter with new catheter 24 French every 30 days. Record review of the catheter change order dated 5/29/2024 was blank. Record review of Resident #5's nursing progress notes dated 5/29/2024 revealed there was no note for resident refusal or nurse note of why the catheter was not changed. Record review of Resident #5's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June 2024 revealed order on 2/29/2024 to replace old catheter with new catheter 24 French every 30 days. Record review of the catheter change order dated 6/29/2024 was blank. Record review of Resident #5's nursing progress notes dated 6/29/2024 revealed there was no note for resident refusal or nurse note of why the catheter was not changed. Record review of Resident #5's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2024 revealed order on 2/29/2024 to replace old catheter with new catheter 24 French every 30 days. Record review of the catheter change order dated 7/29/2024 was blank. Record review of Resident #5's nursing progress notes dated 7/29/2024 revealed there was no note for resident refusal or nurse note of why the catheter was not changed. Record review of Resident #5's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2024 revealed order on 2/29/2024 to replace old catheter with new catheter 24 French every 30 days. Record review of the catheter change order dated 8/29/2024 was documented as changed. Record review of Resident #5's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for September 2024 revealed order on 2/29/2024 to replace old catheter with new catheter 24 French every 30 days. Record review of the catheter change order dated 9/12/2024 was changed. Record review of Resident #5's nursing progress notes dated 9/12/2024 revealed there was no note for resident refusal or nurse note of why the catheter was not changed. Record review of Resident #5's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for October 2024 revealed order on 10/10/2024 to replace old catheter with new catheter 24 French every 30 days. Record review of the catheter change order dated 10/10/2024 was blank. Record review of Resident #5's nursing progress notes dated 10/10/2024 revealed there was no note for resident refusal or nurse note of why the catheter was not changed. Record review of Resident #5's catheter care task 30-day lookback dated 10/1/2024 through 10/30/2024 revealed that inconsistent catheter care was provided sporadically. The 30-day lookback revealed that there were days when no catheter care was documented by certified nurse assistants. Observation on 10/31/24 at 11:11 AM with Registered Nurse (RN) T and Certified Nurse Assistant (CNA) C of Resident #5's observed the suprapubic catheter site with no dressing in place to suprapubic catheter site, secure device noted to right thigh. Resident #40: In an interview on 10/28/24 at 09:48 AM with Resident #40 revealed that the facility nurses were not changing the suprapubic urinary catheter as ordered by the physician. Resident #40 stated that she went to the hospital with an infection, and it hurt at the suprapubic catheter opening. Resident #40 stated that she had to ask to go to the hospital. The state surveyor Observed a catheter bag hanging at the bedside. Resident #40 stated that they don't clean it, and they don't change the catheter every month like is supposed to. Resident #40 stated that she went to the hospital and the hospital changed her catheter. Record review of Resident #40's August Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August 2024 revealed to change suprapubic catheter as needed or if unable to flush or becomes dislodged, signs and symptoms of infection. No change was documented. Record review of Resident #40's September Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated September 2024 revealed to change suprapubic catheter as needed or if unable to flush or becomes dislodged, signs and symptoms of infection. No change was documented. Record review of Resident #40's progress note dated 9/10/2024 at 2:15 PM noted suprapubic site is red, swollen and had thick white drainage noted around the site. The drainage had a foul odor . Record review of Resident #40's progress note dated 10/24/2024 at 3:31 PM noted suprapubic site is excoriated/denuded skin . Progress note dated 10/25/2024 at 3:52 AM resident requested to be sent to the emergency room . Record review of Resident #40's progress note dated 10/25/2024 at 10:39 AM resident returned from hospital with antibiotic Bactrim DS twice daily for 10 days for urinary tract infection. Observation on 10/31/24 at 09:52 AM with Certified Nurse Assistant (CNA) C of Resident #40's observation of suprapubic site, noted with urinary catheter opening to be within a skin fold noted a white small ball of material noted to site. Resident #40 stated that they just cleaned it last night. Resident #83: Observation on 10/28/24 at 10:57 AM resident #83 was lying in bed in lowest position with urinary catheter bag and tubing laying on the floor. The state surveyor went back out into the hallway to get Registered Nurse (RN) P. Observation and interview on 10/28/24 at 10:59 AM with Registered Nurse (RN) P came into Resident #83's room. RN P stated that Resident #83 has had frequent falls, and we moved her to this hall for carpet floor and high visual hallway. Observation on Resident #83's catheter bag on the floor and the tubing laying on the floor. Observation on 10/31/24 at 08:31 AM of Resident #83 was Observed lying in bed in low position with urinary catheter bag on the floor. Catheter bag has one sided blue leaf cover that is not under the catheter bag while on the floor. Record review of Resident #83's electronic medical record progress notes documented admitted [DATE] and on 9/10/24 family requested Resident #83 be sent back to the hospital. Record review of Resident #83's electronic medical record revealed on 9/13/2024 Resident #83 hospital discharge summary revealed resident was sent to hospital form nursing home due to urinary tract infection. Discharge diagnosis complicated urinary tract infection. 37668 Resident #11: On 10/28/24 at 11:45 AM, Resident #11 was observed sitting in a wheelchair in their room. An indwelling urinary catheter drainage bag was in place under the wheelchair. The urinary drainage bag and tubing were both directly touching the floor. When queried regarding their urinary catheter, Resident #11 stated, I've had a lot of UTI's and yeast infections since being at the facility. Resident #11 continued, They don't want to give me anything for the yeast infections. When queried how often staff provide catheter care, Resident #11 revealed they do not receive timely care because the facility is short staffed and the staff don't care. Record review revealed Resident #11 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included left leg fracture, diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), depression, urinary retention, and Urinary Tract Infections (UTI's). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required substantial to total assistance to complete all Activities of Daily Living (ADL) with the exception of eating. The MDS further detailed the Resident had an indwelling urinary catheter. On 10/30/24 at 5:17 AM, Resident #11 was observed in bed. The Resident was positioned on their back and their eyes were closed. The indwelling urinary catheter drainage bag was laying directly on the floor. The drainage bag was not hooked to the bed. At 8:20 AM on 10/30/24, Resident #11 was observed laying on their back in bed. The indwelling urinary catheter drainage bag remained in the same position, directly on the floor, and not hooked to the bed. Review of Resident #11's Electronic Medical Record (EMR) revealed a care plan entitled, have altered urinary status indwelling catheter (Initiated: 5/7/24; Revised: 8/23/24). The care plan included the intervention - Catheter care every shift and PRN (as needed) (Initiated: 8/23/24) - Ensure tubing is secured (Initiated: 8/23/24) Resident #81: On 10/29/24 at 10:03 AM, Resident #81 was observed lying in bed with their eyes closed. The Resident's indwelling urinary catheter drainage bag was laying directly on the floor next to the bed. Resident #81's family members, Witness II and Witness JJ were present in the room. When queried regarding the catheter drainage bag being positioned directly on the floor, both Witness II and Witness JJ verbalized the indwelling urinary catheter drainage bag is always directly on the floor when they visit. When queried how often they visit, Witness II and Witness JJ revealed they visit six days a week. Record review revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, dementia, depression, heart disease, Benign Prostatic Hyperplasia (BPH- enlarged prostate) urinary retention, and left leg below the knee amputation. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required partial to total assistance to complete all ADL's with the exception of eating. The MDS further revealed the Resident had an indwelling urinary catheter. On 10/30/24 at 5:10 AM and 10:16 AM, Resident #81 was observed laying in bed with their eyes closed. Their indwelling urinary catheter drainage bag was directly on the floor and not hooked on the bed. On 10/31/24 at 11:09 AM, Resident #81 was observed lying in bed on their back. Their Resident's indwelling urinary catheter drainage bag was directly on the floor and not hooked on the bed. On 10/31/24 at 11:45, Resident #81 remained in the same position in bed on their back with their indwelling urinary catheter drainage bag positioned directly on the floor and not hooked to the bed. At 11:49 AM on 10/31/24, Unit Manager Registered Nurse (RN) CC was asked to go into Resident #81's room. When queried regarding the Resident's indwelling urinary catheter drainage bag, RN CC verbalized the drainage bag should not be laying on the floor.

This Citation pertains to Intake Number MI00131408 Based on interview and record review the facility failed to order a critical lab on 08/27/22 and administered three doses of Coumadin (medication used to treat blood clots) without laboratory results reviewed by a physician for one resident (Resident #125), resulting in Resident #125 stat PT (prothrombin time)/ INR (international normalized ratio) not being ordered on 08/27/22 as directed by the facility provider, being administered three doses of Coumadin without laboratory results and review, an INR of greater than 9.95, PT greater than 99 with blood noted in the resident's stool and subsequent evaluation at the emergency room with a Vitamin K infusion. Findings Include: Resident #125: On 11/15/22 at approximately 10:15 AM, review was completed of Resident #125's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Paroxysmal Atrial Fibrillation, Rheumatoid Arthritis, Major Depressive Disorder and Anxiety Disorder. Resident #125 required assistance with her ADL's and was assessed of having a mild cognitive impairment. Further review of her chart yielded the following: Hospital Discharge Records: Discharge Diagnosis: Paroxysmal atrial fibrillation/AFIB on Coumadin: rate controlled; INR therapeutic . Discharge Medications: .Warfarin 3 MG (milligrams) tablet; Take 1 tab (tablet) by mouth in the evening . Physician orders: - Warfarin Sodium Tablet 3 MG give 1 tablet by mouth one time a day for anticoagulation. Ordered on 8/5/2022 Care Plan: Focus: (Resident #125) is on Anticoagulant therapy r/t: Atrial fibrillation . Initiated on 8/30/22 about three weeks after her admitted . Hospice Progress Notes: 8/30/22: .Pt (patient) had critical INR level and was having active GI (gastrointestinal) bleeding, facility NP (Nurse Practitioner) and Pt's daughter wanted her sent to the hospital for treatment . 8/31/22: .Was recently rehospitalized to treat critical INR levels and bleeding d/t (due to) Coumadin therapy, which has been discontinued . On 11/15/22 at 9:30 AM, an interview was conducted with Nurse AA regarding Resident #125's Coumadin administration and PT/ INR laboratory results. Nurse AA reported she worked night shift on Saturday (8/27/22) and was never informed in report by Nurse CC that a stat lab had been ordered for the resident. Nurse AA further reported she was not aware Resident #125's Coumadin was on hold for 2 days prior. Nurse AA continued prior to administering the residents Coumadin she searched for the PT/INR results on both medications carts, medical records and other places but was not able to locate it. She reported at that time there was not a specific form dedicated to residents who were prescribed Coumadin for a quick reference for staff and added all facility staff did not have access to the lab portal to view laboratory results. Nurse AA reported she does take responsibility for administering Resident #125's Coumadin without having the PT/INR results and contacting the provider. After this incident the facility began to implement procedures and processes for residents prescribed Coumadin. Nurse AA reported while she takes responsibility for her actions no other staff members were reprimanded for the systemic failures. She continued she was informed by management that she would take blame for the totality of the incident when there were multiple failures. Nurse AA reported the nurse that initially took the order from the physician or Nurse Practitioner did not input the order, this pertinent information was not passed off in report and there was no streamlined process. On 11/15/22 at approximately 2:05 PM, Nurse CC was interviewed regarding the process for ordering labs. The nurse reported they receive the initial order from the provider, and they usually input it into their electronic medical records. Once the order is in the system a facility nurse must confirm the order in the record and then put the order into the laboratory system Nurse CC reported if it's a stat lab the process is the same, she clarified if the order is not put in the lab portal it will not be drawn, as their electronic medical record and lab system are not integrated. Nurse CC reported Monday and Thursdays are standing lab order days for PT/INR's and the orders would be added at admission or when they medication was began. Nurse CC was asked if residents on Coumadin and their PT/INR results were discussed during shift report, and she reported it is. Nurse CC was queried if she recalled caring for Resident #125 on 8/27/22. Nurse CC stated there were two nurses working on the Bay until 2 PM. At 2 PM she took report from Nurse DD as she was providing care for Resident #125 until she left at 2 PM. Nurse CC expressed she cannot recall if she was aware of the stat lab that was ordered or if this information was passed off in report to her. Nurse CC stated she does not believe she reported on anything regarding Resident #125's Coumadin and PT/INR when she gave report to Nurse AA. Nurse CC continued the stat lab would have been completed on night shift prior to their arrival. On 11/16/22 at 11:00 AM, an interview was conducted with Nurse DD regarding Resident #125's labs. Nurse DD was not able to recall the resident or anything to do with the incident. Nurse DD reported typically in report they would discuss pending PT/INR lab and all residents that are prescribed Coumadin. Further review was completed of Resident #125's medical records and the following was found: Provider Progress Notes: 8/26/22 at 00:00: Patient is [AGE] year-old female with a past medical history of Paroxysmal A. Fib on Coumadin . Patient was seen today to follow-up on fall and PT/INR results regarding anticoagulant management. INR returned therapeutic at 4.32. New orders given . Patient has no evidence of bleeding. Patient denies bloody nose or blood in the stool. No reports of hematuria or hematochezia. No overt bruising is noted . Long term (current) use of anticoagulants: INR 4.32. HOLD Coumadin x 2 days. No active signs of bleeding. Recheck INR on Saturday, 8/27/2022 INR goal range 2-3 . 8/30/22 at 00:00: Patient is [AGE] year-old female with a past medical history of Paroxysmal A. Fib on Coumadin . Patient was seen today to follow-up on PT/INR results regarding anticoagulant management. INR results reviewed this morning, noted with supra-therapeutic at greater than 9.95. Nursing reports blood in stool, started this morning, no other active bleeding .New orders given for patient to be sent out to the emergency room for further evaluation and treatment for elevated INR . Nursing Progress Notes: 8/30/22 at 10:11: Coumadin placed on hold for elevated INR . 8/30/22 at 16:41: Resident returned from ER (emergency room ) via stretcher. Assisted to bed by RN (Registered Nurse). MAR (Medication Administration Record): - Resident #125's Coumadin was held on 8/25/22 and 8/26/22. It was administered on 8/27/22, 8/28/22 and 8/29/22. Laboratory Orders: 8/25/22: - The INR: 4.32 and a note at the bottom of the lab that stated, Hold Coumadin x 2 day & (today and Friday) recheck on Sat 8/27/22). It was signed by Nurse Practitioner BB on 8/26/22. 8/29/22: - The INR was greater than 9.95 and PT was greater than 99.10. The laboratory result indicated therapeutic range for PT is 9.6-12.2 and INR is 2.50-3.50. It can note noted there are no progress notes from facility nurses on 8/26/22 indicating Resident #125's Coumadin was placed on hold and stat PT/INR was ordered by Nurse Practitioner BB. Additionally, Resident #125's stat INR lab was never ordered by facility staff and her Coumadin was restarted on 8/27/22 with the scheduled lab being drawn on 8/29/22. Resident #125 was administered three doses of Coumadin without lab results and review by facility providers. On 11/17/22 at 1:55 PM, an interview was conducted with Nurse Manager C regarding access to the laboratory portal for facility staff. Manager C reported she does have admin access for the laboratory portal to provide access to facility nurses. Manager C expressed all licensed nurses have access and they did have a universal log in for agency staff but was unsure if it is active currently. Manager C explained agency staff would rely on facility nurses if they needed to search the laboratory site. It was explained to Manager C that during interviews it was reported all staff do not have access to the laboratory website. She was queried if after the incident with Resident #125 if an audit was completed to ensure all facility staff log in credentials are active and if they have the link for the laboratory website. Manager C reported there was no audit completed for current access nor did they check if facility staff had the website for the lab portal. On 11/17/22 at approximately 2:30 PM, a review was completed of the Human Resource files of Nurse AA and Nurse X. Nurse X: Was hired on 10/21/2019 and ended her employment with the facility on 10/1/2022. Nurse X had two disciplinary actions in 2022. -One on One Educational Opportunity on 8/4/22: Completing assessments before leaving shift. Reporting change in condition to on call manager . -Corrective Action on 8/11/22: Dressing change orders were not completed .Dressing monitoring orders were not completed .charge nurse falsified documentation . Charge Nurse Skills Checklist: -The checklist indicated Nurse X was competent in nurse-to-nurse shift report, Coumadin procedures, lab draw procedures, how to contact the lab and how to contact physician with lab results. This competency was completed on 6/15/22. Nurse AA: Corrective Actions: - Dressing change orders were not completed .Dressing monitoring orders were not completed .charge nurse falsified documentation . This was presented to Nurse AA on 8/31/22. -8/31/22: Resident was given Coumadin on 8/27/22, 8/28/22 and 8/29/22 without knowing most recent INR. 8-25-22 INR was 4.32. Anyone getting Coumadin has scheduled INR checks. It is expected that a nurse know the most recent INR level before administering Coumadin .When you administer a medication without knowing required results, the resident could be given medication that is not needed. This incident, the resident received 3 doses of Coumadin and the most recent INR result was 4.32. Continuing to administer Coumadin when the INR is elevated can lead to internal bleeding and increased risk of bleeding and decreased clotting ability . Charge Nurse Skills Checklist: -The checklist indicated Nurse AA was competent in Coumadin procedures, lab draw procedures, how to contact the lab and how to contact physician with lab results. This competency was completed on 5/27/22. The facility was asked to provide their policies and procedures on PT/INR Monitoring, Stat/Routine Labs and Anticoagulant. The polices provided were newly formed polices with the date of 11/28/22 when the incident with Resident #125 was discovered on 8/30/22. It is unknown what procedures Nurse's AA and Nurse X were deemed competent when their Charge Nurse Checklist was completed. Additionally, these policies were implemented upon request from this writer not during investigation and training related to the deficiency. Review was completed of the FRI (Facility Reported Incident) investigation, and it yielded the following results: Investigation Summary: .On 8/30/22 during morning rounds it was noted that (Resident #125) had an INR of greater than 9.95 and a PT of greater than 99 with some noted blood in her stool .(Nurse Practitioner BB) ordered for resident to be transferred to the ER for a Vitamin K infusion .It was noted that on 8/25 (Resident #125) had an INR of 4.32. The Coumadin was ordered to held for two days and an INR was to be obtained on 8/27/22. The lab was not drawn, and the Coumadin was restarted on 8/27/22. The next scheduled INR was to be obtained on 8/29/22 with the results being an INR greater than 9.5 and a PT greater than 99 . Incident and Accident Report: Lab results for PT/INR not relayed to facility staff and Coumadin given to resident without lab results reviewed by PCP .Resident sent to ER, daughter updated. Witness Statements: Nurse AA Interviewed (Nurse AA) regarding the INR not being rechecked and giving Coumadin. (Nurse AA) stated she didn't know that I needed to be rechecked and she stated that she did understand what the Coumadin number was and that she normally wouldn't have to give Coumadin .She stated normally there is a box that it should be entered into. When asked about there being a box she said no and she didn't look back at the prior number. Medication error was explained to (Nurse AA) and verbal education given regarding the risk of administering Coumadin without knowing the INR and verifying the order. (Nurse AA) also stated she did not see the lab come in on 8/29 and did not know that a lab was supposed to be redone that day. Nurse X Interviewed (Nurse X) and she stated (Nurse Practitioner BB) put the Coumadin on hold on 8/25 but did not enter for a new lab to be done. Did not remember if there was an order. It can be noted there were only two witness statements for the FRI investigation. The statements were not signed nor dated by Nurses X and AA. Furthermore, the statements were not in depth to understand the system error. Nurse AA statement revolved on educating and questioning if she knew the policies and procedures. Nurse X was not reprimanded for not inputting the stat order as directed by Nurse Practitioner BB nor was she questioned as to why she did not order it, put in a subsequent progress note and provide the information in shift report. The statements did not provide much insight into what occurred. Furthermore, there were many more nurse that could have been interviewed to gain insight into the deficiencies and Nurse Practitioner BB was not interviewed to gather who she provided the order to and the conversation that ensued. A timeline was not present it he investigation that indicated where the drop in communication was nor was there a root cause analysis to overhaul the systemic failure. On 11/21/22 at approximately 11:00 AM, an interview was conducted with Nurse Practitioner (NP) BB regarding Resident #125. Practitioner BB reported Resident #125's PT/INR came back elevated, and she placed her Coumadin on hold for two days (8/25/22 and 8/26/22) with a stat lab ordered of 8/27/22. Practitioner BB reported the nurse should have waited to administer her Coumadin until the lab resulted or contacted on call for further instruction. Practitioner BB reported she communicates any new orders with the nurse for that unit but on this day she does not recall who she informed. Practitioner BB reported many times she will input her own orders in the electronic medical records and other times will verbally tell the nurse. She further explained that nurse will them have to input the order in the lab portal to ensure it is completed. Practitioner BB reported on 8/30/22 Resident #125 was sent to the emergency room for evaluation as her PT/INR was above 9 and blood in her stool. Practitioner BB continued their lab is not consistent and while the Vitamin K treatment could have been administered at the facility, she was not confidant they would respond timely. Practitioner BB expressed there are concerns with the communication between the nurses and ensuring lab orders are acutely inputted. On 11/21/22 at 1:47 PM, phone call was placed to Nurse EE, there was no answer and voicemail was left requesting return phone call. Nurse EE was the 3rd shift nurse on 8/26/22 into 8/27/22 that should have been provided with report regarding the stat lab and ensured her lab was completed. On 11/21/22 at 1:53 PM, phone call was placed to Nurse X, there was no answer and voicemail was left requesting return phone call. Nurse X was the nurse that took the verbal order from Nurse Practitioner BB for the stat PT/INR lab to be drawn on 8/27/22 for Resident #125. On 11/21/22 at 2:42 PM, an interview was conducted with the DON (Director of Nursing) regarding the procedure to order labs. It was explained the laboratory comes between 4 AM-6 AM, Monday- Friday and its always the same person and in his absence the company does not send anyone else. If a lab is ordered, it has to be entered into the electronic medical record and the lab portal. The DON reported agency staff do not have access to the lab portal. The DON stated once their providers give an order for a lab, it is inputted into the medical record and the nurse then must confirm the order. The provider will either input the lab themselves into the medical record or give a verbal order to a facility nurse. Either way, the lab still must be confirmed in the system and then put into the lab portal. The DON was queried if during their investigation if they ascertained why the stat lab was never ordered. The DON reported the nurse that was provided with the order did not input the order into the lab portal or the resident's medical record. At the time this occurred the nurse (Nurse X) was not disciplined, and the DON was uncertain why she was not disciplined as she did not follow the process. This writer and the DON reviewed the staff assignment sheet from 8/26/22 and 8/27/22 and found that on 8/26/22 Nurse DD worked from 6 PM-12 AM and then returned from 6 AM -2 PM. Nurse EE (worked night shift on 8/26/22 into 8/27/22) and would have given report to Nurse DD and Nurse CC upon their morning arrival. The DON was queried if they were interviewed regarding the incident and DON reported she thought she did. The DON was not able to locate any witness statements from Nurse's CC', DD and EE, to find if they were aware of the stat lab order for Resident #125 and where the breakdown occurred. It was further discussed with the DON the concerns regarding the missing interviews, review of the process of inputting labs once provided, administering Coumadin without laboratory results and contacting the providers, integrating their providers to ensure a streamlined process going forward, reviewing laboratory access for the facility staff, holding all culpable staff responsible and completing a root cause analysis to effect systemic change. The DON expressed understanding of the concern and stated they had nothing else to add to the file. On 11/17/22 at 11:30 AM, an interview was held with Staff Development Nurse G regarding education provided after Resident #125 stat PT/INR was not ordered as directed and Coumadin given for 3 days without the most recent PT/INR results. Staff Development Nurse G stated they began training with staff in early September on the new process. Nurse G was queried if they included the process to order labs and ensuring staff had active lab portal account. Nurse G stated this was not included in their training. She was further queried if discussion was held with their Nurse Practitioner and Medical Director regarding the lab process and better ways to streamline it and if the report process was addressed. Nurse G reported their IDT (interdisciplinary team) determined communication was a concern amongst their staff and developed a new 24-hour report system for staff (this was not included in the FRI investigation) and the Nurse Practitioner and Medical Director were not integrated on the laboratory process as that was not apart of their education to facility staff. Nurse G reported the nurses input the order for PT/INR's outside of their standing PT/INR lab days. She reported whomever the provider verbally gave the order to is who should have it into the lab portal and the medical record. On 11/30/22 at 4:00 PM, a review was completed of the facility policy entitled, Provision of Quality of Care, dated 10/19/22. The policy stated, Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents choice .1. Each resident will be provided care and services to attain and maintain his/her highest practicable physical, mental and psychosocial well-being. 2. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan .

This Citation pertains to Intake Numbers MI 918 and MI 949 Based upon observation, interview and record review the facility is placed in Immediate Jeopardy for its failure to ensure appropriate interventions, assessment and monitoring were in place to prevent a resident-to-resident assault, resulting in Resident #502 strangling Resident #501. On 2/3/22, at approximately 7:00 PM, Resident #502 walked into Resident #501's room, unprovoked, grabbed his shirt with one hand and strangled Resident #501 with his other hand. Resident #502 proceeded to drag Resident #501 into the hallway where he continued to strangle him. Nurse A separated the residents and Resident #502 punched Nurse A with a closed fist in the face and neck. Resident #502 was continually being physically aggressive with facility staff as they attempted to deescalate the situation. As Nurse B was walking down the hallway (unaware of the situation at hand) Resident #502 abruptly grasped Nurse B by her top and neck, as he pinned her against the wall. Resident #502 was yelling obscenities and threatening to kill facility staff. Resident #502 was delusional as he believed Resident #501 had set him on fire. Local law enforcement arrived at the facility and detained Resident #502, and he was transported to the emergency room for a Mental Health Evaluation and admitted to the hospital with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] These deficient practices placed all facility residents, facility staff, agency staff, contracted employees and visitors at substantial risk of being physically assaulted. Immediate Jeopardy: Immediate Jeopardy began on 2/3/2022 at approximately 7:00 PM. Immediate Jeopardy was identified on 03/10/22 The Administrator was notified of the Immediate Jeopardy on 3/14/2022 at 12:49 PM and instructed to provide a plan of correction to remove the immediacy. Immediate Jeopardy was abated or removed on 03/14/22. Findings include: Resident #501: On 2/8/22 at approximately 1:15 PM, a review was completed of Resident #501's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review was completed of Resident #501's chart and the following were reviewed: Incident and Accident Report: 2/3/22 at 19:00: Observed the resident (#502) from the next room grabbing (Resident #501) by the shirt collar and pulling him to the hallway from (Resident #501's room). He came in my room and trying to choke me, I was trying to escape from him, and I was screaming. Progress Notes: 2/3/22 at 20:17: Resident was sitting by the nurses station in the chair with his Pajamas and shoes. Head to toe assessment completed, Skin is clear only two red marks on both side of the neck. No pain reported. Resident stated his heart beat is fast . 2/4/2022 at 14:58: Resident back with his sister from LOA. Skin assessed, No more redness around his neck and no bruises. Resident denied pain. We continue with current plan of care. emergency room Records: Resident #501 presented to the emergency roiagnom on [DATE] after he was assaulted by Resident #502. The records stated: .This is a [AGE] year old-male presents for evaluation post assault .apparently another resident walked into his room and attempted to grab him by the neck. He was able to call for help. He did sustain some scratches to his neck .Small superficial abrasions noted to the right lateral neck . Within the hospital records was a copy of the Paramedic report that stated, .Arrived to find pt alert and orientated sitting in chair. Staff stated another resident came into his room while he was trying to sleep and attacked him .Pt had superficial scratches by his bilateral collar bones . On 3/8/22 at 11:00 AM, a review was completed the Police Report related to the incident that occurred on 2/3/22. The reported stated the following: Narrative from Officer K: .I (Officer K) arrived on scene and observed (Resident #502) laying on the floor. Due to him assaulting (Resident #501) and staff, I placed (Resident #502) in handcuffs for safety. I then took (Resident #502) to a chair where he could be comfortable. I attempted to speak to him regarding the incident but due to his mental state, he was unable to provide me with a statement. I then spoke with staff who told me that (Resident #502) walked into (Resident #501)'s room and began choking him. Staff attempted to pull (Resident #502) away but then he hit staff. From there, (Resident #502) went into the hallway and laid on the floor until I arrived. I was unable to gather a stated from (Resident #501). (Paramedics) arrived on scene and transported (Resident #502) . On 2/9/22 at 1:10 PM, an interview was conducted with Resident #501's Family Member R regarding the assault. Family Member R reported they were informed Resident #501 had been choked by another facility resident. Family Member R reported she arrived at the facility relatively quickly and Resident #501 was with the DON (Director of Nursing). Family Member R reported Resident #501 informed her he was getting ready for bed and his door was partially closed. Resident #502 entered his room, grabbed him by the throat and was chocking him. Resident #501 was able to scream help! twice and facility staff responded. Family Member R offered that Resident #501 had long, finger like marks on both sides of his neck. She reported he was very upset and stayed at her house that evening after being evaluated at the emergency room . Resident #502: On 2/8/22 at approximately 1:00 PM, a review was completed of Resident #502's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #502 was assessed as being severely cognitively impaired but was still rendered as capable to make his own decisions by a facility physician on 12/13/21. The resident was one person assist for the majority of his Activities of Daily Living (ADL's). Further review was completed of his medical record and the following was found: Behavioral Charting: The facility provided a summary of behavioral charting from the last week of December 2021 until Resident #502 was discharged from the facility (on 2/3/22). According to the document provided by the facility Resident #502 did not have any behaviors exhibited. Progress Notes: 12/23/21 at 22:18: Resident has been combative with care and confused .punching at staff when they assisted him. 1/11/22 at 06:02: Resident was found sitting in front of his chair. Resident is restless, crying and saying that he is going to die. Mentions things about the military and previous staff sergeant . 1/11/22 at 09:34: .Spoke with (Medical Group) PA (Physician Assistant) to assess resident about last fall .reported to PA that resident was crying and talking about memory in the military, PA stated no med change at this time until resident go this cardiology appointment. 1/17/22 at 01:56: Resident in his room confused looking for the garage. Pt upset wanting to call his wife does not know how to use the phone . 1/23/22 at 18:56: Resident have increase confusion on this shift . 1/26/22 at 19:24: Resident was fighting staff stating that we killed his family and now he's going to kill us. Staff attempted to redirect resident he became more agitated . 1/29/22 at 02:17: 0200 residents room Specific behavior: pt yelling in confusion What triggered the behavior?: pt yelling send more troops trying to self ambulate in room . 1/29/22 at 05:05: Time and location of behavior: 0500 hallway Specific behavior: resident punching and kicking at staff members What triggered the behavior?: resident saying a man is having an affair with his wife What interventions were attempted?: redirection on call provider informed Outcome of the interventions (behavior stopped, worsened, or unchanged): behavior slightly improved. 1/31/22 at 00:34: .Resident stated he was looking for an airplane accident .Resident responds to ever noise he hears in the hallway . 1/31/22 at 01:55: Resident agitated this shift, he was worried about an airplane crash and started to yell at staff about it. He stated this nurse molested a little girl and he was going to kill this nurse for that. Resident has been verbally aggressive towards staff, no physical actions to this point . 1/31/22 at 21:35: Called out to the hallway from another resident room by CNAs requesting help. Resident was up walking around in the hallway very upset and agitated. Asked the resident if I could help him, he leaned onto the med cart, grabbed a pen, spun around and attempted to stab this nurse with the pen. He stated several times he wanted this nurse to die and how he wanted this nurse to die. CNAs walking with resident and he sat in the bay dinning room. He was yelling and threatening this nurse more . 2/1/22 at 05:52: Medical Staff Progress Note: .He continues to have behaviors and combativeness. He remains confused .Combative behaviors- ER visit on 1/25 and 911 call on 1/31/22 . 2/3/22 at 04:20: Resident upset and talking to his wife on the phone at this time. CNA has been in room with him due him yelling out, standing up and walking to the door . 2/3/22 at 06:06: Resident has remained agitated calling out for his wife and yelling for her staff very hard to redirect. It can be noted Resident #502 was not being followed by psychiatric services, there were no interventions, behavior tracking/monitoring, social services assessment, care plan, petition for inpatient psychiatric hospitalization or [CONDITION(S)] medications to treat and/decrease his psychiatric signs and symptoms. The facility failed to provide meaningful interventions after multiple severe and disruptive mental health episodes as evidenced above. Review was completed of the facility's FRI (Facility Reported Incident) Investigation for the strangulation of Resident #501 and physical assault of multiple facility staff: Incident Summary: .On 2/3/22 staff observed (Resident #502) and (Resident #501) both walking out of Resident #501's room. (Resident #502) had a hold of (Resident #501) initially by the shirt collar and then pulled him by his neck. (Nurse A), was able to get (Resident #501) free from (Resident #502) and staff assisted (Resident #501) to the nurses' station. (Resident #502) remained extremely agitated and punched (Nurse A) in the face and then fell down to his knees. (Resident #502) then got himself off of the floor. He proceeded to go after other staff while the staff closed doors to other residents room, hitting another nurse, in which he lost his footing and again fell to his knees .(Resident #501) had some redness to his neck and reported that his heart was racing .(Resident #502) sat with the police until paramedics arrived. (Resident #502) remained agitated and reported that he had went into (Resident #501's) room because he believed that (Resident #501) had set him on fire .(Resident #502) was transferred to (emergency room ) where he was admitted with [CONDITION(S)] and [CONDITION(S)] and remains there .This incident was isolated and not anticipated . Witness Statements: DON: On 2/3/22 reported from the Administrator that resident ((Resident #502) has an incident resident to resident and he also assaulted multiple staff. The writer went to the facility and observed the (Resident #502) hand cuff on his hand and was in the stretcher with (Paramedics) and three policemen. The other resident was sitting in quiet area by the nurse's station with another staff member. (Resident #502) was escorted to the hospital, the other resident (Resident #501) was assessed by this writer .red marks on both side of his neck were red . CNA F: I was in a patient room I heard screaming, so I walked out the room and see (Resident #502) choking (Resident #501) I screamed (Nurse A) name. (Nurse A) went to break it up. (Resident #502) proceed to hit (Nurse A) and let (Resident #501) go then (Resident #502) fell on the ground for about two minutes. (Resident #502) got up and a nurse walked past he attached the nurse, the secretary to break it up he proceeded to hit and grab her and fell to the ground again then the police arrived. Nurse B: I was walking down the low 100's hallway, going to ask the other nurse a question & I observed a male pt (patient) walking with his shirt off & yelling @ staff. He walked over to me & grabbed the top portion of my scrub top, twisted it, & shoved me against the wall. He proceeded to push his knuckled toward my neck, calling me a [OBSCENITY] & holding me against the wall. Other staff members were coming up and trying to get him to release me. I came to know this pt as (Resident #502). He finally releases me after he saw the other staff coming. Nurse A: Nurse was passing its medications standing at med cart. Nurse heard pt (Resident #501) telling Help! Nurse ran down the hall and observed pt (Resident #502) choking (Resident #501) in a head lock. Nurse immediately pulled (Resident #502) off (Resident #501). (Resident #502) yelled, I am going to kill you, and punched nurse in the jaw. Other staff members assisted nurse .(Resident #502) punched secretary and then he fell on to the floor. (Law enforcement) arrived and handcuffed (Resident #502). Resident #501: I was in my room, other resident came to my room and he choked me so tight I cannot breath. An I was tried .I was screaming . I screamed and walk out of the room. No pain but my heart is beating fast. The FRI investigation failed to mention the multiple past attacks by Resident #502 on facility staff and obvert oversight of the residents documented behavioral health crises. On 3/8/22 at 2:00 PM, an interview was conducted with CNA (Certified Nursing Assistant) E regarding the assault on Resident #501. CNA E explained she was working on the opposite end of the hall and while she was providing resident care, she heard yelling and screaming. CNA E exited the resident's room and was informed by staff Resident #501 was attacked by Resident #502. They began to close all the resident's room doors to ensure their safety. CNA E stated she took Resident #501 to the nurse's station as he was in a panic and freaking out. She reported Resident #501 informed her Resident #502 pushed him against the wall and choked him in the corner. CNA E expressed there was no provocation that led to this incident. Amid trying to calm Resident #501 down, Nurse B walked down the hallway and Resident #502 pushed her against the wall. CNA E stated Resident #502 became combative at night and would target facility staff. She reported he would say nonsensical things and say people were attacking him as he thought he was fighting in a war. She reported his thought process was disorganized, and he was not in touch with reality. CNA E explained he tried to stab and has assaulted other facility staff prior to this incident. CNA E was queried if management was aware of his behaviors, and she stated they were. On 2/8/22 at 2:20 PM, an interview was conducted with CNA F regarding the incident with Resident #501 and #502. CNA F explained she and another staff were boosting a resident in the bed and they heard screaming. She reported they initially thought it was another resident that screams frequently, but when they heard more screaming, they went to investigate. CNA F walked out the room and saw Resident #502 had one hand on Resident #501's neck and his other hand wrapped up in his shirt closer to his neck. CNA F continued Resident #501 was crying and yelling for staff to get Resident #502 off him. CNA F then screamed for Nurse A who ran down the hallway and attempted to break the residents up. While freeing Resident #501 from #502's grasps, Resident #502 attacked Nurse A, as he thought the nurse had been having sexual relations with his wife. Resident #502 lost his balance and fell after assaulting Nurse A. CNA F reported the resident was making verbal threats and scaring the other residents on the unit. CNA F reported he said he just needed a gun to finish the job. CNA F stated when they asked Resident #501 what occurred, he reported Resident #502 dragged him out of his room and choked him. CNA F reported they ended up calling the police and as they were waiting, they were trying to calm Resident #502 down as he was still walking about the hallway. She reported as Nurse B was walking down the hallway Resident #502, grabbed the nurse and pinned her against the wall. CNA F stated she and CNA E were trying to break them up and their receptionist came to assist, and Resident #502 also assaulted her in the process. CNA F stated once police arrived Resident #502 cooperated with them and was transported to the hospital. She reported he was not allowed to return to the facility. CNA F was queried if Resident #502 had other aggressive behaviors in the past. CNA F explained the resident was frequently angry as he was paranoid and believed someone was out to get him. She reported once she entered his room and he was on his knees and told CNA F urgently to, Get down! Get down! The bombs are coming! She reported Resident #502 would only behave like this at night after his wife left. She reported the other residents were scared and questioned if they were going to be attacked as well. On 2/8/22 at approximately 3:00 PM, an interview was conducted with Nurse Q regarding Resident #502. Nurse Q reported on one occasion she was working on the hall and heard staff screaming her name. She responded and saw Resident #502 walking down the hallway and she knew he was not supposed to walk due his [CONDITION(S)]. Nurse Q asked Resident #502 where he was going and tried to redirect him. Resident #502 began to hit her and was able to hit her in the stomach. Nurse Q stated Resident #502 began to chase her around the nurse's station and grabbed the pager and threw it down on the desk. Nurse Q stated he swung at her again, but she was able to duck down to avoid being punched. The nurse reported the resident stated he behaved in that manner because they (facility staff) had killed his family and he was not supposed be at the facility. Nurse Q reported they contacted police and he was transported to the emergency room for evaluation but was sent back. Once he arrived back the aides were attempting to help him, and he instantly became combative with them. Nurse Q offered that the week after this Resident #502 tried to stab Nurse C, and some days later is when he choked Resident #501 and [NAME] Nurse B to the wall. Nurse Q stated she arrived at work on the evening of 2/3/22 after the incident occurred. She reported his family called and were upset he was not allowed to return to the facility. Nurse Q stated with all those incidents occurring there was nothing put in place to protect the residents or staff from Resident #502. She reported all the incidents occurred at night around 7 PM-10 PM. On 2/8/22 at 3:25 PM, an interview was held with Social Services Director G regarding Resident #502 and the facility's behavioral and mental health interventions. Director G reported the facility's Corporate Social Worker completed Resident #502's initial social work assessment, as she had been assisting with resident assessments since their census is increasing. Director G reported the only interaction she had with the resident was during his Care Conference on 12/23/2021. Director G was queried if Resident #502's behaviors were discussed, and she reported they discussed them during their morning meeting and nursing stated they would follow up on the concerns that were mentioned. Director G was queried regarding care planned and pharmacological interventions for Resident #502. Director G and this writer reviewed the resident's care plan, and both acknowledged there was no care planned interventions related to his behaviors and mental health concerns (although there were multiple incidents prior to the resident being choked). Director G further acknowledged the absence of interventions after each incident (physical assault of staff, hallucinations, delusions, paranoia, etc.) and [CONDITION(S)] medication management. Review was completed of the MAR (Medication Administration Record) and Resident #502 was prescribed [MEDICATION(S)] (depression medication) and no other scheduled [CONDITION(S)] medication to address his continued, increased and evident mental health episodes. Director G was queried as to how Resident #502 was overlooked and Director G was not able to provide an answer as to how this occurred. On 2/8/22 at 4:40 PM, an interview was conducted with Receptionist I regarding her involvement with Resident #502 on the evening of 2/3/22. Receptionist I reported around 8 PM she kept hearing someone screaming and when went to investigate. Receptionist I observed Resident #502 swinging his hands to hit the aides. She reported she was informed Resident #502 had choked Resident #501. She reported he had an unsteady gait but as another nurse was walking by, Resident #502 grabbed the nurse and pinned her against the wall. As they were trying to get him to let go of the nurse, he ended up falling, she reported he attempted to grab her, as she was attempting to get the other nurse free from his grips. Receptionist I reported it is typical of Resident #502 to escalate at night and he was always taking about gun and made threats to kill facility staff by shooting them. Receptionist I was queried regarding Resident #501's demeanor throughout this ordeal and she reported he was scared and his whole neck was reddened from the incident. On 2/8/22 at 4:50 PM, an interview was conducted with CNA J regarding her interactions with Resident #502. CNA J reported she was training another aide and they were preparing to take the trash to the dumpster. They saw Resident #502 walking down the hallway and they knew he was not supposed to walk due his [CONDITION(S)]. CNA J stated she asked the resident way he was walking and he responded by calling her a [OBSCENITY] , and told CNA J she killed his whole family and began shouting and attempted to hit CNA J. She reported he was escalating and they were unable to calm him down and he continued to yell, that she had killed his family. CNA J reported she yelled for Nurse Q who came running and Resident #502 attempted to swing on the nurse, but she was able to duck down and missed being hit. CNA J stated the resident continued to try and attack them and he threw the pager at them. CNA J reported he told Nurse Q, she was going to be the first person he kills at the facility. The CNA reported other staff responded and attempted to calm the resident to no avail. He was screaming explicit's at the staff and threatening them. CNA J stated Resident #502 then chased Nurse Q and tried to hit her again. She reported once police arrived, he began to cry and calmed down. CNA J explained he behaved like this after his wife visited and he was verbally aggressive with the staff in the past, but she has never observed his behave in this manner. She continued there is nothing mentioned in their Kardex about Resident #502's behaviors or any interventions that may be effective. Review was completed of Resident #502's Incident and Accident Reports since his admission to the facility. Many of the incidents were falls but the resident presented as homicidal, delusional, paranoid and responding to internal stimuli. There were no interventions put in place to address the resident's rapidly deteriorating mental health. 1/11/22 at 05:51: Resident was found sitting in front of his chair. Resident is restless, crying, yelling and saying that he is going to die. Mentions things about the military and previous staff sergeant. 1/25/22 at 23:45: CNA called nurse because resident was walking in the hallway cussing and unsteady gait when trying to assist resident back to room resident started swinging and punching he punch CNA in stomach yelling all you [OBSCENITY] es killed my family now I'm going to kill you. Resident started chasing staff. Staff continued to encourage resident to have sit so that he does not fall. Resident grew more agitated and started swinging . 1/30/22 at 20:51: Resident witnessed standing from bed and falling onto the bed then floor. Did not hit head. Resident stated he was looking for an airplane accident. 2/3/22 at 19:00: Resident was observed dragging another resident from his shirt out to the hallway and the other resident screaming for help. Resident (#502) screaming I am gonna kill you. Immediately both resident were separated. Resident (#502) was very agitated and hit the nurse with his fist twice on the face and neck. Kept away from other and called 911 . On 3/9/22 at 12:20 PM, an interview was conducted with Resident #501 regarding his assault by Resident #502. Resident #501 stated he was in his room on the night of the incident and Resident #502 entered his room and he asked who he was. He reported Resident #502 dragged him out the room and proceeded to choke him. He reported facility staff were able to pull Resident #502 off of him. He reported he had redness and fingerprints on his neck. On 3/9/22 at 12:45 PM, an interview was conducted with Nurse C regarding his encounters with Resident #502. Nurse C reported the resident was calm and cooperative during the day but at night is when they would incur issues. He reported Resident #502 became fixated on his financial and insurance issues and Nurse C would attempt to redirect him. He reported in January, Resident #502 was yelling out into the hallway regarding some insurance issues and staff attempted to redirect and reassure the resident, but it was not effective. Nurse C stated he was in another room administering medications and was told he was needed in the hallway. He reported he was walking behind Resident #502 as he and the resident grabbed a pen off of the nurse's cart, spun around and tried to stab him with the pen. He reported he was able to move out the way and he is not sure what made the resident respond in this manner. Nurse C reported the resident kept saying that he wanted him (Nurse C) to die. Nurse C explained he called to receive a onetime order of [MEDICATION(S)] as the resident did not have any scheduled medications to assist with his robust behaviors. He reported there was no new interventions put in place after this occurrence. He added police and paramedics were contacted but by the time they arrived the resident had calmed down and they refused to transport him. On 2/9/22 at 2:36 PM, an interview was conducted with Nurse B regarding the incident with Resident #502. Nurse B reported it was her first or second night working at the facility, and she as assigned to the back of the building. Nurse B reported she had a question for Nurse A and was walking toward the front of the building when she heard the commotion. She reported she was on the opposite side of the hallway from Resident #502 and observed staff members walking behind him. Nurse B reported suddenly Resident #502 lunged toward her, grabbed her by the top of her scrub top toward her neck and was holding bot of his hands on her neck as he pinned her against the wall. Nurse B reported she does not know what provoked the resident but in that moment she was frantic. She informed the DON she did not feel safe in their building but since the resident was not allowed to return that eased her insecurities. On 3/9/22 at 2:40 PM, an interview was conducted with the DON regarding the strangulation of Resident #501 by Resident #502. The DON explained Resident #502 was admitted for [CONDITION(S)] and when they would raise the head of his bed higher than 15 degrees he would faint. The resident had a host of appointments to evaluate his [CONDITION(S)] and offer solutions. The DON offered he fell on [DATE] and they requested their medical group review his medications but they refused to make any adjustments until his appointment with the Cardiologist on 2/2/22 (one day prior to him choking Resident #501). The DON acknowledged there was no interventions in place after each incident, care plan, behavioral charting by the CNA's or [CONDITION(S)] medications that addressed his displayed mental health symptoms. The DON denied Resident #502 being placed on 15-minute checks or 1:1's after the any incidents. The facility completed medical workups related to the residents' [CONDITION(S)] and negated the multiple mental health signs and symptoms. Review was completed of Resident #502's paramedic run reports and emergency room documentation. The following was revealed: Paramedics responded to the facility two times prior to the assault of Resident #501. 1/25/22 at 9:33 PM: .Arrived on scene at (facility) to find [AGE] years old Male with Homicidal ideations. Police beat us on scene because the patient was attempting to hurt staff. Out dispatch advised us the patient had now went homicidal and was attempting to kill staff. Police had the patient in a chair when we walked in. We stood there waiting for some information about the patient. We then were able to have the patient come and sit on the stretcher. The patient advised me the staff has killed his military friends and family. Patient kept crying saying they were going to hurt him next .the staff advised the patient woke up from sleeping came out to their desk and started punching them saying they killed my family and calling them explicit names. They advised the patients wife stated he was on the air force and has [CONDITION(S)] from it. The staff advised me he frequently goes behind his bed and tells imaginary people to get down . 1/31/22 at 11:54 PM: .Arrived on scene, PD in pts (patient) room. Pt is lying in bed awake and alert. Pt is calm and cooperative and speaking to PD. RN explained tonight the pt was able to walk out his ROM and stand at the nurses cart. Nurse explained the pt tried to stab him with a pen. RN explains the pt has a new onset of agitation .The pt has been transported to (emergency room ) multiple times in the past two months for his anger at night time .Pt explains he does not trust his nurse .Family is not wanting pt to be transported to (emergency room ) for evaluation .Pt is lashing out at the nurses during the night and causing the nurses to be scared to care for him .RN administered [MEDICATION(S)] to the pt. RN is advised is pt has another outburst tonight the RN can petition pt to be seen for psychiatric evaluation . 2/3/22 at 8:08 PM: .Arrived on scene at (Nursing Home) to find [AGE] years old Male with irritability and anger. Complaint is for Psychiatric . emergency room Documentation: Resident #502 presented to the emergency roiagnom on [DATE] for evaluation after an incident at the facility. The report stated, The patient is a 76 y male presenting to the ED .for mental health evaluation .(Paramedics) were called as the patient woke up from sleep and started fighting staff. The patient states the nurses were hitting him and therefore decided to push them off him. He does have a history of [CONDITION(S)] from the Air Force .Patient is agitated and hallucinating .Did order 5 MG [MEDICATION(S)] PO as the patient is slightly agitated with staff, however he refused to take it as he is paranoid . On 2/10/22 at 12:40 PM, an interview was conducted with Nurse A regarding the assault on Resident #501 by Resident #502. Nurse A explained he was at his medication cart (on opposite side of the hall) and he heard Resident #501 scream for help. He looked over and saw Resident #502 had Resident #501 in a chokehold; he stated Resident #502 was standing behind Resident #501 with his arm wrapped around his neck. Resident #501 was y [TRUNCATED]

This Citation pertains to Intake Numbers MI 918 and MI 949 Based on observation, interview and record review the facility failed to provide Resident #502 with the appropriate behavioral health services to meet his intensive mental health needs, resulting in, Resident #502 strangling Resident #501, punching Nurse A twice and physically assaulting Nurse B, all whilst making homicidal statements toward facility staff. Findings include: On 3/8/22 at 11:00 AM, a review was completed the Police Report related to the incident that occurred on 2/3/22. The reported stated the following: Narrative from Officer K: .I (Officer K) arrived on scene and observed (Resident #502) laying on the floor. Due to him assaulting (Resident #501) and staff, I placed (Resident #502) in handcuffs for safety. I then took (Resident #502) to a chair where he could be comfortable. I attempted to speak to him regarding the incident but due to his mental state, he was unable to provide me with a statement. I then spoke with staff who told me that (Resident #502) walked into (Resident #501) room and began choking him. Staff attempted to pull (Resident #502) away but then he hit staff. From there, (Resident #502) went into the hallway and laid on the floor until I arrived. I was unable to gather a stated from (Resident #501). (Paramedics) arrived on scene and transported (Resident #502) . Resident #501: On 2/8/22 at approximately 1:15 PM, a review was completed of Resident #501's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review was completed of Resident #501's chart and the following were reviewed: Incident and Accident Report: 2/3/22 at 19:00: Observed the resident (#502) from the next room grabbing (Resident #501) by the shirt collar and pulling him to the hallway from (Resident #501's room). He came in my room and trying to choke me, I was trying to escape from him, and I was screaming. Resident #502: On 2/8/22 at approximately 1:00 PM, a review was completed of Resident #502's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #502 was assessed as being severely cognitively impaired but was still rendered as capable to make his own decisions by a facility physician on 12/13/21. The resident was one person assist for the majority of his Activities of Daily Living (ADL's). Further review was completed of his medical record and the following was found: Behavioral Charting: The facility provided a summary of behavioral charting from the last week of December 2021 until Resident #502 was discharged from the facility (on 2/3/22). According to the document provided by the facility Resident #502 did not have any behaviors exhibited. Progress Notes: 12/23/21 at 22:18: Resident has been combative with care and confused .punching at staff when they assisted him. 1/11/22 at 06:02: Resident was found sitting in front of his chair. Resident is restless, crying and saying that he is going to die. Mentions things about the military and previous staff sergeant . 1/11/22 at 09:34: .Spoke with (Medical Group) PA (Physician Assistant) to assess resident about last fall .reported to PA that resident was crying and talking about memory in the military, PA stated no med change at this time until resident go this cardiology appointment. 1/17/22 at 01:56: Resident in his room confused looking for the garage. Pt upset wanting to call his wife does not know how to use the phone . 1/23/22 at 18:56: Resident have increase confusion on this shift . 1/26/22 at 19:24: Resident was fighting staff stating that we killed his family and now he's going to kill us. Staff attempted to redirect resident he became more agitated . 1/29/22 at 02:17: 0200 residents room Specific behavior: pt yelling in confusion What triggered the behavior?: pt yelling send more troops trying to self ambulate in room . 1/29/22 at 05:05: Time and location of behavior: 0500 hallway Specific behavior: resident punching and kicking at staff members What triggered the behavior?: resident saying a man is having an affair with his wife What interventions were attempted?: redirection on call provider informed Outcome of the interventions (behavior stopped, worsened, or unchanged): behavior slightly improved. 1/31/22 at 00:34: .Resident stated he was looking for an airplane accident .Resident responds to ever noise he hears in the hallway . 1/31/22 at 01:55: Resident agitated this shift, he was worried about an airplane crash and started to yell at staff about it. He stated this nurse molested a little girl and he was going to kill this nurse for that. Resident has been verbally aggressive towards staff, no physical actions to this point . 1/31/22 at 21:35: Called out to the hallway from another resident room by CNAs requesting help. Resident was up walking around in the hallway very upset and agitated. Asked the resident if I could help him, he leaned onto the med cart, grabbed a pen, spun around and attempted to stab this nurse with the pen. He stated several times he wanted this nurse to die and how he wanted this nurse to die. CNAs walking with resident and he sat in the bay dinning room. He was yelling and threatening this nurse more . 2/1/22 at 05:52: Medical Staff Progress Note: .He continues to have behaviors and combativeness. He remains confused .Combative behaviors- ER visit on 1/25 and 911 call on 1/31/22 . 2/3/22 at 04:20: Resident upset and talking to his wife on the phone at this time. CNA has been in room with him due him yelling out, standing up and walking to the door . 2/3/22 at 06:06: Resident has remained agitated calling out for his wife and yelling for her staff very hard to redirect. It can be noted Resident #502 was not being followed by psychiatric services, there were no interventions, behavior tracking/monitoring, social services assessment, care plan, petition for inpatient psychiatric hospitalization or [CONDITION(S)] medications to treat and/decrease his psychiatric signs and symptoms. The facility failed to provide meaningful interventions after multiple severe and disruptive mental health episodes as evidenced above. On 2/8/22 at 3:25 PM, an interview was held with Social Services Director G regarding Resident #502 and the facility's behavioral and mental health interventions. Director G reported the facility's Corporate Social Worker completed Resident #502's initial social work assessment, as she had been assisting with resident assessments since their census is increasing. Director G reported the only interaction she had with the resident was during his Care Conference on 12/23/2021. Director G was queried if Resident #502's behaviors were discussed, and she reported they discussed them during their morning meeting and nursing stated they would follow up on the concerns that were mentioned. Director G was queried regarding care planned and pharmacological interventions for Resident #502. Director G and this writer reviewed the resident's care plan, and both acknowledged there was no care planned interventions related to his behaviors and mental health concerns (although there were multiple incidents prior to the resident being choked). Director G further acknowledged the absence of interventions after each incident (physical assault of staff, hallucinations, delusions, paranoia, etc.) and [CONDITION(S)] medication management. Review was completed of the MAR (Medication Administration Record) and Resident #502 was prescribed [MEDICATION(S)] (depression medication) and no other scheduled [CONDITION(S)] medication to address his continued, increased and evident mental health episodes. Director G was queried as to how Resident #502 was overlooked and Director G was not able to provide an answer as to how this occurred. Review was completed of Resident #502's Incident and Accident Reports since his admission to the facility. Many of the incidents were falls but the resident presented as homicidal, delusional, paranoid and responding to internal stimuli. There were no interventions put in place to address the resident's rapidly deteriorating mental health. There were multiple opportunities for the facility to implement behavioral health intervention. 1/11/22 at 05:51: Resident was found sitting in front of his chair. Resident is restless, crying, yelling and saying that he is going to die. Mentions things about the military and previous staff sergeant. 1/25/22 at 23:45: CNA called nurse because resident was walking in the hallway cussing and unsteady gait when trying to assist resident back to room resident started swinging and punching he punch CNA in stomach yelling all you [OBSCENITY] es killed my family now I'm going to kill you. Resident started chasing staff. Staff continued to encourage resident to have sit so that he does not fall. Resident grew more agitated and started swinging . 1/30/22 at 20:51: Resident witnessed standing from bed and falling onto the bed then floor. Did not hit head. Resident stated he was looking for an airplane accident. 2/3/22 at 19:00: Resident was observed dragging another resident from his shirt out to the hallway and the other resident screaming for help. Resident (#502) screaming I am gonna kill you. Immediately both resident were separated. Resident (#502) was very agitated and hit the nurse with his fist twice on the face and neck. Kept away from other and called 911 . On 3/9/22 at 12:20 PM, an interview was conducted with Resident #501 regarding his assault by Resident #502. Resident #501 stated he was in his room on the night of the incident and Resident #502 entered his room and he asked who he was. He reported Resident #502 dragged him out the room and proceeded to choke him. He reported facility staff were able to pull Resident #502 off of him. He reported he had redness and fingerprints on his neck. Review was completed of the facility's FRI (Facility Reported Incident) Investigation for the strangulation of Resident #501 and physical assault of multiple facility staff: Incident Summary: .On 2/3/22 staff observed (Resident #502) and (Resident #501) both walking out of Resident #501's room. (Resident #502) had a hold of (Resident #501) initially by the shirt collar and then pulled him by his neck. (Nurse A), was able to get (Resident #501) free from (Resident #502) and staff assisted (Resident #501) to the nurses' station. (Resident #502) remained extremely agitated and punched (Nurse A) in the face and then fell down to his knees. (Resident #502) then got himself off of the floor. He proceeded to go after other staff while the staff closed doors to other residents room, hitting another nurse, in which he lost his footing and again fell to his knees .(Resident #501) had some redness to his neck and reported that his heart was racing .(Resident #502) sat with the police until paramedics arrived. (Resident #502) remained agitated and reported that he had went into (Resident #501's) room because he believed that (Resident #501) had set him on fire .(Resident #502) was transferred to (emergency room ) where he was admitted with [CONDITION(S)] and [CONDITION(S)] and remains there .This incident was isolated and not anticipated . On 3/9/22 at 2:40 PM, an interview was conducted with the DON regarding the strangulation of Resident #501 by Resident #502. The DON explained Resident #502 was admitted for [CONDITION(S)] and when they would raise the head of his bed higher than 15 degrees he would faint. The resident had a host of appointments to evaluate his [CONDITION(S)] and offer solutions. The DON offered he fell on [DATE] and they requested their medical group review his medications but they refused to make any adjustments until his appointment with the Cardiologist on 2/2/22 (one day prior to him choking Resident #501). The DON acknowledged there was no interventions in place after each incident, care plan, behavioral charting by the CNA's or [CONDITION(S)] medications that addressed his displayed mental health symptoms. The DON denied Resident #502 being placed on 15-minute checks or 1:1's after the any incidents. The facility completed medical workups related to the residents' [CONDITION(S)] and negated the multiple mental health signs and symptoms. Review was completed of Resident #502's paramedic run reports and emergency room documentation. The following was revealed: Paramedics responded to the facility two times prior to the assault of Resident #501. 1/25/22 at 9:33 PM: .Arrived on scene at (facility) to find [AGE] years old Male with Homicidal ideations. Police beat us on scene because the patient was attempting to hurt staff. Out dispatch advised us the patient had now went homicidal and was attempting to kill staff. The patient advised me the staff has killed his military friends and family. Patient kept crying saying they were going to hurt him next .the staff advised the patient woke up from sleeping came out to their desk and started punching them saying they killed my family and calling them explicit names. They advised the patients wife stated he was on the air force and has [CONDITION(S)] from it. The staff advised me he frequently goes behind his bed and tells imaginary people to get down . 1/31/22 at 11:54 PM: .Arrived on scene, PD in pts (patient) room. Pt is lying in bed awake and alert. Pt is calm and cooperative and speaking to PD. RN explained tonight the pt was able to walk out his ROM and stand at the nurses cart. Nurse explained the pt tried to stab him with a pen. RN explains the pt has a new onset of agitation .The pt has been transported to (emergency room ) multiple times in the past two months for his anger at night time .Pt explains he does not trust his nurse . 2/3/22 at 8:08 PM: .Arrived on scene at (Nursing Home) to find [AGE] years old Male with irritability and anger. Complaint is for Psychiatric . On 2/10/22 at 1:00 PM, an interview was conducted with Medicaid Specialist H, regarding her involvement with monitoring and assessment of Resident #502. Medicaid Specialist H stated she has been at the building about twice a week since October/November 2021. Medicaid Specialist H explained she assisted with resident interviews, discharge planning, reviewing and adjusting care plans and communicating needs to the physician. Medicaid Specialist H stated she completed the initial interview with Resident #502 upon his admission and he was assessed at cognitively impaired during that assessment. Medicaid Specialist H explained it was never communicated there were issues with the resident that the facility needed her to address. Medicaid Specialist H reported she does not know where the disconnect occurred as they did talk about Resident #501 in morning meeting. After Resident #502 choked Resident #501 he was transferred to the local emergency room and admitted to the hospital with the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Is a [AGE] year old .male who was brought to the emergency department complaint of aggressive behavior .apparently the patient got up in the middle of the night and went into the patient's room and attempted to choke him. Police were called and the patient was sent to the emergency department this time the patient will not be allowed to return to that extended care facility .Subsequent to the admission of the patient we had evaluation by behavioral health secondary to what appeared to be development of paranoia associated with dementia. The patient was having significant episodes of paranoia exhibited here in the hospital as well as his skilled nursing facility .started on [MEDICATION(S)] for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Patient appears to be having episodes of psychotic paranoia .The patient had previously been placed on medication for depression but this appears to be far beyond that at this point the patient with me was paranoid questioning everything trusting nobody. Affect flat, mood incongruent. Thought process tangential and disorganized. Paranoia present. Patient is guarded on exam .does appear to be responding to internal stimuli, insight, judgement and impulse control poor. Patient states, they tried to set me on fire and are following me around. RN reports no behaviors today. She reports he gets paranoid and gets upset easily. Has been physically and verbally aggressive with staff and using on and off restraints . The facility had multiple opportunities prior to the strangulation of Resident #501 to provide sufficient and individualized behavioral health services to appropriately meet his mental health needs but failed to do so. Resident #502 exhibited signs of paranoia, delusions, responding to internal stimuli, homicidal statements auditory/visual hallucinations and physical and verbal aggression. The facility grossly disregarded obvious signs and symptoms of a mental health crises that directly lead to Resident #502 being strangled. Review was completed of the facility policy entitled, Behavior Health Services Policy, effective 10/21. The policy stated, It is the policy of this facility that all resident receive necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning .The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status .Facility staff shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents . Review was completed of the facility policy entitled, Behavioral Management Plan, the policy stated, Residents who exhibit behavioral concerns may require a behavior management plan to ensure they are receiving appropriate services and interventions to meet their needs. The interdisciplinary team .should develop a behavioral care plan for each resident with identified behaviors through the RAI process .Behaviors should be documented clearly and concisely by all facility staff. Documentation should include specific behaviors, time and frequency of behaviors, observation of what may be triggering behaviors, what interventions were utilized, and the outcomes of the interventions .

This Citation pertains to Intake Number MI 851. Based on observation, interview, and record review the facility failed to replenish Automated External Defibrillator (AED) pads for their one AED device in the facility, resulting in failure to utilize the AED when Resident #701 was found unresponsive by Licensed Practical Nurse (LPN) A, on [DATE] at 3:30 AM. LPN A immediately began to perform Cardiopulmonary Resuscitation (CPR) on the resident. The facility's crash cart was brought into the resident's room and, as the nurses attempted to attach the AED, it was found there were no AED pads. LPN B searched both crash carts for AED pads but was not able to locate any. An AED was not applied to Resident #701 until paramedics arrived at the facility at 0345 hours and took over life saving measures using their own AED. Resident #701 was pronounced dead at the scene. The facility's last code (Resident #703) was on [DATE] (five and one-half months prior to Resident #701 coding), and facility management was alerted at that time that there were no AED pads for the machine. These deficient practices placed 46 residents with designated Full Code statuses at significant risk of not receiving competent life-sustaining measures during an emergency, resulting in undue suffering, and possible death. Immediate Jeopardy: The Immediate Jeopardy began on [DATE] at 3:30 AM. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 9:45 AM and instructed to provide a plan of correction to remove the immediacy. The Immediate Jeopardy was removed on [DATE]. Findings Include: On [DATE] at approximately 10:45 AM, the DON (Director of Nursing) and this writer inspected the two crash carts in the facility. The first crash cart (on the Bay) housed the AED which is located on top of the crash cart. There was a checkoff list located on a clipboard on the cart and the DON explained facility nurses verify the tag (on the crash cart) has not been tampered with and confirm the number on the tag matches the number listed on the checkoff list. The DON expressed this is a daily task that is completed by facility nurses. The DON was queried if there is a list of items/equipment that is in/on the crash cart (as there was not one on the clipboard) and the DON expressed in the past there was a list. The DON explained if the nurse had to utilize the cart or the tag was not secured, they would restock, replace, and retag the cart. This writer checked the oxygen tank and both valves indicated it was empty and the DON verified they were empty. There was no documentation found in or around the crash cart that indicated when the last time staff verified the oxygen tank was full, backboard was in place, suction machine was in place, and their AED had pads. The Coast crash cart was inspected as well and there was the same checkoff list located on a clipboard for facility nurses to verify the tag number. On [DATE] at 11:00 AM, an interview was conducted with the Administrator and DON regarding Resident #701. The Administrator and DON stated they were made aware once the EMS (Emergency Medical Service) arrived on scene that Resident #701 was found unresponsive, and they did not have any AED pads. The DON reported she asked them if they had looked in the bottom drawer on the Bay for the AED pads, they reported they did and did not locate them. They then were asked if they opened the cart on Coast and was informed, they did not. The DON reported she asked if she needed to come in and give them the pads and they declined and explained the paramedics were already there and using their AED on Resident #701. The DON reported the previous Administrator would have had an extra set of AED pads in their office and so would the DON. They both expressed there should always be pads on the AED device. The Administrator and DON reported they do not know why there were not pads on the AED when Resident #701 coded. They added they were then informed the paramedics provided them with two sets of AED pads prior to them leaving. The DON was asked when she arrived at the facility did, she check the carts or other spaces in the building for AED pads and she reported she did not. On [DATE] at approximately 11:15 AM, a review was completed of the facility's, Emergency Cart Tag Checklist, from [DATE] for the Coast and Bay Unit. Coast Unit: The checklist indicated on [DATE] Nurse B checked that the cart tag was secured and the number on the cart and Tag Checklist coincided with one another. It also showed on [DATE] (day Resident #701 coded) Nurse B changed the tag number on the crash cart from 84 to 53. Bay Unit: The checklist indicated on [DATE] the Crash Cart was not marked off as checked. The securement tag was changed on [DATE] from 83 to 99 by Nurse D. On [DATE] at 11:35 AM, an interview was conducted with Nurse E regarding their crash cart procedures. Nurse E reported night shift nurses are responsible for checking the crash carts on their shifts. Nurse E explained the facility purchased new crash carts and now the night nurses look at the serial number on the tag that secures the cart to ensure it matches the one on the checklist. Nurse E stated they do not physically go in each drawer and ensure all needed items are there. Nurse E expressed if the seal is broken, then they will fully go through the cart and then retag it. Nurse E reported there is not a list of the items that are located on the cart but stated in the past there was one and they had to open the cart every night and check to make sure all the equipment was there. On [DATE] at 11:50 AM, an interview was conducted with Nurse J regarding facility policy for checking the crash carts. Nurse J expressed night shift nurses are responsible for checking the carts and she has not encountered a code since beginning at this facility. Nurse J reported it is her understanding the night nurses check to ensure the tag on the cart is secured and the serial number on the tag and checklist coincide with one another. On [DATE] at 11:55 AM, an interview was conducted with Nurse G regarding the facility's crash cart policies. Nurse G explained she has never checked the crash cart as that is a night shift task. Nurse G stated a few days ago the tag on the crash cart was broken and she was instructed by the Unit Manager to go through the cart and verify everything was there. Nurse G was queried if there was a list of items that are supposed to be in the cart for her to reference while going through it. Nurse G stated there was not, and she used the labels on the drawers to reconcile. On [DATE] at 12:10 PM, an interview was held with Nurse H regarding the facility's crash cart. Nurse G explained night shift check the crash cart every night and if they use the cart or see the seal is broken, they check, restock, and retag the cart. Nurse H reported there was an incident when a resident coded and there were no AED pads in the building and the paramedics provided the facility with some after the code. On [DATE] at approximately 12:30 PM, a review was completed of Resident #701's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent assessment Resident #701 was cognitively impaired and relied heavily on staff for the majority of his Activities of Daily Living (ADL). Further review of Resident #701's medical records revealed: Care Plan: Focus: (Resident #701) relies on his DPOA/sister, to make decisions and manage his affairs. Advance Directives have been discussed and decisions as follows: CPR. Progress Notes: [DATE] at 04:31: approximately 0330 nurse walked into the room to check the pts (patient) temperature, pt was found unresponsive and not breathing, no pulse present, nurse immediately yelled for help and for staff too call 911. nurse started cpr, 2 other nurses ran into the room and assisted with cpr. [DATE] at 04:36: (Paramedics) arrived and took over cpr, CPR was continued until 0419, MMR and Paramedics pronounced the patient deceased . [DATE] at 05:10: This nurse was called to patient room approximately 330 am, no pulse or breath sounds noted. CPR started. Numerous rounds of CPR performed. EMS called to facility and continued CPR. Paramedic .called time of death at 0419. On [DATE] at approximately 12:45 PM, a review was completed of Resident #703's medical records and it revealed the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent assessment the resident was cognitively intact, and one person assist for the majority of her ADL's. Further review of Resident #703's medical records revealed the following: Care Plan: Focus: (Resident #703) is independent in decision making. Daughter .also helps manager her affairs. Treatment sheet reviewed and decision as follows: CPR. Progress Notes: [DATE] at 16:42: Code Blue notes: Resident was observed on phone with family at 9:25 a.m. per staff report. At 9:30 a.m. resident was unresponsive with no heart rate and no respirations. Code Blue called and CPR initiated by (Physician Assistant) .CPR started at 9:31 a.m.Oxygen is 2L/min/AmbuBag. Resident monitored per AED and no shocks required. 9:38 a.m. (Paramedics) arrived epi given by (Paramedics) at 9:45 a.m. per IV .Compressions taken over by (Paramedics) staff at 9:47 a.m.EMS to (local hospital). [DATE] at 09:51: Code Blue was called arrived on unit called POA no answer was able to get a hold of POA's husband. Updated on situation as he able to be given HIPPA information. He stated he will try and get a hold of his wife, Residents wife was updated on residents status at the time. This writer stayed on the phone with her until (paramedics) was able to leave with (paramedics) . On [DATE] at 1:20 PM, an interview was held with Nurse F regarding the crash cart. Nurse F reported there use to be a list attached to the cart so if they had a code, they knew what to restock the cart with. Nurse F reported when night shift checks the cart, they only ensure the tag is secure. Nurse F was queried if there were no AED pads in the cart would they know where to get them from and Nurse 'F responded, No. Nurse F added in the past management would fully check the carts every week for supplies and restock as needed. On [DATE] at 1:45 PM, an interview was held with Nurse E regarding Resident #703. Nurse E reported the last code in the building was [DATE] with Resident #703. The nurse explained they used the crash cart from Coast unit but went to Bay unit to get the AED. Nurse E stated at that time there were pads on the AED and they were able to attach the AED to Resident #703. Nurse E stated she attempted to replace the AED pads within the device but was not able to locate any. Nurse E alerted upper management shortly after the incident that there were no AED pads on the device. On [DATE] at 2:12 PM, an interview was held with Nurse D regarding Resident #701 coding on [DATE]. Nurse D reported an aide informed her there was a code and she quickly went over to Bay unit to assist. Nurse D reported Nurse A was already performing CPR on Resident #701 who was unresponsive. Nurse D stated they directed an aide to get the backboard and she started to assist Nurse A with the resident. Nurse D stated as they went to apply the AED to the resident it was found there were no AED pads in the machine or on the crash cart. They used the ambu bag, while Nurse B went to look for AED pads on the Coast crash cart. Nurse B was unable to locate any AED pads on Coast unit crash cart. They also attempted to use the oxygen tank (that was on the crash cart), but it was empty, and they had an aide get an oxygen concentrator and connected it to the ambu bag. Nurse D stated at this point 911 had already been contacted and once they arrived, they took over life saving measures and utilized their on AED machine on the resident. Nurse D reported there were no AED pads in the building that they had access too and prior to the paramedics leaving they provided the facility with two pairs of AED pads. On [DATE] at 2:36 PM, an interview was conducted with Nurse B regarding Resident #701 coding on [DATE]. Nurse B reported once she was alerted of the code, she ran to Resident #701's room and Nurse A and D were already doing CPR. Nurse D reported she went to place the AED pads on the resident and found there were no pads inside the machine. Nurse B reported she went through the crash cart and the were no extra AED pads. Nurse B reported she then ran to the Coast to check that crash cart and was unable to find any additional AED pads. Nurse B explained once the paramedics arrived, they connected their own AED machine and there was no shock delivered. They administered life saving measure for about 40 minutes and then pronounced the resident. Nurse B explained when they check the crash cart (on night shift), they only check to ensure the tag number coincides with the number on the checklist and that the tag is secured. Nurse B reported there is no list the facility provided that indicated what is supposed to be in/on the crash cart. On [DATE] at 3:15 PM, an interview was conducted with CNA C regarding Resident #701 coding on [DATE]. CNA C reported Nurse A went into Resident #701's room and instructed her to go get Nurse B and D as they had a code. CNA C stated she went to get both nurses as she was unsure how to utilize the paging system in the building. CNA C stated once she alerted the nurses, she retrieved the crash cart (with the AED) from the Bay and took it into the room and called 911. CNA C stated 911 instructed her to stand by the door so she could let the paramedics in once they arrived. The CNA stated once they arrived, she was informed another unit was in route and it was requested she wait at the door for them as well. CNA C stated she was not involved looking for the AED pads. On [DATE] at 4:15 PM, the Administrator and DON were queried if there was a facility investigation completed regarding AED pads not being readily available to staff during a code. They reported there was not an investigation completed as once they were alerted to incident there were AED pads in the building as the paramedics had provided them. The DON reported there was a CPR/BLS class held at the facility in September and the instructor checked their AED and there were pads. The DON added there are also extra AED pads in the DON and Administrator office at the time of the code that were accessible to staff. A conversation was held that during a code staff should not have to search two offices for essential lifesaving items and these items should be readily available to the staff on the crash carts. The Administrator was asked if there was an extra set of pads in her office on [DATE] and the Administrator reported she is still organizing her office from the past Administrator and is not sure if they were in there at the time of the code. On [DATE] at 4:30 PM, an interview was conducted with CPR Coordinator I who instructed the last CPR/BLS class at the facility on [DATE]. Coordinator I reported it is their routine to check the AED indicator lights at some point during the class. But Coordinator I was not able to state for certain that this occurred in September. It can be noted there was no documentation provided from the facility that indicated the last time their AED machine was checked for AED pads. Nor was there documentation indicating all necessary items (suction machine, backboard, oxygen tank level, AED, and AED pads, etc.) were on the cart in case of a code. Facility staff all reported they only check the tag number on the crash cart coincides with the number on their checklist and that the tag is secure. On [DATE] at approximately 4:50 PM, a review was completed of the Prehospital Care Report for Resident #701. The report indicated 911 was contacted by the facility at 3:36 AM on [DATE] and the responding Paramedic unit was notified by dispatch at 3:38 AM. The unit arrived at the facility at 3:45 AM. The report further stated, .Arrived on scene at (facility) to find [AGE] year old male with unresponsive (unspecified coma) .Staff states they had seen pt an hour prior and he was groaning as if he was in pain . Staff found pt pulseless and not breathing. Staff initiated CPR .Upon our arrival approx., 10 minutes later the pt was placed on our monitor and was found to be in asystole .Pt had dark coffee ground emesis, CPR was continued, Pts airway had to be suctions due to blood. Pt did not have any positive change. ACLS (Advanced Cardiac Life Support) guidelines were followed. Pt remained in asystole for the duration of the event. Cease efforts were called . On [DATE] at 5:45 PM, an interview was conducted with LPN A regarding the incident with Resident #701. LPN A explained he was assigned as the nurse on Bay (front of the building) and there were also two other nurses in the building that evening ([DATE]). He continued he had an order to check Resident #701's temperature and when he entered the room, he was unresponsive and he immediately began CPR, yelled for assistance and for someone to call 911 as they had a resident that coded. LPN A stated LPN D responded to the room first and placed a backboard underneath the resident and assisted with chest compressions. LPN A reported they started bagging the resident and provided two rescue breaths, but it was not effective. He continued they attempted to utilize the oxygen tank, but they did not have the key to engage it and instead they used the concentrator. LPN A reported he does not recall who brought the crash cart into the room but when they opened the AED there were no AED pads inside the device nor were there any on the crash cart in the room with them. LPN B quickly went to the other crash cart on Coast (back of building) to search for AED pads and was not able to locate any. LPN A continued EMS arrived in about ,d+[DATE] minutes and took over life saving measures. He reported the paramedics attached their own AED to Resident #701, but no shock was delivered as he was in asystole (flatline) and was pronounced deceased at the scene. LPN A reported before the paramedics left, they provided them with two sets of AED pads for their machine. LPN A reported before he found Resident #701 unresponsive, he checked the crash cart and signed off on the checklist. LPN A was queried as to what is checked on the crash cart and he explained he was educated to verify the tag was not tampered with and to verify the tag number matched the one on the checklist. LPN 'A reported they (facility nurses) do not check that the AED pads are there, and they only verify the tag number coincide with number on the checklist. LPN A expressed if the tag was tampered with, he would have to contact management to restock it. LPN A further reported he has never seen a list of all the items in their crash cart. On [DATE] at 9:45 AM, Immediate Jeopardy (IJ) notification was presented to the Administrator that was identified on [DATE]. The facility provided an abatement plan that was reviewed and accepted on [DATE] by State Agency Survey Manager. The Immediate Jeopardy was abated on [DATE], based on onsite interviews, observations and record review that occurred on [DATE]. The abatement plan was as follows: Element #1 Resident #701 expired on [DATE]. Element #2. 46 residents of the facility were determined to be a full code and had the potential to be affected. Element #3. AED pads were replaced on the crash cart by (Paramedics) on [DATE]. On [DATE] the AED was placed on top of the crash cart so that AED pads could be verified daily. On [DATE] the Emergency Cart Checklist was updated to include daily verification of the AED and AED pads as well as daily verification of the oxygen, backboard and suction machine. If the crash cart lock is breached the contents of the entire cart will then be verified. Both crash carts were inspected on [DATE] by the Unit Managers to determine that the contents in and on the crash cart were those that were listed on the Emergency Cart Checklist. The Cardio-Pulmonary Resuscitation Procedure and AED procedure were reviewed by the NHA and DON and were found to be appropriate. The licensed nurses' education was initiated by the DON and Unit Managers regarding the Emergency Cart Checklist, Cardiopulmonary Resuscitation, and the AED procedure on [DATE]. Facility employee education was initiated regarding the location of both crash carts in the facility on [DATE]. Element #4. Ad hoc QAPI meeting was held on [DATE] for implementation of the new Emergency Cart Checklist. The DON and/or designee will verify the Emergency Cart Checklist is being completed properly 5 times per week for four weeks and then 2 times per week and will then be reviewed in QAPI for further recommendations. Any non-compliance issues will be immediately addressed and taken to QAPI. The DON is responsible for sustained compliance. On [DATE] at 10:00 AM, a review was completed of the facility policy entitled, Automated External Defibrillator (AED) Policy/Procedure) dated [DATE]. The policy stated, The purpose is to establish guidelines for and define the use and care of Automated External Defibrillator (AED), and to ensure the most effective and efficient delivery of AED service for persons in emergencies where the need for an AED is required .Operations Procedures 1. Verify that the patient is unconscious and confirm absence of pulse and respirations. 2. If patient has not pulse and is not breathing, the AED unit should be placed on the patient as soon as possible . On [DATE] at 10:15 AM, a review was completed of the facility policy entitled, Cardiopulmonary Resuscitation (CPR) & Emergency Cardiovascular Care (ECC). The policy was not dated but stated, .To imitate Cardiopulmonary Resuscitation (CPR) & Emergency Cardiovascular Care (ECC), using an AED device when necessary, for residents with full-code status and residents who have not declared a code status in the event of cardiopulmonary arrest Complete the following steps, if the resident has been declared a full code: 1. If thorough circulatory, airway breathing (C-A-B) assessment determines there is no pulse or respiratory activity, a licensed staff member will: a. Call for help to initiate a 911 call and page code according to facility protocol, including location. b. Simultaneously with the initiation of CPR/ECC, direct staff member to obtain an emergency cart/and AED device. c. Start chest compression according to the American Heart Association recommendations and follow manufactures recommendations with AED device arrives. d. Continue to follow American Heart Association recommendation for use of AED and CPR/ECC. e. Direct a member of the response team to contact the attending physician and responsible party/DPOA/guardian. This staff member shall also complete hospital transfer sheet including a copy of advance directives/code status and make these documents available to Emergency Response Personnel. f. Defer all resuscitation efforts to Emergency Response Personnel once they arrive and declare that they will assume responsibility of maintaining life support interventions. Per the Administrator, there is not a specific policy for crash cart equipment the crash as the cart is labeled with expected contents.

This citation contains two Deficient Practice Statements (DPS). DPS 1: Based on interview and record review the facility failed to notify hospice immediately after a resident expired for one (Resident #71) of five residents reviewed for hospice notification resulting in the hospice company being delayed approximately 13 hours of being aware of the death, incomplete hospice notification, and to offer power of attorney condolences timely. Findings include: During an interview on [DATE] at 2:30 PM, Clinical Manager B was asked when nurses should call hospice after a resident expires. Clinical Nurse Manager B initially stated, No specific time frame, but then stated as soon as possible. Review of hospice progress note, dated [DATE] at 12:21 PM, stated, Attempted to make a routine visit with patient this morning and was told by staff that patient passed away last night. Facility did not call (hospice company) to make aware of patient passing. Spoke to Nurse D who stated that Nurse Y pronounced patient at 2307 (11:07 PM) on [DATE]. (Hospice company) reached out to family and gave condolences . Review of facility nurse's progress note, dated [DATE] 23:07, stated, Note Text: Rounding to resident's room. No spontaneous movement present. No response to verbal or tactile stimulation. Pupils were dilated and fixed. No breath sounds or heart sounds. No pulses present. Resident (Resident #71) was pronounced @ (at) 23:07 (11:07 PM). Physician,and DON (Director of Nursing) and daughter (Power of Attorney) notified. The hospice company wasn't notified immediately as required upon Resident #71's death; the notification occurred approximately 13 hours after time of death. Review of Resident #71's hospice note, dated [DATE] at 7:05 AM, stated, Facility aware to call (hospice company) if anything changes with patient or needs arise. Review of the facility's Hospice Care plan, revised [DATE], stated, The facility will immediately contact and communicate with the hospice staff, attending physician/practitioner and the family resident representative regarding any significant changes in the resident's status, clinical complications or emergent situations. DPS 2: This Citation pertains to Intake Number MI 873. Based on interview and record review the facility is placed in Immediate Jeopardy for its failure to obtain an oxygen order upon the resident's request for oxygen and failed to provide oxygen therapy for a resident diagnosed and care planned as being dependent on supplemental oxygen and who requested oxygen for comfort measures at the end of his life for one (Resident #71) of five residents reviewed for end of life care resulting in severe respiratory distress, significant drop in oxygen saturation levels, and death. Date IJ (F-695-Respiratory Care) Occurred: [DATE] Date IJ Was Identified: [DATE] Date IJ Notification Served: [DATE] Date Abatement (Removal) Plan Approved: [DATE] Date IJ Abated (Removed): [DATE] Date Abatement (Removal) Plan Verified [DATE] Findings include: Review of Resident #71 's medical record reflected Resident #71 was initially admitted to the facility on [DATE], hospitalized on [DATE], readmitted on hospice services on [DATE], requested oxygen on [DATE], and expired on [DATE]. Review of Resident #71's nurse's (Nurse R) progress note, dated [DATE] at 5:29 PM, stated, Resident has been asking for oxygen and I had to educate resident about his order from hospice that he is not to have any oxygen at all, will continue to monitor. During an interview on [DATE] at 8:35 AM, Nurse R was asked why oxygen wasn't ordered when #71 requested it and stated, I don't know and That man (Resident #71) was always on oxygen (previously). Nurse R reported, I would never deny someone asking for oxygen to not get any. During an interview on [DATE] at 9:03 AM, Clinical Nurse Manager B confirmed there was no documentation Resident #71 received oxygen from [DATE] - [DATE]. Nurse B confirmed all documentation showed he was on room air (no supplemental oxygen). When asked for a comfort measures policy, Nurse B reported there wasn't a policy, but that they follow hospice orders. Nurse B reported facility staff should have called the doctor or hospice to follow up on the oxygen request. Nurse B confirmed there was no documentation of follow up on Resident #71's request for oxygen. When asked if Resident #71 should have been given oxygen after he requested it Nurse B stated, Yes. Nurse B confirmed the nurse (Nurse R) should have called and got an order for [REDACTED]. During an interview on [DATE] at 8:02 AM, Hospice Nurse V confirmed Resident #71 was readmitted to the facility on hospice services on [DATE]. When asked if oxygen was a comfort measure, Nurse V stated Absolutely. Nurse V confirmed hospice never received a request/call/notification from the facility that Resident #71 or the Power of Attorney X wanted oxygen on [DATE] or after. Nurse V confirmed if they had been notified, they would have ordered oxygen for Resident #71. During an interview on [DATE] at 10:21 AM, Hospice Nurse W reported the facility never contacted her or the hospice company to let them know Resident #71 had changed his mind and wanted oxygen on [DATE] or after. When asked if oxygen was a comfort measure Nurse W stated, It is. Nurse W reported had she been told Resident #71 was requesting oxygen she would have proceeded to get an order for [REDACTED].>The hospice attending doctor, Doctor Z for Resident #71, was called on [DATE] at 10:57 AM. The call was never returned. During an interview on [DATE] at 10:58 AM, Nurse Practitioner U confirmed oxygen was a comfort measure and reported she couldn't think of any reason why oxygen would have been contraindicated for Resident #71. During an interview on [DATE] at 10:28 AM, Power of Attorney (POA) X for Resident #71 stated, I had no idea he was requesting oxygen. When asked if she would have wanted Resident #71 to receive oxygen if he requested it POA X stated, Yes. POA X reported she saw Resident #71 towards the end of life and he was agitated. POA X stated I don't think he (Resident #71) was as comfortable as he could have been. During an interview on [DATE] at 5:21 PM, Clinical Nurse Manager B confirmed there was no documentation of any order from hospice indicating not to give Resident #71 oxygen. Review of Resident #71's physician order [REDACTED].#71's oxygen order prior to discharge to the hospital on [DATE] Oxygen at 4 liters continuous revised [DATE] and was discontinued when he went out to the hospital. Prior to this the oxygen order was Oxygen 4L continuous. started [DATE]. Review of Resident #71's Hospice Certification Statement, dated [DATE], stated, Terminal Diagnosis: [REDACTED]. The narrative stated, Patient resting in bed appearing to have an increase work of breathing and agitated. Per patient and family wishes no 02 (oxygen) is to be used at any point. On [DATE] Resident #71 changed his mind/wishes and requested oxygen per the facility progress notes. Review of Resident #71's Hospice Guidelines, dated [DATE], included [DIAGNOSES REDACTED].Severe [MEDICAL CONDITION] (as documented by) .Disabling dyspnea (shortness of breath) at rest. The narrative summary, dated [DATE], stated Recent admit to hospital for SOB (shortness of breath). Review of Resident #71's hospice note, dated [DATE] at 7:05 AM, stated, Facility aware to call (hospice company) if anything changes with patient or needs arise. Review of Resident #71's hospice note, dated [DATE] at 1:58 PM, stated, She (Daughter of Resident #71) states she visited last night and was there early morning, expressed concern regarding pt (patient) comfort mgt (management). Review of Resident #71's hospice vitals included: - On [DATE] at 11:55 AM SpO2 (oxygen saturation) was (!) 80% At Rest w/o (without) Oxygen. - On [DATE] at 1:25 PM SpO2 was (!) 71% At Rest w/o Oxygen. - On [DATE] at 10:00 AM SpO2 was (!) 69% At Rest w/o Oxygen. Review of the facility progress note, dated [DATE], stated, Spo2 (oxygen saturation) 56% on room air. Review of Resident #71's care plan, initiated date [DATE], stated I require supplemental oxygen. Review of the facility's IJ Removal Plan, dated [DATE], stated, DON and corporate consultant reviewed the policies for comfort measures and end-of-life care that includes the provision of oxygen as needed. Facility policy also confirmed oxygen was a comfort measure. Review of the facility's Hospice Care policy, revised [DATE], stated, The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative . On [DATE] at 2:50 PM, notification of Immediate Jeopardy, that began on [DATE] at approximately 5:29 PM, was given to the Administrator, which was the result of the facility's failure to provide requested comfort measures (supplemental oxygen) at end of life for Resident #71 when he asked for it resulting in continued oxygen saturation levels to drop and for respiratory distress. On [DATE], the surveyor confirmed that the facility implemented the following to remove the immediate jeopardy: During an interview on [DATE] at 12:01 PM, the IJ Removal Plan/Abatement Plan was reviewed with the Nursing Home Administrator (NHA) and Director of Nursing (DON). All items were discussed and verified to have been started or completed. Element #1: Resident #71 passed away. On [DATE], this was confirmed through record review. Element #2: On [DATE] at 4:45 PM the Director of Nursing identified the residents on end of life, hospice and palliative care, as well as receiving oxygen therapy. On [DATE] at 5:00 PM the Management nurses initiated assessment of each of these residents and reviewed their clinical records reviewed to ensure that they are receiving the appropriate comfort measures, including oxygen therapy. The nurses included a review of the resident's current orders for oxygen. The nurses clarified orders for oxygen with the physician if needed. The review of the individual residents was completed on [DATE]. On [DATE] at 12:38 PM, the facility provided documentation to show ten residents matching the criteria were identified and reviewed. Element #3: On [DATE] at 5:15 PM the DON and corporate consultant reviewed the policy and procedure for Notification of Change and deemed it appropriate as it requires the nurses to notify the physician and medical decision maker of resident's condition changes. On [DATE] at 12:05 PM, the Director of Nursing discussed the policy and procedure review. On [DATE] at 5:00 PM the DON and corporate consultant reviewed the policies for comfort measures and end-of-life care that includes the provision of oxygen as needed. On [DATE] at 2:18 PM the policy was revised and signed. On [DATE] at approximately 11:00 AM, the Director of Nursing provided the revised policy on hospice care/comfort measures. On [DATE] at 5:00 pm the DON developed the process for the licensed nurses to document oxygen therapy. On [DATE] at 12:05 PM, the process that was developed was explained to the surveyor by the Director of Nursing and how staff will document oxygen therapy in the medical record. The DON confirmed this was also included in the all nurses in-service education. Audit sheets were provided that showed audits had begun and were ongoing. On [DATE] at 5:30 PM the DON and corporate consultant initiated education with the licensed nurses on the following: 1. The above policies with emphasis on recognition of respiratory changes. 2. Administration of oxygen in accordance with physician orders. This includes oxygen saturation levels. 3. The policy on notification of changes and the nurses' responsibility to notify the physician and medical decision maker of changes in condition 4. The nurses' responsibility to follow the Hospice orders and to notify Hospice of changes in resident's conditions. 5. The nurses' responsibility to document oxygen therapy on the MAR indicated [REDACTED] The DON excused licensed nurses on approved leaves from attending the education. The DON will arrange for these nurses to receive the education on their first scheduled shift back to work or via virtual. The DON / designee continued the education until [DATE] when the last nurse was educated. On [DATE] at 12:14PM, the DON confirmed all 22 licensed nurses employed had received the in-service education and showed the sign-in sheet to show education had been completed by end of business on [DATE]. Element #4: On [DATE], the DON assigned the leadership staff audits and checks to complete daily, including the weekend and off shifts to determine compliance with oxygen therapy, identification of changes in conditions, and notification of medical decision maker, hospice and the physician, and whether or not new orders were received. The DON assigned a second audit to the nursing managers to determine compliance with documentation of oxygen therapy. On [DATE] at 12:38 PM, the DON provided audits which confirmed audits had began on [DATE] and confirmed were ongoing.

Based on interview and record review, the facility failed to: (1) prevent 2 in-house acquired pressure ulcers for 2 Residents (#66 and #72), (2) ensure 1 residents (Resident #66) head of the bed (HOB) was at a 30 degree or higher angel while the Enteral Feeding (tube feeding), (3) failed to obtain an oxygen order upon the resident #71's request for oxygen and failed to provide oxygen therapy for a resident diagnosed and care planned as being dependent on supplemental oxygen and who requested oxygen for comfort measures at the end of his life, and (4) perform an annual facility assessment to meet the needs of Residents, resulting in pressure ulcers with unnecessary medications and increase infections with hospitalization s, aspiration pneumonia, [MEDICAL CONDITION] (low oxygen level), an in-accurate facility assessment with the likelihood to affect resident quality of life and quality of care. Findings include: Pressure Ulcers: Review of facility 'Pressure Ulcer Prevention and Management' Policy dated 4/20/16, revised 2/14/17, documented: To establish a system to prevent and manage resident(s) pressure ulcers. Under definition of Pressure Ulcers - are localized injuries to the skin and underlying tissue that occur as a result of pressure or shearing force. A pressure ulcer can develop when pressure on an area of skin increases temporarily cutting off circulation to the affected area and leading to tissue death. Resident #66: Review of skin assessment dated [DATE], documented Sacrum-stage 4 pressure ulcer with tunneling. (No other areas were documented as non-intact skin on assessment). Review of skin assessment dated [DATE], documented area of non-intact skin as: Sacrum 10 x 6 x 1.2 (no centimeters specified). Right Lower leg (front) 6.2 x 1 x 0. Right Heel 1.6 x 1.8 x 0. Left toes- L great toe. 1.2 x 1 x 0. Other-L (left) plantar foot (ball of foot) 1.6 x 2 x 0. R plantar foot 1.8 x 5 x 0. Other- R forearm 3 x 1 x 0. (there were new identified areas of non-intact skin.) Under Treatment initiated Sacrum-tx in place, right plantar foot-tx in place, new right medial heel 1.6 x 1.8, left plantar 1.6 x 2.0, and left great toe bottom 1.6 x 2.0-MD aware, tx in PCC (Point Click Care). Review of skin assessment 8/13/20, under identified areas, documented Sacrum-open area, Right Lower Leg-open area, Right Heel-open area, Other-left great toe bottom, open area. (Review of skin assessments documented above reflected approximately 21 in-accurate or incomplete weekly skin assessments, and several weeks of missing skin assessments for Resident #66). An observation of Resident: #66's wounds was made on 8/12/20 at 9:15 AM, by 2 Surveyors onsite, accompanied by RN T, to observed wounds on Resident #66: observation of Coccyx: Large stage 3 open wound. Bleeding noted on wound and dressing, looks to have recently had dead tissue taken off. Tunneling noted at 11 and 8 o'clock. Resident nodded his head up and down when asked if he had pain (yes). Observation of right lower shin area, approximately 6 inches length, 1-inch width, open area with dressing un-dated on it. Observation of Right Heel: dressing un-dated, no open areas, mushy heel only. Observation of Right bottom of foot (ball of foot): Dressing dated 9/10/20, approximately 4 inches in length and ½ inch width area, Stage II open area. Observation of Left bottom of foot (ball of foot): Dressing dated 8/10/20 not open. Observation of Left great toe: area was noted to be circular, approximately 1 inch, dark brown/black color, with small amount of dried blood. There was no dressing in place. Resident #66 was observed with both of his feet touching/up against the foot board of the bed. He had on blue Prevalon boots on both feet. (PU's on the balls of his feet were from pressure, due to his feet being against the foot board) RN T was not able to answer any questions on Resident #66's wounds at all and stated, I am an Agency nurse. All I was told in report that he had a pressure ulcer. Further observation reflected RN T did not apply a dressing to left great toe when it was brought to her attention that there was no dressing in place. Physician note Patient has history of a feeding tube dysfunction along with a sacral ulcer stage 3-4 on his coccyx status [REDACTED].status [REDACTED].>A second observation was made on 8/17/20 @ 12:15 PM, Resident #66 resting in bed. Eyes were open and Resident #66 able to nod his head yes or no to simple questions. Resident #66 was asked if he was in any pain and nodded yes. Resident #66's call light was observed to be on his right side and tucked behind the assist bar. (Resident has right sided weakness from a previous stroke). Resident #66 was asked if he was able to use his call light and shook his head no. There was Enteral Feeding connected and running at 60 ml/hr. of [MEDICATION NAME] 1.5 Cal with water flush hung and running via pump @ 45 ml/hr. Resident #66 was resting on a specialty mattress. Resident #66 had a Foley catheter in place and tubing and dignity bag observed hanging on the right side of the bed. Resident #66 was positioned slightly toward his right side with a pillow. LPN D entered room and was asked about wounds for Resident #66. LPN D indicated she had seen his wounds before, but it had been awhile as the night shift nurse changes the dressings. LPN D indicated she was not exactly sure what wounds were still opened. LPN D was asked if there was a Unit Manger and indicated yes and she is probably in her office. Surveyor and LPN D observed Resident #66's feet (both) pressed against the foot board of the bed. LPN D indicated that Resident #66 is so long and should be in a longer bed, and he slides down constantly. LPN D was asked if that was how he got pressure ulcers to the bottom of both feet and said 'probably'. Resident #66 had on bilateral Prevalon boots to feet (blue boots), and toes were poking out of the boots. Resident #66 had a flat pillow under his calf's, but his heels were still resting down on the bed. LPN D verbalized she was going to get another pillow to raise up his heels. Certified Nursing Assistant CC entered room to assist LPN D with moving Resident #66 up in the bed. LPN D and CNA CC adjusted resident up in the bed and turned Resident #66 to his left side. Surveyor observed large dressing in place to Sacral area dated 8/17/20. Resident #66 was placed on his back and LPN D pointed out a right shin wound which had dressing in place, dated 8/17/20, and a right lateral ankle wound, with dressing in place, dated 8/15/20. LPN D indicated that dressings are to be changed every 48 hours. There was also a dressing on to left great toe dated 8/17/20. LPN D showed Surveyor Resident #66's right heel, which was not open, and left heel that had dry, flaky skin, and not opened. Resident #66 also had a Foley catheter in place and at insertion site was noted to have some odorous purulent draining coming from the insertion site at the tip of penis. Resident #66 also had [MEDICAL CONDITION] in place with full bag of soft brown stool noted. LPN D indicated she was going to change the bag. LPN D indicated that Resident #66 was set to go to urologist appointment that day, to get the Foley changed, as only a Dr. X may change, due to difficulties getting the Foley back in. LPN D and CNA CC cleaned up Resident #66, placed a clean brief on him, and a gown, repositioned him in bed, and left the room after hand washing. (There was not a dressing on the right heel or left heel per current active orders.) Resident #72- Review of Resident #72's readmission assessment's skin section, dated 8/27/19, didn't identify any heal wound. Progress note dated 8/19/20 stated, open area to RT (right) heel. The progress note, dated 8/30/19, stated Wound care the right heel . Review of Resident #72's facility History & Physical assessment, dated 8/29/2019, stated, Wound .Stasis/venous. The section that shows skin issues/description was blank. Unclear where wounds were. The documentation was inconsistent regarding left and right heel. The care plan revision history/cancellations in Resident #72's was reviewed and only the left heel was noted, no right heel. Review of Resident #72's minimum (MDS) data set [DATE] indicated there were 3 stage 2 pressure ulcers. Review of Resident #72's care plan identifies this left heel wound as a diabetic ulcer on 9/26/19. Review of Resident #72's most recent skin assessment, Weekly Skin Assessment, dated 1/21/2020, stated, Left heel .left heel wound healing, dry, no drainage. There was no measurement or identification of what type of wound this was. During an observation and interview on 8/12/20 at 9:15AM, with Nurse T present Resident #66's left great toe had no dressing on it and the area was noted to be circular; approximately 1 inch, dark brown/black color with small amount of dried blood. Resident #72 was observed with both of his feet touching the foot board of the bed. During the observation, a new dressing was never applied to the toe or addressed as requiring one. When Nurse T was asked for detail on the wounds, she stated, All I was told in report was he had a pressure ulcer. Tube feeding: A second observation of Resident #66 was done on 8/17/20 at 9:50 a.m. accompanied by Nurse Manager LPN A, the resident was again in his bed with Nursing Assistant (CNA) AA in his room emptying the resident's urinary catheter bag. The residents tube feeding was running at 60 cc's per hour with the HOB still observed to be at a 25 degree angle. No staff member had raised the resident's bed since the observation made at 9:22 a.m. During an interview done on 8/17/20 at 9:50 a.m., Nurse Manager A stated It should be 32 degrees up. During an interview done on 8/17/20 at 12:10 p.m., Nurse Manager, RN B stated, a tube feeding should be 30 degrees or higher with it running. We don't have an educator. During an interview done on 8/17/20 at 12:16 p.m., the DON stated, It should be above 30 degrees (the HOB while tube feeding is running), I am the educator, I haven't have time to educate, I haven't educated on that, not since I have been here; I started in July (6/20). During an interview done on 8/17/20 at 2:52 p.m., the DON stated, we have no education on that (instructions on how to properly use the magnetic protractor angle locator). Review of the residents Tube Feeding, and Dysphagia care plans dated 11/6/19, stated Elevate HOB 30-45 degrees during and thirty minutes after tube feed. Review of the facilities Enteral tube feedings Lippincott policy (un-dated, given to this surveyor by Nurse Manager A) stated, Position the patient with the head of the bed elevated to at least 30 degrees or upright in a chair to prevent aspiration. Oxygen use: During an interview on 8/12/2020 at 8:35 AM, Nurse R was asked why oxygen wasn't ordered when #71 requested it and stated, I don't know and That man (Resident #71) was always on oxygen (previously). Nurse R reported, I would never deny someone asking for oxygen to not get any. During an interview on 8/12/20 at 9:03 AM, Clinical Nurse Manager B confirmed there was no documentation Resident #71 received oxygen from 4/17/20 - 4/23/2020. Nurse B confirmed all documentation showed he was on room air (no supplemental oxygen). When asked for a comfort measures policy, Nurse B reported there wasn't a policy, but that they follow hospice orders. Nurse B reported facility staff should have called the doctor or hospice to follow up on the oxygen request. Nurse B confirmed there was no documentation of follow up on Resident #71's request for oxygen. When asked if Resident #71 should have been given oxygen after he requested it Nurse B stated, Yes. Nurse B confirmed the nurse (Nurse R) should have called and got an order for [REDACTED]. During an interview on 8/12/20 at 8:02 AM, Hospice Nurse V confirmed Resident #71 was readmitted to the facility on hospice services on 4/17/2020. When asked if oxygen was a comfort measure, Nurse V stated Absolutely. Nurse V confirmed hospice never received a request/call/notification from the facility that Resident #71 or the Power of Attorney X wanted oxygen on 4/20/20 or after. Nurse V confirmed if they had been notified, they would have ordered oxygen for Resident #71. During an interview on 8/12/20 at 10:21 AM, Hospice Nurse W reported the facility never contacted her or the hospice company to let them know Resident #71 had changed his mind and wanted oxygen on 4/20/20 or after. When asked if oxygen was a comfort measure Nurse W stated, It is. Nurse W reported had she been told Resident #71 was requesting oxygen she would have proceeded to get an order for [REDACTED].>The hospice attending doctor, Doctor Z for Resident #71, was called on 8/12/20 at 10:57 AM. The call was never returned. Facility Assessment: Record review of the facility assessment presented on 8/17/2020 to the state surveyor for the extended survey portion of the immediate jeopardy survey revealed: Date of assessment or update: 4/1/2019 and Date of assessment reviewed with QAA/QAPI committee: 4/26/2019.

This citation pertains to MI 201. Based on observation, interview, and record review the facility failed to prevent the worsening of pressure ulcer, document pressure ulcer assessments completely, and ensure wound treatments in place for two residents (Resident #66 and #72) of two residents reviewed for pressure ulcers resulting in worsening/increase in size of a pressure ulcer, incomplete wound care assessment, a dressing not being present as ordered, and the potential for an increase in pain or further development/worsening of pressure ulcers. Findings include: Resident #72: During an interview on 8/14/2020 at 2:29 PM, documentation (any and all wound assessments) for the wounds noted in the facility's progress notes on 10/21/19 and 10/31/19 were requested from Clinical Nurse Manager B. No additional information on the wounds were provided by the end of survey. Review of Resident #72's facility History & Physical assessment, dated 8/29/2020, stated, Wound .Stasis/venous. The section that shows skin issues/description was blank. Unclear where wounds were. The documentation was inconsistent regarding left and right heel. The care plan revision history/cancellations in Resident #72's were reviewed and only the left heel was noted; no right heel. Review of Resident #72's minimum (MDS) data set [DATE] indicated there were 3 Stage 2 pressure ulcers. During an observation and interview on 8/12/20 at 9:15AM, with Nurse T present Resident #72's left great toe had no dressing on it and the area was noted to be circular; approximately 1 inch, dark brown/black color with small amount of dried blood. Resident #72 was observed with both of his feet touching the foot board of the bed. During the observation a new dressing was never applied to the toe or addressed as requiring one. When Nurse T was asked for detail on the wounds, she stated, All I was told in report was he had a pressure ulcer. Review of Resident #72's physician orders [REDACTED].at bedtime every 2 day(s) for Left great toe bottom. Resident #66: According to the Admission Record printed on 8/17/20, Resident #66 was [AGE] year old male originally admitted to the facility 10/5/19, with [DIAGNOSES REDACTED]. Resident #66 is currently receiving palliative care in the facility. According to the medical record census, Resident #66 was discharged out of the facility on 10/22/19, readmitted [DATE], discharged [DATE], readmitted [DATE], discharged [DATE], readmitted on [DATE]. According to Minimum Data Set (MDS), dated [DATE], Resident #66's Brief Interview for Mental Status was not scored and documented as severely impaired cognition. Resident #66 also coded as extensive assist with two person assist for Activities of Daily Living (ADL) Care, to include bed mobility and transfers. According to MDS, Resident #66 was coded as 'Yes' to one Pressure Ulcer, 'Yes' to unhealed Pressure Ulcer and 'No' to turning and repositioning program. 'No' to nutrition/hydration to manage skin condition. Resident #66 received nothing by mouth and all nutrition was provided by enteral feeding via peg tube. Review of facility 'Pressure Ulcer Prevention and Management' Policy dated 4/20/16, revised 2/14/17, documented: To establish a system to prevent and manage resident(s) pressure ulcers. -Under definition Pressure Ulcers - are localized injuries to the skin and underlying tissue that occur as a result of pressure or shearing force. A pressure ulcer can develop when pressure on an area of skin increases temporarily cutting off circulation to the affected area and leading to tissue death. Staging: Suspected Deep Tissue Injury/Unstageable is characterized by a purple or maroon localized area of intact skin or blood-filled blister that results from damage to underlying soft tissue from pressure or shear. The depth of the suspected deep tissue injury is unknown. Stage I- pressure ulcer characterized by intact skin with non-blanchable redness of localized area, usually over bony prominence. Stage II- pressure ulcer is characterized by partial-thickness tissue loss of the dermis, presenting a shallow, open ulcer with red-pink wound bed without slough (yellow tissue). The ulcer is superficial and presents clinically as an abrasion, blister (intact or open) or shallow crater. Stage III-pressure ulcer is characterized by full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, and muscle aren't exposed. Slough may be present but doesn't obscure the depth of tissue loss. Undermining and tunneling may be present. Stage IV- pressure ulcer is characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (black dead tissue) may be present on some parts of the wound bed. Undermining and tunneling are common. The depth of Stage IV varies by anatomic locations. Unstageable-pressure ulcer is characterized by full-thickness tissue loss which the base of the ulcer in the wound bed is covered by slough, eschar, or both. Until enough slough or eschar is removed to expose the base of the wound, the true depth and, therefore, stage, can't be determined. Down/Back/Reverse Staging is a process for the assessment of the depth of tissue damage. Not a report of healing improvement. The healing pressure ulcer should be documented by objective parameters such as: current measurements and depth--not current stage. Weekly documentation-- shall be completed in the electronic medical record. The charge nurse shall complete a skin assessment on all residents weekly. Treatment shall be initiated when appropriate physician orders [REDACTED]. If no progress is seen in 2 weeks, treatment and/or interventions shall be re-evaluated and documented. Review of 'Skin Assessment' Policy dated 4/12, revised 12/17, documented under objective: To ensure prompt identification, intervention, and prevention of impaired skin integrity. Under 'Policy'-It is the policy of this facility to perform full skin assessments to assure all residents receive an accurate assessment of skin integrity and determine residents needs for intervention and/or prevention of impaired skin integrity and pressure injuries. Under 'Provisions'-A full body, head to toe, skin assessment will be completed by a nurse upon the admission/re-admission of a resident. Skin assessments will be performed weekly after the initial assessment. The skin assessment shall also be performed with change in condition, or after a newly identified pressure injury or breakdown in skin integrity. If indicated, a care plan for skin integrity will be developed. Under 'Documentation of skin assessment'-Include date and time of the assessment, name, position title, observations-skin condition and how the resident tolerated the procedure. Describe wound (measurements, color, type of tissue in wound bed, draining, odor, pain). Document if the resident refused assessment and why. Document other information as indicated or appropriate. At the bottom of the form, The Director of Nursing (DON) has overall responsibility and authority for administration of policies, procedures, and guidelines, related to policy-generated the area for which the signing authority has responsibility. Review of Resident #66's current active orders dated August 17, 2020, documented treatments for wound care: 1: Dakins (1/2 strength) Solution 0.25 % (Sodium Hypochlorite). Apply to sacrum topically at bedtime for PI (pressure injury) 4 (stage IV). Cleanse sacrum with normal saline. Apply moisture barrier to skin around wound. Apply wet gauze with Dakins solutions, pack in wound bed, cover with Allevyn dressing or ABD dry dressing. 2: Cleanse right plantar foot (ball of foot) with wound cleanser, pat dry, apply Dakins solution to wound bed, cover with Allevyn dressing, every 2 days, and PRN (as needed) for MASD (moisture associated skin damage). 3: Cleanse wound to right lower leg with normal saline, pat dry, apply Allevyn, change every 2 days and PRN. 4: Cleanse with wound cleanser and pat dry left plantar foot (ball of foot), cover with Allevyn q (every) 48 hours and PRN. 5: Spray with wound cleanser, pat dry right heel medial, cover with heel cup and wrap with coban q 48 hrs. and PRN at bedtime every two days. 6: Spray with wound cleanser and pat dry left great toe bottom, cover with Allevyn every 48 hours and PRN. 7: Cleanse left heel with wound cleanser, pat dry, apply no-sting skin prep to area, cover with Allevyn dressing. Change every 2 days and PRN until resolved. Review of previous active orders documented an order for [REDACTED]. Review of the current active orders did not reflect an order to assess skin weekly per facility policy. Resident #66 was sent out of the facility on 2/18/20 and returned to the facility on [DATE]. Review of re-admission skin assessment dated [DATE], reflected open areas to Coccyx and no measurements documented or described. Left Hip, no measurements or description provided. Review of skin assessment completed on 2/29/20, documented Coccyx-'open wound on coccyx stage 4, tx (treatment) in place', no measurements or description provided. Left Trochanter (hip), open wound left lateral hip, tx in place, no description or measurements, and new identified area of non-intact skin for Left ankle, open (outer), no description or measurements documented. Tx in place. Review of Progress Notes dated 3/4/20, documented sacrum dressing changed with moderate amount of bloody drainage with yellow tinge by hospice nurses, cleaned with NS pat dry applied new dressing to sacrum and left hip, measurements given nurse sacrum 12 x 15 cm, 8 x 4 cm, dressing secure and clean and intact with no signs of pain at this time (SIC). Review of skin assessment dated [DATE], documented open areas for Left Trochanter with treatment in place, Sacrum, treatment in place, no measurements or description and newly identified open areas for Left and Right Toes, with no description or measurements documented. Review of skin assessment dated [DATE], documented Left Trochanter, and under Description, documented 'dressing'. Sacrum listed as well, and under Description documented as 'ulcer'. (2 weeks between assessments) Review of skin assessment dated [DATE], documented Left Trochanter and Sacrum as non-intact skin with no description or measurements documented. Review of skin assessment dated [DATE] documented Sacrum and under description as 'Tissue beefy red, small amount of red drainage'. On the skin assessment was a new identified area documented as non- intact skin 'Left thigh (front)' as Tissue beefy red, no drainage. Review of Progress Notes dated 5/7/20, documented New wound observed to right lower leg, notified Guardian, and Dr., new orders received and implemented, also informed DON. Review of skin assessment dated [DATE], documented non intact areas of skin 'Right lower leg (rear) and under Description as yellow slough, size 10 cm x 3 cm. Review of skin assessment dated [DATE]-'Coccyx- Stage 4 open wound. Right lower leg (rear) yellow slough 10 cm x 3 cm. Other-left hip Stage #2. Review of skin assessment dated [DATE], (14 days between assessments) documented Sacrum--coccyx-Stage #4, open wound. Right Lower leg (rear)--yellow slough, tx in place continues. Left iliac crest (rear)-left hip Stage #2, healing tx in place. Review of skin assessment dated [DATE], (1 month and 4 days between assessments) documented Skin Intact and under areas to document and describe was blank. Review of skin assessment dated [DATE], documented Skin Intact and under identified areas was blank. Review of skin assessment date 7/11/20, documented 'Sacrum' Stage 4 pressure ulcer with tunneling. There were no other documented areas of non-intact skin. (Tunneling indicated worsening of wound). Review of skin assessment dated [DATE], documented Sacrum Stage 4 pressure ulcer with tunneling. Review of skin assessment 7/24/20, documented Skin Intact and under identified areas listed Sacrum Stage 4 pressure ulcer with tunneling. Review of Progress Notes dated 7/26/20, documented right plantar foot 2.0 x 4.0 x 0.1, MD awarer (SIC), order updated to treat every 48 hrs. and spray with wound cleanser, apply Dakin's and cover with Allevyn q 48 hrs. Guardian aware. Review of skin assessment dated [DATE], documented Sacrum-stage 4 pressure ulcer with tunneling. (No other areas were documented as non-intact skin on assessment). Review of skin assessment dated [DATE], documented area of non-intact skin as: Sacrum 10 x 6 x 1.2 (no centimeters specified). Right Lower leg (front) 6.2 x 1 x 0. Right Heel 1.6 x 1.8 x 0. Left toes- L great toe. 1.2 x 1 x 0. Other-L (left) plantar foot (ball of foot) 1.6 x 2 x 0. R plantar foot 1.8 x 5 x 0. Other- R forearm 3 x 1 x 0. (there were new identified areas of non-intact skin.) Under Treatment initiated Sacrum-tx in place, right plantar foot-tx in place, new right medial heel 1.6 x 1.8, left plantar 1.6 x 2.0, and left great toe bottom 1.6 x 2.0-MD aware, tx in PCC (Point Click Care). Review of skin assessment 8/13/20, under identified areas, documented Sacrum-open area, Right Lower Leg-open area, Right Heel-open area, Other-left great toe bottom, open area. (Review of skin assessments documented above reflected approximately 21 in-accurate or incomplete weekly skin assessments, and several weeks of missing skin assessments for Resident #66). An observation of Resident: #66's wounds was made on 8/12/20 at 9:15 AM, by 2 Surveyors onsite, accompanied by RN T, to observed wounds on Resident #66: observation of Coccyx: Large stage 3 open wound. Bleeding noted on wound and dressing, looks to have recently had dead tissue taken off. Tunneling noted at 11 and 8 o'clock. Resident nodded his head up and down when asked if he had pain (yes). Observation of right lower shin area, approximately 6 inches length, 1-inch width, open area with dressing un-dated on it. Observation of Right Heel: dressing un-dated, no open areas, mushy heel only. Observation of Right bottom of foot (ball of foot): Dressing dated 9/10/20, approximately 4 inches in length and ½ inch width area, Stage II open area. Observation of Left bottom of foot (ball of foot): Dressing dated 8/10/20 not open. Observation of Left great toe: area was noted to be circular, approximately 1 inch, dark brown/black color, with small amount of dried blood. There was no dressing in place. Resident #66 was observed with both of his feet touching/up against the foot board of the bed. He had on blue Prevalon boots on both feet. (PU's on the balls of his feet were from pressure, due to his feet being against the foot board) RN T was not able to answer any questions on Resident #66's wounds at all and stated, I am an Agency nurse. All I was told in report that he had a pressure ulcer. Further observation reflected RN T did not apply a dressing to left great toe when it was brought to her attention that there was no dressing in place. A second observation was made on 8/17/20 @ 12:15 PM, Resident #66 resting in bed. Eyes were open and Resident #66 able to nod his head yes or no to simple questions. Resident #66 was asked if he was in any pain and nodded yes. Resident #66's call light was observed to be on his right side and tucked behind the assist bar. (Resident has right sided weakness from a previous stroke). Resident #66 was asked if he was able to use his call light and shook his head no. There was Enteral Feeding connected and running at 60 ml/hr. of [MEDICATION NAME] 1.5 Cal with water flush hung and running via pump @ 45 ml/hr. Resident #66 was resting on a specialty mattress. Resident #66 had a Foley catheter in place and tubing and dignity bag observed hanging on the right side of the bed. Resident #66 was positioned slightly toward his right side with a pillow. LPN D entered room and was asked about wounds for Resident #66. LPN D indicated she had seen his wounds before, but it had been awhile as the night shift nurse changes the dressings. LPN D indicated she was not exactly sure what wounds were still opened. LPN D was asked if there was a Unit Manger and indicated yes and she is probably in her office. Surveyor and LPN D observed Resident #66's feet (both) pressed against the foot board of the bed. LPN D indicated that Resident #66 is so long and should be in a longer bed, and he slides down constantly. LPN D was asked if that was how he got pressure ulcers to the bottom of both feet and said 'probably'. Resident #66 had on bilateral Prevalon boots to feet (blue boots), and toes were poking out of the boots. Resident #66 had a flat pillow under his calf's, but his heels were still resting down on the bed. LPN D verbalized she was going to get another pillow to raise up his heels. Certified Nursing Assistant CC entered room to assist LPN D with moving Resident #66 up in the bed. LPN D and CNA CC adjusted resident up in the bed and turned Resident #66 to his left side. Surveyor observed large dressing in place to Sacral area dated 8/17/20. Resident #66 was placed on his back and LPN D pointed out a right shin wound which had dressing in place, dated 8/17/20, and a right lateral ankle wound, with dressing in place, dated 8/15/20. LPN D indicated that dressings are to be changed every 48 hours. There was also a dressing on to left great toe dated 8/17/20. LPN D showed Surveyor Resident #66's right heel, which was not open, and left heel that had dry, flaky skin, and not opened. Resident #66 also had a Foley catheter in place and at insertion site was noted to have some odorous purulent draining coming from the insertion site at the tip of penis. Resident #66 also had [MEDICAL CONDITION] in place with full bag of soft brown stool noted. LPN D indicated she was going to change the bag. LPN D indicated that Resident #66 was set to go to urologist appointment that day, to get the Foley changed, as only a Dr. X may change, due to difficulties getting the Foley back in. LPN D and CNA CC cleaned up Resident #66, placed a clean brief on him, and a gown, repositioned him in bed, and left the room after hand washing. (There was not a dressing on the right heel or left heel per current active orders.) Surveyor asked to speak to Unit manager and an interview was conducted on 8/17/20 @ 1:00 PM, in Unit manager's office with Nurse A who indicated she had only been Unit Manager for short time and her regular responsibilities were MDS. Nurse A verbalized the previous two nurses that were in place, before her as Unit Manager, quit when COVID-19 started. Nurse A said they had another nurse in the position and she quit as well and had only been Unit Manager for about 2 weeks. Nurse A verbalized she had been covering the unit since mid to late May, and from March to May there had not been anyone in place as a Unit Manager. Nurse A also verbalized that the IDT (Interdisciplinary Team-DON, MDS, and Dietary) had all been sharing the responsibility of overseeing the unit, but that not-one person was really overseeing the unit. Nurse A was asked about wounds for Resident #66. Nurse A verbalized that Resident #66 was admitted with a Sacral wound, Stage IV, and was previously seen in the hospital wound clinic, and had a wound vac at one time. Nurse A verbalized that Resident #66 was not going to the hospital wound clinic anymore because he was Hospice now and that was considered aggressive treatment. Nurse A indicated Hospice is not managing the wounds now, and that the facility is, and communicating to Hospice the status of wounds. Nurse A was asked about Resident #66's sacral wound, and verbalized the sacral wound was horrible. Nurse A indicated the right ankle, balls of both feet, and right shin were wounds that occurred while residing at the facility. Nurse A said that Resident #66 is turned and repositioned frequently, and is on a Low Air Loss mattress, receiving the supplement Prostat to aid in wound healing. Nurse A was asked how often the nurse looks at his skin. Nurse A indicated he should be getting weekly skin assessments. Nurse A was asked to provide skin assessments and other documents related to Resident #66's wounds from the start of wounds to current. Nurse A provided 8 Weekly Wound Measurements from a time frame of 12/20/19, 12/26/19, 1/9/20, 1/17/20, 1/24/20, 2/27/20, 3/6/20, and 5/9/20. Review of Wound Measurements: 2/27/20-Left buttock 3 cm x 2.5 cm. Sacrum-10 cm x 10 cm. 3/06/20-Left Trochanter (hip) 4.5 cm x 3.5 cm x 0.1 cm. Sacrum-Coccyx 12 cm x 12.5 cm x 2.5 cm. 5/09/20-Left Trochanter (hip) 1.5 cm x 1.0 cm pink granulation tissue, no odor, no drainage . Sacrum-12 cm x 11 cm x 3.0 cm. Tissue beefy red, no drainage no odor, no tunneling There were no additional wound measurements provided by the end of the Survey, other than what was documented on some of the skin assessments. Review of Resident #66's care plans reflected several implemented care plans for: Activities, ADL, Terminal Prognosis related to [MEDICAL CONDITION], Fluid deficit, [MEDICAL CONDITION], Right sided weakness, Pain related to wounds, Hospice, [MEDICAL CONDITION], and Alteration in Skin Integrity. Review of Skin Integrity Care Plan documented as 'Focus-' Resident admitted to the facility with Stage IV pressure ulcer to coccyx, left hip, right rear lower leg, and DTI (deep tissue injury) to bilateral heels (resolved). Potential for further pressure ulcer development r/t Disease process, Immobility, Incontinence. readmitted with Stage II to hip (resolved). 7/26/20-Wound to pantar (SIC) of right foot. Initiation date of care plan was 5/7/20 and revised 7/29/20. Under interventions documented: Assess, monitor, wound healing weekly and prn. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing process. Report improvements and declines to the MD. Currently being followed by the Wound Physician (listed Dr name at hospital wound clinic) dated initiated 10/21/19. Also listed as an intervention, followed by wound clinic. (Resident no longer goes to the wound clinic d/t Hospice indicating it is considered aggressive treatment.) Another intervention, with an initiation date 10/21/19, Weekly head to toe skin assessments as tolerated. (Review of Progress noted did not reflect any documented refusals from Resident #66 related to inspection of skin). Additional interventions: Prevalon boots to be on bilateral heels at all times as tolerated. Also spray right plantar foot with wound cleanser, pat dry, apply Dakins solutions, cover with allevyn, change every 48 hrs. and PRN. Also documented under Focus, dated 8/8/20, Resident has alteration in skin integrity: Right plantar foot, Left heel, left great toe, Left plantar area, Right heel. Listed for Interventions: Monitor/document size improvement, weekly with skin assessment. Report abnormalities, failure to heel, s/s (signs and symptoms) of infection, maceration, to MD. Also documented, to have weekly Skin Assessments. There were not any documented interventions for heels to be up off the bed listed on care plan. Review of Resident #66's wounds reflected the facility failed to accurately assess, monitor, document, prevent the development of wounds, or the worsening of wounds, for Resident #66, who had a very high risk for the development of pressure ulcers, failed to implement interventions on care plans and remove interventions with resolved areas along with current physician orders.

Based on observation, interview and record review, the facility failed to assess a urinary drainage catheter for one resident (Resident #364) of two residents reviewed for urinary catheters and failed to administer pain medication timely for one resident (Resident #365) resulting in Resident #364 being hospitalized and Resident #365 passing away with a pain level of 8 without receiving pain medication. Findings include. Resident #364: On 2/25/20, at 9:18 AM, Resident #364 was in their room with a urinary drainage bag hanging on the side of their wheelchair. On 2/25/20, at 2:57 PM, a record review of Resident #364's electronic medical record revealed an original admission on 1/28/2020 with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set Assessment (MDS), dated [DATE] section H, revealed H0300. Urinary Continence - Select the one category that best describes the resident. 9. Not rated. Resident had a catheter (indwelling . was check marked. A resident who has a urinary catheter is considered not incontinent. A review of admission summary, dated 1/28/2020, revealed Resident is catheter. A review of progress notes revealed no assessment for Resident #364's indwelling catheter and no intake and output documented. There were numerous progress notes that stated Resident #364 was incontinent of bladder: 1/30/2020 18:59 Nurse's Note . Incontinent of bladder . 2/3/2020 22:15 Medical Staff Narrative (Progress) Note . Continue current treatment . there was no bladder/urinary catheter assessment documented. 2/5/2020 15:13 Nurse's Note . Incontinent of bladder . A further review of Resident #364's electronic medical record revealed [DATE]20 09:07 Nurse's Note Resident sent to ER. Resident was lethargic, clammy, and hard to awaken. (the physician) informed and wanted resident sent out. (Residents son) notified and requested to send resident to (hospital.) There was no documented assessment for the urinary catheter or urinary output. A review of the hospital documentation admitted : 02/07/2020 ADMITTING Diagnoses: [REDACTED]. 2. Acute [MEDICAL CONDITION] secondary to bladder outlet obstruction due to malplacement of Foley catheter . As per his son, he was brought to ER with increasing confusion and no urine output for 2 days . The patient developed acute [MEDICAL CONDITION]. BUN (bun test measures kidney function; 7 to 20 being normal) was 62 . New Foley catheter was placed in and monitored for renal function. He was given IV bolus and then IV fluids, continuous hydration for several days. The patient was closely monitored. However, he started having great progress, and his renal function basically returned to normal . BUN is 14 . A review of CT ABD,Pelvis . February 7, 2020 revealed The urinary bladder is moderately distended . Foley catheter balloon appears to be located in the proximal urethra and may be causing bladder outlet obstruction. Foley should be replaced or advanced back into the urinary bladder . On 2/27/20, at 10:34 AM, Interim Director of Nurses (DON) was asked to provide any documentation that would prove the facility assessed Resident #364's urinary catheter prior to their hospitalization and the Interim DON stated, there is not I (input) and O (output) from 1/28 to 2/7. The DON was asked to provide the facility policy on intake and output, assessment of a urinary catheter. The facility did not provide the intake and output or urinary catheter assessment policy prior to exit. The facility did provide a Catheter Care Policy Rev:10/17 which revealed It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter . Male: 15. Gently grasp penis . The policy describes how to perform catheter care. Resident #364's balloon of their urinary catheter was misplaced and was in the urethra and upon doing catheter care would most likely have been noticed. Resident #365: On 2/26/20, at 3:00 PM, a record review of Resident #365's electronic medical record revealed an admission on 12/5/2019 at 2:15 PM with [DIAGNOSES REDACTED]. A review of progress notes revealed that Resident #365 did not receive any pain medication for [MEDICAL CONDITION] pain prior to passing away the day of admission: 12/5/2019 14:08 Nurse's Note (company) Hospice nurse . arrived to assist in admission of patient. 12/5/2019 14:15 (2:15 PM) Patient arrived via ambulance stretcher, patient and family orientated to the room and amenities. Patient is aware of self and responds to name. Patient settled into bed and resting at this time with call light available. Will continue to monitor. 12/5/2019 15:34 (3:34 PM) . Following medication reconciliation with the physician this nurse requested pharmacy call for verbal authorization, physician denied request and to send C2 to [AGE]8#. This nurse wrote out C2 forms for [CONDITION] ([MEDICATION NAME]) and [MEDICATION NAME] for physician's signature and faxed at 1518. 12/5/2019 19:21 (7:21 PM) Nurse's Note Pharmacy faxed back unable to process request stating the dosage must be a mistake . Family is becoming more stressed r/t patient's increase in nonverbal pain indicators and length of time since patient had receive her last dos of pain medication form the hospital . 12/5/2019 20:20 (8:20 PM) Nurse's Note Contacted pharmacy concerning C2 and auth to pull form and pharmacy states that they have not received the faxes yet. Family aware and expressing frustration with the transgressions for their loved one. 12/5/2019 22:00 (10:00 PM) Nurse's Note Patient's without Respiration, pulse, blood pressure. Pupils fixed and dilated. Family is at bedside. Phone call placed to Hospice. A review of the Medication Administration Record [REDACTED]. A review of Request for Removal of Controlled Medication From Contingency Supply Date: 12/5/19 revealed hand written documentation . Note: Patient is exhibiting PAIN at 8/10 and been in facility since 1415. On 2/27/20, at 12:34 PM, Unit Manager F was interviewed regarding back up [MEDICATION NAME] and would the facility have that available for residents if needed and Unit Manager F stated, the Omnicell has [MEDICATION NAME] liquid in it. On 2/27/20, at 12:45 PM, the administrator was asked why Resident #365's [MEDICATION NAME] was not provided prior to her death and the administrator stated, we entered her name in wrong and the pharmacy couldn't deliver it. The administrator was asked to provide their pain policy, narcotic policy and their pharmacy agreement. On 2/27/20, at 1:00 PM, a record review of the facility provided Pain Management Rev:11/17 revealed The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .

This citation pertains to Intake Number MI 401. Based on observation, interview and record review, the facility failed to: (1) prevent a fall with injury for Resident #6, (2) failed to follow a therapeutic diet restriction for Resident #364, (3) failed to follow interventions and provide supervision with ambulation for Resident #21, resulting in a fall with injury for Resident #6,a potential choking hazard for Resident #364, and a potential fall for Resident #21. Findings include: Record review of the facility 'Fall Prevention, Analysis and Follow-up' policy, dated 11/2017, revealed the objective of the policy is to assess the risk of falls of all residents, analyze why fall has occurred and determine what interventions are needed to prevent falls from occurring. Fall definition: unintentional change in position coming to rest on the ground, floor or onto the next lower surface. The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Resident #6: Record review of Resident #6's Minimum Data Set (MDS), dated [DATE], revealed an elderly female resident with Brief Interview of Mental Status (BI[CONDITION]) score of 1 out of 15, severe cognitive impairment. Medical [DIAGNOSES REDACTED]. Section G functional status: resident was assessed as extensive assist of 2 person for bed mobility, toileting, dressing, and personal hygiene. Section H: Bowel and Bladder- always incontinent of urine and bowel. Record review of Resident #6's fall incident/accident report, dated 1/13/20 at 10:29 AM, revealed: Aide came of resident's room and told me the resident fell from her shower chair to the floor and that she was actively bleeding. I went to resident's bathroom and resident was lying on the right side, nose bleeding along with right side of forehead bleeding also. Resident was unable to describe event. When asked if she fell out of chair she said yes. Immediate action taken obtained a set of vitals, skin sweep, and asked where she was hurting. Aide assisted with getting resident from floor to wheelchair with the use of a gait belt. Nose and right side of forehead both with active bleeding. Obtained washcloth and ice and applied to both nose and forehead to stop bleeding and help with swelling. Bleeding controlled within a few minutes. Sent to emergency room for evaluation. Record review of Resident #6's 'Neurological Assessment' form, dated 1/13/20, revealed that neurological checks post fall, except that the 8-hour checks on 1/14/20 at 10:00 PM was blank. Nothing was documented at that time for neurological checks post fall. in an interview on 02/27/20 at 08:15 AM, Registered Nurse (RN) E Interim Director of Nursing (DON) revealed that Resident #6's fall on 1/13/20 occurred during a shower in the bathroom. RN E acknowledged that Resident #6 had a fall history prior to the fall from the shower chair with staff present. RN E stated that the Certified Nurse Assistant was with the resident giving a shower and was turning around to get towels and Resident #6 fell out of her shower chair. Resident #6 sustained an injury to the head and was sent to hospital. RN E acknowledged that Resident #6 had another fall on 2/9/20 when she was found on floor and had hit her head on a trash can. Resident #21: On 2/25/20, at 9:00 AM, Resident #21 was observed in their room, on the toilet, with both doorways wide open. Her walker was standing up in the middle of the room. There was no staff in the room. On 2/25/20, at 9:34 AM, Resident #21 was standing in the hallway outside of her room waiving in a motion for help. This surveyor approached resident and she stated, I need help, I can't get this open. Resident #21 was referring to her syrup packet for her breakfast meal. Resident #21 then walked to her bedside table which was raised to the highest in the middle of the room. Resident #21 left her walker aside, grabbed the bedside table, then began to walk backwards pulling the bedside table towards the bed. There was a fall matt on the floor. There was a Physical Therapy staff member (PTA) N across the hall. PTA N was asked if Resident #21 was able to ambulate independently and PTA N stated, No, she is a one person assist. PTA N assisted Resident #21 to a seated position and set up her breakfast meal. Resident #21 was asked how they normally ask for help and Resident #21 stated, I just go in the hallway and yell for help. Resident #21 was asked what the call light was used for and Resident #21 could not answer. On 2/26/20, at 11:15 AM, Resident #21 was observed ambulating in the hallway with five other residents leaving church. Activity Aide M was holding the hand of a resident who was ambulating in a wheelchair. Activity Aide M was asked if they normally assist six residents alone and Activity Aide M pointed to Resident #21 and stated, well, she's probably a one assist as activity aide M continued to hold the hand of a seated resident and did not assist Resident #21 with ambulation. On 2/26/20, at 1:00 PM, a record review of Resident #21's electronic medical record revealed an admission on 1[DATE]18 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set Assessment from 12/12/19 revealed Resident #21 had severely impaired cognition, required one-person physical assist with transfers and ambulation using a roller walker. A review of the Focus . ADL Self Care Deficit r/t functional deficits, cognitive deficits secondary to closed head injury from fall . Date initiated: 12/ 8 . care plan revealed . Interventions Transfers: (the resident) currently requires limited staff assistance x 1 with transfers with use of RW (roller walker) . Ambulation: (the resident) currently requires limited staff assistance x 1 with use of RW . Date initiated: 0[DATE] . Eating-Independent with Eating after staff setup . Date initiated: 12/09/2018 . A review of Focus (the resident) is at risk for falls r/t (related to) functional/cognitive deficits secondary to deconditioning aeb (as evidenced by) weakness, unsteady gait, history of falls, self transfers Date initiated: 12/09/2018 care plan revealed Interventions . Keep call light within reach when in room. Remind (the resident) to use for assistance Date initiated: 12/09/2018 . toilet resident prior to meals and if eating in her room assist her to her recliner and set up tray Date initiated: 11/19/2019 . A review of progress notes revealed four recent unwitnessed falls: [DATE] 15:03 Nurse's Note resident found on the floor in her room with walker by her side . [DATE]20 17:57 Nurse's Note This writer alerted to room [ROOM NUMBER] by CNA (certified nursing assistant) to let this writer know that resident was sitting on the floor . 2/4/2020 14:57 Nurse's Note resident complaining of discomfort to right knee post fall on 2/3/20 . resident with new orders for STAT (now) x-rays . 2/3/2020 21:17 Medical Staff Narrative (Progress) note Pt seen today after a fall at the facility. Per nursing staff patient fell out of her wheelchair . Patient was asked about the event but she is a poor historian and is not able to recall the event . [DATE]20 18:51 Nurse's Note Writer was called to coast dining room by activity aide, stated resident was sitting on the floor. Resident was sitting facing the dining room window with legs stretched out . Resident #364: On 2/25/20, at 9:15 AM, Resident #364 was sitting in their room. Resident #364 coughed and a moderate amount of drainage came out of his [MEDICAL CONDITION] (a hole in the neck where a breathing tube is placed) site. Resident #364 pulled down their shirt collar and revealed white stringy phlegm. On 2/25/20, at 12:58 PM, Resident #364 was sitting in their wheelchair in the room. The call light was on. The Director of Nurses entered and Resident #364 stated, I'm hungry. I'm supposed to be on nectar thick liquids. On 2/25/20, at 2:57 PM, a record review of Resident #364's electronic medical record revealed an original admission on 1/28/2020 with [DIAGNOSES REDACTED].) Resident #364 was sent to the hospital on [DATE] with a readmission on [DATE] with discharge [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. A review of progress notes revealed 2/20/20 13:09 Nurse's Note during breakfast was delivered a pureed breakfast tray from kitchen at 25% of it with no complications or difficulties, order for diet states NPO kitchen given diet order again with education and verbally accepted. A review of the hospital Discharge Summary [DATE] revealed . He had swallow studies done, and he was started on p.o. (by mouth) diet as per Speech, and modified speech evaluation and modified [MEDICATION NAME] swallow studies were completed as well. The patient was tolerating for a few days. However, a couple days back, he had 1 episode where the patient did have some food coming through the stoma and had a little choking noted. Follow up studies was done. He was kept n.p.o. A review of After Visit Summary [DATE] - [DATE] revealed NPO with tube feeding. On 2/26/20, at 12:44 PM, the DON was asked if they were aware that Resident #364 had been given a tray, ate 25% and that the doctor was not notified. The DON denied being notified of the incident. The DON was asked to provide their ADL (activities of daily living), therapeutic diet and accident policies. On 2/27/20, at 9:46 AM, Registered Dietician (RD) L was asked to clarify Resident #364's diet order and RD L stated, NPO means you don't eat food. RD L clarified the process of meal trays by stating the aides document the food intake and the kitchen staff makes the food and delivers it. There is a green slip that is created by admissions and delivered to the kitchen on admission but sometimes the tray card system gets carried over. On 2/27/20, at 10:00 AM, a record review of the facility Resident Summary Report . Meal: Breakfast . Eats in Room (Resident #364) . Special Diets . NPO . Adaptive Equipment . Mug with lid, all hot liquids . On 2/27/20, at 1:00 PM, a record review of the facility provided Therapeutic Diet Rev:11/17 policy revealed . Therapeutic diets based on the individual needs of the resident must be prescribed by the attending physician . Therapeutic diets will be provided to residents in the appropriate form . A review of the facility provided ADL's (activities of daily living) Policy Rev:11/17 revealed A resident who is unable to carry out activities of daily living will received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . The facility will maintain individual objectives of the care plan . An accident policy was not provided.

Based on interview and record review, the facility failed to (1) prevent a recurrent Urinary Tract Infection [MEDICAL CONDITION] with E. coli for Resident #6 and (2) failed to assess a Foley catheter placement for Resident #364, resulting in hospitalization for both residents. Findings include: Record review of facility 'Perineal Care' policy, dated 11/2017, revealed it is the practice of the facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Record review of the facility 'Quality of Life' policy, dated 10/2017, revealed the objective was identify residents who are clinically at risk and provide proactive interventions to manage their medical needs and minimize/eliminate further decline when possible. Resident #6: Record review of Resident #6's Minimum Data Set (MDS), dated [DATE], revealed an elderly female resident with Brief Interview of Mental Status (BI[CONDITION]) score of 1 out of 15, severe cognitive impairment. Medical [DIAGNOSES REDACTED]. Section G functional status: resident was assessed as extensive assist of 2 person for bed mobility, toileting, dressing, and personal hygiene. Section H: Bowel and Bladder- always incontinent of urine and bowel. Record review of Resident #6's Certified Nurse Assistant task charting for a 30-day look back from 1/29/20 through 2/26/20, revealed that the resident was incontinent daily. Record review of Resident #6's medical record on 02/27/20 10:32 AM revealed that on September Medication Administration Record [REDACTED]. Record review of Resident #6's progress notes pages 1-176, revealed that on 9/7/2019 at 7:44 PM the nurse spoke with the physician regarding urinary analysis results dated 9/6/2019. New order [MEDICATION NAME] 250 mg by mouth twice daily for 7 days. Contact with results of culture and sensitivity. Record review of resident #6's Urine analysis culture and sensitivity dated 9/8/2019 revealed that the urinary tract infection organism Escherichia coli ([CONDITION]) was resistant to [MEDICATION NAME] a fluoroquinolone antibiotic. The U.S. Food and Drug Administration is advising that the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with acute sinusitis, acute [MEDICAL CONDITION], and uncomplicated urinary tract infections who have other treatment options. For patients with these conditions, fluoroquinolone's should be reserved for those who do not have alternative treatment options. An FDA safety review has shown that fluoroquinolone's when used systemically (i.e. tablets, capsules, and injectable) are associated with disabling and potentially permanent serious side effects that can occur together. These side effects can involve the tendons, muscles, joints, nerves, and central nervous system. (https://www.fda.gov/Drugs/DrugSafety/ucm 3.htm) Record review of resident #6's physician's progress note, dated 9/24/2019 at 2:06 PM, revealed that the physician was in the facility and assessed Resident #6. There was no mention of Resident #6's having a urinary tract infection that was resistant to [MEDICATION NAME]. Record review of Resident #6's nursing progress note, dated 9/29/2019 at 1:11 PM, revealed a new order received to start resident on [MEDICATION NAME] 250 bid x 5 days for UTI (Urinary tract infection) as when culture reviewed different antibiotic needed. Resident with no symptoms. Primary care physician (PCP) declined repeat UA order done as given. In an interview and record review on 02/27/20 at 12:33 PM with the Director of Nursing (DON) record review of Resident #6's urinalysis, dated 9/8/19, revealed the organism Escherichia Coli was resistant to [MEDICATION NAME]. Record review of Resident #6's physician orders [REDACTED]. Record review and discussion of Resident #6's progress notes with the DON, revealed that on [DATE] the resident went out to the hospital, and came back with [MEDICATION NAME] antibiotic for ,[MEDICAL CONDITION].-difficile. The facility had no hospital notes in the electronic record related to the hospital admission on 11/1/2019. Record review of Resident #6's progress notes revealed that on 2/14/2020 at 2:59 PM Resident #6 was sent out to the hospital for a change in condition of being non-responsive, lethargic and low blood pressure. Record review of Resident #6's 2/14/2020 hospital discharge paperwork revealed a straight catheter urinalysis of Escherichia Coli. Record review of Resident #6's progress note, dated 2/14/2020 at 8:14 PM, revealed that Resident #6 returned via ambulance from Hospital. Resident #6 was diagnosed with [REDACTED]. Coli organism oral every 8 hours for 7 days. Resident #364: On 2/25/20, at 9:18 AM, Resident #364 was in their room with a urinary drainage bag hanging on the side of their wheelchair. On 2/25/20, at 2:57 PM, a record review of Resident #364's Electronic Medical Record (EMR) revealed an original admission on 1/28/2020 with [DIAGNOSES REDACTED].) A review of the admission Minimum Data Set Assessment (MDS), dated [DATE] section H, revealed H0300. Urinary Continence - Select the one category that best describes the resident. 9. Not rated. Resident had a catheter (indwelling . was check marked. A resident who has a urinary catheter is considered not incontinent. A review of admission summary dated 1/28/2020 revealed Resident is catheter. A review of progress notes revealed no assessment for Resident #364's indwelling catheter and no intake and output documented. There were numerous progress notes that stated Resident #364 was incontinent of bladder: 1/30/2020 18:59 Nurse's Note . Incontinent of bladder . 2/3/2020 22:15 Medical Staff Narrative (Progress) Note . Continue current treatment . there was no bladder/urinary catheter assessment documented. 2/5/2020 15:13 Nurse's Note . Incontinent of bladder . A further review of Resident #364's electronic medical record revealed [DATE]20 09:07 Nurse's Note Resident sent to ER. Resident was lethargic, clammy, and hard to awaken. (the physician) informed and wanted resident sent out. (Residents son) notified and requested to send resident to (hospital.) There was no documented assessment for the urinary catheter or urinary output. A review of the hospital documentation admitted : 02/07/2020 ADMITTING Diagnoses: [REDACTED]. 2. Acute [MEDICAL CONDITION] secondary to bladder outlet obstruction due to malplacement of Foley catheter . As per his son, he was brought to ER with increasing confusion and no urine output for 2 days . The patient developed acute [MEDICAL CONDITION]. BUN (bun test measures kidney function; 7 to 20 being normal) was 62 . New Foley catheter was placed in and monitored for renal function. He was given IV bolus and then IV fluids, continuous hydration for several days. The patient was closely monitored. However, he started having great progress, and his renal function basically returned to normal . BUN is 14 . A review of CT (Cat Scan) ABD,Pelvis . February 7, 2020 revealed The urinary bladder is moderately distended . Foley catheter balloon appears to be located in the proximal urethra and may be causing bladder outlet obstruction. Foley should be replaced or advanced back into the urinary bladder . On 2/27/20, at 10:34 AM, Interim Director of Nurses (DON) E was asked to provide any documentation that would prove the facility assessed Resident #364's urinary catheter prior to their hospitalization and the Interim DON E stated, there is not I (input) and O (output) from 1/28 to 2/7. The DON was asked to provide the facility policy on intake and output, assessment of a urinary catheter. The facility did not provide the intake and output or urinary catheter assessment policy prior to exit. The facility did provide a Catheter Care Policy Rev:10/17 which revealed It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter . Male: 15. Gently grasp penis . The policy describes how to perform catheter care. Resident #364's balloon of their urinary catheter was misplaced and was in the urethra and upon doing catheter care would most likely have been noticed.

This citation pertains to Intake Number MI 827. Based on observation, interview, and record review the facility is placed in Immediate Jeopardy for its failure to provide adequate supervision and functioning safety devices to ensure the safety and prevent the elopement for one (Resident #6) of six residents reviewed for elopement, resulting in Resident #6 being outside the facility alone, without staff being aware, and the potential for being struck by a motor vehicle resulting in serious harm, serious injury and/or death. Immediate Jeopardy began on [DATE]. Immediate Jeopardy was identified on [DATE] Administrator was notified of the Immediate Jeopardy on [DATE] at 3:13 PM. A Removal Plan was accepted with a Removal Date of [DATE]. Findings include: Review of Resident #6's elopement care plan, prior to the elopement, with revision date [DATE], stated, (Resident #6) is an elopement risk/wanderer AEB (as evidenced by) Disoriented to place, she looks for her family and dog. Does not understand need for NH (nursing home) placement. This care plan included a goal of (Resident #6) will not leave facility unattended through the review date., revised [DATE]. Resident #6's brief interview for mental status, dated [DATE], score was four which reflected severe cognitive impairment. Review of Resident #6's Elopement Risk Assessment, dated [DATE], stated, If the resident wanders, does the wandering place the resident at significant risk of getting to a potentially dangers place ( .outside the facility) with the response Yes selected. Review of the facility's Resident #6 [DATE] elopement investigation revealed Resident #6 had exited the building at approximately 6:30 PM (This was the last time she was seen prior to being found outside; seen by Nurse C) , without staff being aware the elopement had occurred, and was found outside on the sidewalk past the parking lot near a busy road (Speed limit 35 miles per hour) by Nurse B whose shift was over and was headed home for the night. Nurse B's report stated, While pulling out of the parking lot onto (Road name) and noticed a familiar walker. I parked my car and got out and yelled to (Resident #6) and she turned around. Ran immediately to her and steadied her by a tree. Called the nursing home but no one answered. When family drove in to visit I motioned for the boys to come over. They ran into the nursing home and brought a w/c (wheelchair) out . The facility's investigation revealed Resident #6 was wearing a wander guard alarm bracelet at the time of the [DATE] elopement, the alarm at the front door (the door Resident #6 eloped through) did sound (However, no staff responded), and no staff received a message on their pager that the door had been exited/alarm was set off. Review of the facility's Elopements and Wandering Residents policy, revised ,[DATE], stated This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents ., Elopement occurs when a resident leaves the premises or a safe area without authorization . and/or any necessary supervision to do so., and Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. Staff did not respond to the sounding alarm on [DATE] in a timely manner and this allowed Resident #6 to elope from the facility unsupervised/unattended. Review of (Alarm company's) work order, dated [DATE], stated, a resident (Resident #6) was found in the parking lot last night ([DATE]), and I went to see if our system failed. We have logs confirming our system worked, but the way paging is set up, several people didn't get the page. The alarm company confirmed the alarm system was functioning correctly, however staff didn't respond to the sounding alarm. During an interview with the interim Director of Nursing (IDON) on [DATE] at 9:52 AM, she confirmed Resident #6 had a wander guard on at the time of the elopement on [DATE]. IDON confirmed when staff (nurses and certified nurse assistants) was interviewed post elopement they reported the alarm message didn't go to their pagers but when they did make their way to the front door, after Resident #6 was brought back into the facility, the alarm was sounding, IDON confirmed Resident #6 eloped through the front door (Door #6) on [DATE], and when asked what time Resident #6 exited she stated, Couldn't tell you for sure. When asked how long Resident #6 was outside alone IDON reported Maybe 15 minutes. When asked how the alarm system should work IDON reported when a resident wearing a wander guard approached an exit the alarm would sound and send a message to the staff's pagers and once the door is opened it should send a page on the pagers to alert staff the door is open. She confirmed on [DATE] at 10:30 AM that those pages didn't get sent to the staff's pagers at the time of the [DATE] elopement. When IDON was asked if Resident #6 was found outside alone she stated Yeah, and when asked if Resident #6 was allowed to be outside alone she stated No, absolutely not. During an interview with Nurse B on [DATE] at 10:37 AM, Nurse B confirmed she found Resident #6 outside alone at about 6:35 PM or twenty to seven on [DATE]. She confirmed they re-entered the building through the front door and the alarm was sounding, but it was quieter than it alarms now. When asked how much quieter the alarm was before, Nurse B stated Three quarters quieter. (The front door alarm had likely been too quiet and staff in the back of the building couldn't hear it alarming, which allowed time for Resident #6 to elope without staff being aware). Nurse B showed the surveyor where Resident #6 was found outside, and this was roughly 50 yards from the facility front door and approximately 10 to 15 feet from the road. Nurse B confirmed the road was a busy street. Nurse B reported when she got out of her car and approached Resident #6 she stated I'm going home and was ambulating down the sidewalk (confirmed in the East direction away from the facility). Nurse B stated, It was quite a ways to walk. Resident #6's wheelchair was inside the front door; she had left it when she eloped from the facility. During an observation on [DATE] at 10:37 AM, the sign on the front door facing inwards stated, PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPEN IN 30 SECONDS. The surveyor and interim Director of Nursing (IDON) on [DATE] at 10:55 AM, went throughout the facility and tested the wander guard and door alarms of all exits. When Door #8 was approached by IDON with a wander guard the wander guard alarm didn't sound/function correctly. On [DATE] at 11:22 AM, the Nursing Home Administrator was informed Door #8's wander guard didn't function correctly and she reported she had called the alarm system and would have a staff member placed at the door until the alarm company could fix it. During observation and interview on [DATE] at 1:26 PM, alarm system employee R stated he had adjusted Door #8's alarming that visit so it would alert more responsively. Alarm system employee R stated he adjusted Door #8's alarm by turn up the sensitivity and range has increased (the alarm would sound when a wander guard was in the area). Alarm system employee R confirmed he was the staff who responded after the [DATE] elopement to check the alarm system and indicated the door alarm pages for certain doors only went to certain staff depending on where in the building they were working (Staff working in a certain area of the building would only get pages about door exit alarms for that area of the building in which they were working). On [DATE] at 3:13 PM, notification of Immediate Jeopardy, that began on [DATE] at approximately 6:30 PM, was given to the Administrator, which was the result of the facility's failure to prevent the elopement and ensure the safety of Resident #6, who was not safe to exit the building alone was able to do so, without staff knowing or responding to sounding alarms timely. On [DATE], the surveyor confirmed that the facility implemented the following to remove the immediate jeopardy: 1) Immediately the resident was assessed head to toe, no signs of injury and vitals were within normal limits. All other residents were assessed for the potential to elope, no issues. Completed on [DATE]. It was confirmed this was completed [DATE] and again on [DATE]. 2) The family and Physician were notified on [DATE]. It was confirmed this was completed [DATE]. 3)On the day of the event [DATE], Resident was placed in the memory care unit, which is secured with an alarm system that was verified on [DATE] by Compass Alarm System to be accurately working as well as all the doors were verified by Compass. Contacted Compass, and verified the alarm system and adjusted the system to alert every pager in the community if an exit door alarm is engaged and added an amplified sound screamer that extends the sound beyond the front door. Installed cameras in strategic locations throughout the community including exit doors to ensure the safety of the residents. Completed on [DATE]. It was confirmed the resident's room was changed on [DATE], cameras installed [DATE], and the surveyor confirmed working exit door and wander guard alarms on [DATE] at 1:26 PM. The [DATE] and [DATE] alarm system work orders were confirmed to have been completed. 4) [DATE]- Headcount was completed with no new elopement attempts made. It was confirmed this was completed [DATE] at 5 PM. 5) Staff started re-education on [DATE] on the elopement policy, headcount accuracy. It was confirmed as of 12:02 PM on [DATE] that 42 of 68 employees had received the education. The facility has a planned date of [DATE] to have all staff educated and confirmed no one will be scheduled to work until they've received the training. 6) All residents were assessed for elopement on [DATE], at risk patients had a care plan update that addresses elopement interventions. This was confirmed on [DATE]. 7) On [DATE], Leadership Staff were assigned to complete door checks and elopement drills (including head counts) at random times including the weekend and off shifts, to ensure the safety of the residents at all times. It was confirmed an elopement drill was completed on the Bay unit on [DATE] at 6:45 PM, door checks were started [DATE] at 5 PM and all staff are scheduled to complete elopement drills by [DATE]. 8) On [DATE] a staff was placed at door #8 after it was found unable to alarm until compass arrived and verified the functionality of the door. It was confirmed staff was placed at Door #8 starting at 11:22 am on [DATE] and the alarm system company had resolved Door #8's wander guard functioning [DATE] at 1:26 PM. 9) Treatment Administrator Record, the TAR is where the nurses document the placement and wonder guard functionality Q (every) shift. It was confirmed that each resident's wander guard was tested with each door [DATE] at 6 PM.

This citation pertains to Intake Number MI 688. Based on observation, interview and record review, the facility failed to 1) implement and document (on the care plan and Kardex) pressure ulcer preventive measures for 1 resident (Resident #44), 2) identify and treat coccyx pressure ulcer for 1 resident (Resident #256), and 3) treat 1 resident for a pressure ulcer (Resident #256), of 2 residents reviewed for pressure ulcers, resulting in osteo[DIAGNOSES REDACTED] (infection in the bone),[MEDICAL CONDITION] (infection throughout body), extended healing time and increased antibiotic usage. Findings Include: Resident #44: Review of the Face Sheet, Minimum Data Set (MDS) dated ,[DATE], physician orders [REDACTED].#44 was [AGE] years old, confused and admitted to the facility on [DATE]. The residents [DIAGNOSES REDACTED]. Review of the residents facility Weekly Skin assessment dated [DATE], revealed a scab was found on the residents right heel. Observation of Resident #44 was done on 4/24/19 at 8:30 a.m., he was in bed with his right heel laying directly on his mattress with a dressing over the heel area. Observation of his room revealed no pressure reduction boots, heel wedge or pillow to elevate his right heel off the mattress. During an interview done on 4/24/19 at 8:35 a.m., Nursing Assistant (CNA) II was asked by this surveyor if the resident had any pressure reduction boots or a device to elevate his right heel from the mattress. CNA II stated, He is supposed to have a pillow under his heel, or boots on (pressure reduction boots). CNA II searched the residents room and was unable to locate any pressure reduction boots or a pillow to raise the residents heel off the mattress (to decrease pressure on his right heel, he already had a pressure ulcer on it). CNA II revealed staff had been putting the residents heel up on a pillow; she did not know where the pillow went. This surveyor and CNA II reviewed the residents electronic Kardex; no documentation was found of any pressure reduction boots or to raise the residents right heel off the mattress with a wedge, position device or pillow. CNA II stated, it (preventive measures for the residents right heel, to avoid direct pressure of the mattress) should be on here. Review of residents pressure ulcer care plan (dated 4/9/19) and his care Kardex (un-dated), revealed no documentation of any preventive measures regarding his right heel pressure ulcer (decreasing the pressure from the mattress). During an interview done on 4/24/19 at 8:45 a.m., the MDS Nurse, LPN Y stated He should have (pressure reduction boots) or a pillow for his heel. Review of the residents pressure ulcer care plan dated 4/9/19, and Kardex revealed on 4/24/19 interventions had been added to elevate bilateral heels to be offloaded/elevated on pillow when in bed as tolerated for pressure relief. Bilateral prafo boots (pressure reduction boots) to be in place as tolerated when up in wheelchair. During an interview done on 4/24/19 at 8:57 a.m., MDS Nurse Y stated He did not have anything on his Kardex or care plan, I put it on today (on 4/24/19, after the the concern was identified during the survey). During an interview done on 4/25/19 at 12:14 p.m., the Director of Nursing/DON stated The wound care nurse is supposed to up-date the interventions on the care plan. She quite (MONTH) 14th, and on (MONTH) 26th his (Resident #44) heel pressure ulcer was identified. The DON said the facility has not yet been able to replace the Wound Care nurse; staff nurses are doing resident wound orders. Review of the facility Pressure injury management, Long-term care policy dated 8/12/16, revealed facilities are to have in place (on the residents care plan and Kardex) preventive measures regarding pressure ulcers and treatment measures of existing pressure ulcers. Resident #256: On 4/25/19 at approximately 3:00 PM, a review was completed of Resident #256's medical records, it revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #256 was not able to make her needs known and facility staff had to anticipate her needs. Resident #265's MDS (Minimum Data Set) Assessment did not list the resident being admitted with pressure ulcers. Further review was completed of the resident's records: Hospital Discharge Summary completed on 2/22/19 at 1:26 PM - Discharge [DIAGNOSES REDACTED]. Facility Admission/ Readmission Assessment completed on 2/22/19 - Under Skin Integrity it stated the resident did not have any open areas but had the following skin issues: o Right hand- dry palm o Left hand- dry palm o Small sore of left toes o Blister on outer big toe o Right lower arm bruising o Sore on back of left stump o PICC removal of right arm o Callous on right foot Admission History and Physical completed on 2/25/19 by the Medical Director - Pt (patient) is [AGE] year old admitted from (acute care) hospital with [MEDICAL CONDITION](stroke) with left [MEDICAL CONDITION]. Pt was seen in ICU (intensive care unit) and was seen by neurology and ICU team as well. Pt was stabilized and meds were adjusted however families did not want any aggressive medical care and hence she was sent here for rehab . - Under the anatomical illustration of the human body there is nothing listed for skin conditions and the active [DIAGNOSES REDACTED]. Progress Notes - 2/22/19 at 2:29 PM o Resident admitted on [DATE] from hospital . skin integrity: color natural warm equal dry turgor fair. Open areas: no . - 2/24/19 at 4:04 AM o .Skin (ulcer, rash, bruising, swelling, skin tear, etc): no skin issues noted . On 4/24/19 at 9:00 AM, phone contact was attempted with the complainant but there was no answer and voicemail was left requesting return phone call. On 4/24/19 at approximately 11:15 AM, a review was completed of the skin assessments, shower sheets and wound assessments for Resident #256. It revealed the following: Skin Assessments 2/27/19 - .Resident with old bruising and redness since admit . - Under identified Area/Area's it lists the following: o Left knee (front)-stump o Right antecubital- bruise o Left antecubital- bruise 3/12/19 - .Allevyn dressing to coccyx and to side of right toe-blister opened . - Under identified Area/Area's it lists the following: o Right toes- side of right great toe at the base-blister opened-allevyn dressing applied o Sacrum-allevyn dressing applied 3/20/19 - .Coccyx, right heels and right toes . - Under identified Area/Area's it lists the following: o Right heel-blisters-dressing applied o Right toe (s)- open area- dressing applied o Coccyx- dressing applied Shower Sheets 2/27/19 - Shower sheet indicated there were no new area of concerns. The illustration of the anatomical body did not have any markings on it that indicated skin concerns. 3/2/19 - Shower sheet indicated there were some reddened areas but there were no markings on the illustration of the anatomical body. There is some illegible writing at the bottom of the document. Weekly Wound Measurements 3/14/19 - Under identified Area/Area's it lists the following: o Other- Base of right great toe medial side. 1x1 cm (centimeters). Open area wound base is red. No tunneling or undermining noted. Wound edges are intact and irregular. Scant amount of serosanguinous drainage noted. No odor noted . 3/20/19 - - Under identified Area/Area's it lists the following: o Other (specify)- Base of right great toe medial side. 1.2 x 1.2 cm (centimeters). Open area wound base is red. No tunneling or undermining noted. Wound edges are intact and irregular. Scant amount of serosanguinous drainage noted. No odor noted . o Right heel- 8 x 8 cm depth unknown stage 2 pressure. Intact fluid filled blister skin is white. Edges are intact. Peri wound is pink and blanches . From the documentation presented above it can be ascertained Resident #256 developed the pressure ulcer during her stay at the facility on or around 3/12/19. The last documented shower on 3/2/19 mentioned redness on the resident but did not specify where. It appears the wound nurse was not aware of the pressure ulcer on the resident's coccyx and was not following the progression of the wound or the treatments documented on the weekly skin assessments completed by facility nurses. On 4/25/19 at approximately 9:45 AM, a review was completed of Resident #256's care plan for any interventions regarding pressure ulcers. There were no specific interventions located regarding the development of pressures ulcers on her coccyx or the open areas on her foot. The care plan stated the following: Focus: (Resident #256) has potential for pressure ulcer development r/t (related to) immobility, incontinence. Initiated on 3/7/2019 Interventions: .Inform (Resident #256) and family of any new area of skin breakdown .(Resident #256 requires use of broad chair .treatments as ordered .weekly head to toe skin assessments as tolerated. Further review was completed of Resident #256's progress notes, physician notes and physician orders [REDACTED]. On 3/13/19 a progress note indicated Resident #256 had a pressure ulcer on her coccyx that was covered with a dry dressing. Additionally, there was one subsequent Physician note on 3/15/19 that did not mention an assessment and/or development of coccyx pressure ulcer. Resident #256's Order Summary Report was reviewed for her length of stay at the facility. The following order was indicated: - Right bunion cleanse with normal saline, pat dry, apply calcium ag and cover with alleyvn dressing daily ordered on [DATE]. There were no other treatment orders found for coccyx pressure ulcers. It is not able to be ascertained why facility documentation is inconsistent regarding the development and treatment of [REDACTED]. On 4/25/19 at 1:11 PM, an interview was conducted with Nurse A regarding the admission assessment for Resident #256. The Nurse and this writer reviewed the initial skin assessment together, Nurse A stated if a coccyx wound was not documented in her admission assessment then she did not have one. A review was also completed of hospital discharge records for this resident and it was agreed that the resident was not admitted with a coccyx wound. On 4/25/19 at 2:15, an interview was conducted with CNA (Certified Nursing Assistant) R who reported when Resident #256 was admitted to the facility she did not have a pressure ulcer. On 4/25/19 at 2:27 PM, an interview was conducted with the DON (Director of Nursing) regarding the development of Resident #256's pressure ulcer. The DON and this writer reviewed the resident's assessments, progress notes and physician orders. The DON reported from the documentation it appears the wound nurse (whom is no longer employed at the facility) was not aware the resident had a coccyx wound and was only aware and treating the resident's toe. The DON was not able to locate any treatment orders that matched the coccyx treatment that was documented for the resident. The DON reported it appears Resident #256 acquired a pressure ulcer in the facility that was not being treated or that the facility was not aware of. On 4/26/19 at 4:00 PM, a review was completed of Resident #256's hospital records. The resident was discharged home from the facility on 3/21/19 at 1:10 PM and was admitted to the acute care hospital on [DATE]. The following was in the hospital records: ED (Emergency Department) Provider Notes: - .ED for evaluation of a coccyx wound that family cannot manage at home . He (son of patient) reports that he noticed these wounds last night when he went to change her brief. He reports that he was visited by a home care nurse last night who tried to talk to him about infection risk due to her stool getting into the wounds .There is stage II decubitus ulceration over the coccyx .Given the present symptoms of coccyx wound, my initial clinical impression [MEDICAL CONDITION], differential [DIAGNOSES REDACTED].Patient's lactic acid resulted at 3.4. A [MEDICAL CONDITION] was immediately called .Patient was started on [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic) IV (intravenous) . [DIAGNOSES REDACTED]. - On 4/3/19 Resident #256's pressure ulcer was debrided: .Stage IV ulcer of sacrococcygeal region. Pre-debridement size 6 cm x 7 cm x 2 cm. Post debridement size 13 cm x 7.2 cm x 4.5 cm .patient has osteo[DIAGNOSES REDACTED] in the sacrum . - Discharge Summary: .Patient will require long term IV antibiotic treatment therapy .PICC line placed during admission .patient underwent debridement on 4/3/19 .continue with [MEDICATION NAME] IV 3.375 g every 8 hours for 38 more days . - Discharge Diagnoses: [REDACTED].[MEDICAL CONDITION]-secondary to above improved .

This citation pertains to Intake #MI 071. Based on observation, interview and record review, the facility neglected to notify the nurse and oncoming shift CNA (certified nursing assistant), assigned to care for Resident #913, of aggressive, combative behavior during care and injury to the arm and did not follow care planned interventions for behaviors, for one Resident (#913) of ten reviewed for abuse, resulting in inaccurate, incomplete information conveyed to the physician, a delay of medical treatment, ongoing pain and subsequent hospitalization with surgery. Findings include: A review, of Resident #913's medical record, revealed an admission into the facility on [DATE] and a re-admission on 1/28/19 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment revealed the Resident had moderately impaired cognition and needed extensive assistance of two or more persons with bed mobility, transfers, dressing and personal hygiene. A review of the incident and accident report for Resident #913, revealed: Date of injury, 1/26/19 at 10:00 AM, prepared by Nurse E, Nurse got in report resident had pain to upper left arm, awaiting Doppler STAT (immediately). Upon assessment nurse noticed large egg shaped knot to left bicep. The area did not appear warm or cold to touch, no bruising present. Nurse requested resident to raise her left arm, movement was weak and not able to move in full range of motion. When asked by the nurse what happened resident states, 'I woke up like this.' Nurse asked if she had fallen, had an accident or was grabbed by another resident or staff member. Resident stated, 'no, it just hurts!' Resident denies pain to any other part of her body, no signs of fall, no skin issues present at this time. Immediate Action Taken: Description: Nurse followed head to toe assessment, administered PRN (as needed) pain medication, notified (Doctor), obtained new orders for x-ray of left shoulder STAT. Results showed positive for dislocation without fracture. Notified (Doctor), okay to send to (hospital). Notified unit manager on call and next of kin notified of transfer. A review of the investigative report for Resident #913, revealed: -Incident Summary: Nurse (Nurse K) went in to give insulin to Resident (#913) at 7:30pm (on 1/25/19) and resident was fine with no complaints of pain. At approximately 9:20pm (on 1/25/19) agency CNA's (Certified Nursing Assistant) (CNA CC and CNA DD) went in to give care and resident was also not complaining of pain but was combative during cares. At approximately 10pm (on 1/25/19) CNA (EE) went to check on Resident and she was complaining of pain in her arm. -Investigation Summary: Floor nurse (K) saw resident (#913) at approximately 7:30pm (1/25/19) for her insulin. (Nurse K) stated that (Resident #913) had no signs, symptoms or complaints of pain at that time. (Nurse K) also stated that (Resident #913) was in bed when she gave her the insulin. Then at approximately 9- 9:20pm (1/25/19) Agency CNA's (CC and DD) went into (Resident #913) room to give BM (bowel movement) care. They also stated with verbal and written statements that she had no signs, symptoms or complaints of pain at that time. They state that they had to put her to bed to do BM care and she became very aggressive to the point of hitting her arm on the bed frame. They stated they did not report this to anyone. At approximately 10pm (on 1/25/19) when the next shift CNA (EE) came on shift, she heard (Resident #913) stating her arm hurt and she went to get the nurse. The nurse at this time was now (Nurse B). (Nurse B) states that she assessed and thought it looked like a possible clot due to how it was looking at the time. She called the Dr (doctor) and he gave an order for [REDACTED]. The results came in and it was a dislocation. (Resident #913) was sent to the hospital. The two agency CNA's were questioned again by their own company at our request and they are saying that they are not changing their stories. Based on our timeline and the fact that she had no complaints of pain prior to the two agency CNA's entering her room, we feel her injury happened between the time they entered her room and the time they left her room. Since they will only say she hit her arm on the bed frame during care, I do not know if that would have been enough to cause a dislocation of the shoulder. They admit they did not report her hitting her arm on the bed frame to anyone. -Interviews in the investigation report included: --Interview signed by CNA DD, revealed, Had her from 6A-10p (6:00 AM to 10:00 PM) . At 9PM - 9:20 PM her and (CNA CC) tried to put (Resident #913) into bed (Resident #913) became very aggressive at this time hitting at both (CNA DD and CC) with both arms and fists clenched. Also attempted to kick at them and spit. Transferred to bed and she was still hitting at them and even while they changed her because she was full of BM. When she swing at them 1 time her arm did hit the frame of the bed. Able to move both arms after this. --Interview signed by CNA CC, dated 1/26/19, revealed, As (CNA DD) and I went into change (Resident #913) she was very combative and aggressive towards staff swinging and punching staff. We were trying to change her as she spitted and kicked at us. When we left her she was in no pain she was fine. She stated: get the [***] out my room. --Interview of CNA EE, dated 1/26/19, revealed, On 1/25/19 when I came to the floor I heard (Resident #913) saying 'It hurts, it hurts, my arm hurts. I went in her room to ask her what was wrong. She pointed on my arm where it was hurting on her arm. I told the charge nurse . No care was given because of her pain. P.S. She was checked on quite often to see how she was doing. She would not move her arm. --Interview via phone with Nurse B by Unit Manager C, revealed, Spoke to (Nurse B) at 8AM 1/26/19. (Nurse B) said she was notified by CNA that (Resident #913) was complaining of pain at 11PM. (Nurse B) went into check on her and she noticed that the left arm was swollen slightly pink and warm to the touch and a lump between left elbow and below left shoulder in the fatty part of the arm. She got her pain meds increased and called the physician and he ordered a venous Doppler to be done. (Nurse B) asked her how it happened and she didn't know . (Nurse B) said she had not fallen as far as she knew. She asked (Resident) if she could move the arm and she could move it out to about 90 degrees. (Nurse B) said everyone kept checking on her and the increased pain med helped. (Resident #913) will sit herself on the side of the bed. --Interview signed by Nurse E, revealed, On 1/26/19 I was assigned the long term Unit 8a to 8p (8:00 AM to 8:00 PM). In report I was told (Resident #913) was awaiting a STAT Doppler to rule out possible blood clot to upper left arm. Upon further assessment I found (Resident #913) to have a hard knot on her bicep. I did not believe the area to be warm or cold to touch. I administered PRN medicine for pain. Asked ( Resident ) to move her arm, her range of motion was weak/abcent (absent). Contacted (Doctor) to order STAT shoulder x-ray of lt (left) arm. Results came back as dislocated without fracture . A review of Resident #913's progress notes revealed: -Date 1/25/19 at 11:01 PM, Resident sitting on edge of bed crying states left arm hurts. Left upper arm slightly swollen pink and warm to touch. [MEDICATION NAME] (pain medication) prn (as needed) administered. Called (Doctor) new orders to increase Tylenol to 1000mg (milligrams) every 8 hours increase [MEDICATION NAME] to 50mg every 12 prn venous Doppler left upper arm ., author Nurse B. -Date 1/26/19 at 11:20 AM, Resident sitting on side of bed, rocking back and forth complaining of increased pain to left arm and shoulder, scheduled and PRN medication administered for pain. Spoke with (Doctor), new order for stat x-ray to the left shoulder ordered at this time, author Nurse E. -Date 1/26/19 at 3:00 PM, Resident c/o left shoulder pain, impaired range of motion, PRN medication administered, called (Doctor) for STAT X-Ray to left shoulder. Results positive for dislocation, (Doctor) notified, okay to transfer to (hospital) . (Ambulance service) picked up resident via stretcher, author Nurse E. -Date 1/28/19 at 5:41 PM, Resident arrived back to facility via (Ambulance service) on stretcher at 3:30 PM. She has a left arm sling on. She is resting and appears in no pain. When I asked her if she was in pain she didn't say any words to me., author Unit Manager Nurse C. A review of Resident #913's x-ray on 1/26/19, electronically signed at 1:51 PM, revealed Shoulder complete, min 2V (two view), left. Results: The humerus is anteriorly and inferiorly dislocated with respect to the glenoid, There is no fracture. Acromioclavicular and coracoclavicular joints are also normal. Conclusion: Anterior shoulder dislocation. A review of Resident #913's hospital discharge summary revealed: -History of present illness: (Resident #913) . came in to the acute care facility on 1/26/19 due to shoulder pain, she was evaluated in the Emergency Department by (Doctor). She has a history of dementia, she was transferred to the emergency department from skilled nursing facility due to pain in her left shoulder and swelling in her left for the last 2-3 days. X-rays obtained at the skilled nursing facility was suggestive of dislocation, patient was not able to provide detailed history emergency department due to dementia. Her daughter reported that she visited with mother the day before and she had no pain at that time. Evaluation in the emergency department revealed elevated blood pressure . patient appeared distressed, [MEDICAL CONDITION], tenderness deformity was noted to left shoulder. She had good distal pulses. Sensation was intact. Left shoulder reduction was attempted x (times) 2, for anterior dislocation, however, shoulder was not reduced after 2 attempts, (Doctor) from Orthopedic surgery was contacted, plans were made for reduction under general anesthesia with fluoroscopy after discussion with family and their agreement . -Hospital Course: Patient was seen by Orthopedic surgery, taken to hold are (area) on (MONTH) 27th, had closed reduction under anesthesia, with good results on x-ray, verified. Advised to use sling . A review of Resident #913's care plan revealed: A Focus of (Resident #193) exhibits cognitive loss which effects her communication and has episodes of refusing care and hitting out at staff with care. She was admitted on Psychoactive medication due to hx (history) of this, date initiated, 10/18/18, created by Social Worker M. A Goal of (Resident #913) will have decrease episodes of hitting with care through next review date, date initiated 10/18/18, created by Social Worker M, with a revision on 10/30/18. Interventions that included: - Encourage her to make simple choices-provide options as needed, date initiated 10/18/18. -Introduce yourself and explain what you are there to do in simple terms. Encourage her to assist with care as she is able, such as -hold on to . or assist in turning, etc., date initiated 10/18/18. -Provide step by step instructions to have her assist in her care as she is able, date initiated 10/18/18. -When being physically aggressive; assure safety and re-approach at later time, date initiated 10/18/18. -With increase aggression, assess for pain and offer PRN pain medication as needed, date initiated 2/6/19. On 4/10/19 at 1:15 PM, an interview was conducted with the Social Worker (SW) M, regarding Resident #913's behaviors. When queried regarding a history of combative and aggressive behaviors with care, the SW stated, Almost from day one and from the other facility. When queried if a behavior care plan was in place regarding the behaviors, the SW stated, There should be because she has been pretty resistant with care. When being physical resistive, they (staff) need to make sure she is covered up and re-approach. When care needs to be done, there is not a choice but to care for her. If she is refusing cares and showers then they need to let the nurse know. When it goes on for extended time, they get the unit manager involved. When queried what should the CNAs have done when the Resident had aggressive and combative behavior while having care done, the SW responded, At least consult the nurse. Maybe she wasn't safe to leave at that time. When queried if they could have put the call light on, the SW stated, Yes, should have called the nurse or put the call light on. The SW was asked to identify when the nurse needed to be notified and read part of one of the interviews, (The CNAs tried to put (Resident #913) into bed (Resident #913) became very aggressive at this time hitting at both CNAs with both arms and fists clenched. Also attempted to kick at them and spit. Transferred to bed and she was still hitting at them and even while they changed her because she was full of BM). The SW stated, Wait, you want me to tell you when they should have gotten the Nurse? Back in the beginning, when they were trying to get her to bed and she became aggressive. They should have notified the Nurse, maybe re-approach the Resident. Someone else might have helped. They should not have continued. On 4/10/19 at 1:46 PM, an interview was conducted with Nurse E, who was assigned care of Resident #913 on the morning of 1/26/19. The Nurse stated, I was the one who sent her out to the hospital that day. I got in report that she had a possible [MEDICAL CONDITION]([MEDICAL CONDITION], a blood clot within a deep vein). I went to assess her and her arm had a giant knot. She had no range of motion. There was no [MEDICAL CONDITION] there was no motion at all. She was rocking. She usually doesn't complain of much pain but when we came in she was rocking. I had another nurse assess her also. When queried if the Nurse had assessed a possible injury and not a [MEDICAL CONDITION], the Nurse stated, Yes. It had a hard bump, larger then a marble, smaller then a golf ball. No heat, did not feel warm to the touch. That was why I was questioning that it was a [MEDICAL CONDITION]. It did not feel warm to me. When queried if measurements were taken of the Resident's arm circumference, the Nurse stated, The nurse didn't report any to me. She just said it was hot. She said she had full range of motion but when I went in there she had no range of motion. Her arm was laying in her lap, shoulder was slouched in. The Nurse demonstrated that the Resident's shoulder was dropped. The Nurse explained, I called the Doctor for an x-ray. He was aware I did not think it was a [MEDICAL CONDITION]. I got the results and called the Doctor right away and got her sent out. I had her out after noon or by two. On 4/11/19 at 8:45 AM, an observation was made of Resident #913 lying in bed with the head of the bed elevated. The Resident had a sling to her left arm. When queried about her arm in the sling, the Resident stated, It got cracked. When queried how that happened, the Resident stated, I don't know how. I don't remember. When queried regarding any pain that the Resident had in her arm, the Resident stated, Not now it don't. But before it did. The Resident was unable to elaborate. She was pleasant and cordial and eating breakfast on her own. On 4/11/19 at 9:05 AM, an interview was conducted with Nurse E, regarding the time the Doctor was notified and that the x-ray was ordered. The Nurse stated, I went in to assess her and called for another nurse to come look at her. When we came back up, I called the Doctor then called for the x-ray. The Nurse did not remember the exact time that the x-ray was ordered and called the x-ray service and reported the x-ray was called in at 11:17 AM on 1/26/19 and completed at 1:12 PM. On 4/11/19 at 9:35 AM, an interview was conducted with CNA EE, regarding Resident #913. CNA EE was assigned care on 1/25/19 starting at 10:00 PM. When queried regarding the Resident when she came to work on 1/25/19, the CNA stated, I was walking in to punch in. It was just a couple minutes before my shift started. (Resident #913) was sitting on the edge of her bed. When queried the night time habit of the Resident upon the start of the CNA's shift, the CNA stated, The majority of the time she is laying down in bed. The majority of the time she is sleeping. This was different for her to be sitting up on the side of the bed? The CNA stated, Yes. Her left arm was hurting. She took her right hand and put it on my arm to where it was hurting. She put in on the shoulder area and maybe a little lower. When queried if the Resident elaborated on why her arm was hurting the CNA stated, No. She kept saying 'it hurt, it hurt'. I did not lift up her gown or shirt to look at it. I just wanted the nurse to look at it. Was she able to move it? The CNA stated, I don't recall her moving it. I think it was laying across her lap. She was rocking back and forth, holding her left arm I want to say. When queried what the CNA did after being in with the Resident, the CNA stated, I told (Nurse B) right after I left the room. I went straight to the Nurse to see if she could go look at her. When queried what the Nurse did, the CNA stated, I think she went down, I started doing my rounds. She told me later she was going to order a Doppler study on her. When queried regarding how the Resident did during the night, the CNA stated, She moaned a lot, it was a painful moan. Most of the time she sat at the side of the bed rocking. Usually she sleeps through the night, occasionally you can hear her talking. If she hears noises in the hallway, sometimes she yells out 'You kids go to bed.' When queried if the Resident had slept during the night, the CNA stated, I don't think she did. When queried if she had let the Nurse know the Resident was in pain, the CNA stated, She said she was waiting for the Doppler. Had the Nurse gone back in to assess her? The CNA stated, I couldn't tell you for sure. She just said she was waiting for the Doppler. It didn't come on my shift. When queried regarding the Resident having combative/aggressive behaviors with care, the CNA state, Yes in the past. She yells at you to get out of her room, swings out at you. You re-approach. We leave the room and come back a little later. Re-approach, sometimes it will work. What if she has a soiled brief? The CNA responded, You get someone else to help you. What if she is combative and aggressive with both of you? The CNA stated, Then we go and notify the charge nurse. They try to see if there is someone who she will let change her. Usually we can find someone who will let her change her. When questioned if she had used physical force to change her, the CNA stated, No, never. When queried if she had received report from the CNA who was assigned the Resident's care prior to her shift, the CNA stated, I didn't get report that night. Usually we get report, majority of the time. We give report CNA to CNA at shift change. How come you didn't get report that night? The CNA responded, Why?! When I went to find out who had her, they were already gone. When queried if she had gotten any report from the previous shift of the Resident having combative/aggressive behaviors with care and an injury to the Resident's arm, the CNA stated, No, I didn't. On 4/11/19 at 11:30 AM, an interview with Nurse B, was conducted regarding Resident #913 on 1/25/19. The Nurse stated, The Aides (CNAs) came to me and said (Resident #913's) arm was hurting. I went down to assess her. She was on the edge of the bed and said her arm hurt. It was a little swollen and red. She raised her elbow up and extended her arm out. I called the Doctor and he ordered a Doppler and increase the Tylenol and the [MEDICATION NAME] also. I came in at six (6:00 PM on 1/25/19). It was after the CNA shift change that they came and got me (10:00 PM on 1/25/19). It was the new shift. When queried if the CNA, that was assigned care of Resident #913 before the new shift came on, had notified her of combative/aggressive behavior with care and an injury to the Resident's arm, the Nurse stated, I didn't have any complaints from them, the CNAs that had her. It was the first I heard about it. I had seen (the Resident) in the dining room when I first came on. The agency nurse had her. There was an agency nurse down that hall, I was in the Bay. When queried who the agency nurse was, the Nurse stated, I can't remember who it was. I told them that (the Resident) was complaining that her arm was hurting. That it was a little red and warm, that I had called the doctor and got a Doppler ordered. When queried what was conveyed to the Doctor, the Nurse stated, She was sitting on the bed crying, arm hurt and it was red and warm. He ordered the pain med and Doppler. She was moving it so I wasn't concerned about a fracture. I thought he would order x-rays but he wanted a Doppler first. When queried if the CNAs had notified her that the Resident had combative/aggressive behavior with care and an injury to the arm, the Nurse stated, I would have asked for x-rays if they had. When queried why the CNA came to her and not the agency nurse, she responded, I don't know. I just know they came to me. The Nurse was queried regarding Resident #913's history of combative/aggressive behaviors with care and the staff approach for the behaviors. The Nurse stated, When I have her, I talk her down and if I can't then we let her be and keep re-approaching. I know if she is sitting in a wet diaper, that's not good but its not good for her to be swinging either. I know she likes soda and snack things and 90% of the time that worked. When queried when she would expect the CNA to notify the nurse of the aggressive behavior that the Resident had during care on 1/25/19, the Nurse stated, I would want to be notified when she became aggressive when trying to get her to bed. I would go in and assess her and see why she was so agitated. If I tried talking her down and it didn't work, I would keep re approaching until she let us change her. If a Resident had an injury while care provided, they should notify the nurse for sure. When queried if any CNA had notified her of the combative/aggressive behavior and an injury to the arm, the Nurse stated, No. On 4/11/19 at 1:30 PM, the Director of Nursing (DON) was queried regarding the Nurse assigned to Resident #913 on 1/25/19 night shift. The DON stated she would check and returned a couple minutes and stated, It was (Nurse B). When the DON was informed of the interview with Nurse B, and that the Nurse had stated an agency nurse was assigned to Resident #913, the DON responded that she would check on that. A request was made for the list of residents that both Nurses were assigned and the time punch for the Nurse assigned care of Resident #913. On 4/11/19 at 1:35 PM, an interview was conducted with CNA DD, who was assigned care of Resident #913 on 1/25/19. The CNA revealed she was agency staff and had worked 16 hours that day and stated, I had her from 6 in the morning to 10 at night. (MONTH) 26th I worked a double. That's the way I schedule myself, 16 hours. When queried about the care of the Resident the night of 1/25/19, the CNA stated, . 9:00 to 9:20, she was in the dining room area, I took her to her room and me and (CNA CC) was with me and we tried to get her to bed. When queried regarding the Resident's behavior in the dining area, the CNA stated, She was just ok, watching TV. We took her to her room, she became really aggressive, hitting at both of us and she had her fists clenched. She had BM and her brief was really wet. I couldn't leave her like that, we stood her up. We put the walker in front of her. She would follow directions but still be hitting at us. We got her to stand and transferred her to the bed. When she sat down, swinging and kicking and spitting. She was saying 'leave me the f alone, get the f out of my room.' When we were rolling her from side to side, her arm was still hitting at us. She hit us everywhere. When queried why she continued with care, the CNA stated, We couldn't have left her like that, full of BM. You can't leave that on her and then leave it for someone else to change. When queried regarding her statement that the Resident hit her arm on the bed frame, the CNA stated, We were rolling her from side to side and she just hit it on the side. When queried about giving report to the nurse of the combative/aggressive behavior and injury to the arm, the CNA stated, I couldn't find the nurse. When queried regarding report to the oncoming CNA, she stated, (CNA EE) was with another Resident, she was helping someone else and I couldn't find a nurse. Did you go home after that? The CNA stated, Yes I did. Normally when they come in, you talk to the one assigned to your group. I left, I went home. (CNA EE) was doing patient care, yeah I went home. When queried if report was to be given to the oncoming shift, the CNA stated, Yes. When queried if any report was given regarding the injury to the Resident's arm, the CNA stated, The next day they had me come in and do a statement. You told the facility the next day? The CNA stated, Yes. That is when I did my statement. When queried why she did not report the injury when it had occurred, the CNA stated, I couldn't find no body. They said (CNA EE) was doing care helping another Resident. I didn't know who the nurse was. I did not see her. When I worked from 6 to 10 (Nurse K) was the nurse for morning shift and then I want to say the night nurse was, I don't know. I think (Nurse K) was still here until 9 or 10. I want to say the Nurse was (Nurse B) but I can't remember. I couldn't find her, I didn't know where she was at. The CNA was queried regarding how she handled the aggressive/combative behavior and did a reenactment of the situation. The CNA stated, We tried to redirect her, we were talking to her. She was saying 'umhm' but kept on swinging at us. When queried if she had stopped and called for the nurse, the CNA stated, No. When queried why had she not stopped and called the nurse, the CNA stated, She had poop everywhere. We backed up and she was still swinging at us. We couldn't leave her like that. We just changed her while she flung her arms at us and tried to kick at us. We just turned or ducked out of the way. The CNA demonstrated on a bed how the Resident was swinging her arms all over and hitting the bed with her arm while turned onto her side hitting the side of the bed but not hitting the actual bed frame. When queried if the Resident was held down while she changed her, the CNA stated, No, we just let her hit us, turn our backs or duck out of the way. When queried regarding documentation of the behaviors during care, the CNA indicated she had not charted any of the behaviors. On 4/11/19 at 2:05 PM, the DON had the time punch for Nurse K with a time of 8:01 AM to 8:42 PM on 1/25/19 and an agency Nurse BB, with a sign in sheet for 6:00PM on 1/25/19 to 6:30 AM on 1/26/19. The DON was queried if these Nurses were assigned care of Resident #913 on 1/25/19 to 1/26/19 and indicated that they were assigned care of the Resident. On 4/11/19 at 2:35 PM, an interview was conducted with CNA CC regarding the care for Resident #913 on 1/25/19. The CNA revealed she was an agency CNA. The CNA could not recall what her assignment was on 1/25/19 but remembered assisting CNA DD with care of Resident #913. The CNA stated, It was last round. We took her to her room to be changed. She had a lot of BM. We stood her up and she sat on the bed. She got combative and started swinging and stuff. I turned my back to her and it didn't hurt that much (the Resident was making contact with the CNA while being combative). We proceeded to change her and when we were done, she kept swinging at us and said some cuss words and we left her. When queried when the Resident started with the combative behaviors, the CNA stated, I am having a hard time remembering. I was just stand by assistance. (DD) put the belt on her. She (Resident) was saying some things, cussing at us. When we turned her, she was punching and cussing. She was just a regular combative resident. I don't know exactly when she started with the behaviors. I can't remember, it's been a couple months. She was getting agitated, swinging and punching at us. She told us to get out. When queried regarding an injury to the Resident's arm, the CNA stated, When she was punching us, she might have hit the rail or something. I can't recall. When queried if the Nurse was made aware of the behaviors, the CNA stated, They knew she had these kind of behaviors. I didn't tell the nurse. When queried how the CNA handled the Resident's behaviors, the CNA stated, It was in the middle of care, you got to finish the job. Sometimes you can re-approach her. When queried if the CNAs had stopped care an re-approached, the CNA stated, No. It was too late, we were doing the care. It was a big mess. When queried if the CNA had put the call light on to summon assistance or the nurse, the CNA stated, No. There was no need to. She is like that with everyone. On 4/11/19 at 5:04 PM, a phone call was made to Nurse BB who was assigned care of Resident #913 on 1/25/19 to 1/26/19 with a shift documented from 6:00 PM to 6:30 AM. The Nurse was unable to be interviewed at this time. On 4/16/19 at 11:03 AM, an interview was conducted with Nurse BB, by phone, regarding care of Resident #913 on 1/25/19. When queried if the Nurse had worked on 1/25/19, the Nurse indicated he was unsure. When queried regarding Resident #913, the Nurse stated, I can't picture who she is. When queried if the CNA assigned care of the Resident had informed him of combative/aggressive behavior with care and an injury to the arm, the Nurse stated, I don't remember anyone letting me know that. When queried regarding Nurse B giving report of an assessment of Resident #913's arm and the order for the Doppler, the Nurse stated, I don't recall that. When queried if he had done an assessment, documented the assessment of the arm and pain assessment and where would he have documented that the assessments were completed, the Nurse stated, I don't remember doing one. If I had done one, I would document it in the progress notes. A review of the facility policy entitled, Behavior Policy, with an effective date on 1/1/19, revealed, Responsibility, 1. If someone is identified as having behavior, staff is to document in PCC . 3. Notify responsible party and physician of behaviors . A review of the facility policy entitled, Abuse, Neglect and Exploitation, with a revised date on 11/17, revealed, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation . 1. 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . 'Willful' means the individual deliberately, not that the individual must have intended to, inflict injury or harm . 7. 'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The facility must: 5. Prevention of Abuse, Neglect, and Exploitation-The facility will utilize the followi

Based on observation, interview and record review the facility to 1.) Ensure that an effective and operational external and internal telephone communication system was functional, accessible and available for emergency situations and necessary basic everyday communication within the facility and 2.) Ensure the availability and viability of emergency equipment (crash cart) to provide basic life support prior to the arrival of emergency personnel in the event of a medical emergency, resulting in Immediate Jeopardy for all 51 residents being placed in a state of immediate threat of harm, injury and/or death, related to an ineffective emergency communication system and a lack of emergency equipment. The Immediate Jeopardy was identified on [DATE] at 4:00 PM. 1). During a tour of the facility on [DATE] at 4:00 PM with Maintenance Director C, he indicated there were only a few phones in the clinical areas of the facility. A). A phone was observed at the nurse's desk on the Rehab unit. When Unit Manager D was asked if she knew how to use the phone, the nurse tried to make a call and was unable to do so. The nurse stated, I guess I don't know how. The Unit Manager was asked if she was able to page for assistance on the overhead paging system and after attempting to use the phone paging system, she could not get it to work. B). Administrative Assistant F attempted to page from a phone on her desk, but it did not page into the resident hallway outside of the office. Maintenance Director C stated, Let me try to page from my phone. His phone did not work either and he stated, There must be a dead zone in this area. C). The Maintenance Director attempted to page overhead from a phone hanging on the wall in the main dining room, but it did not function either. D). A phone was observed sitting on a desk in an alcove near the enclosed courtyard; it read, Sign In. The Maintenance Director said the phone was computer-based and someone had to be signed into the computer for the phone to work. He said the phone would not work in an emergent situation unless someone was already signed in to the computer. E). In the Long- Term Care area, recently opened after new construction, a phone was observed on a counter top. The phone had no lights and was not turned on. The Maintenance Director stated, The phone does not work. It runs off a computer program and someone has to be signed into the computer and the program for it to work. F). On the locked Memory Care unit, Nurse N said the only phone on the unit was a red cell phone and was used for both clinical and resident calls. Nurse N said the phone was the only one available for incoming calls to the facility after 4:30 PM, when the receptionist went home for the day and if someone called for the other nursing unit, she had to leave the locked unit and walk the phone over to that area. On [DATE] at 9:20 AM, Nurse S was observed at the medication cart in the locked Memory Care Unit. A red cell phone was sitting on the medication cart. The nurse stated, I use my personal cell phone if I have to call 911. I am more familiar with it. If someone calls on the (red phone) for another area, I have to walk the phone to them. It's a hoof over there numerous times a day. Nurse S was asked if she could page overhead during an emergency and replied, I didn't do it right. It's not working. They showed me how to do it earlier today, but I can't get it to work. The nurse indicated today was the first time she had received training on the phone even though it had been in use for five months now. An interview with the Maintenance Director, on [DATE] at 1:15 PM revealed, We started using the red cell phone in the Memory Care Unit on (MONTH) 9th, (YEAR), that is when we went to a new phone system. 2.) On [DATE] at 8:45 AM, the emergency cart on the rehab hall was inspected and found to not have a backboard on or near it and did not have an ambu bag on it. A backboard is necessary to perform effective cardiopulmonary resuscitation for a person with no heart beat and an ambu bag provides the means to perform rescue breathing for a person who is not breathing on their own. Licensed Practical Nurse (LPN) V was the nurse for the rehab unit for day shift on [DATE] was asked where the backboard for emergency use would be. LPN V responded, isn't it there? (by the emergency cart) On [DATE] at 10:35 AM, the emergency cart was inspected in the presence of the Unit Manager Registered Nurse (RN) E who agreed there were no ambu bags on the cart and stated that the backboard should be in the supply room right by the cart. RN E went into the supply room and said, it's not here. RN E went to the nurses' station by the rehab unit and asked the staff there, do you know where the backboard is? RN D, who was at the nurses' station said no. RN E asked RN D if ambu bags were on order, and RN E replied I ordered three of them after the code we had on Tuesday and they should be here today. The Emergency Cart Checklist, on a clipboard on top of the cart, had a list of supplies that were to be in the cart and a column for each day of the month. The Checklist was labeled for (MONTH) (YEAR), and the line for Backboard (Attached) had a dash though the space, and the line for Ambu bag (2w/O2 tube) had a check for each day of the month. On [DATE] at 8:30 AM, the door to room [ROOM NUMBER] was observed to be closed. room [ROOM NUMBER] was entered and the backboard was observed leaning against the wall and an ambu bag was observed in the trash can. On [DATE] at 11:15 am, the Director of Nursing reported that the facility did not have a policy and procedure for the emergency crash cart. Immediate Jeopardy is due to the facility's lack of a functioning telephone and communications system and the facility's failure to have an operative crash cart with the items necessary for a successful response to an emergency medical situation. These deficient practices place all residents of the facility at risk for physical harm, injury and/or death. The Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 4:30 PM. A plan to remove immediacy was requested. The Immediate Jeopardy was removed [DATE] based on the facilities implementation of the removal plan. Findings include: During an interview with Unit Manager D, on [DATE] at 4:07 PM, the Unit Manager was asked if there had been any recent emergencies in the facility and responded, During a recent Code, on [DATE] (Code Blue- resident with no heartbeat or respirations), the housekeeper came and got me and told me. I was in the conference room. We cannot page overhead, so I didn't know. It was around 10:45 AM and she said grab the crash cart. An interview with Nurse K, on [DATE] at 5:05 PM revealed, On the day of the Code, ([DATE]) I had the Rehab Unit and 2 other halls. One hall by the entrance and one hall by the Memory Care Unit (on the other side of the building). I had to go to the other side to give a resident her medications. A CNA (Certified Nursing Assistant) came and told me about the code. For months I had to go to the other side of the building. Nurse K was asked about paging on the phone system to obtain assistance from other staff during an emergency, such as the Code and said, I've never paged from the phone. If help is needed I have to walk over there (to the other side of the building to the Memory Care unit) to get the nurse. Sometimes I have to use my personal cell phone. The policy for [MEDICAL CONDITION]/cardiopulmonary resuscitation (CPR) was requested from the facility and an email dated [DATE] was provided. The subject of the email was Code Blue. The steps outlined by the email included: Code blue covers CPR, and a all hands on deck policy. Call a code as designated by facility protocol. CODE BLUE - ROOM # - repeated three times over the PA (public address system) During an interview with Registered Nurse (RN) E on [DATE] at 10:34 AM, she stated that on [DATE] she had been sitting at the nurses' station on the Rehab unit when the daughter of the resident in room [ROOM NUMBER] had approached her and asked if someone could help her. The daughter of the resident in room [ROOM NUMBER] said that her mother don't look right. RN E stated that the resident was being discharged and the daughter had been on the phone with her as she was driving to the facility to pick her up. The daughter told RN E that while on the phone her mother had stopped talking to her so she had hurried in to the facility and found her mother unresponsive. RN E said that she had gone to room [ROOM NUMBER] and had seen the resident fully dressed laying on the bed. When RN E checked her breathing and pulse, she found none. RN E stated there was a housekeeper just outside of the room and she yelled to her to go get help. RN E said she then attended to the resident and used her personal cell phone to call 911. RN E said that other nurses brought the emergency crash cart and the backboard to room [ROOM NUMBER]. RN E said the ambulance responded quickly and took the resident to the hospital. An interview with the Maintenance Director, on [DATE] at 1:15 PM revealed, We started using the red cell phone in the Memory Care Unit on (MONTH) 9th, (YEAR), that is when we went to a new phone system. The Maintenance Director and Administrator said there were plans for a new phone system and there was supporting documentation. The documentation was requested and not received prior to exit on [DATE]. A policy related to Communication with telephones, paging and personal cell phones was requested and not received prior to exit on [DATE]. During an interview with the Director of Nursing (DON), on [DATE] at 2:00 PM, she was asked about the facilities phone system and stated, There is no land line in the facility. People call on the weekends and can't get through. There is only one cell phone on the nursing units to take calls. Sometimes there is no signal and calls are dropped. The cell loses its charge. I've called and not been able to get ahold of anyone. The DON was queried how staff called 911 during an emergency and stated, During a recent emergency someone used their personal cell phone. We couldn't even page the nurse. There is no paging option. During an interview with RN H on [DATE] at 2:30 PM, she stated that she had taken the backboard to room [ROOM NUMBER] on [DATE] at about 10:00 AM or 11:00 AM. The facility staff did the following to remove the Immediate Jeopardy: [DATE]: Root Cause Analysis completed. [DATE]: Paging system, phone use and Walkie Talkie education was provided at 6:10 PM on [DATE]. [DATE]: The crash cart on the Rehab Unit was restocked with the backboard and ambu bag, at 5:20 PM. [DATE]: The crash cart #2, on the Memory Care Unit/LTC area was reviewed and found to be stocked and operative, at 5:25 PM. [DATE]: Corporate IT assessed the Dead Zone. [DATE]: Back up plan to use Walkie Talkies until the phone system is functional. [DATE]: Wired telephones will be in place and functional on the units by [DATE]. [DATE]: Auditing-Crash Carts daily, Weekly checks of the phone and paging system. [DATE]: Additional wired phones installed in the kitchen and dining room. On [DATE] beginning at 9:30 AM the two emergency crash carts in the building were checked against the Emergency Cart Checklist form on a clipboard on top of each of the carts in the presence of RN H. The form listed the supplies that were to be on the cart on lines with columns for each day. The last line was for the initials of the nurse who had checked the cart. RN H stated that the third shift nurse was to check the cart every night. On the Rehab unit, all of the columns for [DATE] were checked. However, when every item on the list was compared to the contents of the emergency cart, a large size blood pressure cuff, an extension cord, an ice pack, and two elastic bandages were not in the cart. At station two, all of the columns were checked for [DATE]. However, there was no large size blood pressure cuff, there was one instead of two listed ambu bags, and two ice packs were missing. RN H stated that until the lists were reviewed and updated, the items needed to be in the carts and that she would stock the carts per the current lists. On [DATE] at 9:40 AM, Information Technology Specialist (IT) W and Maintenance Director C were interviewed during a tour of the facility to look at 3 newly installed telephones. One in the newly opened Long-Term Care area, in the back of the building, one in the Memory Care Unit and one in the Rehab unit. Both indicated all of the non-functioning phones had been replaced. However, when inspecting the phones in the kitchen and main dining room, neither was able to page overhead, in case of emergency. IT W stated, I'll order more phones and they will be here today, and further added, We found there was a wire cut during our recent construction and the paging system did not work in the old section of the building. The speakers were not working. Maintenance Director C attempted to page overhead from his personal cell phone and the volume was too low to be understood. The speakers were not audible with the new phones either. IT W said he could try to adjust the volume. At 10:10 AM on [DATE], Nurse H was observed looking for placement of a new phone in the Long-Term Care Area and stated, I was not aware of a new phone in Long-Term Care. It wasn't there when I left on Friday. Nurse H indicated she and Unit Manager E began education with the nursing staff on [DATE] related to use of walkie talkies for temporary communication between nurses and how to page from the prior phone system and cell phone. Education of how to use the new phones had not yet begun. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance due to all staff had not received inservice education and sustained compliance had not been verified by the state agency.

This Citation pertains to Intake #'s: MI 490 and MI 493 Based on observation, interview and record review, the facility failed to operationalize their Fall Management and Wandering/Elopement Policies to ensure residents were monitored for safety and interventions were enacted to prevent future falls, elopement and serious injury for 2 sampled residents (#'s 1 and 2) of 3 residents reviewed for accidents, from a total sample of 8, resulting in Resident # 1 experiencing a fall on 8/17/18 and eloping from the building on 9/12/18 and Resident #2 had a history of [REDACTED]. Findings Include: Resident #1: A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. The MDS dated [DATE] revealed the resident had severe cognitive decline and needed 1-person assistance with transfers, bed mobility, ambulation, dressing and toileting. A review of the Incident and Accident (I&A) reports for Resident #1 indicated the resident was found on the floor in Resident #2's room on 8/17/18 at 4:56 PM, Resident observed in another resident's room sitting on the floor, legs out stretched . The I&A Notes, dated 8/20/18 said, IDT (Interdisciplinary Team) met and frequent checks to be done on (Resident), and Immediate Action Taken, 'Alert and oriented times 1. No injuries. Hand grips equal and strong. Denies Pain.' An I&A dated 9/12/18 at 7:00 PM, revealed the resident eloped from the building on that date, Resident witnessed pushing on door until alarm sounded and exiting the building to the sidewalk. CNA (Certified Nursing Assistant) witnessing incident came running down the hall, yelling for assistance .Resident states, I pushed on the door because I am ready to go, the door opened, and I left. The I&A said the resident was an Active Exit Seeker and Immediate Action Taken, ' .Assessed resident for injury, none to report no new orders.' No preventive measures were documented to decrease reoccurrence. A review of Resident #1's Care Plans provided, Falls, related to confusion, wandering, psychoactive drug use, incontinence and history of falls, initiated 9/1/2017 and last updated 8/8/18 with Intervention: Transfer with limited assist of 1 person without use of assistive device. The Care Plan was not reviewed or updated after the resident was found on the floor in Resident #2's room on 8/17/18. There was no mention of frequent checks on the Care Plan. A review of the Care Plan titled (Resident) has occasions of Wandering and entering other resident's rooms, has poor safety awareness and at risk for elopement, initiated 10/8/15 and revised 7/23/18 had no recently updated Interventions. They were last updated 8/13/18 and had not been reviewed or updated since the resident went out the exit door unaccompanied on 9/12/18. A review of the Elopement Risk Assessments, indicated a reassessment was not completed after Resident #1 left the building on 9/12/18. On 9/19/18 at 9:40 AM, during an interview with Unit Manager D she was asked if Resident #1 had eloped from the building and stated, She went out the door on 9/12/18, but they got her back in right away. On 9/19/18 at 11:00 AM, Resident #1 was observed sitting in the day room of the Memory Care Unit. During an interview with CNA J, on 9/19/18 at 11:10 AM, she was asked if Resident #1 had eloped from the facility and stated, It was the same day that (Resident #2) went out, but a different door. (Nurse S) was the first to see the resident out the door. (The resident) was going down a hill in her wheelchair. It was a little ways past the door .Everyone is supposed to keep an eye on her. The CNA was queried if there was frequent checks and said there was not. On 9/19/18 at 11:40 AM, Unit Manager D was queried about the fall, elopement and frequent checks for Resident #1 and stated, They cut staff. The nurses and aides don't have enough time to follow the plan of care. On days and afternoons there are 2 nurses for the whole building, both have to come out and pick up extra residents on the back halls. There are 5 CNA's and they are spread out taking front and back halls. During the Day they are using the Unit Manager to monitor. After hours and weekends there is no one. The nurses have to split it up. Some halls might have no one on them for monitoring. Falls started increasing when they cut staff. On 9/19/18 at 1:07 PM, no staff were observed on the newly opened Long-Term Care (LTC) back hallway, Confidential Visitor Y stated, You usually have to walk and try to find someone. The Nurse and Nurse Aides from the locked Memory Care Unit share the assignment with the back hallway. It is not visible from the Memory Care Unit. An interview with CNA P, on 9/19/18 at 2:25 PM revealed, The residents don't use their call lights (on the LTC Unit) they yell for help. You can't hear them. CNA U also said, My main concern is some residents don't use a call light. We have to move around to other parts of the building and can't see or hear them. On 9/20/18 at 4:03 PM, during an interview with Confidential Person Z she was queried if the facility called to say Resident #1 had exited the building on 9/12/18 and stated, I was not notified. They never called me. Resident #2: A record review of the Face Sheet and MDS assessment for Resident #2 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The resident began receiving Hospice services on 8/8/18. The MDS dated [DATE] indicated the resident had mild cognitive decline and needed 1-person assistance with bed mobility, transfers, ambulation, dressing and toileting. Resident #2 was discharged to the hospital on [DATE] after falling and fracturing her left hip. A review of the I&A reports for Resident #2 revealed the resident had fallen 6 times (8/2/18 (sitting on floor in room by the bed), 9/1/18 (fell while ambulating self in the hallway), 9/3/18 (fell from recliner in room), 9/5/18 (found on floor by the bed) , 9/6/18 9 (lying on floor in room) and 9/8/18 (sitting beside bed), before falling and fracturing her left hip on 9/17/18. The I&A reports indicated the resident had injured herself during 4 of the incidents prior to the fall with fracture, including: 9/3/18 right knee and back pain, 9/5/18 bruise under left eye and left inner arm with hip and knee pain, 9/6/18 bleeding on right wrist, purple bruise, large bump and pain, 9/8/18 skin tear right wrist. A Fall Risk Assessment, was not completed after Resident #1 fell on [DATE]. The resident fell again on 9/3/18. A review of the Care Plans for Resident #2, Falls, initiated 7/28/18 and revised 9/8/18, indicated the resident had fallen on 8/2/18 and the care plan was not reviewed or modified until 8/13/18, the resident fell 3 times between 9/1/18 and 9/6/18, with no review or modification to the Care Plan with interventions to prevent continued falls. The Care Plan included 5 interventions: 1). Bed in low position and call light within reach, Date Initiated: 07/28/2018, 2). Educate (the Resident) on the importance of using the call light for assistance with Ambulation, Date Initiated: 09/01/2018. 3). Gripper socks on at all times. White socks have been removed from room. Date Initiated: 09/08/2018, 4). Left side landing strip by the bedside for safety. Landing strip to be down only when in bed, Date Initiated: 07/28/2018, 5). Urinalysis ordered & obtained, Culture and Sensitivity is pending, Date Initiated: 09/10/2018. Basic interventions such as Gripper socks on at all times. Remove white socks, was not initiated until the resident had fallen 5 times. Education on the importance of using the call light for assistance was not enacted until the resident had fallen twice. A follow-up to the urine culture was not addressed. On 9/19/18 at 10:42, an interview with CNA O revealed, (Resident #2) fell (9/17/18). They called for the nurse because she was on the floor. She was holding her hip. (Nurse L) got a blanket and pillow, called Hospice and the (emergency responders/ambulance) came. An interview with CNA T, on 9/19/18 at 10:50 AM provided, I came back from lunch and she (Resident #2) was on the floor (9/17/18). She said she was walking towards the sink and she was lying by the sink. She gets up on her own, but she is not supposed to. CNA T was queried if the facility had measures in place to prevent Resident #2 from falling and stated, They weren't using alarms. There was nothing really. You wouldn't know she had fallen until you saw her on the floor. There were no 15-minute checks. She had a patch on her arm from falling. CNA J was interviewed on 9/19/18 at 11:10 AM, I'm not usually her aide, but I had previously seen her on the floor after she fell . She will tell us when she wants to go to the bathroom or bed. An interview with Nurse L on 9/19/18 at 11:50 AM provided, I was called to the room when she fell (9/17/18). She was lying on the left side and grabbed her upper left leg. I had taken her to the room earlier after breakfast. She went to sleep. Nurse L was queried on what measures were in place to aid in preventing the resident from falling, as she had fallen multiple times and stated, The bed was in the low position, mat on floor, bed was up against the wall. I didn't think she could get up from the bed. Other than doing rounds up and down the hall, I wouldn't know she was trying to get up. She doesn't have an alarm on the bed. Some residents do have chair alarms and bed alarms. There was no 15-minute checks or frequent monitoring. The I&A reports also indicated Resident #2 attempted to elope from the building on 9/12/18. This occurred at the same time, but a different door than Resident #1, .CNA witnessed the resident push on the door until it opened and attempt to exit. (CNA) came running down the hall and resident was still attempting to push herself out the door .Nurse witnessed Resident's (left) lower leg pinned between the door and foot pedal with blood pouring from site .Resident states, I was trying to get out of here and open the door, and CNA P stated, I saw her attempt to open the door and pulled her back inside. She has a cut and it's bleeding, it looks bad. The I&A indicated the resident was transferred to the hospital for care. A review of the Care Plan titled, Elopement, history of elopement, initiated 7/28/18 was not revised with any new interventions after the elopement attempt and injury on 9/12/18. The last update to interventions was 8/13/18, which included: Offer emotional and psychological support, Observe for fatigue and weight loss and Assess for fall risk. A review of the Kardex revealed Resident #2 had a history of [REDACTED]. she got out of the facility and she is hardly able to walk but she was running down a busy road. A review of the Elopement Risk Assessments indicated there was only one risk assessment completed 7/28/18, on admission. A reassessment of the Resident's elopement risk was not completed in the medical record after the attempted elopement on 9/12/18. On 9/19/18 at 2:30 PM, during an interview with CNA P she stated, I was assigned twice to her when she fell . She fell two times in the hallway by the door, trying to pull the alarm. There were no new interventions. Basically, they wanted us to do 1:1, but we had 10 residents apiece and numerous residents were trying to get out. An interview with the Director of Nursing (DON) on 9/20/18 at 2:12 PM provided, The elopement risk should have been re-evaluated. We have an Elopement Risk Assessment and the Care Plans should have been updated, and when queried about Resident #2's multiple falls with injury she stated, I thought we should get her up during those anxious times. Usually the resident is trying to tell you something. What is it? I asked the nurse to ask her, Where are you going? A review of the facility policies revealed the following: Elopements and Wandering Residents, dated 6/16 and Revised 11/17, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-center plan of care addressing the unique factors contributing to wandering or elopement risk .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk evaluation and analysis of hazards and risks, implementing interventions . Interventions to increase staff awareness of the resident's risk, modify the resident's behavior or to minimize risks .will be added to the resident's care plan and communicated .Adequate supervision will be provided to help prevent accidents or elopements . Fall Prevention, Analysis and Follow-up, dated 11/17, The objective of the policy is to assess the risk of falls .analyze why a fall has occurred and determine what interventions are needed to prevent falls from occurring .The Fall Risk Assessment will be used to assess the potential risk for falls .will be completed on admission, quarterly, with any significant change of condition and after each fall .A care plan will be developed or revised based on the assessment .

This citation pertains to Intake Number Based on interview and record review the facility failed to prevent one (Resident #503) from being physically restrained by facility staff out of one reviewed for physical abuse resulting in, Resident #503 being physically restrained to the armrests of their wheelchair, leaving multiple bruises and marks on the Residents arms/wrist area with the potential for embarrassment, intense fearfulness of facility staff and exacerbated mental health symptoms. Findings include: Review of the facility's policy entitled, Abuse, Neglect and Exploitation, revised 10/29/17, revealed the following, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation . The facility must ensure the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience .Provide resident, staff and family member's information on how and to who they many report concerns, incidents and grievances . Review of the medical record revealed that Resident #503 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) assessment indicated Resident #503 is moderately cognitively impaired. Review of the initial witness statement dated and signed 4/19/18 and completed by Volunteer E, revealed that on 4/18/18, (Another Resident) gave (Resident #503) some of their pokeno winnings (miniature chocolate candy bar) .Volunteer E walked in and told (Activity Aide C) and she (Activity Aide C) grabbed (Resident #503's) arms and tried getting it back and Resident #503 scratched (Activity Aide C's) arm's up . Review of Volunteer E's 2nd witness statement dated 4/23/18 revealed, I just walked into the Activity Room and witnessed another Resident give (Resident #503) a (name of candy) miniature chocolate candy bar without nuts. I called out to (Activity Aide C) . to let them know what had just happened. I stood next to (Resident #503's) wheelchair the whole time of this incident. At which time (Activity Aide C) walked over to (Resident #503) and restrained both arms by holding them down on the armrest. I asked (Activity Aide C), do you want me to get some help? and (Activity Aide C) stated, No, I can handle this. I also said to (Activity Aide C), 'Since I'm a volunteer I don't know what I 'm supposed to do.' (Activity Aide C) continued to hold (Resident #503's) arms down, at one-point (Activity Aide C) let go of (Resident #503's) left arm at which time (Resident #503) swung at (Activity Aide C) several times .(Resident #503) stated, 'Leave me alone' and 'Please leave me alone,' multiple times. Then (Activity Aide C) held (Resident #503's) left arm again while she still restrained the right arm. (Activity Aide C's) face was red with anger. (Activity Aide C) let go of the left arm a 2nd time that's when (Resident #503) scratched (Activity Aide C's) left forearm. At this time, I was very scared for (Resident #503) and the other residents that were present. After (Activity Aide C) got scratched she finally released (Resident #503's) right arm . I took (Resident #503) down to the nurse and let the nurse know what had happened . On 5/15/18 at 11:04 AM, an interview was conducted with the Administrator and DON (Director of Nursing). The DON and Administrator explained that Volunteer E was so appalled by what happened that she wrote a statement on 4/19/18 and provided it to the HR (Human Resources) Director. The HR Director then informed the Administrator on 4/20/18 about the statements. On Monday, 4/23/18, Volunteer E came to the facility to complete a reenactment of the incident and a second witness statement. Volunteer E explained (during the reenactment) that they were passing out chocolates without nuts and Volunteer E was concerned when Resident #503 ate the chocolate that was provided to them by another Resident, as Volunteer E did know (Resident #503's) dietary needs. Volunteer E saw Activity Aide C and called out for them. Activity Aide C 'flew' around the corner and grabbed Resident #503's wrists and held them down to the armrests of Resident #503's wheelchair. Resident #503 was yelling, Please stop, please let go, Activity Aide C was holding down tightly and Volunteer E kept asking if they needed to go help as they were not trained on what to do in a situation of this nature. Activity Aide C let go of one of Resident 503's wrist and that is when Resident #503 scratched the aide. Activity Aide C moved their grasps to the Resident #503's forearm and for whatever reason let go, and then Resident #503 scratched Activity Aide C's arm. Throughout this entire altercation Resident #503 was yelling out for Activity Aide C to stop. Resident #503 does not have a recollection of this incident During this same interview, the Administrator reported that the incident between Activity Aide C and Resident #503 occurred on 4/18/18 but the investigation was not initiated until 4/20/2018. The Administrator explained that on Wednesday (4/18/18) Activity Aide C came into the office and was waving a paper in front of her face, Activity Aide C then learned over her desk and extended their arms to show the DON and Administrator the scratches they received on the arms. Activity Aide C verbalized that Resident #503 scratched her when she was attempting to take chocolate from Resident #503, because it had nuts in it and Resident #503 is on a mechanical soft diet. The Administrator stated that the DON attempted to educate Activity Aide[DIAGNOSES REDACTED]erent interventions to use during situations. The Administrator reported Activity Aide C became snotty and nasty, with the feedback that was being provided by the DON. During this same interview, the Administrator stated that on Friday (4/20/18) the HR Director reported there was another statement provided by Activity Aide C and a statement by Volunteer E and that the statements were concerning. Once it was realized there was a significant amount of information not provided and the accounts of the incident by Volunteer E and Activity Aide[DIAGNOSES REDACTED]ered substantially, the DON and Administrator requested Activity Aide C come in for an interview. The Administrator stated that before the interview, which occurred on 4/20/18, Nurse G was requested to physically assess Resident #503. Nurse G reported that Resident #503 had scratches and bruises on their arms. The Administrator stated that during the meeting with Activity Aide C they requested Activity Aide C to reenact the incident. The Administrator reported to this surveyor, that during the reenactment, Activity Aide C became red in the face and dug their nails into their supervisor's (the Activities Director I was playing the role of Resident #503) arms. The DON and Administrator explained Activity Aide C was attacking the resident based off the reenactment. Activity Aide C was then suspended pending their investigation and was subsequently terminated from employment on 4/23/18. Review of document entitled, Shower Skin Check dated 4/18/18, untimed, revealed that Resident #503's skin check was clear and there were no abnormalities found. Review of the document entitled Skin Issues for Resident #503 dated 4/20/18 at 4:50 PM completed by Nurse G, stated the following, Writer observed bruise on right upper arm measuring 3x3 cm (centimeters) with scab measuring 0.5 x 0.5 cm. Bruise is yellowish, black. Guest had bruise on left elbow measuring 1 x 0.5 cm, black and blue. Guest has abrasion on right wrist measuring 0.1 x 0.5 cm, red in color, pink surrounding. Guest unable to vocalize where bruises and abrasions came from . On 5/15/18 at 1:05 PM, an interview was conducted with Nurse G regarding Resident #503's skin assessment that was completed on 4/20/18. Nurse G reported they found bruises on Resident #503's right upper arm and left elbow. In addition to an abrasion on their right wrist that appeared to resemble a fingerprint; it was red in color with a pink surrounding. On 5/15/18 at 1:18 PM, during an interview Activities Director I reported that on 4/18/18 Activity Aide C stated Resident #503 had scratched her and that she wanted to go to the emergency room to be evaluated. Activities Director I stated that when further interviewed about what happened, Activity Aide C explained that Resident #503 had chocolate and was trying to get it away and Resident #503 scratched Activity Aide C and called her a [***] . Activities Director I stated she asked Activity Aide C why she was trying to get the chocolate from Resident #503, and that Activity Aide C explained because the chocolate had nuts in it (it was found later that the chocolate did not have nuts in it). Activity Director I reported that during the reenactment, Activity Aide C grabbed her arm and swung her around vigorously and this was troubling to everyone who observed the reenactment. Review of Activity Aide C' Employee File revealed that Activity Aide C's latest abuse training session was on 11/27/17. Further review of the file revealed a document entitled, Corrective Action Plan. Review of this document showed that Activity Aide C was terminated from employment at the facility on 4/25/18 via telephone. The documented stated, (Activity Aide C) forcibly restrained a resident which is classified as resident abuse . During an interview on 5/15/18 at 4:17 PM, in regards to the incident that occurred on 4/18/18, Volunteer E reported that on that day she walked into the activity room and saw another Resident give Resident #503 a (name of candy bar) miniature without nuts. Volunteer E reported there were still a lot of Residents in the activity room, Volunteer E estimated 10+ Residents. Volunteer E explained Resident #503 had put the candy in their mouth and then called Activity Aide C over as they were not aware of the Resident 503's dietary needs and did not want Resident 503 to have any adverse effects. Volunteer E further reported that Activity Aide C came over to where Resident #503 was and held both of Resident #503's arms down to the armrests of the wheelchair. Volunteer E stated she asked Activity Aide C many times if they wanted them to go get help but Activity Aide C declined and stated, No, I got this. Volunteer E further stated that Resident #503 asked multiple times, please stop, but Activity Aide C continued to restrain Resident #503. Activity Aide C let go of one of Resident #503's arm and the Resident swatted at her and then Activity Aide C restrained Resident #503's arm again and held it. Volunteer E stated that during this incident Activity Aide C was getting red (in the face) with anger. Volunteer E reported they continually asked Activity Aide C to stop and she continued to restrain Resident #503. Activity Aide C let go of one arm again and Resident #503 scratched Activity Aide C's arm, then Activity Aide C let go of both arms. Volunteer E stated she quickly wheeled Resident #503 out of the activity room, found a nurse and reported that Activity Aide C had physically restrained Resident #503. Volunteer E was not able to remember what nurse she reported this information too. Volunteer E reported that Resident #503 was extremely terrified, and she could see it in her eyes. Volunteer E reported that as she pushed Resident #503 away from the incident Resident #503 stated, why, why? During this same interview, Volunteer E stated that the next day, Activity Aide C threw her witness statement in the face of Volunteer E and had her read the statement. Volunteer E reported that Activity Aide C wanted her to be untruthful in their account of the incident that took place the day prior. Volunteer E stated they were afraid of Activity Aide C. During an interview on 5/15/18 at approximately 4:50 PM, the Administrator reported the Residents (that were in the activity room during the incident) were traumatized. On 5/15/18 at 12:30 PM a phone call was attempted with Activity Aide C, but the phone number was disconnected.

This citation pertains to intake . Based on interview and record review the facility failed to complete a post fall assessment for 1 (Resident #3) of 2 residents reviewed for falls resulting in the delay of treatment for [REDACTED]. Findings include: Resident #3's face sheet, dated 4/19/18, had [DIAGNOSES REDACTED]. Minimum Data Set, dated dated [DATE], included a brief interview for mental status score of 3 which indicated severe cognitive impairment, transfer and walk in room (with walker) statuses indicated activity of daily living self-performance level of limited assistance and activity of daily living support level of one person physical assist for both. Resident #3's care plan, revised 4/11/18, stated The resident is at risk for falls r/t (related to) confusion, deconditioning, incontinence, unaware of safety needs, hx (history) of falls prior to admission and The resident has potential for pain r/t (related to) joint pain and stiffness r/t to hx of hip and pelvic fx (fracture), revised 7/4/2017. Review of the medical record revealed that Resident #3 experienced a staff witnessed fall on 3/29/18, yet the nurse present, Staff C, didn't report the fall until approximately 12 days later and didn't document any post fall assessment or follow up assessments. The cognitively impaired resident expressed signs and symptoms of increased pain on 3/31/18 at which point an investigation was initiated by the facility and Resident #3 was discovered to have 2 fractures (left humerus and left femur). Record review of the injury of unknown origin (left humerus and left femur fractures) investigation's employee statements revealed on 4/9/18 Nurse C reported at approximately 3/29/18 at 8:30-9:00 PM she was the only staff present at the time of a fall and (Resident #3) became dead weight and we tipped over and fell to the residents left side on the floor mat. 4/19/18 at 3:31 PM, in an interview, Nurse C confirmed she was present at the time of the fall on 3/29/18 and the resident went dead weight and was lowered to the mat but fell the final approximate 12 inches onto her left side. Nurse C stated I thought I prevented a fall and that is why I didn't report it (the fall) until 4/9/18. Nurse C confirmed she did not notify the responsible party or physician after the fall occurred. 4/19/18 at 9:26 AM, Director of Nursing B and Nursing Home Administrator A confirmed that no incident/accident/risk management report was completed following the fall on 3/29/18 and that they did not become aware that the fall on 3/29/18 until 4/9/18. Staff B stated Nurse C did not document any Progress note, risk management (an incident/accident report), no range of motion, vitals or any assessment regarding a fall from 3/29/18 and that physician M initially thought the cause of fracture was possibly a fall. Staff A reported the resident on 3/31/18 was showing increased signs of pain such as moaning. Fall report #1356, revised 4/11/18, Nurse F stated on 3/31/18, The resident did not look comfortable when LT. (left) arm is palpated resident would moan and groan .the cena (certified nursing assistant) then approach and stated that she was beginning to c/o (complain of) LT. leg pain, I went in to assess her leg when I went to touch she moan and groan .we were ordering a x-ray to LT. arm and LT. leg r/t (related to) resident c/o (complain of) pain and discomfort. Review of the radiology report dated 3/31/18 revealed, acute proximal left femur fracture and There is a fracture involving the neck of the humerus. Review of the Step By Step Guide to Falls facility policy, undated, indicated 1. Perform Full assessment on patient before moving, including but not limited to: Full ROM (range of motion), pain assessment, perform first aid as needed, assess mental status . 3. Perform Vitals . 7. Notify Dr (doctor), and On-call nurse manager .If guest is not competent, notify responsible/party/POA. 8. Thorough Documentation Of All The Above Under Incident Note . 9. Complete incident report, under Risk Management 10. Complete Fall Risk Assessment & Pain Assessment. Fall Prevention, Analysis and Follow-up facility policy, revised 1/13, stated Definitions Fall: Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto .bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. When A Fall Has Occurred: . Immediately after a fall the licensed nurse shall do a full assessment of the resident and begin to collect information to help identify the possible root cause of the fall. The licensed nurse shall complete the Risk Management report in (electronic medical record) prior to going off shift. The nurse will contact the resident's physician and will follow orders as appropriate. The nurse will also contact the Administrator, the DON (Director of Nursing) and the residents POA (Power of Attorney) or chosen family member Each resident will be monitored for a minimum of 72 hours after any fall.

This citation pertains to Intake #: MI 772 and MI 753. Based on observation, interview and record review, the facility failed to operationalize their Fall Management and Wandering/Elopement Policies to ensure 15 minute checks were completed, residents were monitored for safety and interventions were enacted to prevent future falls, elopement and serious injury for 3 sampled residents (#1-1, 1-3, 1-6 ) of 3 residents reviewed for accidents, from a total sample of 9, resulting in Resident # 1-1 experiencing multiple falls and sustaining multiple fractures, Resident #1-3 had a history of [REDACTED].#1-6 obtained a wrist fracture after a dresser drawer entrapped her hand. Findings Include: Resident # 1-1 On 1/31/18 at 9:15 am, an interview with Certified Nursing Assistant I revealed, (Resident #1-1) is in the hospital. A record review on 1/31/18 at 10:20 am, indicated Resident #1-1 was admitted to the facility on [DATE] and readmitted on [DATE] and was transferred to the Hospital Emergency Department after falling and sustaining lacerations and fractures and discharged to the hospital on [DATE] for respiratory difficulty with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive deficits and needed extensive 2 person assistance with transfers and toileting and extensive 1 person assistance with bed mobility, dressing, hygiene/bathing and wheel chair mobility. Further Record Review revealed the following: Incident and Accident Reports: Resident #1-1 had 4 falls between 8/25/17 and 1/17/18, with 2 falls resulting in fractures and lacerations. 1/17/18- .was informed to go into (Resident #1-1's room) because of a fall. Upon arriving into room resident was on the floor face down on the window side of the bed. Resident had a laceration on right forearm just below elbow posterior side. Blood was around resident's face .Resident's nose bleeding .trying to open the blinds . 12/18/17- Nursing assistant notified Nurse that Resident had fallen out of the bed .Resident was face down on the floor and nose was bleeding .left elbow skin tear was noted .trying to answer the phone .x-ray of nose was ordered . 10/15/17- .entered the room, resident was on the floor, on (the) right side in front of (the) chair . 8/25/17- .observed resident sliding partway out of wheelchair .sitting on the foot pedals . (Resident) fell asleep . Progress Notes: 1/23/18 physician progress notes [REDACTED].#1-1) had fallen a few days ago and had bleeding from nose, was noted to have fracture Right Humerus at Emergency Department .Sling, follow up with orthopedic surgery .Possible [MEDICAL CONDITION]. Monitor heart rate. [MEDICAL CONDITION] (slow heart rate) was noted at acute care facility . 1/19/18 Psychiatry Progress Note: (Resident #1-1) is known to me from .(Resident #1-1) experienced another fall onto her face and right arm incurring a closed displaced [MEDICAL CONDITION] neck of the right Humerus (arm bone), closed [MEDICAL CONDITION] olecranon process(elbow bone) and closed [MEDICAL CONDITION] bone .placed in a sling .requires mechanical lift .is currently non-weight bearing on her left upper extremity . 12/26/17: .Post fall, denies pain, skull x-ray negative . No mention of additional interventions. 11/3/17: No mention of a fall on 10/15/17. 9/10/17: No mention of a fall on 8/25/17. Fall Risk Assessments: Ratings: 6/1/17 Moderate Risk for Falls, 9/1/17 High Risk, 12/4/17 Moderate Risk. The Fall Risk Assessments were not completed after each fall. Only with each MDS assessment (quarterly and annually). Care Plans: Fall Care Plan: Updated during the survey- The Fall Care Plan in the Electronic Medical Record (EMR) and visible to staff on 1/31/18 at 10:45 am, did not match the Care Plan provided by the facility on 1/31/18 at 3:30 pm, approximately 3 hours after requesting the documents from the Administrator and Director of Nursing (DON). The facility had updated the care plan to include: Mechanical lift (Hoyer with sling) and 2 person staff assist (added on 1/29/18 after the resident was discharged to the hospital), Be sure the resident's call light is within reach and encourage to use it, Bed to be kept in lowest position when not providing care, Bilateral landing strips to be in place on floor next to bed. None of the above interventions were visible on the resident's care plan in the EMR, nor did the Care Plan indicate it had been updated for review since 10/16/17. The last updated intervention on the Fall Care Plan viewed in the EMR on 1/31/18 at 10:45 am was dated 8/28/17. Potential/actual impairment to skin integrity, revised 11/20/17. There were no new interventions to address the left elbow skin tear that occurred during the fall on 1/17/18. Resident #1-3 On 1/30/18 an overhead automated page was heard in the Bay area of the facility announcing that Exit Door #3 was opened. On 1/30/18 at 3:05 pm, Resident #1-3 was observed walking up and down the hallway between her room, the Main Entrance door and Exit door #3. The resident demonstrated confused speech and was talking about leaving to find someone. The hallway, including the resident's room, was partitioned off with multiple sets of double closed doors. There were 3 sets of closed doors that had to be entered before reaching the Nurses Desk; 1 Nurse and 3 Certified Nursing Assistants (CNA's) total worked in the partitioned off areas. Resident #1-3 would not be visible from the Nurses Desk when she was near her room or Exit Door 3. Per CNA U, a CNA had to be present in Resident #1-3's room area at all times. This area also had double closed doors that separated the CNA's assignment. An interview with Certified Nursing Assistant (CNA) B, as she pointed out Exit Door #3 that Resident #1-3 wandered out of, revealed, There was never a sign telling us not to go out it. The key to get out was in large letters on the door. It is gone now. They told us in an in-service not to use the door except for after hours, after a resident (Resident #1-3) went out the door. Three key pads were observed beside the door. Two were used to exit the facility and 1 keypad was to reset the Wander Alert system. A sign was posted next to the key pads with the code to exit the building. The instructions said to place the code in the 2 exit keypads. Per CNA B the Wander Alert keypad was newly added. A record review on 1/31/18 at 11:40 am revealed, Resident #1-3 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the resident had severe cognitive decline and was independent with transfers, ambulation and toileting and needed supervision with dressing and eating and 1 person assistance with hygiene/bathing. The following records were also reviewed: Elopement Investigation: On 11/20/17 at approximately 4:15 pm, Resident (#1-3) was seen entering our Main Entrance in front of the building. Our receptionist noticed (Resident #1-3) coming from the right turning to enter into the office. (Resident #1-3) left out of Door 3 which is our service entrance and it has a key pad for security. The alarm to this door did not sound and has a delayed time for locking. At approximately 4:10 pm Resident (#1-3) was seen by (CNA U) standing in the main hallway in front of the dining room (near Exit Door 3) .A sign is on Door 3 stating to use this entrance only after hours .Resident (#1-3) was put on 1:1 24 hrs./day for exit seeking until reevaluated due to (Resident #1-3) wearing a Wander Guard, a new system will be installed to Service Door 3 . Incident and Accident Reports: 9/5/17- Resident walking facility looking for nephew .got up by front lobby, got past the first door at Door 5 but did not exit building. Interventions: IDT (interdisciplinary team) to re-direct and monitor exit behavior .Resident frequent exit seeker .observed at nurses station 2 approximately 10 minutes before alarm heard sounding at Door 5 . Resident continues on 15 minute checks. 11/20/17- (Resident 1-3) was outside the building walking up to the reception door. It looked like she was coming from the direction of Door 3. We let her in . Interventions: IDT met and reviewed. Resident will be placed on 1:1 until re-evaluated. A Wanderguard will be place on Service Door 3 . Elopement Risk Assessments: 11/1/17- Wanderguard to ankle remains in place, has been having increased wandering due to room change up front. Closer to 2 exit doors at this time. Continues to wander facility . 11/21/17- Wanderguard remains in place to ankle. Active elopement made out Door 3 on 11/20/17 . Care Plans: Elopement Risk/Wanderer, No new interventions after attempted elopement on 9/5/17 or after exhibiting increased wandering on 11/1/17. The Wanderguard on the left ankle was already in place since 11/5/2015. The Elopement Risk Care Plan in the EMR did not match the Care Plan provided by the facility. The Care Plan in the EMR had not been updated since 8/15/17. The Care Plan provided by the facility on 1/31/18 at approximately 4:00 pm, indicated the resident was on 15 minute checks every shift, dated 12/5/17. physician progress notes [REDACTED].>5/23/17, 7/18/17, 9/10/17, 11/3/17 and 12/26/17 (This was all of the progress notes present in the resident's chart.)- None of the progress notes mentioned wandering or interventions to aid in prevention of elopement from the facility. On 1/30/18 between 1:30 pm and 3:30 pm, an alarm sounded in the Bay area unit 4 times, stating Exit Door 3 was open, indicating the proper exit code had not been put into the keypads prior to someone exiting through the door. On 1/30/18 at 4:10 pm, Director L stated, Exit Door 3-It's our temporary entrance after hours. During the day time hours it's only used for large equipment, kitchen deliveries and the ambulance. 4:30 pm: Director L tested each exit accessible exit door with the following results: Door 1 in the Bay area- would not release to open. Director L stated, Oh, this is big. I will call and get this fixed right now. Door 11- alarmed and paged overhead in the Bay area, when opened, but not in the rest of the facility. Door 12- the door was marked an Exit, but would not open. It had been cemented shut during the current construction remodel and no one was aware that during an emergency it could not be opened to evacuate residents. Director L stated, We will post this is not an exit immediately. Boiler Room Door- did not alarm overhead when opened. The DON stated, No it didn't alarm. She was standing in the hallway. Door 16- blocked with equipment and inaccessible. Director L stated, It does not alarm overhead. The construction people must have cut a cable. Exit Door 3- did not alarm overhead in the area surrounding the door, the Coast unit, where Resident #1-3 resided. It only alarmed in the Bay area. The dietary staff, across from the door said they could not hear an alarm that the door was opened. At 4:45 pm, Director L attempted to repair Bay Door 1. It alarmed for greater than 3 minutes and no staff came to investigate the opened door. There were 3 CNA's and 1 nurse working in the 3 hallways of the Bay unit. Nurse V was assigned to the area and passing medications on the next hall and stated, No, I can't hear it. There was no staff present on the hallway containing Exit door 1. There were resident's residing on the hall. The DON and Administrator assigned a staff member to the hall with Bay Door 1 to watch the door, as the alarm was not audible throughout the unit or rest of the building. Director L, DON and Administrator stated the doors would be repaired immediately to provide audible alarms throughout the building and staff would be assigned to watch doors 3 and 1. On 1/31/18 at 9:30 am, Resident #1-3 was observed sitting in her room and stated, I don't want to stay here any longer. At 1:56 pm on 1/31/18, Confidential Person H was interviewed and stated, They called a couple times when she left the facility before, this last year. They said one time they found her between 2 doors. They didn't tell me much this time. They said she went out a door near the front. On 1/31/18 at 2:05 pm, Social Worker (SW) D was interviewed and said Resident #1-3 received 1:1 staff observation, until the Wander Alert system was added to Exit Door 3. A progress note written by SW D on 11/22/17 indicated the resident was no longer receiving 1:1 monitoring. A Work Order received from Director L dated, 12/5/17, provided the Wander Alert system was not added to Exit Door 3 until 12/5/17 at 4:00 pm. A review of the [MEDICATION NAME] Club, list of residents who wander, (there were 7 residents on the list) was noted by Nurse A, (Resident #1-3) is really the only resident who walks and could get out the door. A review of the 15 Minute Checks, documents for Resident #1-3, on 1/31/18 at 2:15 pm revealed, there were no 15 minute checks, documented yet that day, 1/31/18. Per CNA G, the night shift started the form each day at 12:00 am. Further review of the documents between 12/5/17 and 1/30/17, indicated there were no 15 minute check, forms for 1/28/18, 1/21/18, 1/20/18, 1/19/18, 1/18/18, 1/16/18, 1/14/18, 1/9/18, 1/7/18, 1/3/18, 1/1/18 and 12/24/17. The majority of the other days were blank for extended periods of time throughout the day. An interview with Nurse A revealed, You expect them (the CNA's) to complete it, when queried why the forms were missing on many days and incomplete on other days. On 1/31/18 at 5:20 pm, there was no staff observed on the Coast hallway, where Resident #1-3 resided. Per Nurse A, there was always to be at least 1 CNA on the hall if there was a resident on the hall, to observe the residents for safety. A resident was observed lying in bed at the far end of the hallway. The DON was accompanied to the Coast hallway to observe there was a resident in their room, but no staff were present on the unit. Resident #1-6 On 1/31/18 at 9:40 am, a record review of an emergency room Visit report, indicated Resident #1-6 experienced a closed [MEDICAL CONDITION] end of the right ulna with arm pain, written by Doctor W on 1/25/18. At 10:05 am, on 1/31/18, the resident was observed sitting in a wheelchair in her room. A purple wrapped cast was present on the right arm from wrist to elbow. There was a dresser with a TV sitting on it in the corner of the room and a nightstand was sitting next to it positioned behind the bed, so the drawers could not open. CNA I stated, A drawer fell on her arm. They put clips on the drawers so she can't get them open on her own. Further record review at 11:12 am, revealed Resident #1-6 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment, dated 11/3/17 indicated Resident #106 had severe cognitive decline and needed extensive with most Activities of Daily Living (ADL's). The resident was able to feed self with some assistance. Additional record review revealed the following: Incident and Accident Reports: 1/23/18: Called to room .observed resident sitting in geri chair holding her right wrist, crying and repeating it hurts. CNA states that resident pulled a drawer out from the dresser and it was lying on top of resident's wrist. Resident complained of discomfort when ROM (range of motion) attempted. Dime size bruise noted on the back of her wrist, dark purple in color. No swelling noted. X-ray ordered and dresser removed from room. 1/24/18, 12:23 am: Nurses Note- X-ray here to compete x-ray of right wrist. 1/25/18: IDT (interdisciplinary team) met and reviewed fall, x-ray results showed [MEDICATION NAME] installed on all 6 drawers in room. 2 being on the nightstand and 4 on the dresser. Care Plans: A review of the Care Plans in the EMR on 1/31/18 at 11:12 am, did not reveal any care plan addressing the resident's recent injury related to the dresser drawer falling on her arm. There was no mention of a right arm cast or interventions to prevent a further incident. At 2:17 pm, on 1/31/18, Nurse A was followed to Resident #1-8's room. Nurse A was demonstrating how Resident #1-6's arm had become stuck between 2 drawers. Resident #1-8's dresser drawers were loose, did not close properly and appeared unsafe. On 1/31/18 at approximately 4:30 pm, the DON provided new and updated Care Plans including Bone Fracture dated 1/31/18, with interventions documented on 1/31/18. Actual Impairment to Skin Integrity, revised 1/31/18, with intervention, Drawer pulls were place onto drawers to keep drawers from pulling out, dated 1/31/18. Nurse K was interviewed at 5:35 pm, on 1/31/18 and queried why the care plans in the resident's medical record had not been updated for all staff to see and utilize to provide care to the residents and stated. It should be the nurse on the floor who updates the care plans. I update the care plans with the MDS assessments. An observation on 1/31/18 at 5:55 pm, indicated Resident #1-6 was eating in the dining room. Her TV was sitting on the floor of the room and it was on. The dresser was gone from the room and the nightstand was placed in front of the bathroom door blocking it from use. On 1/31/18 at 6:05 pm, Director L was queried if all resident's drawers had been inspected for safety and stated, No, we don't do routine inspections on the dressers. We will check all of the drawers. The DON and Administrator were interviewed at 6:06 pm and indicated they were aware of the malfunctioning doors and alarms, Care Plans not updated with repeated resident attempts of elopement and falls and would ensure the dressers in disrepair were inspected. On 1/31/18 a 6:10 pm, a review of the following g Facility Policies occurred: Fall Prevention, Analysis and Follow Up dated revised 11/17 revealed, The community shall ensure that a system is in place for managing falls and identifying interventions related to residents at risk for falls, The goal of the community is to ensure that the residents environment remains as free from accident hazards as possible and that each resident receives adequate supervision and assistance to prevent accidents .The Fall Risk Assessment will be used to assess the potential risk for falls. The Fall Risk Assessment will be completed on admission, quarterly, with any significant change of condition and after each fall. The Nurse shall document the incident .If the initial intervention based on systematic evaluation does not prevent another fall, other interventions will be initiated . Elopements and Wandering Residents, dated revised 11/17, Elopement occurs when a resident leaves the remises or a safe area without authorization .The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .

Based on observation, interview and record review, the facility failed to prevent a fall for 1 resident (Resident #2) of 4 residents sampled, resulting in Resident #2 sustaining a fall while left on the toilet alone with no alarm in place and requiring being hospitalized for [REDACTED]. Findings: Record review of facility 'Fall Management' policy, dated 4/7/17, revealed that a system is in place to manage falls and identifying interventions related to the resident's at risk. The goal is to ensure that the resident environment remains free from accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. Fall/accident prevention: (1.) Based on previous evaluations, data from admission and at a minimum quarter assessments, the staff shall identify interventions related to the resident's specific risks and causes to prevent the resident from falling and to minimize complications from falling. (4.) Safety devices may be used which include, but not limited to, an alarm, motion detector, mat on the floor or low bed shall be provided on admission and as needed when a resident is at risk for a fall. (5.) A care plan shall be developed within 48 hours of admission, reviewed updated quarterly and revised after each fall with interventions. Record review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed a [AGE] year-old female with cognitive skills for daily decision rated as being moderately impaired, decisions poor, cues/supervision required. Active [DIAGNOSES REDACTED]. An observation was conducted on 7/18/17 at 12:00 PM of Resident #2, while seated up in her wheelchair with bilateral leg rest in place and chair alarm box with pad in the seat of the wheelchair. Resident #2 stated that she fell off the toilet and that she just went down (to the floor). Resident #2 stated that she was by herself in the bathroom. Record review of Resident #2's Activity of Daily Living (ADL) care plan, dated 3/6/17,- Toilet use: The resident requires extensive assist x 2 staff participation to use toilet. Personal hygiene- The resident requires extensive assist x 2 staff participation with personal hygiene. Record review of Resident #2's Risk for fall care plan, dated 4/11/17, related to confusion, deconditioning, gait/balance problems, incontinence, unaware of safety needs and history of falls prior to admission. Interventions, dated 3/6/17, revealed that the resident is to have bed and chair alarms-check presence, function and activation every shift and as needed. Record review of Resident #2's fall incident report, dated 5/12/17 at 6:40 PM, revealed that Certified Nurse Assistant (CNA) I went to answer a bathroom (call) light for Resident #2. Resident #2 was noted to be sitting on the toilet. Resident #2 stated that she was finished using the bathroom. CNA I placed a gait belt around Resident #2's waist and helped her to stand and pulled up her brief. Resident #2 stated that her legs felt weak so CNA I lowered Resident #2 back to the toilet seat and told the resident that she was going to get some help. In an interview on 7/18/17 at 2:17 PM, Certified Nurse assistant (CNA) I, revealed that she did respond to the bathroom call light and did put a gait belt around Resident #2 while she was on the toilet and stood her up to pull up the brief. CNA I stated that Resident #2 stated that her legs felt weak and was lowered back onto the toilet. CNA I stated that she left the bathroom and went out into the hallway to find help. CNA I stated that she heard Resident #2's telephone ringing when she was in the hall. CNA I stated that Resident #2 had slid off the toilet with her knees bent as if she squatted on the floor. In an interview on 7/18/17 at 3:00 PM, Licensed Practical Nurse (LPN) K revealed that she had assessed Resident #2 at the time of the fall and that the resident had no pain or injury reported. LPN K stated that she spoke with the Unit Manager about the fall and that the unit manager stated that no x-rays were needed. LPN K stated that CNA E had taken Resident #2 to the bathroom put her on the toilet and left her there. CNA I responded to Resident #2's bathroom light and then also left her on the toilet. Record review of Resident #2's Hospital emergency room notes, dated 5/14/17 (2 days after the fall), revealed that the resident had a closed fracture of the left femur.

Based on observation, interview and record review, the facility failed to prevent facility-acquired developments of pressure ulcers and to follow the plan of care for pressure ulcer treatment for 2 of 4 residents (#4, #8) of 15 sampled residents, resulting in Resident #4's care plan and standards of practice not being followed, and Resident #8, who was cognitively impaired, was allowed to develop pressure ulcers of the lateral right great toe area and a necrotic right heel. Findings include: Record review of facility 'Pressure Ulcer Prevention and Management' policy, dated 2/14/17, revealed the policy was to establish a system to prevent and manage resident pressure ulcers. Pressure ulcers are localized injuries to the skin and underlying tissue that occur as a result of pressure or shearing force. A pressure ulcer can develop when pressure on an area of skin increases temporarily cutting off circulation to the affected area and leading to tissue death. Staging: Stage II- pressure ulcer is characterized by partial thickness tissue loss of the dermis presenting as a shallow, open ulcer with red-pink wound bed without slough. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. An unstageable pressure ulcer is characterized by full-thickness tissue loss in which the base of the ulcer is the wound bed and is covered by slough, eschar (dead tissue), or both. Until enough slough or eschar is removed to expose the base of the wound, the true depth and therefore, stage can't be determined. Letter of avoid ability: The 'Letter of unavoidability' maybe used to provide physician certification of unavoidable wounds due to resident condition despite proper implementation or care interventions. Documentation: Record the presence of infection and pain. Document the resident's response to the interventions. Resident #8: Record review of Resident #8's Minimum Data Set (MDS), 8/25/16, revealed an [AGE] year-old female, who was admitted on [DATE]. Record review of the MDS noted that there were no skin issues noted during the MDS assessment period. Review of the cognitive/decision making assessment revealed the resident was severely cognitively impaired, required extensive assist with bed mobility, transfers and activities of daily living. The MDS pain assessment was noted as the resident was not able to answer in response to pain. Observation on 3/21/17 at 9:00 AM, during the entrance tour of the annual survey, noted Resident #8 to be seated in a maroon broda chair with foot rest. Observation of Resident #8 revealed a gauze dressing to the right lower extremities with a blue provelan boot (blue puffy/padded boot) in place with a noted odor. Record review of Resident #8's Minimum Data Set (MDS), 1/17/17, revealed an [AGE] year-old female who was admitted on [DATE]. Record review of the MDS noted that there was an unstageable (eschar) skin issue noted during the MDS assessment period. Review of the cognitive/decision making assessment revealed the resident was severely cognitively impaired, required extensive assist with bed mobility, transfers and activities of daily living. The MDS pain assessment was noted as the resident was not able to answer in response to pain. Observation on 3/21/17 at 1:30 PM of Resident #8, during a two person transfer from broda chair to bed with gait belt, revealed that the resident did not bear weight on her feet/legs and was noted to wince and grimace with movement and transfer. Observation on 3/21/17 at 1:45 PM of Resident #8's right foot dressing change revealed that Registered Nurse (RN) H gathered her supplies and went to the resident's room. Registered Nurse (RN) H then propped up the right leg on a folded towel and the resident winced and grimaced with movement. Registered Nurse (RN) H removed the blue provelan boot from the right foot with odorous drainage noted to boot and through the gauze dressing. RN H began to cut the dressing off the foot and the resident leaned up on her elbows apprehensively and grimaced. RN H cleansed the lateral heel wound with saline and patted the wound dry. Observation of the right lateral heel revealed measurements of 5 cm X 5 cm diameter black tissue area with black/dark skin going up the back of the heel. RN H applied skin prep to the area. Observation of the right lateral great toe wound revealed drainage with area measurement of 5.2 cm in length and 2.5 cm wide over the bony prominence. Observation on 3/21/17 at 1:55 PM of Resident #8's post dressing change with RN H revealed that the odorous provelan boot with noted drainage from the old dressing was placed back on the right foot with potential for causing cross contamination. Record review and interview on 3/23/17 at 8:45 AM of Resident #8's wound care notes by unit manager Registered Nurse J revealed that on 11/17/16 the right heel wound was a stage II measuring 1.8 cm X 4.3 cm. RN J acknowledged that the pressure ulcers were facility acquired. RN J reviewed the wound care documents and the electronic record for a letter of unavoidability, but there was none to be found. RN J reviewed all of Resident #8's Care plans and there was no mention of the development or treatment of [REDACTED]. Interview and record review on 3/23/17 at 10:35 AM with Licensed Practical Nurse (LPN) 'N, the wound care nurse, revealed that treatment records reviewed revealed that in October 2016 Resident #8 had prevalon boots for prevention. On 11/16/16 the treatment record revealed a blister to the right heel and on 11/17/16 stage II an open area to right heel. LPN N stated that she did not know how the pressure ulcers developed and that staff should have noted red or mushy heels before they became a blister or open area. LPN N was asked to review the 'skin care' care plan and was asked about the treatment of [REDACTED]. According to the Admission Record, dated 3/21/2017, Resident #4 was a [AGE] year-old male, who was originally admitted to the facility on [DATE]. The Admission Record, dated 3/21/2017, listed [DIAGNOSES REDACTED]. The Care Plan for Resident #4, initiated 6/4/2013, indicated that he was unable to express his needs and wants and that staff was to anticipate and meet all of his needs for comfort and care. According to the Weekly Skin/Wound Note, dated 3/16/2017, Resident #4 had an open unstageable pressure ulcer on his buttocks that measured 11.8 centimeters (cm) by 5 cm. The note indicated that the area was beefy red and had two darker areas of coloration. On 3/21/2017 at 2:05 PM, Certified Nursing Assistant (CNA) staff X was observed as she transferred Resident #4 from his broda chair into his bed in his room using a mechanical lift with assistance of another CNA. An observation of the pink broda chair, that Resident #4 had been sitting in, revealed that there was no cushion in the seat of the chair. The seat of the pink chair itself was a thin layer of foam covered by vinyl. CNA Staff X stated that she normally worked from 10:00 PM until 6:00 am and that she had been mandated to stay over for first shift on this date. CNA Staff X stated that she usually gets Resident #4 out of bed early, at 5:45 am, because he was a third shift get up. On 3/21/2017 beginning at 2:15 PM, Registered Nurse (RN) Staff DD was observed as she provided wound care to the pressure ulcer on Resident #4's buttock while he was laying in his bed. When Resident #4's buttocks were exposed, there was no dressing in place over the pressure ulcer. The wound extended over the coccyx and buttocks at about the size of the palm of a medium sized female hand. There was one area of yellow slough tissue and one area of black eschar on the base of the wound. The lower edge of the wound on the right buttock was actively bleeding. There were three additional dark red areas over his lower right buttock. Resident #4 was thin with his hip bones protruding. When asked at that time, CNA X could not recall if a dressing had been in place when she had gotten him up at 5:45 am on this morning. CNA X stated that she had not laid him down after breakfast because she had been unaware that he had been assigned to her. CNA X thought that perhaps another CNA had laid him down between breakfast and lunch. When RN Staff DD began the treatment for [REDACTED].#4's buttocks on 3/21/2017 at 2:15 PM, she opened two packages of gauze pads, each containing two four inch by four inch gauze squares. RN DD stacked the four gauze pads into her right hand and squirted normal saline on them. RN DD then took the stack of gauze pads and wiped at the pressure ulcer on Resident #4's buttocks. RN DD then removed the top gauze pad and used the next pad in the stack, which had an area of blood on it that had seeped through from the top pad, and wiped the pressure ulcer again. RN DD repeated this process a third time to blot at the open area. RN DD then applied a new dressing to the wound. When the technique used by RN DD was described to the interim Unit Manager, Licensed Practical Nurse (LPN) Staff N on 3/23/2017 at 11:00 am, she shook her head and said, that was not right, she should have sprayed the area with the normal saline and held the four by four's under the wound. According to Resident #4's care plan, dated 11/23/2016, interventions for the care of the pressure ulcer on his buttock included the use of a pressure reducing/relieving cushion on his geri chair with a revision date of 3/27/2015. Resident #4's care Kardex, printed on 3/22/2017 indicated that he required a full body Pressure relieving/reducing cushion on geri-chair.On 3/22/2017 at 8:15 am, Resident #4 was observed in the sunshine dining room being fed his breakfast. There was no cushion on his chair. On 3/23/2017 at 11:00 am, the interim Unit Manager, LPN Staff N stated that Resident #4 was to have a pressure-reducing cushion on his chair and was surprised that no cushion was in his chair. LPN N asked what other interventions were used to relieve pressure for Resident #4. LPN N stated that he was to be up for meals only. LPN N was reminded that Resident #4 was on the third shift get up list which meant he would be up in his chair for more than two hours and 15 minutes before breakfast was served. LPN N said, I just realized that when I said it. That will be changed and he will be off the get up list today.

This citation pertains to MI 024. Based on observation, interview and record review, the facility failed to prevent the elopement and ensure the safety of 1 resident (Resident #101), who was severely cognitively impaired with long and short term memory loss, decreased safety awareness, had a recent fall in the facility (on 6/5/16), a known wanderer with a history of removing his wander alarm bracelet (an alarm device for notification of elopement), out of a total sample of 8 residents, resulting in placing residents at high risk for injury, serious harm or death. This citation pertains to MI 024. The Immediate Jeopardy began on 6/11/16 at 6:45 p.m., when Resident #101 eloped out of the front lobby exit door (door #5) alone and unsupervised. A review of the facility incident report (dated 6/11/16), investigation (un-dated) and per an interview done on 6/16/16 at 10:40 a.m., with staff member I (Dietary Cook), revealed that on 6/11/16 at approximately 6:40 p.m. to 6:45 p.m., Resident #101 eloped from the facility through the front lobby door. Staff member I (Dietary Cook) noticed the resident, as she was leaving work on 6/11/16 at approximately 6:45 p.m., in the middle to the street (Morrison Street). Staff member I was unable to redirect the resident back into the facility so she walked arm-in-arm with him as she called the facility for immediate assistance. Staff member I said she was unable to get station I or station II to answer the phone so she called the kitchen and asked staff member L (Dietary Aide) to get her help. Staff member L paged using the overhead speaker nurse stat to door # 3 (the alleyway door). Staff members G (Charge Nurse, LPN) and N (Charge Nurse, LPN) who were not aware Resident #101 was missing and assisted to get him back into the facility. The door alarm failed to be activated because the resident had removed his wander alarm bracelet, which was later found in his room hidden in a shirt pocket. Resident #101 was outside approximately 5 minutes. Per interviews done on 6/16/16, (at 8:30 a.m., 2:48 p.m. and 3:15 p.m.) with staff member A (Administrator), staff member B (Director of Nursing) and F (Nurse Manager), Resident #101 had previously removed his wander guard alarm on 6/10/16 (the day prior to his elopement) and staff had to put another one on him. The Immediate Jeopardy was identified at approximately 6/16/16 at 1:30 p.m., based on review of the facility incident report (dated 6/11/16), facility staff written statements (dated 6/11/16 through 6/16/16) and per interviews done on 6/16/16 (at 6:55 a.m., with staff member Q Social Worker #1, at 7:00 a.m., with staff member H Charge Nurse RN, at 8:30 a.m., with staff member A Administrator, at 9:10 a.m., with staff member H MDS Nurse LPN, at 9:20 a.m., with staff member J Director of Maintenance, at 10:25 a.m., with staff member D Human Resource, at 10:40 a.m., with staff member I Dietary Cook, at 11:10 a.m., with staff member L Dietary Aide, at 11:30 a.m., with staff member M Social Worker #2, at 11:45 a.m. and with staff member N Nurse Manager LPN, at 12:15 p.m.). Additional interviews were done on 6/16/16 with facility staff (at 2:48 p.m., with staff member B Director of Nursing/DON, at 3:00 p.m., with staff member E Charge Nurse LPN, at 3:15 p.m., with staff member F Nurse Manager RN, at 3:43 p.m., with staff member G Charge Nurse LPN, at 4:00 p.m., with staff member K Dietary Aide, at 4:15 p.m., per phone with Visitor #1 and at 4:25 p.m., with Visitor #2). Resident #101 eloped from the facility front lobby door on 6/11/16 at approximately 6:45 p.m., his wander alarm bracelet did not activate the door alarm system due to his having removed it and hid it. Staff member I (Dietary Cook) observed the resident in the middle of the road (Morrison Road) alone, unsupervised, unbeknownst to facility staff. Staff member I phoned the facility and requested immediately assistance because the resident would not come back inside the building with her. The resident had on a sweat shirt, zipped up summer coat, jeans, socks and tennis shoes. The weather in Saginaw MI on 6/11/16 was, 90 degrees Fahrenheit, which put the resident at risk for heat stroke. The resident was returned to the facility with the assistance of staff member N (Charge Nurse, LPN) and 2 properly functioning wander alarm bracelets put on the resident, one his wrist and one on his shoe. The Administrator was notified on 6/16/16 at 4:40 p.m., of the Immediate Jeopardy that began on 6/11/16 at 6:45 p.m., due to the facility's failure to prevent the elopement and ensure the safety of Resident #101, who was assessed by the facility upon admission to be at high risk for elopement, fitted with an wander alarm bracelet and who eloped through the front lobby doors, which did not activate due to the resident removing his wander alarm bracelet. The resident had a history of [REDACTED]. Findings Include: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 6/6/16, nurses, social services and physician notes dated 5/24/16 through 6/13/16, Physical Therapy (PT) notes dated 5/25/16 and History & Physical dated 5/19/16, revealed Resident #101 is an [AGE] year-old male, who was admitted to the facility on [DATE], was confused with short and long term memory loss, had decreased safety awareness and dependent on staff for assistance with his Activities of Daily Living (ADL's). The residents [DIAGNOSES REDACTED]. The resident had impaired cognition with sundowners (increased decreased cognition towards the end of the day) with documentation of multiple attempts to leave the facility prior to his elopement on 6/11/16. Review of the Social Service note dated 5/31/16 at 9:37 a.m., stated Res. (Resident #101) scored a 0 on his BIMS (cognitive assessment) on 5/30/16. Re (he) has clear speech and is able to express his thoughts, feelings and desires. He is frustrated that his mind is gone, even with cueing was unable to recall. Review of the facility Incident report, dated 6/5/16, revealed on 6/5/16 at 11:16 a.m., Resident #101 was found by staff on the floor in the hallway, without injury. Review of nurse's notes, dated 6/5/16 at 11:48 a.m., stated a staff member came to this writer and stated this resident was on the floor, this writer asked resident what happened and he stated that one minute he was walking and the next minute he was on the floor. Review of nurses notes, dated 5/25/16 at 4:06 p.m., stated Multiple attempts to elope through front door. Review of the admission elopement assessment dated [DATE], revealed the resident was scored as a 5 (at high risk for elopement). Review of Resident #101's facility elopement (dated 5/31/16), cognitive (dated 5/31/16), nutritional (dated 5/26/16) and fall care plans (dated 5/26/16), revealed he was at risk for falls, was an elopement risk due to having sundowners, had long term memory loss, impaired decision making, impaired safety awareness, verbalized he wanted to go home and had attempted to leave the facility. Review of the facility incident report (dated 6/11/16) and the investigation (un-dated), revealed on 6/11/16 at approximately 6:40 p.m. to 6:45 p.m., Resident #101 eloped from the facility through the front lobby door. Staff member I (Dietary Cook) noticed the resident was walking outside the building as she was leaving work on 6/11/16 at approximately 6:45 p.m., he was observed in the middle to the street (Morrison). Staff member I was unable to redirect the resident back into the facility, she called the facility and staff members G (Charge Nurse, LPN) and N (Charge Nurse, LPN) assisted to get the resident back into the facility. The door alarm failed to be activated (alarm) because the resident had removed his wander alarm bracelet, which was later found in his room, hid in a shirt pocket. The resident was outside approximately 5 minutes. Review of the nurse's notes, dated 6/11/16 at 8:20 p.m., stated PT (patient) found outside on the corner of Davenport and Morrison. Noticed and redirected by staff. Per staff interviews done with staff member Q (Social Worker #1) on 6/16/16 at 7:15 a.m., staff member E (Charge Nurse, LPN) on 6/16/16 at 3:00 p.m. and staff member F (Nurse Manager, RN) on 6/16/16 at 3:15 p.m., revealed the resident had a BIMS (cognitive assessment) of 0 on 5/30/16 (indicating severe cognitive impairment), was unsteady, required supervision of one for locomotion off the unit, wandered the facility daily, frequently followed his family to the lobby door when they left, had verbalized he wanted to go home and had removed his wander alarm bracelet on 6/10/16 (the day prior to his elopement) and was at high risk for elopement. During an interview done on 6/16/16 at 2:48 p.m., staff member B (Director of Nursing/DON) stated we knew on Friday (6/10/16, day prior to elopement) he had taken it (wander alarm bracelet) off, no one had charted it, I did educate them (staff). During an interview done on 6/16/16 at 10:40 a.m., staff member I (Dietary Cook) stated It was at 6:45 p.m., I just punched out. I saw him (Resident #101) in the middle of the street (Morrison Street), I didn't know at first he was a resident. He had a light coat on, jeans and tennis shoes, it was very hot. He was confused, he thought he just ate at the facility. I had to walk with him, he said he was headed South/East. He insisted on us walking toward the stop sign, we got to the stop sign (on corner of Davenport and Morrison), I called the facility. He wanted to go across the street (cross the busy one-way road, Davenport). I had his arm guiding him towards me. I called the facility twice, no one answered. I called (staff member L (Dietary Aide in the kitchen), I asked her to please get someone out here, it was an emergency. (Staff members N (Charge Nurse) and G (Charge Nurse) came about 5 minutes later. We were on the corner (Morrison and Davenport) when they came out, he gave the nurse's a little fuss when they tried to get him back in. He said he walked out the front door (lobby door), he said he wanted to go home. During an interview done on 6/1/6/16 at 11:10 a.m., staff member L (Dietary Aide) stated (Staff member I, Dietary Cook) called me and asked me to call somebody to help her because (Resident #101) was outside. I got on the pager and called for a nurse Stat, I came outside and showed them where he was at. I saw him and (staff member I, Cook) at the stop sign (corner of Morrison and Davenport). They had to talk him into going back in. During an interview done on 6/16/16 at 3:43 p.m., staff member G (Charge Nurse, LPN) stated ( she and member N, Charge Nurse, LPN) were paged on 6/11/16, by (staff member I, Cook), he (the resident) was at Morrison and Davenport. It was about 94 degrees that day, he had a sweat shirt, a summer coat and jeans on, his face had perspiration on it, he was hot. (Staff member N, Charge Nurse, LPN) got him to come back in, I never looked to see if his (wander alarm bracelet) was on, it never occurred to me. During an interview done on 6/16/16 at 3:00 p.m., staff member E (Charge Nurse, LPN) stated I knew he (the resident) was an elopement risk, it was passed on through report. His (wander alarm bracelet) is usually checked every shift, we all knew we should chart it in the nurses note's. On Friday (6/10/16, day prior to elopement) (staff member F, Nurse Manager RN) and I checked and his (wander alarm bracelet) was gone. I did not chart in nurses notes. I have noticed when his (the resident) family goes to leave he gets close to the lobby door, he has expressed he would like to go home, he has dementia, he is confused. During an interview done on 6/16/16 at 11:45 a.m., staff member N (Charge Nurse, LPN) stated I heard Nurse Stat, I took off running. I got to the door and (staff member L, Dietary Aide) was going out the door, I followed and saw him (the resident) standing at the corner (the corner of Morrison and Davenport) with (staff member I, Cook). I had to talk him into coming back in, he was convinced he was going home. It was like 94 degrees that day (on 6/11/16), he had on a sweat shirt and a jacket and jeans and tennis shoes. That's how I got him back in, he was hot, he did say he was hot. On Saturday 6/11/16 at 6:00 p.m., the outside temperature in Saginaw Michigan was 90 degrees Fahrenheit. (http://www.wunderground.com) The elderly are at a higher risk for dehydration and heat stroke due to hot weather. Factors that may be increase the risk of heat stroke are heart disease, circulatory problems, decreased thirst sensation, not feeling hot and medications such as diuretics (pull out fluids) or pain medications (decrease awareness); heat stroke if not treated can lead to death. (Lippincott Manual of Nursing Practice, ninth edition, Wolters Kluwer/Lippincott Williams & Wilkins, 2010) During an interview done on 6/16/16 at 9:10 a.m., staff member H (MDS Nurse, LPN) stated I found his (wander alarm bracelet) in his room in a shirt pocket hanging in the closet (on 6/11/16, after the resident's elopement), it was ripped. The administrator got new bracelets (thicker, stronger, gray colored cloth-like), they came in on 6/15/16, and we put one on him (Resident #101). Staff member H (MDS Nurse) said when she found the residents wander alarm bracelet, it was ripped in half, she did not keep it, she through it away. On 6/16/16 at 9:15 a.m., staff member H and this surveyor took a wander alarm bracelet like the one the resident had on prior to his he elopement on 6/11/16 (thin white plastic-like) and were easily able to ripe it in half. Resident #101 had ripped his wander alarm bracelet off on 6/14/16, to deactivate the facility front lobby door wander alarm system. Per observation of Resident #101 done on 6/16/16 at 9:15 a.m., accompanied by staff member H (MDS Nurse, LPN), he did not have a new thicker gray colored wander alarm bracelet on, he had one of the white thin plastic-like ones on, the same kind he had ripped off. During an interview done on 6/16/16 at 3:15 p.m., staff member F (Nurse Manager, RN) stated on 6/10/16 around lunch time (12:00 p.m. to 1:00 p.m.) I got the straps for her (staff member E (Charge Nurse, LPN) and we put the (wander alarm bracelet on his right wrist. I did not look for his (wander alarm bracelet, the one he had taken off on 6/10/16), I did not tell the CNA's (Nursing Assistants), I was the weekend manager at the time (on 6/11/16 when the resident eloped). I did talk with the Director of Nursing, she did educate me. Per observation and interview done on 6/16/16 at 9:20 a.m., staff member J (Director of Maintenance) accompanied by this surveyor, measured the distance from the facility front lobby door to where Resident #101 was observed in the middle to the road by staff member I to be 369 feet, and the distance from the lobby door to the corner of Davenport and Morrison where the resident was observed by staff members G (Charge Nurse, LPN) and N (Charge Nurse, LPN) to be 502 feet. The resident walked out the lobby door, alongside the front of the building into the alleyway which had 2 speed bumps approximately 6 inches in height, broken pavement, a chain link fence with sharp metal fence sections exposed, a rusted old metal bike rack sitting to the right of the Director of Nursing's exterior window, a section of removed pavement (trench-like) approximately 14 to 16 inches in width by 15 feet in length and a slopped and uneven sewer drain at the end of the alleyway leading to the roadside curb (6 inches in height) and into the road. The resident walked past the east end of the building which had 15 metal bed frames piled up and a 7 foot deep by 13 feet in length and 5 feet width dug hole near the facilities electrical box. The sidewalk leading to the corner of the street (Morrison) and the busy one-way road (Davenport) was uneven with cracked sections of cement. Resident #101 had a history of [REDACTED]. Review of the nurse's note's dated 5/24/16 at 8:02 p.m., stated He (the resident) can get restless frequently throughout the day and will walk the building searching for his wife who always gets away on me. Review of the nurse's note's dated 5/25/16 at 4:06 p.m., stated Resident wandering around the facility. Multiple attempts to elope through front door. (Family member) was here to visit for a little while. He attempted to follow her out the door but staff was able to redirect him. Review of the nurse's note's dated 6/3/16 at 10:55 a.m., stated Res (the resident) does get a bit more persistent with his wandering when he is fatigued and as the day/eve (evening) goes on (sundowners), staff are aware of elopement risk. Review of nurse's note's dated 6/3/16 at 11:37 p.m., stated he (Resident #101) had been wandering around facility looking for an exit. He says he is trying to get to Graham Road. He says he needs to get home to his wife as she doesn't know where he is. After multiple redirections, he finally decided he was going to lay down. Review of Resident #101's physician orders [REDACTED]. Review of the physician order [REDACTED]. Review of Resident #101's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 5/16 and 6/16, revealed no documentation of placement check for the residents wander alarm bracelet until 6/12/16 (he eloped from the facility on 6/11/16). During an interview done on 6/16/16 at 11:30 a.m., staff member M (Social Worker #2) was asked by this surveyor what the facility procedure for obtaining a wander alarm bracelet for a resident was, she stated we chart elopement risk assessment, you need a doctor order and then put it on (apply the alarm bracelet on the resident), it gets checked every shift. The nurse calls for the doctor order. During an interview done on 6/16/16 at 11:45 a.m., staff member N (Nurse Manager) stated I am not sure if we need an order for [REDACTED]. During an interview done on 6/16/16 at 12:15 p.m., staff member B (DON) stated yes, you need an order for [REDACTED]. I had (staff member C, MDS Nurse) go back and make sure there is orders and the nurses can show they are checking the resident's (wander alarm bracelets) for placement (a total of 14 facility residents had wander alarm bracelets). I was aware he (Resident #101) did not have an order for [REDACTED]. Review of the facility elopement policy dated 6/11/16, revealed a physician order [REDACTED]. Review of Resident #101's hospital ED (emergency room ) documentation dated 5/18/16 (prior to admission to the facility) stated He (Resident #101) presented to the emergency department after falling off a ladder at home, he has baseline dementia, psychiatry was consulted due to acute delirium and confusion. The resident hospital [DIAGNOSES REDACTED]. Review of the facility Psychotherapy Intake Note's dated 6/7/16, revealed Resident #101 had poor judgment, poor insight, was orientated x 1 (not oriented to person, place and time, orientated to 1 area only), presented with mood indicators of anger, annoyed, poor coping, wanting to go home, persistent, poor insight and forgetfulness. Review of the Psychotherapy Note's dated 6/7/16, stated he is very persistent about going home and does not understand why he would not be able too, he does not seem to have the insight into what his memory deficits and cognitive decline could lead too (to) in reference to causing himself harm. Review of the facility PT (Physical Therapy) Evaluation & Plan of Treatment dated 5/25/16, revealed Resident #101 exhibited forward leaning of his trunk when ambulating due to underlying muscle weakness/paresis and stated Due to the documented physical impairments and associated functional deficits, the patient is at risk for falls, further decline in function and immobility. The resident was at high risk of falling when he eloped on 6/11/16, he was alone, unsupervised and had walked near/by several environmental safety hazards including uneven, broken, raised and missing ground and/or pavement and numerous sharp metal fence areas and bed frames. The immediate jeopardy was removed as of 6/11/16, based on confirmation during observation, interview and record review conducted on 6/16/16 at 5:25 p.m. that the facility had implemented the following to remove the immediate jeopardy. 1. On 6/11/16 at approximately 6:47 p.m., (when notified by staff member I, Dietary Cook) Resident #101 was outside of the building, he had eloped, staff immediately ran to get the resident and assisted him back into the facility without incident. 2. On 6/11/16 at 6:50 p.m., Resident #101 was brought back into the facility, he was assessed by the staff member H (Charged Nurse, RN), and the resident denied pain/discomfort with no injuries found. 3. On 6/11/16 upon return to the facility, staff placed a wander alarm bracelet on Resident #101's right wrist, and on 6/11/16 at 7:35 p.m., they placed a second wander alarm bracelet on his right shoe (camouflaged within the laces and shoe tongue). 4. On 6/11/16 at approximately 7:06 p.m., all facility exit doors were checked by staff member H (Charge Nurse, RN) for functionality with all door alarms sounding; all doors were found to be operating correctly. The front lobby door (door #5) was also checked and found operating correctly. 5. On 6/11/16, the facility notified pertinent staff members of Resident #101's elopement, Power of Attorney (POA notified at 8:17 p.m.), Physician (notified at 8:16 p.m.), Administrator (notified at 6:52 p.m.) and Director of Nursing/DON (notified at 6:55 p.m.). 6. On 6/11/16 at 7:34 p.m., staff member A (Administrator) contacted all Department Managers and mandated them to come into the facility; to assist with the investigation. 7. On 6/11/16 at 7:40 p.m., all facility exit doors were checked a second time by staff members A (Administrator) and staff member J (Director of Maintenance) for functionality, with all door alarms sounding and operating correctly. The front lobby door (door #5) was also checked and found to in working condition. 8. On 6/11/16 at 7:45 p.m. (7:45 p.m. to approximately 8:15 p.m.), all 14 facility residents with wander alarm bracelets were checked for placement and functionality, with 14 out of 14 wander alarm bracelets on and in working condition. 9. On 6/11/16 at 8:30 p.m. (8:30 p.m. to approximately 11:00 p.m.), all 14 residents identified as elopement risk and with wander alarm bracelets; kardex's were reviewed and up-dated accordingly. 10. On 6/11/16, all 14 residents with wander alarm bracelets physician orders [REDACTED]. 11. On 6/11/16, staff members A (Administrator) and B (Director of Nursing/DON) reviewed and up-dated the facility Elopement policy (dated 6/11/16). 12. On 6/11/16 at 7:24 p.m., staff member B (Director of Nursing/DON) initiated all staff mandatory education regarding the elopement policy and procedure (dated 6/11/16). A total of 19 staff members were educated on 6/11/16. 13. From 6/12/16 through 6/16/16, a total of 82 staff members were educated on the elopement policy and Procedure by staff member B (DON). On 6/20/16, a total of 4 additional staff members were educated on the elopement policy/procedure by staff member B (DON). A total of 22 staff members and 4 agency nurses, will be educated with documentation on the facility elopement policy (dated 6/11/16); prior to their next working shift by staff member B (DON) or designee. Although the Immediate Jeopardy was removed on 6/11/16, the facility remained out of compliance at a scope of isolated, and severity of no actual harm with potential for more than minimum harm that is not immediate jeopardy, pending completion of staff education regarding elopement (22 staff members and 4 agency nurses not documented as educated on elopement) and the facility's ability to sustain compliance as verified by the State Agency. It was further confirmed by this surveyor, during observations made on 6/1/16 at 11:20 a.m. that Resident #101 had a wander alarm bracelet on his right wrist with the correct gray colored band and it was in working condition. ( )

Based on observation, interview, and record review the facility failed to follow the facility mechanical lift policy for 2 (#101 and #102) sampled residents reviewed for mechanical lifts from 4 residents observed for mechanical lifts from a total sample of 3 residents resulting in a fall during a mechanical transfer with a fracture for resident #101. Findings include: According to Resident #101' s annual Minimum Data Set (MDS) assessment dated [DATE], Resident #101 was an [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. According to Resident #101's Nurse Aide Care Guide, Transfer: the resident requires Mechanical Aid (Hoyer lift) for transfers and 2 staff assistance. Following Resident's fall on 4/15/16 the care guide was updated to state, under Safety: 2 CNAs present during entire mechanical lift transfer with appropriate hoyer sling. According to Resident #101's Incident report documented by Registered Nurse (RN) R dated 4/15/16 at 17:35 PM, CNA states, I need help the hoyer tipped and she's on the floor. Upon entering room (Resident #101 's), noted bed side table by sink, hoyer lift with legs open pointed towards bed, wheelchair to the right of hoyer lift by the wall with the bakes locked. 3 of 4 hoyer rings of hoyer sling, that resident was in, was attached to the hoyer lift. The 4 th ring belonging to the rear hook of the hoyer lift was hanging loose, towards the same direction the resident was on the floor. There was a second hoyer lift sling attached to the hoyer lift, but hanging from only one ring (front right ring). Bottom of hoyer sling hanging approximately 3 feet above door. Resident (#101) lying left side down on floor facing bed. Left side of face on floor next to wheel on left side of bed, approximately an inch from corner of wall. The left leg of hoyer lift running directly under resident left ribs and left hip . According to Resident # 101's x-rays of left ribs dated 4/15/16 revealed Irregularity is noted in the 4 th through 6 th ribs consistent with non-displaced fractures of undetermined clinical age. Additionally on the X-ray report, Medical Director D documented, could possibly be old, but no previous rib x-rays to compare. On 4/25/16 at 11:30 AM, Resident #101 stated there were 2 CNA's present prior the transfer but CNA K was walking another resident and didn't stay during the transfer and there was only one CNA present at the time of the transfer (CNA J). CNA J did not have the things fastened and I slid to the floor, they had to call an ambulance to get me up. Resident #101 was asked if it hurt and responded, Of course it hurt! My neck hurts, my ribs hurt, my hand and wrist hurts. Resident #101 was ask on a scale of 1-10 what was your pain level and responded, Well, they are giving me pain meds so it is hard to tell, sometimes when they turn, dress me and change me I could scream it is so painful and scary I would say maybe a 6. Resident #101 stated, I fell from the level of the bed to the floor and the staff were having trouble with the slings and didn't have the right sling that day. There was talk of a shower sling during the transfer. On 4/25/16 at 2:43 PM, initially CNA, J reported on 4/15/16 she with the assistance of CNA K put Resident #101 into the sling and hooked it to the hoyer and were raising her up in the presence of another Resident #104, when this resident started yelling. CNA K took resident #104 out as she was doing 1:1 with this resident. CNA J stated, Resident #101 was not lifted up off the bed when CNA K was present. Then CNA J stated, CNA K was there for part of the lift, stated CNA K was doing a 1:1, and left the room to get a different sling. Returned and assisted to get Resident #101 on to the sling, hooked to the hoyer and lifted off the bed. Resident #101 was then reported to have been yelling, and agitated due to the other resident yelling, CNA K stated, I instructed CNA K to get the other resident out and I will find somebody else. CNA J reported Resident #101 was moving around in the sling turning the hoyer around. CNA K was reported to have turned around and shut door. CNA J stated, I was going to put resident back to bed. I was trying to make it (the hoyer) back to the bed with resident in the sling and hoyer, she was too heavy, was going to put back her back on the bed, then the hoyer tilted to the left. CNA J stated, could not find someone else, then stated, I had taken it back around to the bed and it tilted. The legs were closed when moving, can't be closed when moving and can't be open until you get the wheel chair. That is why you have to people. CNA J was asked how many staff were available on the unit at the time and was unable to respond. CNA J was asked what the facility policy for the mechanical lift when transferring a resident and stated. There have to be two staff when you transfer a resident. On 4/25/16 at 12:20 PM, a message was left requesting a return call and on 4/27/16 at 4:32 PM, CNA K was unavailable. According to CNA Ks' written statement, dated 4/15/16 CNA J and I went head and started to get the sling under (Resident #101 ) then (Resident #101 ) said that she didn' t want (Resident #104) in her room anymore because (Resident #104) was looking around (Resident #101's) room. I then felt it was best to take (Resident #104) out of the room. Resident #101 was still on the bed and had not been lifted up at all when I left the room with (Resident #104). On 4/28/16 at 3:01 PM, CNA K stated, That day (4/15/16) I had been assigned to work a 1:1 and it was around 5:30 PM, I was in the hall when CNA J assigned to Resident #101 came out in the hall and asked for assistance. I helped get the sling under Resident #101. Resident #101 got upset with Resident #104 in her room. Resident #104 started to get away. CNA K reported, Resident #104 and I went on our way. When I went out of the room Resident #101 was flat out of the bed, not hooked up to the sling. It is a two person job. I would have not left if she was in the hoyer. I would not have left the sling was lifted up at all. When I left the sling was under Resident #101. CNA K was asked, did you assist with attaching the loops of the sling to the hoyer? No CNA K was asked, where there 2 slings in the room and stated, I helped to get a full body sling under Resident and only saw one sling. On 4/25/16 at 1:40 PM, Registered Nurse (RN) R reported she was at the nurses' station, signing in medications when she heard CNA J yelling for a Nurse or CNA and stated, I need help the hoyer tipped and she's on the floor. RN R stated, when I entered Resident #101's room I saw the bedside table over by the sink. CNA J was present and Resident #101 was on floor next to the bed on top of the base of the hoyer with the legs open and facing the bed. The hoyer sling was hanging with 3 hooks attached, and one on lower left by patient was hanging loose. The sling was approximately 3 feet from the floor. Resident was out of the sling and directly on top of the hoyer legs. There was a second sling hanging on the hoyer one ring attached to the hoyer. RN R reported CNA J was to have unhooked, removed and threw the sling on the bed. RN R stated, I was unsure where it was during the transfer, unsure which hook it was attached to at the time I had entered the room, I just made note it was there and it was unusual and it was the first thing she did when I walked in the room was to remove it. On 4/25/16 at 12:22 PM, Assistant Director of Nursing (ADON) C reported she had been informed by Licensed Practical Nurse (LPN) O that assistance was needed and upon entering the room it was observed RN R and CNA J were present in the room. ADON reported Resident #101 was laying on floor on the lift, on the left side, next to bed, next to the wheel at the head of the bed. Observed two slings, one lose, the second also attached to the hoyer. Resident #101 was assessed and back was hurting. ADON C reported had not wanted to get resident up with lift due to possible back injuries, an attempt to back board was not successful with 5 people due to resident's weight, and ambulance was called for assistance. ADON C reported CNA J was observed to have removed the second sling from the room. RN D was reported to have placed the lift and other sling in the conference room. ADON C reported there were at least 4 other CNA's, and at least 3 nurses available RN R , Licensed Practical Nurse (LPN) H and herself (ADON C) to assist with the transfer at the time of the incident. On 4/25/16 at 1:25 PM, Certified Nurse Aide (CNA) F and CNA G were observed to transfer Resident #101 from the wheel chair to the bed. The wheel chair was not locked during the transfer. On 4/25/16 at 3:30 PM, Environmental Services Director L reviewed the facility mechanical lift policy, and manufacturer lift recommendations. ESD L reported the lifts are inspected monthly, and were last inspection done on 4/1/16, inspected the lift following the incident and could not identify any concern with the lift at the time of the incident. It was noted there was an inspection card on the mechanical lift dated 4/1/16. On 4/27/16 at 3:10 PM, Nursing Home Administrator (NHA) A reported CNA J and K had been suspended, pending progressive disciplinary action due to their actions related to Resident #101 injuries and disregard to facility policy for mechanical lift transfer. NHA A stated, had spoken with the facility human resources and the legal department at 11:30 AM, plan to proceed with reporting both CNA J and CNA K as required by the State of Michigan license and regulation. According to the facility policy Mechanical lift, dated 1/6/12, 3. All residents will be lifted using 2 assistants. 4. i. Re-check to assure all loops of the sling are firmly attached all the way down on each sling arm. All loops should be placed under the safety latch on the sling arm. According to Invacare manufacture recommendations Page 15, transferring the Patent - Wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport. Page 16, Lifting the Patient, When using an adjustable base lift, the legs must be in the maximum Open/Locked position before lifting the patient. When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar If any attachments are not properly in place, lower the patient back on to the stationary surface and correct this problem - otherwise, injury or damage may occur. ( ) Resident #102 According to Resident #103' s quarterly Minimum Data Set ((MDS) dated [DATE], Resident #103 was a [AGE] year old female with [DIAGNOSES REDACTED]. On 4/25/16 at 1:20 PM, Certified Nurse Aide (CNA) H and CNA I were observed to transfer Resident #103 from a broda chair (reclining chair) to the bed. The loops of the sling were not observed to have been checked for placement during the transfer by either staff CNA H or CNA I. According to the facility policy Mechanical lift, dated 1/6/12, 3. All residents will be lifted using 2 assistants. 4. i. Re-check to assure all loops of the sling are firmly attached all the way down on each sling arm. All loops should be placed under the safety latch on the sling arm. According to Invacare manufacture recommendations, Page 16, Lifting the Patient, When using an adjustable base lift, When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar If any attachments are not properly in place, lower the patient back on to the stationary surface and correct this problem - otherwise, injury or damage may occur.

This citation pertains to MI 596. Based on observation, interview, and record review, the facility failed to ensure the use of safety devices (Bed Fall Alarm) and implement fall interventions in 2 of 5 sampled residents (Resident #103 and Resident #105) identified as at risk for falls, in a total sample of 5 residents, resulting in Resident #103 being found on the floor and sustaining a laceration requiring 8 sutures to her forehead, bruises to her left shoulder, back, and right and left leg and Resident #105 being observed on the bathroom floor with a potential for injury . Findings include: Resident #103: Review of the Face Sheet in the medical record dated 10/15/12 revealed Resident #103 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #103 had moderate cognitive impairments and required extensive assistance with Activities of Daily Living (ADL's). Review of Fall Risk assessment dated [DATE] and updated 9/12/12 revealed Resident #103 had a fall risk score of 13 on 6/5/12. The assessment revealed a total score of 10 or above represented a high risk for falls. Review of the Fall Care Plan dated 4/2/12 and updated 9/11/12 revealed a pressure sensitive alarm to the bed was put in place on 7/13/12. Review of the Rehabilitation/Restorative Progress Note dated 7/13/12 revealed Registered Nurse (RN) #3 initiated a pressure sensitive alarm to Resident #103's bed. Review of the weekly alarm audit dated 9/8/12 revealed Resident #103's pressure alarm to her bed and self-releasing seat belt alarm were in place and functioning. Review of a written statement dated 9/10/12 revealed Certified Nursing Assistant (CNA) #22 assisted Resident #103 to bed on 9/10/12 at 7:30 pm. The statement revealed CNA #22 could not find the bed alarm at the head of the bed. The statement revealed CNA #22 lowered Resident #103's bed and left the room. The statement revealed on 9/10/12 at 8:45 pm, CNA #22 and RN #14 walked into Resident #103's room and found her sitting upright on the floor bleeding profusely. Review of the Incident/Accident Report dated 9/12/12 revealed on 9/12/12 at 8:40 pm, Resident #103 was found on the floor, sitting upright, leaning against her chair with her legs extended straight out in front of her. Review of the report revealed Resident #103 sustained a 2.75 centimeters (cm) laceration to her left eyebrow, skin tear to her left elbow, bruises to her left shoulder, back, and right and left leg. The report revealed the Physician and Family were notified and Resident #103 was sent to the hospital for treatment. Review of the Fall Assessment Worksheet dated 9/10/12 revealed Resident #103 had pressure sensitive alarms and were not on or sounding at the time of the incident. In an interview on 12/10/12 at 3:10 pm, RN #14 reported after Resident #103 fell on [DATE], the fall alarm was at the foot of the bed and was turned off. Review of the Facility Investigation Report-5 Working Days dated 9/14/12 revealed Resident #103 was sent to the hospital on [DATE] and required eight sutures to her forehead. Review of a Discipline Form dated 9/10/12 revealed CNA #22 failed to place and activate a bed alarm. The form revealed Resident #103 fell out of bed and had to be taken to the hospital emergency room . In an observation on 12/7/12 at 2:55 pm, Resident #103 was sitting in her recliner with fall alarms in place and functioning. Resident #103 had no apparent injuries at that time. ( ) Resident #105: Review of the Face Sheet in the medical record dated 12/7/12 revealed Resident #105 was a [AGE] year old female admitted to the facility on [DATE]. Review of the Hospital Discharge Summary date 12/7/12 revealed Resident #105 had [DIAGNOSES REDACTED] (brain disease). Review of a Physician's Progress Note dated 12/10/12 revealed Resident #105's [DIAGNOSES REDACTED]. Review of a Fall Risk assessment dated [DATE] revealed Resident #105 had a total fall risk score of 24. The assessment revealed a total score of 10 or above represented high risk. The assessment revealed a prevention protocol should be initiated immediately and documented on the care plan. In an interview on 12/12/12 at 12:40 pm, Certified Nursing Assistant (CNA) #19 reported Resident #105 was self-transferring out of bed and had trouble walking and notified the nurse. CNA #19 reported Resident #105 did not have any fall interventions in place. Review of the Nurse's Note dated 12/11/12 revealed Licensed Practical Nurse (LPN) #16 instructed Resident #105 on how to use to bedside call light and the bathroom call light. Review of an Incident/Accident Report dated 12/11/12 revealed on 12/11/12 at 1:40 pm, Resident #105 was found sitting on the bathroom floor with no injuries noted. Review of Resident #105's medical record during the onsite investigation from 12/7/12-12/13/12 revealed there were no Fall or Activities of Daily Living (ADL's) care plans in place. In an observation on 12/12/12 at 1:15 pm, Resident #105 had no fall interventions in place. In an interview on 12/12/12 at 3:30 pm, Licensed Practical Nurse (LPN) #16 reported she did not implement fall interventions on 12/11/12 at 1:40 pm because she was waiting for Restorative Therapy to evaluate Resident #105 for falls. LPN #16 reported she was unaware that Resident #105 had a fall risk score of 24. In an interview on 12/12/12 at 2:10 pm, Registered Nurse (RN) #14 reported she did not implement a fall care plan when Resident #105 was admitted on [DATE]. RN #14 reported she should have implemented a fall care plan because of Resident #105's fall risk score of 24. Review of the Fall Analysis and Prevention Policy dated 10/11/11 and reviewed 9/11/12 revealed the licensed nurse would assess the resident for fall potential upon admission with resident-specific interventions instituted immediately. The policy revealed the Fall Risk Assessment would be used to assess the potential risk of falls. The policy revealed safety devices including, but not limited to, an alarm, motion detector, mat on the floor or low bed would be provided on admission and as needed when a resident was at risk for a fall. The policy revealed "When a resident has fallen, temporary interventions such as an alarm will be instituted as soon as possible to prevent further falls." Review of the Resident Care Plan (undated) revealed Resident #105 was oriented to person and required extensive assistance with ambulation/mobility. Review of a Social Services Admission Note dated 12/10/12 revealed Resident #105 was very confused, with poor judgement, insight, and reasoning. The note revealed Resident #105 was unable to make sound decisions. In an interview on 12/12/12 at 1:50 pm, RN #3 reported fall interventions for Resident #105 were now in place. Review of the Incident/Accident Report dated 12/11/12 revealed on 12/12/12 at 1:50 pm, pressure alarms to the wheelchair and bed were initiated for Resident #105. ( )

This citation pertains to MI# 934 Based on observation, interview and record review, the facility failed to prevent and provide necessary treatment to promote healing of pressure sores in 1 of 6 sampled residents (Resident #104), from total sample of 6 residents, resulting in Resident #104 developing two open skin areas on her buttocks. Findings include: Record review of Resident #104's minimum data set ((MDS) dated [DATE] and 2/24/12 revealed the resident had a brief interview of mental status (BIM's) score of 14 (cognitively intact), had functional limitations of the lower extremities, and wheelchair use for mobility. The bladder/bowel assessment revealed Resident #104 had urinary and bowel incontinence. The 2/24/12 annual MDS assessment revealed that Resident #104 was noted to have two pressure ulcers, one stage I pressure ulcer (intact skin with non-blanch able redness of localized area usually over a bony prominence), and one stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister). Record review of Resident #104's treatment record for the month of April 2012, revealed that Resident #104 was to receive the treatment of [REDACTED]. The treatment record noted the wound dressing was to be changed on the 7-3 shift. Review of the back side of the treatment record for the month of April 2012, revealed that on 4/2/12 on 3 PM- 11PM shift nurse noted 0.2 x 0.2 x <0.1 open area, pink granulation. There was no mention of Allevyn patch placement or treatment. In an interview on 4/9/12 at 10:55 AM, Resident #104 reported she had a sore on her bottom and that it had cleared up, but then came back. Resident #104 stated that her certified nurse assistant (CNA) told her that the sore was getting worse. An observation on 4/9/12 at 2:25 PM of Resident #104's buttocks area with CNA #7 while performing cares revealed Resident #104 had no Allevyn protective patch in place. Resident #104's buttocks area were noted to have open area on the left buttocks with skin rolled up at edges of wound estimated to be one inch in length by one inch width in size. A midline red raw appearing area at the top of the buttocks crack was observed. In an interview on 4/9/12 at 2:25 PM during the observation CNA #7 stated that she first seen Resident #104's bottom a couple of months ago and that the open area looked like a pimple, and then started to open and get bigger. CNA #7 stated that she was off for a weekend and when she came back to work it (Resident #104's buttocks sore) looked worse. CNA #7 stated that Resident #104's granddaughter is a nurse and when she came to visit she requested to see the Resident #104's buttock sore. In an interview on 4/11/12 at 12:30 PM, Registered Nurse (RN) #4 reported that she had last seen the Resident #104's buttocks on 4/2/12, and that there was only one open area and that it was being treated with an Allevyn patch. Record review of physician orders [REDACTED]. In an observation on 4/11/12 at 1:40 PM, of Resident #104 being transferred to bed and then rolled on to her right side for observation of buttocks area. Observation was done with RN #4 and license practical nurse (LPN) #5, Resident #104's brief was removed and there was no patch noted to the buttocks area, or located within the brief. Observation revealed there to be a scant amount of white barrier cream in place, the area was cleansed with antimicrobial skin cleanser. LPN #5 took measurements as instructed by RN #4, of a new midline open area at the top of the buttocks crack was measured at 1.2 centimeter (cm) x 0.5 cm. Left buttocks open area was measured at 5 cm x 3.6 cm. RN #4 stated she was not aware of the second open area located at the top of Resident #104's buttocks. Record review of the facility 'Pressure Ulcer Policy & Procedure' dated 12/12/11 revealed "section III. Daily/weekly skin assessment: The licensed nurse or skin nurse will complete a skin assessment on all residents weekly. Abnormalities will be documented and treatment started when appropriate". Record review of Resident #104's April 2012 treatment record revealed that the treatment and skin assessment were done on 4/10/12 by the afternoon shift nurse. Review of the backside of the treatment record revealed that there were no measurements or notes that described or assessed the new open area to the top of the midline crack area. #

This citation pertains to MI# 345 Based on observation, interview and record review the facility failed to provide adequate supervision and properly working assistive devices to prevent accidents in 2 (#101, #103) of 4 sampled residents, resulting in resident #101 rolling from her bed and being found on the floor with her personal tab alarm attached and motion sensor alarm not alarming, resident #103 being observed by state surveyor in bed with personal (tab) alarm not attached and motion sensor alarm not turned on and flipped backwards so that the sensor lens was not pointed at the resident. Findings include: Resident #101 Record review of the facility Incident/Accident Report dated 2/10/11 at 9:40 AM revealed that resident #101 on floor (matt) next to bed lying face down, family in building at this time. Vital signs initial incident supine position: Temperature 0, Pulse 0, Respirations 0, Blood Pressure 0, were noted. Record review of the facility incident report/24 hour report to the state agency dated 2/11/11 revealed: Staff called to the room by resident's family. Noted resident lying prone on bedside mat. Upon assessment resident noted to be absent of pulse, respirations and blood pressure. Resident was noted to have expelled clear fluid secretions from her mouth onto the bedside mat, and stool into her brief. She was also noted to have a 0.5 centimeter scratch by the right side of her nose, and a 1 centimeter scratch on her right cheek. No blood was present, no bruising, hematomas or lacerations were present. An interview on 2/15/11 at 9:23 AM with staff member #15 revealed that the resident was found face down on her belly at the side of the bed with the bed in the lowest position, with her string/tab alarm still attached and a motion sensor alarm at the bedside night stand. The staff member stated "...alarm was still attached to her gown, motion sensor was on when she fell , but the bed was lowered and the motion alarm was on the bedside stand, too high to sense the motion. No alarms were sounding. Staff #6 had to wave her hand in front of it to tweet it, it was on, but didn't alarm at the time of the fall. No alarm sounded. The string alarm was still attached, string was too long..." Record review of the unit managers typed statement dated 2/10/11 revealed that the bed was in low position, personal/string alarm was fastened to her gown and not sounding, and the motion detector was on the night stand, directed toward the head of the bed, turned on but not sounding. Resident #103: Observation on 2/14/11 at 12:20 PM of resident #103 while lying in bed revealed a tab alarm next to his pillow but not attached to the resident, the resident was observed to roll onto his back and the motion sensor located at the foot of the bed did not alarm. Observation of motion sensor alarm revealed that it was flipped backwards and not turned to the on position. The housekeeper that was outside of the room door went to get the nurse for the resident. On 2/14/11 at 12:30 PM, the safety coordinator in charge of alarm devices, came to the room and could not explain why the tab alarm was not attached or why the motion sensor was flipped backwards and turned off. An interview on 2/14/11 at 1:00 PM with the staff #13 revealed that she could not explain why the tab alarm was not attached, and that she was the one to lay the resident down in bed. The staff member stated that the motion detector had flipped over when she laid the resident down and she stated that she just didn't flip it back. #