Every finding on record at Autumn Woods Residential Health

Based on interview and record review, the facility failed to notify the responsible party of changes in the status of a resident's wounds for one resident of three resident's reviewed for notification of changes in resident health status. Findings include:This citation pertains to intake 3091616. A review of the record for R901 revealed R901 was admitted into the facility on [DATE] and discharged to the hospital on [DATE]. R901's diagnoses included Pressure Ulcer of the Sacral (buttocks) Region, Heart Failure, and Diabetes. A nurse progress note dated 05/09/26 at 10:16 AM documented, .new skin issue, location: buttocks . abrasion . 7.57 centimeters (cm) by 9.14 cm . A review of the progress notes revealed the responsible party was not notified of the sacral/buttocks skin issue until 05/21/26. Wound care notes by Nurse Practitioner (NP) A documented:-05/20/26, Patient is reported to have an opening to the sacral area. Wound will be classified as unstageable due to presence of eschar (dead, black skin tissue). Treatment will be honey and calcium alginate . -05/27/26, Patient was reported to have an opening to the sacral area. Wound was classified as unstageable due to presence of eschar. Treatment will be honey and calcium alginate. No signs of infection such as odor or increased pain . -06/03/26, Patient was reported to have an opening to the sacral area. Wound was classified as unstageable due to presence of eschar. Treatment was honey and calcium alginate. Treatment will now be updated to Santyl and calcium alginate due to increase in dimensions and slough (nonviable skin) tissue . Deteriorating. Pressure Unstageable Sacrum - Measures 7.4 x 6.9 cm. 100% slough/eschar. Moderate serosanguinous drainage. No odor. Edges attached. Fragile peri-wound . Plan for debridement (removal of slough) . -06/10/26, Wound management of sacral ulcer, worsening, treatment change .Treatment was updated to Santyl and calcium alginate due to increase in dimensions and slough tissue. Faint odor present this week. Treatment changed to Dakin's (low strength bleach) soaked gauze. Frequent turning and pressure-relieving mattress ordered . A review of the electronic medical record revealed no documentation of the change in the wound condition and treatment between 05/27/26 and 06/10/26 having been reported to R901's responsible party. On 07/15/26 at 4:49 PM, the Director of Nursing (DON) reported notification of changes for wounds for R901 should be in the wound notes. A review of the wound notes revealed no documentation for the changes after 05/21/26. Notification was requested and the progress note dated 05/21/26 was provided by the facility. At 5:20 PM, additional documentation for notification of the responsible party about wound condition and treatment changes was requested and not received prior to survey exit. On 07/15/26 at 5:34 PM, the DON reported the sacral wound began as an abrasion and worsened into an unstageable wound. The DON reported they were not saying staff should not have reached out to the responsible party related to the identified wound changes but since the wound was determined to be unstageable and as this was the worst for staging it could not get worse for this type of wound. A review of the policy titled, Notification of Changes revised 08/29/24, revealed, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. Definitions: Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction), or commence a new form of treatment to deal with a problem (for example, the use of any medical procedure, or therapy that has not been used on that resident before. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification . 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition .

This citation pertains to Intake 2985599. Based on observation, interview, and record review, the facility failed to assess one resident (R806) for self-administration of medications out of two residents reviewed for self-administration of medications. Findings include: On 5/27/2026 at 2:56PM, an observation of R806's room revealed a medication cup with 4 tablets inside was sitting in front of the resident on a table extending over their bed. R806 stated nursing staff usually watches them take their medications before they leave the room, but this time the nurse left them (the pills) there about an hour ago, but they were half asleep and was not totally sure.Review of R806's electronic medical record (EMR) revealed they were admitted into the facility 7/3/2024 with diagnoses of Type 2 Diabetes, altered mental status, and muscle weakness. Review of R806's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.A review of R806's medication orders revealed the following:Hydralazine 25 milligrams (mg)- give 2 tablets by mouth every 8 hours, with administration times of 0500 (5:00AM), 1300 (1:00PM), and 2100 (9:00PM).Acetaminophen 325mg- give 2 tablets by mouth every 6 hours, with administration times of 0000 (12:00AM), 0600 (6:00AM), 1200 (12:00PM), 1800 (6:00PM).On 5/27/2026 at 3:04PM, an interview was conducted with Licensed Practical Nurse (LPN) B. LPN B admitted they did leave the medications sitting on R806's table without making sure they were taken by the resident saying, medications should not be left at a resident's bedside, and if a resident is sleeping during the time of administration the medicine should be brought back to the medication cart.On 5/27/2026 at 3:34PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed medications should not be left at a resident's bedside if they do not have an order for self-administration of medications.Further review of the active orders and assessments in R806's EMR did not reveal an order or assessment for self-administration of medications.A facility policy titled Medication- Resident Self-Administration of last reviewed/revised 1/30/2024 revealed that .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.

This citation pertains to Intake number 2803493.Based on interview and record review, the facility failed to administer pain medication per physician order and resident preference for one (R900) of three residents reviewed for pain management. Findings include:On 3/26/26 at 3:00 PM, an interview with R900 revealed a few days ago, I was waking up in severe pain in the morning. R900 further revealed they did not think they were receiving their night-time dose of pain medication. An inquiry regarding whether they had asked the nurses not to wake them in the night for pain medication, R900 said they want to be awakened for night-time medication, even if they are asleep, so the pain does not get so bad.A review of the medical record revealed R900 was admitted to the facility on [DATE] on the hospice service with the relevant diagnoses: CREST Syndrome Scleroderma and Rheumatoid Arthritis. The Minimum Data Set (MDS) assessment's most recent Brief Interview for Mental Status (BIMS) indicates intact cognition. A review of R900's care plan revealed the following pertinent interventions under hospice care: Administer medications as ordered and observe for effectiveness, initiated on 2/9/26, revised on 2/11/26. Evaluate for verbal and non-verbal signs and symptoms relating to pain. Provide care based on resident preferences related to end-of-life comfort measures.A review of the medication orders for R900 revealed:A order by Primary Physician (PP) D, dated 2/19/26 at 6:50 PM, or Morphine 100 mg(milligrams)/5ml(milliliters), give two ml every four hours and, An order entered on 2/19/26 at 7:36 PM by the Nurse Practitioner, E for Morphine 100mg/5ml, give two ml every two hours as needed for breakthrough pain. A review of the medication administration record (MAR) for the month of March (2026) revealed seven doses (3/6/26, 3/11/26, 3/15/26, 3/16/26, 3/19/26, 3/20/26, and 3/25/26) of Morphine was to be given at 12:00 AM (midnight) but were not administered. Further review revealed the medication was not given because R900 was sleeping as indicated by number 7 documented by Registered Nurse (RN) E on the MAR.On 3/26/26 at 3:30 PM, an interview with the Unit Manager (UM), C confirmed the Morphine doses were not given according to both the electronic medical record and the narcotic sign-out sheets. UM C indicated the medication should have been given (adminstered) unless the resident requested not to be awakened. On 3/26/26 at 4:00 PM, an interview with the Director of Nursing (DON) indicated medications should be given as ordered.A review of the policy Pain Management last reviewed on 10/26/23 revealed The facility will 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 resident's goals and preferences.A review of the policy Hospice last reviewed 10/26/2023 revealed The plan of care will include directives for managing pain and other uncomfortable symptoms and will be revised and updated as necessary.

This citation pertains to intake 2626685.Based on interview and record review the facility failed to ensure interventions were implemented to monitor one resident (R901) of three reviewed for risk of elopement: Findings include:A review of the facility reported incident investigation summary revealed: On 01/21/2026 at approximately 8:45am, certified nursing assistant (CNA A) noted that (R901) was no longer sitting on the sofa where 45 minutes earlier. (CNA A) began looking for the resident. After not being able to locate (R901) staff from all departments began searching the facility inside and on the grounds. The Police Department was contacted due to the concern of cold weather. At approximately 9:15am, the police received a call from a medical clinic that an individual matching the description of (R901) was in their lobby .37 miles away, (R901) was returned to the facility and escorted to the secured unit. R901 ambulates with a steady gait and denied injury. The surveillance cameras were reviewed beginning at 7:15am. (R901) was observed in the hallway on one east low hall sitting in a chair. Staff were observed going up and down the hall. The nurse was present with the medication cart. At approximately 7:20am, (R901) got up from the chair, looked around and proceeded to go to the dayroom and sit down on the sofa. At 8:01am on the outdoor view of the employee entrance, (R901) was observed walking down the sidewalk toward the front of the building. The resident was admitted from (the hospital) on 01/20/2026 at 8:45pm with a diagnosis of Alzheimer's Dementia and was living alone prior to hospitalization. R901 was unable to answer questions for (Brief Interview for Mental Status) BIMs assessment. The nursing staff identified the risk for elopement and were monitoring the resident throughout the night shift. It appeared that the resident was actively waiting for an opportunity to exit the building and followed another resident who went out to smoke through the patio exit around 8:00am. On 02/03/26 at 12:29 PM, Licensed Practical Nurse (LPN) F reported they had been on the day R901 exited the building. LPN F reported R901 had only been in the facility less than 24 hours when the code for the elopement was called. They had heard R901 followed a smoker out. LPN F was asked about the alarm on the interior door R901 exited out of and reported they thought it was new. It was observed that the smokers exited into a fenced and gated courtyard.On 02/03/26 at 1:40 PM, an anonymous resident confirmed to be a regular smoker reported the alarms to the door for the smoker's exit were new and were not activated when the smoker went out during the day.On 02/03/26 at 2:08 PM, Unit Manager G reported the interior set of doors R901 walked out of was not alarmed before, but the second set of doors had always had an alarm. Unit Manager G reported the one east nurse would unlock the smoker's exterior exit doors in the morning and lock them again after 8 PM prior the elopement of R901. It was reported the doors were open for independent smokers to come and go without defined exit times from around seven am to seven pm. Unit Manger G was also the staff who returned R901 to the facility and noted R901 was confused by basic questions when picked up from the medical building. On 02/03/26 at 2:17 PM, LPN H reported they had observed R901 sitting in the gray chair in the siting area around the smoker's area exit doors with breakfast when they started their medication pass and within 45 minutes R901 was gone. LPN H reported the aides were also passing meal trays just like a regular day. LPN H reported R901 had not been in the facility 24 hours at that point and that the hospital had not disclosed the exit seeking concern for R901. LPN H noted that according to the night nurse R901 had attempted to exit and had to stop and that on follow up indicated R901 could have been moved upstairs sooner.On 02/03/26 at 2:41 PM, CNA A, reported they had been giving a resident a (15-20 minutes) shower when R901 exited building. CNA A reported they had last seen R901 around time they were done passing breakfast trays (like 7:50 AM). CNA A noted before R901 eloped residents could just go out and smoke during the day. CNA A reported they had not received any report from the night shift CNA about R901's exit seeking but did overhear the nurses talk about it during report. CNA A commented they had thought R901 was a visitor when first observed sitting in the hallway as they came on shift. On 02/03/26 at 3:00 PM, LPN I reported normal staffing on the unit when R901 arrived on the unit around 9PM as an unexpected admission. LPN I noted they did not receive any report from the hospital nurse, and the transport staff had not indicated R901 to be an elopement risk when asked. Diagnoses were urinary tract infection and dementia. LPN I further noted on assessment R901 did not recognize their own name and thought the transporters were friends. R901 had stayed in their room for a few hours until around 1:00 AM when R901 came out spoke with staff and went back into their room when redirected by staff. R901 came out of their room again around 4 AM and had been given something to eat and around five am R901 was out again looking for the bathroom. LPN I reported they had told the oncoming nurse that R901 was exit seeking may have to transfer to the second floor. LPN I further noted observed as they left the oncoming nurse was talking with two nursing assistants and told they had to keep an eye on R901. LPN confirmed that a CNA had overheard their report to the oncoming nurse. LPN I reported that prior to the elopement, the smoking exit was locked nightly and then unlocked before they left. On 02/03/26 at 3:40 PM, R901 was seated in their room playing a guitar. R901 did not recall leaving the building or being picked up and returned to the facility. The visitors indicated the forgetfulness and exit seeking were new. On 02/03/26 at 4:09 PM, the incident with R901 was reviewed with the Administrator and their assistant who indicated video of the elopement by R901 was no longer available. It was indicated they thought R901 was aware enough to wait for staff to leave the area before walking out with the smoker. A cause for the elopement was noted as the new surroundings and R901 looking for sisters or a girlfriend and interventions were not implemented to prevent the elopement of R901. It was also noted that based on bed availability, if a nurse observed exit seeking behaviors, they could call management to get the resident moved to the second floor. A review of the record for R901 revealed R901 was admitted in the facility 01/20/26. Diagnoses included Alzheimer's and Dementia. A review of the care plan documented , .at risk for altered activity patterns initiated 01/23/26 . has behaviors related to Dementia .Anxiety .Exit seeking .initiated 01/21/26 .A review of the facility Smoking Policy revised 01/2026 documented designated smoking times and the need for supervision during the smoking periods. Past Noncompliance received 02/03/26. POC date: 01/21/26. Compliance with POC noted upon observation, interview and record review on site 02/03/26.The IDT met on 1/21/26 for review of the incident. Immediate policy changes on the smoking times were changed to ensure the door would remain alarmed unless a staff member was actively supervising the area. All residents were reassessed for elopement risk. The Resident Council President was advised of the policy change and residents who smoke were informed in writing that smoking times were being limited. Additionally, education was provided to all staff that when a resident is assessed as being at risk for elopement, they should be moved to the secured unit. They were advised that the DON or NHA should be contacted if bed availability is an issue. The resident was not harmed and is adjusting to the secured unit without issues.Root Cause Analysis: Resident scored as a risk for elopement upon admission assessment and staff did not put an intervention in place to prevent (R901) from potentially leaving the facility.Element One: (R901) has returned to the facility and has been moved to Two East the locked unit. Upon returning to the facility the resident was assessed for pain and injury with none being noted. Resident was seen by the provider upon returning. Care plan was reviewed and updated.Element Two: Like residents are identified as residents that score as a risk on the elopement assessment. Elopement assessments completed on all residents and those identified at risk will have interventions placed and care plans updated.Element Three: The Unsafe Wandering and Elopement policy was reviewed and deemed appropriate. The ADON/Designee will educate nurses on immediately putting an intervention in place when a resident is deemed at risk. Education completed 01/21/26. Those not educated will be prior to their next scheduled shift. The Smoking policy was reviewed and updated. The ADON/Designee educated staff on smoke times and ensuring that the door is alarmed at all times unless scheduled. Education completed 01/21/26. Those not educated will be prior to their next scheduled shift.Element Four: Staff will audit patio door hourly to ensure that it is alarmed at all times unless it is a scheduled time. The clinical team will audit new admission charts daily to review the resident's elopement risk and ensure that for those at risk an intervention is in place,

This citation pertains to Intakes: 2578720, 2584022, 2586062 Based on interview and record review, the facility failed to thoroughly assess and document skin bruising for an injury of unknown origin for one resident (R50) of one reviewed for abuse. Findings include:A review of documentation submitted to the State Agency (SA), revealed R50 was admitted into the facility for 7-days of respite care, and was discharged with bruising on various areas of their body without explanation. The resident was taken to a community agency that coordinates healthcare services with the facility for a skin assessment, and was later transferred to the hospital for further evaluation. Further review of the documentation submitted noted photos of bruises in various healing stages most notably on the resident's body, specifically neck, left shoulder and hand.A review of R50's medical record revealed they were admitted into the facility on 7/22/25 and discharged on 7/29/25 with diagnoses which included Alzheimer's Disease, Severe Protein-Calorie Malnutrition and Diabetes. Further review revealed the resident was severely cognitively impaired, and required one-person assistance for toileting and transfers, and needed supervision for eating, ambulating and bed mobility. Further review of the medical record revealed a Nursing Evaluation Summary dated 7/22/25 noting no skin integrity issues for R50. On 8/13/25 at 10:47 AM, Licensed Practical Nurse (LPN K) was interviewed via phone, and confirmed she was the admitting nurse for R50. She explained that a skin assessment was completed for the resident, and did not identify any marks, bruises or wounds on the resident's body. Further review of the medical record revealed the following progress note:7/23/2025 19:53 (7:53pm) NP (nurse practitioner/PA physician assistant) Progress Note .Patient seen and examined at bedside. Chart reviewed; nursing assessment reviewed. Patient is being seen for chronic and any acute health conditions at this time .Skin: Intact with no visualized rashes .On 8/13/25 at 12:06 PM, an interview was completed with Certified Nursing Assistant (CNA N), assigned CNA to R50 the date of admission and discharge. CNA N explained that the morning of R50's discharge, she dressed the resident for the day and noted to have observed redness to the resident's right arm. CNA N explained that she reported the skin issue to a nurse, but didn't remember which nurse it was.A review of the Facility Reported Incident (FRI) revealed the following, .Although [R50] had multiple bruises of various stages of healing, we could not substantiate the causes of all the bruises, except the hand. We could however assess that they were most likely caused by [their] poor trunk control, unsteady gait, laying on [their] right side in awkward positions at various times prior to and during [their] stay. The bruises on [their] chest and shin appeared to be more advanced in healing than the hands, arm and shoulder. Indicating that they possibly occurred prior to the hand, arm and shoulder. The scratches on [their] thigh was due to a small area of irritation which [R50] scratched [themselves] .On 8/13/25 at 2:10 PM, an interview was completed with the Director of Nursing (DON), who acknowledged that she had seen the photos of R50 with the various stages of bruises. The DON explained that the facility could not determine how R50 sustained the bruising but admitted that something was missed by facility staff as it would have been impossible to have provided care to the resident and not have noticed the bruising. A review of the facility's Wound Care policy revealed the following, .2. All CNAs will check the resident's skin daily during routine care for evidence of skin injuries. Any new findings will be brought to the attention of charge nurse and/or Unit Management for immediate intervention .

Based on observation, interview, and record review the facility failed to ensure safe storage of medication for one resident (R149) of four residents reviewed for medication storage. Findings include:On 8/11/25 at 9:49 AM, an observation on R140's bedside table, a medication cup of pills containing approximately eight pills, two blue oval, two large round white, one small round white, one small yellow round, one white capsule, and one yellowish clear gel capsule. Two bottles of Nystatin Powder were also on the bedside table on 8/11/25, 8/12/25, and 8/13/25. When R149 was queried, they revealed their nurse always leaves the pills for them to take when they are ready. Further inquiry revealed R149 identified the medication as some are blood pressure pills. They also indicated the powder is for under my folds.A review of the Electronic Medical Record (EMR) revealed on 4/7/23, R149 was admitted with the following relevant diagnoses: End Stage Renal Disease with dependence on Renal Dialysis, Chronic Heart Failure, Diabetes, Dependence on Oxygen, and Polyosteoarthritis. Further review of R149's EMR revealed intact cognition. The EMR further revealed R149 used a walker and/or wheelchair for mobility and required partial/moderate assistance for basic activities of daily living. On 8/13/2025 at 11:57 AM, Licensed Practical Nurse (LPN) B revealed R149 liked to have their meds given to them to take on their own time. On 8/13/2025 at 1:00 PM, the Director of Nursing (DON) revealed that medications should not be at the bedside, the nurse is expected to watch the resident consume medications.A review of the EMR revealed the resident did not have a Self-Medication Administration Assessment. A review of the facilities policy Medication Administration dated 1/17/2023 revealed . 15. Observe resident consumption of medication .A review of the facilities policy titled, Medication-Resident Self-Administration of, dated 1/30/24 revealed the following .3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration; b. The resident's physical capacity to: swallow without difficulty, open medication bottles, and administer injections; c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for; d. The resident's capability to follow directions and tell time to know when medications need to be taken; e. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff: f. The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs; and, g. The resident's ability to ensure that medication is stored safely and securely. Further the policy states .7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy .13. The care plan must reflect resident self-administration and storage arrangements for such medications.

Based on interview and record review, the facility failed to complete an annual pre-admission screening and resident review (PASARR) for one resident (R8) out of two reviewed for PASARR's. Findings Include:A review of the medical record revealed R8 was admitted into the facility on 5/5/2025 with the following medical diagnoses, Cerebral Infarction and Bipolar Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 14/15, indicating an intact cognition. R8 also required assistance with bed mobility and transfers.A review of the most recent PASARR was dated 6/28/2024.On 8/13/2025 at 11:23 AM, an interview was conducted with the Social Service Director (SSD) D. SSD D reported they would have to look and see if an annual was completed for R8.A request for an updated PASARR for R8 was requested and not received by the end of the survey.A request for a facility policy related to PASARR completion was requested and not received by end of survey.

Based on observation, interview, and record review facility failed to honor a resident's preference for a room change for one resident (R184) of three residents reviewed for rights and preferences. Findings include: On 08/11/2025 at 10:17 AM, R184 was asked about their care at the facility, R184 explained they were not happy. R184 expressed multiple concerns for them, locked closet with no access to clothes, not being allowed to leave the locked unit, not permitted to go outside since September 2024, and other residents wander in and out of their room. R184 reported they have made a request for a room change to Unit Manager (UM) G and Guardian P. R184 expressed staff do not listen to their concerns and feels very aggravated. On 08/12/2025 at 1:25 PM, an unknown male resident was observed sitting on R184's bed and putting on R184's tennis shoes. R184 remarked, this happens all the time, it's frustrating. The UM G was made aware of the observation and was then observed to remove the unknown male resident. A review of the medical record for R184 revealed, R184 was admitted to the facility on [DATE] with diagnoses of Diabetes, High Blood Pressure, and Dementia without Behavioral Disturbances. The Minimum Data Set (MDS) assessment dated [DATE], indicated R184 had a moderate cognitive impairment. On 08/12/2025 at 1:27 PM, Licensed Practical Nurse (LPN) H was asked about R184 care on the locked unit and indicated the environment is overstimulating for R184 affecting their desire to come out of the room for meals and activities. LPN H reported R184 often request to go downstairs to the vending machine, but staff is not always available and R184 has to wait.On 08/13/2025 at 8:21 AM, Social Worker (SW) E revealed R184 was moved initially to a private room on the locked unit after R184 was no longer able to get along with the roommate. After a 12-day hospital stay in December, R184 returned to a different room that was no longer the private room but now into a semi-private room on the locked unit. On 08/13/2025 at 8:45 AM, the Director of Nursing (DON) was interviewed about R184 being in a locked unit. The DON stated there is not specific criteria for placement on the locked unit.On 08/13/2025 at 10:54 AM, an interview with Registered Nurse (RN) J was conducted and asked about R184 documented behaviors. RN J reported behaviors are documented in the nurse's progress notes. A review of R184's medical record progress notes revealed, for June 2025 through August 11, 2025, revealed no documented behaviors. Further review revealed plan of care responses dated 07/13/2025 through 08/13/2025 with no documented behaviors. Further review of R184's medical record revealed a progress note from the Psychiatry Physician Assistant (PA) F dated 04/18/2025, [R184] reports frustration, stating [R184] does not want to be in the memory care unit and wants to be outside, as [R184] does not believe [R184] belongs there. [R184] reports[their] sleep has been poor and requests medication to help. [R184] also reports having anxiety as well as a little bit of depression . On 08/13/2025 at 11:20AM, attempt to reach PA F by phone was unsuccessful. On 08/13/2025 at 11:38 AM, attempted contact with R184's Guardian P, voice message was left with no return call by the end of the survey.On 08/13/2025 at 1:10 PM, a request was made for the facility's room change criteria policy. No policy was provided by the end of survey.

Based on interview and record review, the facility failed to ensure formulated advance directives were completed properly for one resident (R8) out of two reviewed for advanced directives. Findings include:A review of the medical record revealed R8 was admitted into the facility on 5/5/2025 with the following medical diagnoses, Cerebral Infarction and Bipolar Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 14/15, indicating an intact cognition. R8 also required assistance with bed mobility and transfers.Further review of the medical records revealed a capacity determination letter signed by a physician on 5/14/2025 and a Licensed Psychologist on 5/12/2025, deeming R8 incapable of making decisions regarding medical treatment. As well as an advance directive signed by R8 dated 7/2025.On 8/13/2025 at 11:23 AM, an interview was conducted with Social Service Director (SSD) D. SSD D reported R8's sisters were supposed to be getting guardianship, but they did not know where they were in the process and would have to follow up. SSD D reported they did the capacity determination because they needed to know what her capabilities were to make decisions. SSD D was asked why R8 signed their own advance directives after being deemed incompetent. SSD D stated they allowed R8 to sign their own advance directives at the time because they seemed coherent enough, although no new capacity determination had been completed.A request for a facility policy related to advance directives was requested but not received by end of survey.

Based on observation, interview, and record review the facility failed to maintain a homelike environment for two sampled residents (R151 and R184) of six reviewed for environment. Findings include: R151On 8/12/2025 at 9:38 AM, R151 was sitting in a wheelchair in their room. R151's bed footboard was observed to be in disrepair with exposed wood and with duct tape around it. On 8/13/2025 at 9:44 AM, R151's bed remained in the same condition. R151 was asked about the condition of the footboard and provided no explanation about its condition. A review of R151's medical record revealed that R151 was admitted to the facility on [DATE] with diagnosis of Alzheimer's. A review of R151's Minimum Data Set (MDS) assessment dated [DATE] noted R151 with impaired cognition. A review of R151's care plan noted, Focus: Resident has impaired cognitive functioning r/t (related to) Dementia, Intellectually Disabled, decreased memory, decision making, difficulty w/recall, impaired thought processes. Date Initiated: 12/17/2024. Goal: Resident will have reduced complications related to their cognitive function through next review. Date Initiated: 12/17/2024. Interventions: Encourage family/responsible party to bring in familiar personal items to promote a homelike environment. Date Initiated: 12/17/2024.On 8/13/2025 at 2:13 PM, the Maintenance Director was asked about the condition of R151's footboard and explained he was not aware of the bed being an issue.R184On 8/11, 8/12, and 8/13/2025, R184's floor tile was observed to be in chipped, stained, and in disrepair. A review of the facility's policy titled, Maintenance Inspection dated, 3/12/22 noted, Policy: It is the policy of this facility to utilize a maintenance inspection program in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and public. Policy Explanation and Compliance Guidelines: 1. The Director of Maintenance Services will perform routine inspections of the physical plant using the TELS program.

Based on observation, interview, and record review, the facility failed to implement fall care plan interventions for one resident (R8) out of three reviewed for falls. Findings include:On 8/11/2025 at 11:32 AM, R8 was observed in the bed with a cane on the right side of the bed, R8 reported they use the cane for mobility. R8 reported they have had a couple falls in the facility.On 8/13/2025 at 10:56 AM, request for R8's Incident and Accident reports was requested but not received by the end of survey.A review of the care plan revealed the following intervention, Mat to floor next to bed left side of bed.On 8/11/2025 at 11:32 AM, no floor mat was observed on the left side of the bed.A review of the medical record revealed R8 was admitted into the facility on 5/5/2025 with the following medical diagnoses, Cerebral Infarction and Bipolar Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 14/15, indicating an intact cognition. R8 also required assistance with bed mobility and transfers.On 8/12 at 9:33 Am, no fall mat was observed on the left side of the bed.On 8/13/2025 at 10:37 AM, no fall mat was observed on the left side of the bed.On 8/13/2025 at 12:08 PM, an interview was conducted with Unit Manager (UM) W. UM W reported that were unsure why R8 did not have a fall mat and that maintenance may have moved it. On 8/13/2025 at 12:30 PM, a Quality Assurance and Improvement Plan (QAPI) meeting was held with the Nursing Home Administrator (NHA). The NHA reported they expect current fall interventions are expected to be implemented. The Interdisciplinary team (IDT) meets following a fall, the interventions should be reviewed and any intervention that is deemed appropriate will be added to the care plan and should be followed immediately.A request for a facility policy related to falls was requested but not received by the end of survey.

Based on observation, interview, and record review the facility failed to provide routine finger nail care for two sampled residents (R16 and R20) of six reviewed for activities of daily living. R16On 8/12/2025 at 9:25 AM, R16 was observed in bed with long nails, with a yellowish tint, and a buildup of brown debris under them. R16 was asked if they preferred their nails at the observed length. R16 was observed to hold their hands up towards their face and expressed that the nails were long and that they should be cut. On 8/13/2025 at 9:40 AM, R16 was asked if the staff had cut their nails, R16 reported they had not been cut. R16's nails were observed in the same condition.On 8/13/2025 at 9:47 AM, Unit Manager, Licensed Practical Nurse (LPN A) was asked to observe R16's nails. LPN A expressed, R16's nails were long and needed to be cut. LPN A was asked the expectation for resident's nails to get cut. LPN A explained, it is as needed, and nails are to be checked on shower days.A review of R16's care plan noted, Focus: The resident has an ADL self-care performance deficit related to absence of right leg below knee, history of joint replacement surgery and muscle weakness. Date Initiated: 08/14/2023. Goal: Resident's Activities of Daily Living (ADL) needs will be met through next review. Date Initiated: 08/14/2023 Revision on: 03/13/2025. Interventions: PERSONAL HYGIENE: Dependent - 1 person assist Date Initiated: 08/14/2023.R20On 8/11/2025 at 9:52 AM, R20 was observed laying on their bed, R20's nails were observed to be long and with brown debris under their nails.On 8/13/2025 at 9:40 AM, R20's nails remained in the same condition. R20 was asked if they preferred their nails at that length, R20 explained, the nails needed to be cut. On 8/13/2025 at 9:50 AM, LPN A made an observation of R20's nails and was asked when R20's nails are to be cut. LPN A explained that she will cut them if R20 lets them. LPN A was asked if R20's refusal was documented or care planned. LPN A stated staff have been directed to document refusals and that she was not sure if it was care planned.A review of R20's care plan noted Focus: The resident has an ADL self-care performance deficit related to dementia, muscle weakness, osteochondritis dissecans, chronic kidney disease, old myocardial infarction and hypertrophic disorder of the skin. Date Initiated: 11/30/2023. Goal: Resident's Activities of Daily Living (ADL) needs will be met through next review. Date Initiated: 11/30/2023. Interventions: PERSONAL HYGIENE: Supervision - offer setup help as needed Date Initiated: 03/11/2024.On 8/13/2025 at 2:06 PM, the Director of Nursing (DON) was asked the expectation for nail care, the DON explained that nail care is to be completed during activities of daily living care.A review of the facility's policy titled, Nail Care dated, 8/20/24 noted, Policy: The purpose of this procedure is to provide guidelines for the care of a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: . 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis .

Based on interview and record review, the facility failed to schedule a hematology (specialty for diseases of the blood) appointment for one resident (R8) out of one reviewed for consultation appointments. Findings Include:On 8/13/2025 at 10:40 AM, R8 was observed in their bed. R8 stated they were doing okay, but their hands have been hurting them.A review of the medical record revealed R8 admitted into the facility on 3/7/2025 with the following medical diagnoses, Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 12/15, indicating an impaired cognition. R8 also required assistance with bed mobility and transfers.Further review of the medical record revealed an active order with a start date of 3/18/2025 for a hematology appointment follow up.On 8/13/2025 at 2:05 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they were unaware of a hematology appointment and would look into it.No further information was received by the end of the survey.A request for a policy related to outside appointments was requested and not received by the end of survey.

Based on observation, interview and record review, the facility failed to ensure timely monitoring for two ventilator residents (R3, R35) of four residents reviewed for respiratory care needs. Findings include: R3 On 08/11/2025 at 9:36 AM, R3 was observed to be in bed and restless with non-purposeful movements of the arms and legs. R3 had a tracheostomy (artificial airway inserted via a throat incision) which was connected to a mechanical ventilator (assists resident to breath effectively) via a corrugated plastic tubing (circuit). On 08/11/2025 at 10:42 AM, R3's restlessness continued and the circuit connecting the tracheostomy to the ventilator became disconnected at the tracheostomy site with a movement of R3's left arm which tangled the circuit tubing. An alarm sounded and a red light turned on above the outside of the resident's doorway. No staff were observed to be in the hallway. At 10:44 AM, staff came around the corner from the nurse station, turned back toward the nurse station and then walked up the hall to the room of R3 and reconnected the circuit to the tracheostomy. On 08/12/2025 at 8:08 AM, 9:15 AM, 11:23 AM, and 2:29 PM, R3 was observed to be in bed, calm and without restlessness. A review of the record for R3 revealed R3 was admitted into the facility on [DATE] and most recently re-admitted on [DATE]. Diagnoses included Tracheostomy Status and Dependence on a Ventilator. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented moderately impaired cognition and dependence or the need for substantial/maximal assistance for activities of daily living. R35On 08/11/2025 at 9:46 AM, R35 reported staff had taken 45 minutes to respond to their call light and get them onto the beside commode. R35 had a tracheostomy connected to a mechanical ventilator. R35 then reported they had become disconnected from the ventilator on 08/10/25. At 11:33 AM, R35 was observed to be seated upright in a recliner at the left side of the bed. R35 reported it had taken twenty minutes for staff to respond to the call light to get them off the bed side commode earlier in the morning. R35 was asked about what happened on 08/10/25. The spouse was present. R35 related they did not recall how the circuit became disconnected nor how long they were disconnected. The spouse indicated R35 had quit breathing. R35 recounted the tube had become disconnected in two places. This was identified as at the tracheostomy site and at the inline valve along the circuit tubing. R35 noted they had been showered earlier in the morning and was up in the recliner as on any other day. R35 recalls putting on the call light to use the bathroom and a few minutes later the circuit had become disconnected. R35 reported they were able to get the circuit reconnected at the valve but not at the tracheostomy. R35 reports they struggled with the tubing and trying to breath and may have passed out. The spouse reported they had spoken with R35 around 11 AM and R35 was fine. The spouse reported they had arrived in the room at the time staff were in with R35 on 08/10/25 and reported R35 was out of it at the time. The spouse reported additional times R35 has had to wait longer than 20 minutes for assistance to get back into bed. R35 was observed to be able to suction themselves, pedal a foot bike independently, feed themselves and converse appropriately during the days of the survey. On 08/11/2025 at 10:10 AM, Respiratory Therapist (RT) O reported someone should have heard the alarms going off. They had returned from break and noted the incident with R35. RT O reported R35 may have been disconnected for about three minutes. RT O reviewed the alarm menu for R35's ventilator and reported the last disconnection on 08/10/25 was at 12:14 PM. RT O also noted alarms for low pressure and low volume. On 08/11/2025 at 4:26 PM, the Corporate RT Director RT Q reported there should be an immediate response from staff to red light alarms. On 08/12/2025 at 11:23 AM, R35 was seated in a recliner using a foot bike independently. On 08/12/25 at 11:26 AM, the alarm activations were reviewed with RT X and confirmed disconnection means the circuit was disconnected and started at 12:08 PM and continued to alarm at 12:09 PM, 12:10 PM, 12:11 PM, 12:13 PM and 12:14 PM. An explanation of the alarms was not provided. On 08/13/2025 at 7:58 AM, R35 was asked again to review the events of 08/10/25. R35 reported it was a regular day with the regular routine. R35 reported they were up in the recliner with the circuit tubing off toward the right. They had put on the call light to use the bathroom and the call light had been on for two or three minutes, when circuit became disconnected in two places one at valve and at tracheostomy site. R35 reported they were able to reconnect at valve, but was not able to reconnect at the tracheostomy site. R35 reported they were struggling to breath and does not recall any coughing. On 08/13/2025 at 8:02 AM, RT O, reported that the unit was fully staffed on 08/10/25 but they had gone on break around 11:30 AM. RT O also reported that when the monitor reads disconnection it is only a disconnection, otherwise will say low minute volume or low pressure. On 08/13/2025 at 10:06 AM, R35 was seated in a recliner, suction wand in hand, sitting straight upright, and watching TV. On 08/13/2025 at 10:10 AM, the unit manager for the vent unit was asked to review the alarm activations for 08/10/25. Minute by minute low pressure, low minute volume and disconnect alarms were recorded from 12:08 PM until 12:14 PM. The unit manager reported they would have to speak with the corporate RT manager to review the settings. At 11:11 AM RT Manager Q reviewed alarm activations from 12:08 PM to 12:14 PM and noted the alarm activated and reset in the same minute. RT Q speculated R35 may have been coughing or putting it on and off. It was noted that R35 had attempted to reconnect the circuit to the tracheostomy, but was not able to. It was further noted that there was alarm activation for a period of six minutes when additional review of the alarms indicated only a single event, not seven in succession as on 08/10/25. On 08/13/2025 at 11:27 AM, the Director of Nursing (DON) reported they had spoken with the staff involved in regard to the disconnection of R35 from the ventilator. The DON reported they were shown where R35 may have been off the ventilator for two to three minutes. The DON deferred to the corporate RT Manager for vent unit concerns. On 08/13/2025 at 11:47 AM, Certified Nursing Assistant (CNA) S (R35's assigned CNA) reported it was busy on the opposite hall with more high level or red alarms which needed attention. CNA reported they had completed the lunch tray pass between 11 AM and 11:30 AM and had gone to the restroom sometime after that. Upon returning to the unit, they noted the red alarm for R35 was activated and went into see R35 and observed R35 disconnected from the ventilator. CNA S reported RT R and Licensed Practical Nurse (LPN) T responded first. CNA S reported R35 kept leaning, not able to sit upright and R35's speech was not clear. On 08/13/2025 at 12:01 PM, LPN U reported they were on the vent unit on the opposite hall from R35 on 08/10/25. LPN U reported it was a busy day as two residents had been alarming off and on, all day and one of the resident's had to eventually be sent out. LPN U noted the nurse from the other hall was trying to help them also. On 08/13/2025 at 12:07 PM, LPN T reported R35 was lethargic and had a deer in the headlights look when they entered the room of R35 during the disconnection on 08/10/25. LPN T confirmed it was a busier than usual day and noted they had been down the other hall when CNA S called them. LPN T also noted around 12 PM the aides would have been in the rooms doing vitals. A review of the record for R35 revealed R35 was admitted into the facility on [DATE]. Diagnoses included, Acute and Chronic Respiratory Failure, Tracheostomy Status, Dependence on Ventilator and Dependence on Supplemental Oxygen. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a Brief Interview for Mental Status score of 15/15 and the need for supervision for eating, and dependence for toileting, and transfers. The active care plan did not provide interventions related to alarm response. A review of the user manual for the facilities ventilators revealed in section six: low minute volume alarm, priority high, will be given when the monitored minute volume does not reach the alarm limit for 15 seconds. Possible cause: mismatch between breath rate and inspired volume. changes in airway resistance and or compliance, decreased breath rate . A low pressure alarm will be given when unit fails to reach the low pressure limit for 15 seconds. Possible cause: disconnection of patient circuit, mismatch between pressure setting and alarm setting, leakage from mask or other components . Disconnection: when measured flow exceeds the expected leakage flow at the set pressure for 15 seconds. Possible causes: too high leakage, has removed mask, circuit disconnection, pilot pressure tube disconnection, patient circuit or cannula disconnection . A review of the undated facility information sheet titled, Ventilator Alarms revealed, Check Circuit Alarm = Pinched or detached tubing, problem with exhalation valve, too high of pressure; Circuit Disconnect = tubing detached; High inspiratory pressure = cough, pinched tubing, bearing down needs suctioned; Low Minute Ventilation = Leak in Circuit, not getting adequate breaths; Low expiratory pressure = leak in circuit, might need air in cuff.

Based on interview and record review, the facility failed to provide mental health services in a timely manner for one resident (R186) out of three reviewed for mood and behavior. Findings include:A review of the medical record revealed R186 admitted into the facility on 5/13/2025 with the following medical diagnoses, Schizophrenia and Bipolar Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15, indicating an impaired cognition. R186 also required assistance with bed mobility and transfers.Further review of the physician's orders revealed that R186 received Haldol (Antipsychotic) injection, once a month.On 8/13/2025 at 11:04 AM, a request for psychiatric notes for R186 was requested and not received by the end of survey.On 8/13/2025 at 11:23 AM, an interview was conducted with Social Service Director (SSD) D. SSD D reported they are on the list to be seen, and they just switched to a new Nurse Practitioner. SSD D reported the new Nurse Practitioner comes in every Monday and will be seeing R186 soon.On 8/13/2025 at 12:30 PM, a Quality and Performance Improvement (QAPI) meeting was held with the Nursing Home Administrator (NHA). The NHA stated they expect Psychiatry (Psych) evaluations should be completed within the first week of admission pending consent by either the resident or guardian/power of attorney. They reported the Psychologist is here every other week and the Psych Physician's Assistant is here weekly. The NHA reported that consents for treatment can be verbal if documented and sometimes the psych evaluation is delayed or does not happen if consent is not provided.A request for a facility policy related to behavioral services was requested and not received by the end of survey.

Based on observation, interview, and record review, the facility failed to properly store a nebulizer mouthpiece for two residents (R6 and R191) out of two reviewed for nebulizer storage. Findings include:R6 On 8/13/2025 at 10:40 AM, R6 was observed in bed and wearing oxygen. R6 reported they were about to get out of bed and in their chair. A nebulizer mouthpiece was noted to be laying on the nightstand, with no barrier beneath it and an undated line. R6 was asked if they use the nebulizer mouthpiece often and they stated they use it everyday. On 8/13/2025 at 1:02 PM, Licensed Practical Nurse (LPN) “V”. LPN “V” reported they do store the nebulizer mouth pieces in a bag. LPN “V” reported that R6 had just used the nebulizer before they went outside. LPN “V” reported they were going to find a bag. A review of the medical record revealed R6 admitted into the facility on 3/7/2025 with the following medical diagnoses, Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 12/15, indicating an impaired cognition. R6 also required assistance with bed mobility and transfers. On 8/13/2025 at 2:05 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they expected the nebulizer mouthpiece to be stored in a bag. R191 On 8/11/2025 at 3:09 PM, R191 was observed sitting in the hallway. Observed on R191's nightstand was a nebulizer machine and the mouthpiece lying flat on top of the nightstand table. The mouthpiece was not observed inside of a plastic bag and did not appear to be drying. On 8/13/2025 at 10:08 AM, R191 was observed asleep in bed. The nebulizer remained in the same condition as on 8/11/25. On 8/13/2025 at 10:05 AM, LPN A was asked R191's order for the nebulizer and stated, Every 12 hours. LPN A was asked how the nebulizer should be stored when not in use. LPN A stated, in a plastic bag. A review of R191's medical record revealed, R191 was admitted to the facility on [DATE] with diagnosis of Acute Respiratory Failure with Hypoxia. A review of R191's quarterly Minimum Data (MDS) set assessment dated [DATE] noted R191's with a severely impaired cognition. A review of R191's care plan noted, Focus: Resident has an impaired pulmonary/respiratory status related to respiratory failure and tracheostomy. Date Initiated: 04/20/2025. Goal: Resident will have reduced complications related to their altered pulmonary/respiratory status through next review. Date Initiated: 04/20/2025. Interventions: Administer medications as ordered. Observe for effectiveness and report adverse side effects to Physician . On 8/13/2025 at 1:00 PM, the Infection Control Nurse was asked the facility's expectation for the storage of nebulizer when not in use. The Nurse explained they are to be stored in a bag when not in use. A review of the facility's policy tilted, Nebulizer dated 6/23/25 noted, Purpose: Small volume nebulizers convert liquid medication into a fine mist, allowing for the delivery of the medication deep into the lungs. Appropriate cleaning and storage techniques of small volume nebulizers decrease the risk of introducing bacteria into the airways, and reduces the potential of pulmonary infections . Cleaning:1. Twist open the nebulizer cup and dump out any residual remaining from treatment. 2. Rinse nebulizer cup and components with water. 3. Allow the nebulizer cup and components to airdry on a clean absorbent towel. 4. Once dry store the nebulizer cup and mouthpiece in a bag and label. 5. Replace nebulizer and tubing weekly per procedure .

This citation pertains to Intakes 1226813 and 2590504.Based on observation, interview and record review the facility failed to ensure call lights were in reach for four residents (R119, R160, R4 and R239) of six residents whose care needs were reviewed. Findings include: On 08/11/2025 11:19 AM, 11:25 AM, 1:11 PM, 2:00 PM, 2:56, and 4:34 PM, R4 was observed to be in bed with the call light on the floor at head of bed. R160 was observed to be in bed with the call light cord and button looped over a hook on the wall below the call box, and R119 was observed to be in bed, with the call light looped over the call box and vent cart. On 08/12/2025 8:18 AM, 9:17 AM, 11:30 AM, R4 was observed to be in bed with the call light on the floor at head of bed. R160 was observed to be in bed with the call light cord and button looped over a hook on the wall below the call box, and R119 was observed to be in bed, with the call light looped over the call box and vent cart. On 08/12/2025 at 11:37 AM, R239 was observed to be in bed with the call button hanging down below the bottom of the bed frame. On 08/13/2025 at 8:54 AM, R239 was observed to be in bed. An aide had exited the room re-entered and exited. The call cord and call button were on the floor at the left side of the bed. A review of the record for R4 revealed, R4 was admitted into the facility on [DATE]. Diagnoses included Renal Failure and Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition and total dependence on staff for Activities of Daily Living. A review of the record for R119 revealed, R119 was admitted into the facility on [DATE]. Diagnoses included Malnutrition and Respiratory Failure. The MDS dated [DATE] documented severely impaired cognition and total dependence on staff for Activities of Daily Living. A review of the record for R197 revealed, R197 was admitted into the facility on Diagnoses included Respiratory Failure and Stroke. The MDS dated [DATE] documented severely impaired cognition and total dependence on staff for Activities of Daily Living. A review of the record for R239 revealed, R239 was admitted into the facility on [DATE]. Diagnoses included Chronic Respiratory Failure and Diabetes. The MDS dated [DATE] documented severely impaired cognition and total dependence on staff for Activities of Daily Living. A review of the policy titled, Call Lights: Accessibility and Timely Response revised 12/28/23, revealed, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance . Special accommodations will be identified on the resident's person-centered care plan, and provided accordingly. (Examples include touch pads, larger buttons, bright colors, etc.) .

This citation pertains to Intake MI00152547. Based on observation, interview, and record review, the facility failed to ensure a clean environment for one resident, (R702) of three residents reviewed for home-like environment. Findings include: A review of the complaint submitted to the State Agency revealed the resident's room was observed as dirty upon visitation. On 4/28/25 at 10:58 AM, attempts to arouse R702 were made to no avail however, an observation of the resident's room revealed unidentifiable brown stains on the fitted and flat linen sheets the resident was laying on. The floor of the room was sticky underneath the surveyor's shoes, the door had what appeared to be an unidentifiable dried liquid on it, the baseboards throughout the perimeter of the room were observed as stained with an unknown caked on substance. The resident's bathroom was also observed with feces on the toilet seat. A review of R702's medical record revealed the resident was admitted into the facility on [DATE] with diagnoses that included Schizoaffective Disorder, Muscle Weakness and Hypertension. Further review revealed the resident had a severe cognitive impairment, and independent for transfers and bed mobility. On 4/28/25 at 12:32 PM, the Director of Nursing (DON) and surveyor observed the resident's room together, which was observed in the same condition as previously observed. The DON confirmed the room needed cleaning. A review of the facility's Room Cleaning Procedures revealed the following, Cleaning of every resident room is done daily .4. Sinks and Toilets are cleaned with a disinfectant cleaner inside and out .10 . flooring is dust mopped and then wet mopped with the specified floor cleaner. 11.Walls and doors are spot washed with a disinfectant cleaner when soiled. 12.Bathing Room tiles are wiped down and floors damp mopped with a disinfectant cleaner .

This citation pertains to Intake MI00148207. Based on observation, interview, and record review, the facility failed to maintain privacy from electronic devices (camera) located in the room of one resident (R704) of three reviewed for privacy. Findings include: On 11/20/24 at 10:30 AM, a sign was observed on the outside of R704's the door. The sign revealed, Introduce oneself to the mother on camera when entering resident room. Once in R704's room an approximately 4 x 6 inch camera was observed on R704's overbed table located below the window. R704's bed was about two feet away from the camera. On the left side of the same window toward the head of the bed, a (name of) camera (used to monitor in real-time) was observed affixed to the wall next to the window about 10 inches from a larger camera. Both cameras were facing R704's room entry door. On 11/20/24 at 10:45 AM, Licensed Practical Nurse (LPN) B was queried about the function of the cameras. LPN B revealed, the camera is connected to R704's mother's phone. LPN B further explained, they know voices can be heard by R704's mother because she has responded to care staff who have triggered the camera from the hallway. A review of R704's Electronic Medical Record (EMR) revealed, R704 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Cardiorespiratory Condition, non-verbal, and with a tracheostomy. Further review of R704's medical record indicated, R704's cognition as severely impaired and dependent of staff for all mobility and activities of daily living. On 11/20/24 at 12:55 PM, an observation was made along with the Assistant Nursing Home Administrator (ANHA) of R704's room which revealed, two cameras that faced room R704's entry door towards the hallway. The ANHA confirmed the cameras should not be facing the room entry door, saying, they are in the wrong position. The family must have moved them. When queried who was responsible to ensure the cameras are not infringing on other residents privacy, the ANHA revealed nursing staff should be ensuring cameras were facing R704 only. On 11/20/24 at 1:34 PM, the Director of Nursing (DON) revealed, R704's mother was contacted regarding placement of the cameras. R704's mother was given an explanation the cameras could not face the entry door because it could affect the privacy of any resident passing the doorway or talking in the hall. The DON explained that R704's mother became very irate and indicated she had every right to place the cameras in R704's room anywhere she wished. The policy Promoting/Maintaining Resident Dignity, revised on 10/26/23 revealed the following: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . 12. Maintain resident privacy.

This citation pertains to Intake MI00147638 Based on interview, and record review, the facility failed to prevent verbal and physical abuse for one resident (R801) out of four reviewed for abuse. Findings include: A review an investigation summary revealed the following, On 10/14/2024 at around 7:00 AM, Nurse D and Certified Nursing Assistant (CNA) E reported to A.D.O.N (Assistant Director of Nursing) . that they observed Licensed Practical Nurse (LPN) C yelling profanities at R801 for trying to sleep on the couch in the dayroom during their midnight shift on 10/13/2024 between 2:30am -3:30am. When R801 refused to get up off the couch LPN C continued to yell at them then got behind the couch and started lifting the couch to get R801 off. R801 then rolled onto the floor. Staff helped R801 up and took R801 to the room . A review of the medical record revealed R801 was admitted into the facility on [DATE] with the following diagnoses, Presence of Right Artificial Joint and Depression. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating R801 was unable to complete the assessment. R801 also required staff assistance with bed mobility and transfers. On 10/24/2024 at 9:53 AM, R802 was observed in bed. R802 did not recall the incident or falling. On 10/24/2024 at 10:35 AM, a phone interview was conducted with Family Member (FM) H. FM H stated they were also the guardian of R802 and heard they had a fall. FM H stated they know R802 can be a little mean sometimes, but they have had a lot of falls in the facility. FM H stated they were not informed a staff member was involved in R801 falling on the floor. O 10/24/2024 at 12:33 PM, a phone interview was conducted with CNA E. CNA E stated LPN C was always verbally antagonizing residents or saying little mean stuff, but nothing to this degree. CNA E stated that was the first time they saw them harm someone or be that mean to a resident and they knew they had to report it. CNA E felt LPN C tipped the couch purposely to make R801 roll off. On 10/24/2024 at 1:21 PM, an interview was conducted with the Assistant Nursing Home Administrator (ANHA). The ANHA stated they were told about the incident and suspended the nurse immediately. The ANHA stated they reviewed the video and confirmed LPN C did act in an unacceptable manner, and they terminated LPN C. A review of a facility policy titled; Abuse Policy noted the following. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse, neglect, or misappropriation of personal property by anyone.

This citation pertains to intake MI 978. Based on interview and record review, the facility failed to prevent resident to resident physical abuse of Perpetrator Resident (R906) towards one Resident (R907) out of two residents reviewed for abuse, resulting in hospitalization requiring stitches, severe pain, and mental anguish utilizing the reasonable person concept. Findings Include: On 8/17/2022 at 9:00 AM, R907 was observed resting in bed. An interview was attempted, however, R907 did not wake up or respond to verbal communication. A review of the medical record revealed that R907 admitted into the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 99, indicating R907 was unable to complete the interview. R907 also required extensive two person assist with bed mobility and transfers. A review of R907's progress notes revealed the following, Date: 7/3/2022 at 15:34 (3:34 PM). Note Text: Writer called to the resident's room, Writer observed the resident lying in bed with a laceration above (their) left eye. Entire body assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was able to voice concerns and stated to call (their) brother. NP (Nurse Practitioner) on call notified, family notified with no answer, message left. Resident transferred to (Name of local hospital) via 911 . Date: 7/3/2022 at 15:47 (3:47 PM). Note Text: Nurse writer alerted by staff that resident was struck in the head with a wheelchair leg by roommate (R906). Nurse writer assessed resident for injuries .Upon Nurse assessment resident has a laceration above left eyebrow, swelling to face minimum and pain at 10 for resident . Date: 7/6/2022 at 22:35 PM (10:35 PM). Note Text: Resident arrived via stretcher from (Name of local hospital), accompanied by 2 paramedics, vital signs stable, resident alert upon arrival, 3 sutures observed over left eye . On 8/18/2022 at 1:59 PM, an interview was conducted with the Nursing home Administrator regarding the incident. The NHA stated that R907 was telling R906 to shut up and R906 hit R907. The NHA stated that R906 has never shown any aggressive behavior and there have been no incidents with R906 since. The NHA stated that R907 and R906 are on different floors and R907 was put in a private room to prevent any other incidents. Review of the facility's Abuse Policy dated 10/2021 revealed the following, It is the policy of (Name of facility) to maintain an environment free of abuse and neglect.

Based on observation, interview and record review, the facility failed to implement effective interventions to manage constipation, and monitor bowel patterns for three Residents (Resident #72, #123 and #200) of five reviewed for a change in condition, resulting in an immediate jeopardy (IJ) with the likelihood of serious injury, harm and/or death. Findings include: Resident #72 On 04/26/2022 at 09:48 AM, Resident #72 was awake in bed. Resident #72 had a hospital gown on, and observed to have bilateral contracted hands. The Resident made eye contact and smiled when spoken to, but was unable to answer questions appropriately. Resident #72's abdomen was visible underneath their gown and was round and protruding. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #72 was admitted to the facility on [DATE] with a severely impaired cognition. Resident #72 needed extensive assistance with activities of daily living (ADL's) and had been diagnosed with Depression and Spastic Quadiplegic [CONDITION(S)]. A record review of the progress notes for Resident #72 revealed the following: 2/4/2022 00:00 (midnight) Visit Type: Acute .CHIEF COMPLAINT Abdominal distention reported by telehealth .being seen today for reports of abdominal distention from overnight telehealth. On exam today, pt (patient) is resting in bed. Per nursing staff, distention of abdomen is at pts baseline. Bowel sounds present in all 4 quadrants. Abdomen soft with no guarding. Tube feedings resumed. BM are not reported on [EMR]. Abdominal xray complete on 2/2 shows no acute findings. No acute concerns per nursing. ASSESSMENTS AND PLANS .Gastrostomy status: Resume [MEDICATION(S)] feeds. Abdominal xray shows no acute findings .Constipation, unspecified: Milk of mag (MOM) ordered one time dose. Continue current bowel protocol of Milk of mag prn 72 hours, senna, and [MEDICATION(S)]. Monitor BM and report concerns. 2/4/2022 17:26 (05:26 PM) Health Status Note .[Doctor/Dr. C] visited resident and gave order to resume TF (tube feeding) and to give a prn (as needed) dose of milk of magnesia. 2/7/2022 00:00 (midnight) Progress Notes .Visit Type: Follow Up .Abdominal distention, fecal impaction .being seen today for follow-up of abdominal distention. Abdominal x-ray obtained on Friday 2/4 (2022) showed a suspected fecal impaction with no bowel dilation, G-tube (gastrostomy tube, a method of artificial feeding that directly infuses in the stomach) in place with no evidence of free air. [Electronic Medical Record/EMR] reports bowel movements twice on 2/4 (2022) and twice on 2/6 (2022). Tube feedings resumed. Patient currently on bowel regimen. On exam today, bowel sounds are present in all 4 quadrants. Abdomen distended at baseline, with no guarding. Vital signs are stable. No acute concerns per nursing .Date of Service: 02/04/2022 .Generalized abdominal pain. Test Procedure .ABDOMEN, 1 VIEW Findings: 2 frontal supine views of the abdomen and pelvis were obtained. Please note this examination is limited due to patient motion artifact. There is a G-tube present with its bulb in the region of the left mid abdomen. There is a moderate to large amount of stool in the rectum with otherwise no additional evidence of large or small bowel dilatation. There was no definite evidence of free air. There was no definite evidence of a mass. Impressions: 1. Suspected fecal impaction without evidence of large or small bowel dilation .Constipation, unspecified: Abdominal X-ray shows likely fecal impaction on 2/4. Four BM (bowel movements) documented since imaging was obtained. Continue current bowel regimen of Milk of mag prn 72 hours, senna, and [MEDICATION(S)]. Monitor BM and report concerns . No progress notes from 02/07/2022-03/05/2022 pertaining to bowel or stomach concerns. 3/6/2022 01:57 (AM) .This writer received report of resident episode of emesis r/t tube feeding formula which STAT X-ray was ordered for the resident. The technician arrived at 22:30 (10:30 PM) and attempted to obtain the image. The resident became combative, and continued to yell, 'Get out! Stop! and leave him alone. This writer attempted to calm him down and explain why the x-ray was necessary. Resident still refused to cooperate and the technician said to reschedule the imaging for in the morning. 3/7/2022 00:00 .Nurse reports patient is complaining of abdominal pain. Nurse reports last BM is unknown, patient had an emesis earlier today and abdomen is very hard. Advised to hold tube feeds and ordered a stat abdominal X-ray. Nursing to continue to monitor and care team notified . 3/7/2022 00:00 CHIEF COMPLAINT 1 episode of emesis. pt being seen today due to reports of one episode of emesis on 3/5 (2022), which appeared to be tube feeding formula. PEG (percutaneous endoscopic gastrostomy) tube in place. [MEDICATION(S)] .for nausea ordered. Abdominal xray ordered, but technician was unable to obtain due to pt?s refusal. On exam today, pt calmly expressed .wish to cease the tube feeding as it causes .N/V (nausea and vomiting). However, pt is unable to pass swallow test for PO (by mouth) intake. Pt?s abdomen is distended and protuberant on exam, which is pts baseline. Pt has hx of constipation. Xray technician on site at exam attempted to complete order for abdominal xray, but pt became very combative yelling that .wouldn?t do it. Pt refuses xray because the procedure requires hard board to be placed underneath .Gastrostomy status: Pt refuses tube feedings due to side effects. Peg tube in place and functioning properly. Constipation, unspecified: Abdominal xray ordered, pt refused procedure. Abdomen distended at baseline. No tenderness. Bowel sounds present. Continue current bowel regimen. Nausea with vomiting,unspecified: Secondary to tube feeding. [MEDICATION(S)] ordered PRN. 3/7/2022 19:03 (07:03 PM) resident c/o of stomach pain, resident wont allow me to assess bowel sound . Feeding/ medication on hold. Stat xray ordered. Will resume feeding and medication once physician reviews results. 3/8/2022 00:00 .Visit Type: Acute. Follow up on Abdominal xray .pt being seen today for follow up on Abdominal xray results, ordered, Pt?s abdomen is distended and protuberant on exam, which is pts baseline. Pt has hx (history) of constipation. Bowel sounds present in all 4 quadrants, no further emesis (vomit) noted, abdominal xray results revealed, no obstruction noted, nonspecific bowel gas pattern noted, Will continue to monitor .Imaging: PROCEDURE: ABDOMEN, 1 VIEW .Findings: Gastrostomy tube projects over the left upper quadrant in similar configuration to prior. No bowel obstruction or pneumoperitoneum .Unspecified abdominal pain: C/O of abdominal pain, unable to elaborate on BM, abdominal distended at baseline, abdominal xray ordered, no obstruction noted. (Authored by Nurse Practitioner D). 3/10/2022 13:53 (01:53 PM) Nutrition/Dietary Note .continues on NPO (nothing by mouth) and tube feeding d/t (due to) dysphagia (difficulty swallowing). On TF: [MEDICATION(S)] 2.0, 60 cc/hr (cubic centimeters per hour) from 6 pm- total 1000 cc . and 1767 cc water flushes. GI (gastrointestinal): Had abd (abdominal) pain/ loose stools, possibly laxatives induced, on [MEDICATION(S)] (anti nausea and vomiting medication) and [MEDICATION(S)] (gas medication) improved per Nsg (nursing). TF+ supplements+ water flushes are adequate to meet the est. nutritional and fluid needs. No new interventions this time. Care plan updated. Will continue to monitor TF tolerance . No progress notes from 03/11/2022-03/29/2022 pertaining to bowel or stomach concerns. 3/30/2022 14:12 (02:12 PM) Nutrition/Dietary Note .Nutrition follow up assessment summary: (Resident #72) continues on NPO and tube feeding d/t dysphagia. On TF .GI: Last BM: 3/18/22 per B & B (bowel and bladder record): Notified physician and Nsg and requested to evaluate/ treat for possible constipation. 4/2/2022 16:31 (04:31 PM) Transfer to Hospital Summary .Resident transferred to .hospital by .ambulance via stretcher @ 1600 (04:00 PM) per NP .for evaluation d/t coffee brown emesis (blood in vomit) x2. No c/o (complaints of) pain or emesis during transfer . 4/11/2022 .Initial history and physical .General: (Resident #72) was recently in the hospital for coffee-ground emesis and diagnosed with acute GI bleeding acute constipation, [CONDITION(S)] (a systemic infection that has spread to the blood), acute [CONDITION(S)] (disease of the brain often associated with toxins from infection) .Patient is not complaining of any pain at all at this time and .only complaint is that (Resident #72) gets tired very easily .ASSESSMENTS AND PLANS .Gastrointestinal hemorrhage, unspecified: admitted for coffee-ground emesis with suspected GI bleed however hemoglobin was stable and no overt signs of bleeding were found otherwise and patient was stable with no evidence now of GI bleeding and discharged back .Constipation, unspecified: Fecal impaction disimpacted on April 3, 2022, but no obvious obstruction found, and all abdominal pain, nausea and vomiting have resolved, and now on bowel protocol with 2 scheduled medications and to as needed and we will continue to monitor closely .[CONDITION(S)] .Metabolic [CONDITION(S)]: Patient seems to have returned to baseline, will continue to monitor. Authored by NP D. A record review of Resident #72's Bowel and Bladder Elimination record revealed that Resident #72 had no documented bowel movement from 03/18/2022-03/30/2022. A record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #72 had an as needed order for MOM every 72 hours for no bowel movement within 72 hours and a Senna order for as needed for two pills every day for constipation. Neither the Senna or MOM order were signed out as being administered for the Month or March. A record review of the hospital records for the 03/30/2022 admission revealed the following for Resident #72: .Preliminary Report .Coffee-ground emesis with suspected GI bleed .no evidence of coffee-ground emesis on examination .One blood culture is positive .Constipation, reviewed and discussed/staffed CT (cat scan) of abdomen and pelvis findings with CT of abdomen and pelvis impression shows large amount of stool that fills the rectal vault with stool extending through the sigmoid colon suggesting patient may be impacted . Surgical Consult 04/03/2022- .(Resident #72) initially admitted from nearby nursing home for coffee-ground emesis. The patient found to have significant fecal impaction was seen by surgical team. Digital disimpaction as well as the chemical disinfections is in progress . On 04/28/2022 at 01:24 PM, an interview was completed with the Director of Nursing (DON) and Nursing Home Administrator (NHA). The NHA and DON were asked about the process of residents experiencing nausea, vomiting and having constipation concerns. The NHA explained that the facility staff would call the provider, go in and assess the resident and determine the cause of the concern. The NHA further stated, We just met with the MD (Medical Director) to set up a protocol (a bowel protocol to monitor bowel patterns). The NHA was asked what brought them to the conclusion of needing a bowel protocol and stated, We had a couple people with some bowel issues recently. The NHA was asked what was followed for Resident #72 and explained that she would specifically have to look into it. The DON, whom was also a Nurse Practitioner, was asked what the clinicians are expected to do/order with bowel concerns and nausea and vomiting and stated, I would properly assess and identify what is going on and make recommendations from there (based on individual assessment). On 04/29/2022 at 02:04 PM, Dr. C and NP D were interviewed in regard to Resident #72 having no documented bowel movement 03/18/2022-03/30/2022 and what was done in response. Both NP D and DR. C had not offered and explanation. They were asked if they were told about the Resident not having a bowel movement for that long and stated that they had not known. The NP was asked what she would have done if she had known the duration of no bowel movements and stated, If I would have known, I would have ordered an abdominal xray, some laxatives, I would have for sure done something. Resident #123 On 04/26/2022 at 11:28 AM, Resident #123 was observed in bed in their room awake. Resident #123 was alert and oriented to person, place and time and had clear speech. Resident #123 was asked if they had any problems that required hospitalization and explained that recently they had problems with their tubefeeding requiring hospitalization . A record review of the MDS assessment dated [DATE] revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating an intact cognition and needed extensive assistance with bed mobility and transfers. Further record review indicated that Resident @123 had several hospital readmissions with the most recent admission to the facility on [DATE]. A record review of the progress notes for Resident #123 revealed the following: 1/2/2022 00:00 .Patient is complaining of mild headache, poor appetite, feverishness, lower abdominal pain and left flank pain and mild shortness of breath today .Abdominal: Soft, nondistended, normal active bowel sounds+ mild to moderate lower abdominal tenderness diffusely with no guarding or rebound, patient does have left flank tenderness that is mild but not right flank tenderness .Unspecified abdominal pain: Lower abdominal pain mild to moderate and left flank pain .ordered stat and 1 view abdomen ordered .Patient is having mild left flank pain and feeling feverish with poor appetite, temperature is not elevated and urine is yellow but clear in Foley no guarding or rebound distress, no nausea or vomiting or diarrhea is present, patient is complaining of constipation but does have a bowel movement listed out today and on the 30th, however we will maximize .bowel protocol by giving .a dose of [MEDICATION(S)] and the Dulcolax suppository tonight .Constipation, unspecified: Continue current bowel protocol with extra dose of [MEDICATION(S)] and Dulcolax suppository tonight and 1 view x-ray of abdomen . Authored by Dr. C. 1/3/2022 00:00 .being seen for follow-up of multiple concerns. Patient recently reported feeling feverish with mild SOB (shortness of breath), lower abdominal tenderness and left flank pain .continues to have poor PO intake which has been an ongoing issues for several months now .Patient tells me .has not had a BM in a week - per nursing documentation .had a BM last night following suppository administration. Discussed with dietary who states patient had a few bites of breakfast today and has encouraged nursing to push oral nutrition. Dietary recommended the addition of a multivitamin along with current house supplements. Patient also endorsing left flank and lower abdominal pain. There is no guarding, but patient states pain is severe when abdomen is palpated, especially the left side. There is no distention noted. No nausea or vomiting or diarrhea. Location: Lower abdominal pain, left flank pain. Quality: Sharp. Severity: 10/10. Duration: Constant. Abdominal: Soft, lower abdomen is tender to palpation, L>R, nondistended, normal active bowel sounds .Unspecified abdominal pain: Lower abdominal pain mild to moderate and left flank .Patient is having mild left flank pain and feeling feverish with poor appetite, temperature is not elevated and urine is yellow but clear in Foley no guarding or rebound distress, no nausea or vomiting or diarrhea is present, patient is complaining of constipation but does have a bowel movement listed out today and on the 30th, however we will maximize his bowel protocol by giving him a dose of [MEDICATION(S)] and the Dulcolax suppository tonight .Constipation, unspecified: Continue current bowel protocol with extra dose of [MEDICATION(S)] and Dulcolax suppository tonight and 1 view x-ray of abdomen . 1/4/2022 11:28 (AM) Nutrition/Dietary Note .Resident has a poor po intake consuming 25%< of foods .self feeds with set up and encourage meal completion. Receiving a regular/mech soft diet, food preferences reviewed . 1/7/2022 00:00 Follow-up abdominal pain and XR, lab review .being seen today for multiple concerns. Radiology recently reviewed x-ray of abdomen revealed ileus (the cessation of the natural movement of the bowel) and suspected partial obstruction to the small bowel. Patient with long term loss of appetite and weight loss .Patient today endorses mild right sided lower abdomen tenderness to palpation. No masses or guarding. Patient states .sometimes has vomiting .tells me .had a bowel movement yesterday but it had to be induced with a suppository. We discussed possibly having a PEG tube placement, but agreed to discuss further after further elevation of abdomen with a CT Test Procedure: ABDOMEN, 1 VIEW Findings: 4 views of the abdomen and pelvis were obtained. There are dilated loops of small bowel in the abdomen .There is a paucity (small or insufficient) of colonic gas .Impressions: Appearance of the small bowel may be due to ileus or partial obstruction. Follow-up imaging is recommended .Order placed for patient to have abdominal CT for further investigation. Clear liquid diet ordered at this time. Suppository to be given today .Patient with significant weight loss over the last 3 months .Patient currently being worked up for ileus versus obstruction . 1/7/2022 14:33 (02:33 PM) Discharge Summary .PT was sent to [local hospital] for a CT of GI for possible obstruction. 1/10/2022 00:00 .Initial history and physical .Bowel obstruction, resolving .(Resident #123) who was just discharged from the hospital today regarding bowel obstruction that seems to be resolving at this time. The latest CT showed bowel obstruction resolving and patient had loose formed stool out today with abdominal pain decreasing. Ultrasound did show dilated gallbladder with sludge, but no stones or clear indication of [CONDITION(S)]. Patient does have right upper quadrant abdominal pain radiating around to .right side. Patient has had some ongoing mild nausea which lately has been .baseline but no vomiting. Patient is able to take fluids and well but has very little appetite for food. Abdominal: Soft, diffuse abdomen is tender to palpation, R>L (right greater than left), nondistended, normal active bowel sounds .Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction: Seem to be improved on last CAT scan done and soft formed stool out prior to discharge today, patient still nauseated but no vomiting and some mild diffuse abdominal pain, will increase [MEDICATION(S)] from as needed to scheduled daily . Authored by NP D. A review of the January 2022 MAR for Resident #123 revealed the following information: Resident #123 had an as needed order for [MEDICATION(S)] and [MEDICATION(S)] every 24 hours for constipation. Neither of these medications were signed out as given. A record review of the care plan for Resident #123 revealed no care plan for constipation. A record review of the facility Bowel Management policy dated 09/2021 revealed the following: Standard-A daily record of each resident's bowel movements will be maintained for monitoring purposes to prevent constipation, promote regularity, and determine if medication and/or dietary intervention is necessary. Policy-It is the responsibility of nursing personnel to document, monitor and implement appropriate measures relative to the management of bowel function .3. Each time a resident has a bowel movement; it is recorded under the appropriate date and shift using the BM Record Sheet. If resident toilets self, ask them at end of each shift if they had a bowel movement and record. 4. Record should reflect approximately size using: S = small, M = medium, and L = Large. Number of times should also be noted, e.g., L x 2 . 6. The 10-6 Charge Nurse is to review documentation each day in order to determine if any intervention is indicated. If a resident has not had a bowel movement in 2 days, the nurse will write the resident's name on the Bowel Intervention Sheet. NOTE: Do not count a small BM. 7. The 6-2 med. nurse will check the bowel intervention sheet generated by night shift and administer Milk of Magnesia with the 9 AM by medication pass to the appropriate residents. 8. The 2-10 shift Charge Nurse will check with the C.N.A.'s as to which residents listed on the intervention sheet have had a BM. If a resident has not had a medium or large BM, one Dulcolax suppository should be given with the 9 PM medication pass. 9. The 10-6 Charge Nurse will check with the C.N.A.'s as to which residents listed on the intervention sheet have had a BM. If resident has not had a medium or large BM, a Fleet's enema is given when the resident awakens towards morning. 10. If no results are noted form the above noted interventions, the physician will be notified for further orders. 11. If the resident is noted to have a chronic problem with constipation (meaning that the bowel regime has been implemented three or more times per month), the dietitian and the physician should be notified for further interventions. The Administrator was notified of Immediate Jeopardy on 04/28/2023 at 03:05 PM and a plan of correction was requested to remove the immediacy that began on 01/07/2022. The facility provided the following removal plan. Immediate Jeopardy was removed on 04/29/2022 as validated by the team on 05/04/2022. Facility IJ Removal Plan #1 - On 4-28-22, beginning at 4:30PM: 1)The Registered Nurse (RN) Unit Manager assessed resident #72 for nausea, vomiting, abdominal distension, and/or abdominal pain. None of these symptoms were noted upon RN assessment. 2)The Assistant Director of Nursing (ADON) assessed resident #200 for nausea, vomiting, abdominal distension, and/or abdominal pain. None of these symptoms were noted upon RN assessment. #2 - Beginning at 4:30 PM on 4-28-22, the current bowel patterns of all in-house residents were ascertained by use of the report function in the facility's EMR by the MDS nurse: 1)Any resident who was found not to have had a documented bowel movement within the past 3 days was assessed by a licensed nurse and had intervention(s) implemented as clinically indicated. In addition, these residents were placed on 24-hour report for continued clinical monitoring. 2)Any resident identified who had not had a documented bowel movement within the past three days, have been added to the Nurse Practitioner (NP) schedule for assessment/evaluation and further treatment on Friday, 4-29-22. #3 -Beginning at 4:28 PM on 4-28-22, the facility's Director of Nursing reviewed the shift report for the past 72 hours to identify any residents with emesis or abdominal pain or who received antiemetic medications that could be related to bowel function. #4 - All residents identified were treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . #5 - On 4-28-22 at 5:30PM, the DON and Medical Director reviewed the policy titled Bowel Management Protocol and revised the policy to include the addition of weekly bowel management audits and QAA Committee reporting. #6 -The DON and Medical Director reviewed the Acute Change of Condition policy and deemed it appropriate on 4-28-22 at 5:50PM. #7 - The ADON / Staff Educator began training the licensed nurses on these policies on 4-28-22 at 7:00 pm. 75% of the facility's licensed nurses will be trained by 4-29-2022 at 11:59pm. The licensed nurses are responsible for initiating the bowel protocol and assessing the residents. The remaining nurses will be contacted by telephone by the ADON with 100% of staff completed by 11:59PM on 5-2-2022. #6 -Daily, the unit nurses are responsible to check the [EMR] alerts to identify residents who have no bowel movement documented for the past 3 days. The nurse is responsible to complete an assessment of the resident's abdomen as well as for complaints of nausea and vomiting to determine if additional intervention/bowel protocol is to be started. The ADON, Unit Manager, or other licensed nurse assigned by the DON will conduct weekly bowel management audits using the Bowel Management Audit tool. Results of the audit will be shared with the DON and follow-up action (including progressive discipline) may result. DON will report on the results of the bowel management audit to the QAA Committee monthly. The facility will achieve compliance with the implementation of the bowel protocol management on 4-29-2022. Although the Immediacy was removed on 04/29/2022, the facility remained out of compliance at pattern with actual harm that is not Immediate Jeopardy as sustained compliance could not be verified by the state agency. Resident 200 (R200) On 4/26/22 at 9:07 AM, R200 was observed in their bed, wearing a hospital gown and watching TV. R200 was observed to have a [CONDITION(S)]. R200 was receiving ventilator assistance (a machine that helps a patient breathe (ventilate) when they cannot breathe on their own due to a critical illness). R200 was able to mouthed words, however, it was difficult to understand. A review of R200's medical record noted an admission to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R200 requires total assistance with Activities of Daily Living. A review of the medical record noted R200 was admitted to the hospital on 2/17/22 and 4/12/22 for : 2/15/2022 11:24 (AM) Physician Note by Physician J . Abdominal pain likely ileus vs. small bowel obstruction . Pulmonary medicine . 2/17/2022 22:27 (10:27 PM) .Resident awake in bed. VSS (vital signs stable). Alert. Denies pain. No distress noted. Results for Abd Xray (Abdominal Xray): Abdominal Distention R/O (rule out) Peritoneal Free Air. (Physician J ordered Transfer to Hospital . 2/24/22 19:58 (7:58 PM) Pulmonary medicine . returns from acute care February 22, 2022 where (R200) presented to the ED with abdominal distention, CT (computerized tomography) abdomen findings suggestive of acute [CONDITION(S)] with colonic ileus (intestines are not moving correctly and cannot push food through the digestive system) . 4/6/2022 11:54 (AM) Health Status Note Note Text: Resident has emesis x2 times (vomited twice) after [CONDITION(S)] no acute distress noted . 4/7/2022 01:01 (1:01 AM) Nurse K noted in the progress note: Patient has had emesis twice on night shift that smells of feces and is yellow in color. Patient stated (R200) has not had a bowel movement in three days. patient was given [MEDICATION(S)] (medications to prevent nausea and vomiting) for nausea as a first attempt after first emesis on night shift. patient refused tube feed due to nausea. (Physician J) was notified and nurse is waiting instructions . An attempt was made to call Nurse K on 4/28/22 at 1:12 PM, a voice message was left, did not receive a return call prior to the survey exit. 4/7/2022 07:10 (7:10 AM) verbal order was given by (Physician J) order was put in for abdominal x-ray . 4/8/2022 13:08 (1:08 PM) Resident complaints of abdominal pain, nausea and vomiting, stat abdominal x-ray ordered . A review of R200 radiology report on 4/8/22 noted the following: PROCEDURE: ABDOMEN, 1 VIEW (Abdominal X-Ray) . Impressions: Findings suggest a partial or early small bowel obstruction. Large fecal bolus overlies the rectum. Correlate for fecal impaction . 4/9/2022 07:19 (7:19 AM) . physician aware about the x-ray result , order received and given . 4/9/2022 07:30 (7:30 AM) soap and suds enema (enema to stimulate bowel movement) and [MEDICATION(S)] given as ordered no bowel movement during night . 4/9/2022 13:10 (1:10 PM) .resident has emesis x 2 times after giving [MEDICATION(S)] . 4/9/2022 15:17 (3:17 PM) .Bowel movement x 1(1 time) after enema (medium size) 4/12/2022 07:47 (7:47 AM) . Resident had emesis on night shift. Feeding was stopped. Dr. [NAME] was notified, and orders were given for abdominal x-ray stat (immediately), . [MEDICATION(S)] 30 ml daily via peg tube . soap sud enema one time only . 4/12/2022 15:30 (3:30 PM) . physician aware the stat abdominal x-ray order received to send hospital for bowel obstruction. A review of R200 radiology report on 4/8/22 noted the following: PROCEDURE: ABDOMEN, 1 VIEW . Impressions: Interval worsening in gaseous distention of the small bowel loops which may be related to worsening ileus or developing small bowel obstruction . A review of the hospital notes dated 4/12/22 at 8:37 PM from the emergency department noted the following: Patient recently underwent abdominal x-ray imaging for progressively worsening constipation .findings consistent with ileus or developing small bowel obstruction . In addition that the Patient admitted to ICU (Intensive Care Unit) related to ventilator dependent status. On 4/28/22 at 1:52 PM, Physician J was interviewed by telephone to discuss R200 abdominal obstruction, the nurse revealing R200's emesis smelled like feces, and their tube feeding not being stopped. Physician J stated, Standard protocol is to hold the TF (tube feeding) and put them on [MEDICATION(S)] .The situation was (R200) had some n/v (nausea and vomiting) and a lot of times they thought it was related to [CONDITION(S)]. When they (the nurse) called and told me someone is throwing up and nauseous, I said to hold the TF, get an x-ray, and they slowly resolve. At one point I was trying to give (R200) a little bowel rest to see if it would clear out itself. It didn't so we sent (R200) out. Initially we thought it was a small bowel obstruction. The images were showing that she had an ileus at the hospital. Physician J was informed that the nurse documented in the medical record that the resident emesis smelled like feces. Physician J stated, I can't remember that, or anybody telling me that it smells like feces. We would have sent (R200) to the hospital immediately if the nurse told me that. A review of the medical record did not note an order to stop the tube feeding. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R200 continued receiving enteral feeding and H2O on the following dates: 4/6/22, resident refused on 4/8/22 and 4/10/22. Pro-Stat Liquid (liquid protein medical food) Give 30 cc via PEG-Tube one time a day for nutrition .received on 4/5/22, 4/6/22, 4/7/22, 4/8/22, 4/9/22, 4/10/22, 4/11/22, 4/12/22. On 4/28/22 at 2:43 PM, an interview was conducted with the Director of Nursing and Unit Manager to discuss R200's abdominal concerns. The Unit Manager revealed, So at that time on 4/6/22 (R200) had an emesis the [CONDITION(S)] nurse called me and the calcium was high. Our lab showed 12.6 but [CONDITION(S)] showed 14. I then called (Physician J) who said call nephrologist and they told [CONDITION(S)] nurse to give iv medication. I had to call pharmacy for the medication, and it was available the next day. (Physician J) said I would send (R200) to the hospital from my perspective. Nephrologist said we can do the iv medication. Usually with the emesis and the high calcium we relate it to [CONDITION(S)]. Then night shift stated that they held the TF, they said they held it and put refused because there isn't a button for hold .there should be a note saying why they held the TF (tube feeding). The DON stated, That's what my point is, if feces were put in the note then it should have been an emergency and sent out immediately .I am working with the medical director to see how we can revamp many of the protocols and policies. I do understand how refuse is different from hold. But the system can be a little confusing. The DON was informed of the inability to find in the medical record documentation of abdominal assessment b [TRUNCATED]

Based on observation, interview, and record review the facility failed to manage pain, ensure medication was administered as ordered, and ensure ordered pain medication was available for one sampled Resident (R161), resulting in ongoing and untreated pain. Findings include: On 4/26/22 at 9:36 AM, R161 was observed laying on their right side in bed. R161 was asked about their stay at the facility and stated, I'm in pain, I have hemorrhoids and haven't gotten any medication all day. This has happened more than once. I'm in pain. I feel like screaming and swearing. R161 was asked if they had told the staff that they were in pain and stated, They know I'm here and that I have hemorrhoids. On 4/26/22 at 10:58 AM, R161 was asked if they received their pain medication and stated, I'm still in pain. The Nurse couldn't find the medication. She has to call and get it. On 4/26/22 at 11:31 AM, Nurse M was asked about R161's medication for the hemorrhoid pain and reported, [R161's] cream is not in the cart and I have to call the Doctor. A review of R161's progress note revealed, 4/21/2022 14:30 (2:30 PM) Health Status Note Text: Guest was crying out stating, [R161] hemorrhoid's were acting up, writer observed no bleeding or external hemorrhoid's. None observed at the anal opening. Guest states [R161] pain is 8/10. Writer notified the NP (Nurse Practitioner), orders given to start Preparation H scheduled pain medications given. Currently in bed resting, call light in reach. A review of R161's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Dispensed 4/26/22. Date Received 4/26/22. Supply/Medication: Preparation H. Direction Apply topically to rectum/hemorrhoids every 12 hours as needed for hemorrhoids. Source: [local pharmacy]. Further review of R161's medical record revealed, R161 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Start Date: 4/21/22. Biofreeze Gel 4% Apply to lower back every morning and at bedtime for Back pain. Start Date: 4/15/2022., and [MEDICATION(S)] Acetaminophen 325mg. Give 1 tablet by mouth every 6 hours for Chronic pain. Start Date 3/21/22. A review of R161's care plan did not address care or interventions to treat R161's hemorrhoid pain. On 5/04/22 at 12:39 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were asked the facility's expectation for medications. The NHA stated, To be given as ordered and for it to come the same day or the next day. Also for the nurses to be on top of it following up. A review of the facility's policy titled, PAIN CONTROL PROGRAM dated 1/2022, noted OBJECTIVE: The facility, to the extent possible: Recognizes when the resident is experiencing pain and identifies circumstances when pain can be anticipated. Evaluates existing pain and causes. Manages or prevents pain consistent with the assessment and plan of care, current clinical standards of practice, and the resident's goal and preferences .

This citation pertains to intake numbers: MI 801, MI 868 and MI 949. Based on observation, interview and record review, the facility failed to assess and monitor wounds/skin and/or reposition per standards of care for three of three Residents (Resident #900, #901 and #902) reviewed for pressure ulcers (a wound formed over a bony prominence from prolonged pressure to the area), resulting in the development of new wounds, the potential of worsening wounds, pain, and hospitalization . Findings include: Resident #902 (R902) On 12/16/2021 at 10:44 AM, an interview was completed via telephone with Confidential Witness D. According to Confidential Witness D, Resident #902 was currently in the hospital. Confidential Witness D explained that they had no idea Resident #902 had a wound until the R902 was admitted to the hospital and the hospital staff had told them. Confidential Witness D stated, There is no way they were repositioning (Resident #902). Confidential Witness D also explained that the Resident #902 had no wounds prior to their admission to the facility. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #902 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #902 had a Brief Interview for Mental Status score of 11 out of 15, indicating a mild cognition and needed extensive to total care with activities of daily living. The MDS revealed no wounds. A record review of the Progress Notes for Resident #902's revealed the following: 10/19/2021 19:31 (07:31 PM) Admission Summary .resident admitted from .hospital alert and responsive .on coming nurse do admission and skin assessment. A record review of the initial skin assessment dated [DATE] revealed that Resident #902 had no wounds. A record review of the skin assessments revealed one shower sheet for 10/29/2021 reflecting Resident #902 had no open areas. There were no other skin assessments received prior to the end of the survey process. A record review of the initial Braden scale (a tool utilized to determine the risk for skin breakdown) revealed that Resident #902 was a high risk for the development of a pressure ulcer. A record review of the skin care plan (created 10/20/2021) for Resident #902 revealed the following: Focus .Resident is at Risk for pressure injuries r/t (related to): disease process .limited mobility. Goal-The resident will have intact skin, free of redness, blisters or discoloration by/through review date. On 12/20/2021 at 02:50 PM, Wound Nurse B was interviewed regarding the management of skin within the facility. Wound Nurse B explained that the facility does an initial skin assessment upon admission and then the nurses do skin checks with showers twice per week. Wound Nurse B was asked about the skin of Resident #902 and explained that she was asked to look at Resident #902's skin because of redness to the coccyx area but did not feel there were any skin concerns with the Resident. On 12/20/2021 at 03:12 PM, the Director of Nursing (DON), along with the Nursing Home Administrator (NHA) were interviewed in regard to the prevention of pressure ulcers and explained that they had a Wound Nurse and Physician's Assistant that came in weekly to address wounds. The DON explained that nurses do skin assessments twice per week during shower days. The DON was asked where the skin assessments were located and explained that they should be in the electronic medical record. There was no explanation offered as to where the rest of the skin assessments were for Resident #902 during their stay at the facility. A review of the facility policy titled Wound Care Policy (no date) revealed the following: 2. Assessment of the resident's skin will be completed to define prevention methods. The skin assessment will include skin integrity and tissue tolerance .IDENTIFICATION 1. All residents will have a complete skin assessment within 24 hours of admission by a charge nurse. The resident's skin will be assessed twice weekly on shower/bath days and a skin worksheet will be completed and the findings will be documented under the Skin Observation Tool on (electronic medical record). Resident #900 (R900) A review of intake MI 868 revealed the following, . Hospital called me again at 5:00 a.m. on the morning of 11-19-21 and said that [R900] had to have major surgery and they had to do it within an hour. I told them I was on the way. They ended up doing a massive cutdown in [R900] rectum area and had to take off most of [their] inner thigh to the outside of [their] leg. The surgeon then came out and told the family we need to say our Goodbyes because [R900] would not survive. A little less than 6 hours later [R900] passed away with [CONDITION(S)] Sacral Wound. ([CONDITION(S)] had spread through [their] blood) This should not have happened Someone should have noticed the decube (Pressure Ulcer) if care had been done in a timely manner. The Death Certificate States it had been going on for at least a month. Someone should have been able to smell the infection at the Nursing Facility before it had gone as far as it had. A review of R900's medical record revealed that R900 was admitted into the facility on [DATE] with the following diagnoses, Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), Muscle Weakness, and Chronic [CONDITION(S)] with [CONDITION(S)]. A review of R900's Minimum Data Set (MDS) Assessment revealed a score of 99 on their Brief Interview for Mental Status (BIMS) indicating they were unable to complete the interview. R900 was also dependent of staff for all ADL's. There were no skin alterations noted on the MDS. On 12/20/2021, a review R900's admission skin assessment noted only a peg (percutaneous endoscopic gastrostomy) tube at the abdomen. No other open areas were noted on the assessment. Further review of R900's skin observations revealed they were completed on the following days: 11/15/2021-Red area noted on coccyx 11/17/2021-Open area Additional skin observations were requested, but not received prior to exit of the survey. A review of R900's wound note dated 11/17/2021 at 5:51 PM revealed the following, Right gluteal abrasion, this wound measures 1.0 cm (centimeter) x 0.2 cm with no appreciable depth. Wound has a scant amount of serosanguineous drainage. There is no slough, eschar, tunneling, or undermining. Wound edges are attached. Periwound area is without redness, warmth, swelling, or signs of induration or infection. Wound is to be cleaned with normal saline daily and [MEDICATION(S)] applied. Wound can be covered with bordered gauze. Right posterior thorax abrasion, wound measures 1.0 cm x 0.5 cm with no appreciable depth. There is a scant amount of serosanguineous drainage. There is no slough, eschar, tunneling, or undermining. Wound edges are attached. Periwound area is without redness, warmth, swelling, or signs of induration or infection. Wound is to be cleaned with normal saline daily and [MEDICATION(S)] applied. Wound can be covered with bordered gauze. Medications and labs have been reviewed. No changes or additions to medications at this time. Nursing staff to notify provider of any acute changes in patient's wound status. Further review of R900's progress note by the infectious disease physician dated 11/18/2021 at 17:26 (5:26 PM) revealed the following, .Seen by Infectious Disease: Skin examination shows a necrotic foul-smelling sacral decubitus ulcer which is unstageable. There is surrounding [CONDITION(S)] and induration. [R900] white count is 24,000. Impression [CONDITION(S)] secondary to necrotic-infected sacral decubitus ulcer with surrounding [CONDITION(S)] . Recommendation: I believe that this patient needs to be hospitalized in order to undergo extensive debridement of decubitus ulcer. The patient will also require broad-spectrum antibiotics. This was discussed with nursing staff who is going to contact [Physician]. If [R900] remains in in this facility combination of [MEDICATION(S)] and [MEDICATION(S)] that has already been ordered by [Physician] would be appropriate. On 12/20/2021 at 11:14 AM, a phone interview was conducted with Wound Care Provider (WCP) A. WCP A stated that they saw R900 one time but could not remember the circumstances as to why they saw them. WCP A stated that R900 had two small wounds, one on their back and right glute. WCP A stated that they did not see a sacral wound or notice an odor. WCP A was queried as to how the wound deteriorated significantly over 24 hours when the infectious disease physician assessed it. WCP A stated that it is very possible for a wound to deteriorate over 24 hours. WCP A stated that the facility is severely understaffed like most places are, which means that people are not being properly turned or changed. WCP A stated that if R900 was sitting in something such as stool for a prolonged period then that would cause the wound to deteriorate rapidly. On 12/20/2021 at 2:41 PM, an interview was conducted with Wound Care Nurse (WCN) B regarding R900 wounds and lack of skin assessments. WCN B stated that they were on vacation when R900 came into the facility. WCN B stated that when they came back into the facility they went and looked at R900 skin with WCP A and saw an abrasion to the right glute with minimal drainage. WCN B was queried regarding the lack of skin assessments completed for R900. WCN B stated that skin assessments are supposed to be completed on shower days by the floor nurse. WCN B stated that they do not know why R900 did not have them completed. On 12/20/2021 at 3:12 PM, an interview was conducted with the Nursing home Administrator (NHA) and Director of Nursing (DON). The NHA stated that skin assessments are completed by the floor nurse, and they should be completed twice weekly or weekly. The NHA stated that they should be completed with the showers and then entered into the computer by the nurse. The NHA and DON were queried regarding R900's wound and what may have caused it to deteriorate. The NHA stated that it could have been a Kennedy wound (Terminal Pressure Ulcer). The NHA stated that all residents on the third floor are put on an alternate pressure mattress no matter what. A review of a policy titled, Wound Care Policy, revealed the following: 1. All residents will have a complete skin assessment within 24 hours of admission by a charge nurse. The resident's skin will be assessed twice weekly on shower/bath days and a skin worksheet will be completed and the findings will be documented under the Skin Observation Tool on POC. Resident #901 (R901) On 12/20/21 at 8:53 AM, Confidential Witness C was interviewed via phone, and they explained that R901 had pressure sores that they were not made aware of, and that R901 is not repositioned every 2 hours per their care plan. On 12/20/21 at 9:29 AM, R901 was observed lying in bed on their back. Attempts to speak to R901 were made however due to their cognitive impairment, an interview was unable to be conducted. A wedge (used for maintaining positioning schedules to prevent pressure) was observed lying on R901's nightstand. A review of R901's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R901's most recent Minimum Data Set Assessment revealed that the resident was significantly cognitively impaired and required total dependence for all Activities of Daily Living (ADLs). A review of R901's census record revealed that the resident remained in the facility from admission, with their first hospitalization on [DATE]. A review of R901's care plan revealed the following, Focus: [R901] has pressure injury and is at Risk for Skin Integrity r/t (related to): Hx (history) of pressure injuries, Incontinence, Limited Mobility-4/15/21 IDT (interdisciplinary team) review coccyx st (stage) 3 (3 x 0.5) clean wound w/ santyl txt (treatment) Resident has skin abrasion to Back of left side of head 5/13/2021 - IDT review - Sacral wound has healed. Pink epithelial tissue remains. Remains at risk for further development. 9/10/21- readmitted with st. 3 to sacrum, wound care nurse assessed, tx in place as well as interventions. readmit 11/23/21- 3 unstag (unstageable). wounds (sacral/coccyx, bilateral outer feet), tx. ordered, wound consult ordered and vit. C/zinc supplements added Date Initiated: 04/09/2021 Revision on: 11/24/2021 .Interventions: Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Skin assess daily with ADLs and report any changes. Date Initiated: 04/09/2021 .Turn/reposition Q (every) 2 hours/PRN (as needed). Date Initiated: 04/09/2021. Revision on: 11/24/2021. Further review of R901's medical record revealed the following skin assessments: -8/3/21: Skin Observation Tool (Licensed Nurse)-Full Assessment. bath given, excoriation on buttocks skin protective applied skin remain both Up in chair. -8/5/21: Skin Observation Tool (Licensed Nurse)-Full Assessment. shower given hair washed 4th and 5th digit excoriation, buttocks excoriation. -8/25/21: Skin Observation Tool (Licensed Nurse)-Full Assessment. Right Buttock: shower given hair washed 4th and 5th digit excoriation, buttocks excoriation. -8/30/21: Skin Observation Tool (Licensed Nurse)-Full Assessment. Bed bath given, stage 2 wound to (R (right)) buttocks, zinc based ointment to bilateral buttock. On 12/20/21 at 11:37 AM, 1:09 PM, 2:26 PM, and 3:32 PM, R901 was observed lying in the same position as they had been since being observed at 9:29 AM. R901's wedge was still observed sitting on the nightstand. On 12/20/21 at 3:12 PM, an interview was completed with the Director of Nursing (DON) and Nursing Home Administrator (NHA) regarding the facility's expectation for turning and repositioning. The NHA explained that turning and repositioning is completed every 2 hours, and that there was a turning and repositioning schedule for residents in their rooms, and at the nurses' station. The DON and NHA were asked who was responsible for ensuring that the schedule was being followed, and they explained that it is the nurses' responsibility. The DON and NHA were asked about R901's identified stage II pressure ulcer, that was reflected on their skin assessment dated [DATE]. As the previous documented identification of R901's buttocks reflected excoriation on 8/25/21. The DON and NHA indicated that they would follow up with the surveyor regarding this. On 12/20/21 at 3:20 PM, the DON provided a skin assessment completed on 9/1/21 indicating the following, skin intact, no skin tears, open areas. Skin intact. A review of R901's skin assessments were reviewed, and the following skin assessment described the following on 9/2/21, Skin Observation Tool (Licensed Nurse)-Full Assessment. Bed bath given, (R) buttock wound under care, treatment applied.

This citation pertains to intake 0. Based on interview and record review, the facility failed to ensure one sampled resident (R#901) was free from an adverse reaction to controlled pain medication ([MEDICATION NAME]), and failed to document non-pharmacological interventions and response to interventions attempted for pain relief, resulting in medication changes that led to lethargy and requiring their return to full ventilatory support. Findings include: A review of intake 0 revealed: (R#901) was supposed to be discharged from the nursing home on August 4th but .had an 'episode' and needed to be put back on a ventilator .(R#901) had [MEDICAL CONDITION] . (and) ended up having to go back on the vent because of the [MEDICATION NAME] so I guess (R#901) needed it .They had (R#901) on [MEDICATION NAME] for pain. Why? (R#901) did not want to be on [MEDICATION NAME]. They were giving (R#901) too much .(Former Unit Manager (UM) E) told us the reason was because it was a cheap pain medication. A review of R#901's record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and discharged on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was cognitively intact and required total assistance from staff for activities of daily living (ADLs). A review of R#901's medical record revealed the following: Effective Date: 7/15/2020 16:51 (4:51 PM) Writer (Discharge Planner) spoke to (R#901) regarding .interest in beginning discharge planning. At this time (R#901) is still ventilator dependent, but .is anticipated do first 24 weaning trial this evening overnight .(Physician) is aware that discharge planning has begun. (R#901) is motivated to return home . Effective Date: 7/15/2020 18:01 (6:01 PM) Note Text: [MEDICAL CONDITION] medicine service: (R#901) is continuing to show clinical improvement .been [MEDICAL CONDITION] trials up until midnight. (R#901) is sitting at the side of (the) bed .is pleasant and smiling .trials of PMV (Passy-Muir valve) have resulted in dyspnea. The ventilator is on standby. (R#901) is [MEDICAL CONDITION] (placed over a breathing tube in a tracheotomy incision in the throat, and through which humidified oxygen is given). (R#901) remains on full ventilatory support at night .has shown improvement tolerating spontaneous breathing trials . Late Entry Effective Date: 7/16/2020 12:04 Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Late Entry Effective Date: 7/17/2020 10:01 Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 7/17/2020 18:41 Type: Health Status Note .Ambulated down the hall with Physical therapy no issues noted. Resident complains of pain at times. Pain medication given as ordered. Resident VS (vital signs) is WNL (within normal limits) . Author: (Licensed Practical Nurse (LPN) B). Effective Date: 7/18/2020 23:03 (11:03 PM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 7/19/2020 13:57 (1:57 PM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Late Entry Effective Date: 7/20/2020 07:53 (AM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Late Entry Effective Date: 7/21/2020 22:28 (10:28 PM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 7/22/2020 21:39 (9:39 PM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 7/23/2020 15:24 Type: Health Status Note Note Text: Resident continues off the vent for 7 days. Tolerating well. Physical Therapy ambulating resident down the hall. Resident was .ordered a Pain Management consult with (Physician A) . (LPN B). Effective Date: 7/23/2020 23:35 (11:35 PM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). A review of a handwritten consult note from Physician A dated 7/23/2020 revealed: .Has pain in back .(illegible writing) .[MEDICATION NAME] 7.5/325 not helping .A/P (assessment/plan) .-will d/c (discontinue) [MEDICATION NAME] 7.5 -start [MEDICATION NAME] due to CKD ([MEDICAL CONDITION]) . A review at this time of R#901's medication orders revealed the following order: [MEDICATION NAME] Tablet 7.5-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet via PE[DEVICE] every 6 hours as needed (PRN) for Pain -Start Date- 06/18/2020 -D/C Date- 07/27/2020. This medication order allowed for three PRN administrations per day. Review of the administration record for July 2020 revealed that R#901 was not administered the medication at all on 7/2, 7/5, 7/7, 7/10, 7/11, and 7/21. The medication was administered once on 7/1, 7/3, 7/6, 7/13, 7/15-7/17, 7/20, 7/25, and 7/26; twice on 7/4, 7/8, 7/9, 7/12, 7/14, 7/18, 7/22, and 7/24; and three times on 7/19 and 7/23. R#901 did not have any scheduled pain medication. Continued review of R#901's progress notes revealed: Effective Date: 7/24/2020 23:16 (11:16 PM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 7/25/2020 10:31 Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 7/26/2020 14:55 (2:55 PM) Type: Order Note Note Text: The order you have entered [MEDICATION NAME] HCl Tablet 10 MG *Controlled Drug* Give 1 tablet via PE[DEVICE] (feeding tube) every 8 hours for Pain May continue to use [MEDICATION NAME] 7.5/325mg until new meds arrive, Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction: The system has identified a possible drug interaction with the following orders: -QUEtiapine [MEDICATION NAME] Tablet 25 MG (milligrams) Give 1 tablet via PE[DEVICE] one time a day for MOOD & BEHAVIOR Severity: Severe Interaction: Additive QT interval prolongation (a heart rhythm condition that can potentially cause fast, chaotic heartbeats that might trigger [MEDICAL CONDITIONS], or sudden death in severe cases) may occur during coadministration of quetiapine, a moderate-risk QT-prolonging agent, and [MEDICATION NAME] HCl Tablet 10MG. -[MEDICATION NAME] HCl Tablet 200 MG Give 1 tablet via PE[DEVICE] one time a day related to UNSPECIFIED [MEDICAL CONDITION] FLUTTER (I48.92) Hold for HR less than 60 Severity: Severe Interaction: Both [MEDICATION NAME] and [MEDICATION NAME] are associated with a high risk of QT prolongation. Combined use may result in additive effects on the QT interval. -QUEtiapine [MEDICATION NAME] Tablet 100 MG Give 1 tablet via PE[DEVICE] at bedtime for MOOD & BEHAVIOR Severity: Severe Interaction: Additive QT interval prolongation may occur during coadministration of quetiapine, a moderate-risk QT-prolonging agent, and [MEDICATION NAME] HCl Tablet 10MG. -[MEDICATION NAME] Tablet 1 MG Give 1 tablet via PE[DEVICE] every 8 hours for Anxiety Severity: Severe Interaction: Coadministration of [MEDICATION NAME] with benzodiazepines may substantially increase the potential of a fatal outcome due to potentiation of respiratory depressant effects. Author: (LPN C). Effective Date: 7/26/2020 15:03 (3:03 PM) Type: Order Note: Order given to start resident on [MEDICATION NAME] 10MG Q8H (every 8 hours) for pain. Warning black box alert with this medication. Writer received approval from Physician to continue with new order. Order carried out as given. Author: (LPN C). Effective Date: 7/27/2020 00:06 (12:06 AM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 7/28/2020 09:11 (AM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 7/29/2020 13:05 (1:05 PM) Type: Order Note Note Text: The order you have entered [MEDICATION NAME] HCl Tablet 10 MG *Controlled Drug* Give 1 tablet via PE[DEVICE] every 8 hours for Pain Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction .The system has identified a possible drug interaction with the following orders: -[MEDICATION NAME] Tablet 1 MG Give 1 tablet via PE[DEVICE] every 8 hours for Anxiety Severity: Severe, Interaction: Coadministration of [MEDICATION NAME] with benzodiazepines may substantially increase the potential of a fatal outcome due to potentiation of respiratory depressant effects . -QUEtiapine [MEDICATION NAME] Tablet 100 MG Give 1 tablet via PE[DEVICE] at bedtime for MOOD & BEHAVIOR Severity: Severe, Interaction: Additive QT interval prolongation may occur during coadministration of quetiapine, a moderate-risk QT-prolonging agent, and [MEDICATION NAME] HCl Tablet 10MG. -[MEDICATION NAME] HCl Tablet 200 MG Give 1 tablet via PE[DEVICE] one time a day related to UNSPECIFIED [MEDICAL CONDITION] FLUTTER (I48.92) Hold for HR less than 60 Severity: Severe, Interaction: Both [MEDICATION NAME] and [MEDICATION NAME] are associated with a high risk of QT prolongation. Combined use may result in additive effects on the QT interval. -QUEtiapine [MEDICATION NAME] Tablet 25 MG Give 1 tablet via PE[DEVICE] one time a day for MOOD & BEHAVIOR Severity: Severe, Interaction: Additive QT interval prolongation may occur during coadministration of quetiapine, a moderate-risk QT-prolonging agent, and [MEDICATION NAME] HCl Tablet 10MG. Author: (LPN C). Effective Date: 7/30/2020 04:24 (AM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 7/30/2020 07:32 (AM) Type: Order Note Note Text: The order you have entered [MEDICATION NAME] HCl Tablet 10 MG *Controlled Drug* Give 1 tablet via PE[DEVICE] every 8 hours for Pain Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction .(Note contains same drug interaction information as the note from 7/29/2020 at 1:05 PM) Author: (Former UM E). Effective Date: 7/31/2020 03:55 (AM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 7/31/2020 10:30 (AM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 7/31/2020 15:59 (3:59 PM) Type: Therapy Note Note Text: PT (Physical Therapy): .nurse was notified with pt's slight confusion and decline in mobility. No follow up nursing progress note was noted in the record. Effective Date: 7/31/2020 16:19 (4:19 PM) Type: Therapy Note .OT (Occupational Therapy) .Pt (patient) appears to be excessively tired and having difficulty following directions. Nurse on unit notified of patient change in status. No follow up nursing progress note was noted in the record. Late Entry Effective Date: 8/1/2020 10:52 (AM) Note Text: [MEDICAL CONDITION] Note: .Pain: No, , .Interventions include [MEDICATION NAME], re position. The patient's response is , . (blank) Author: (Former UM E). Effective Date: 8/1/2020 12:11 (PM) Type: Health Status Note Note Text: Resident was not easily aroused not eating food, and sleeping. Resident did not eat breakfast or lunch. Writer notified (Physician A) of the resident change in condition. (Physician A) DC (discontinued) [MEDICATION NAME] 10mg and new order [MEDICATION NAME] 7.5-325 every six hours prn (as needed) .Author: (LPN B). Effective Date: 8/2/2020 08:17 (AM) Type: Health Status Note .Pt is on Vent (ventilator). Increased RR (respiratory rate) 18 and Vt (tidal volume) 450 per physicians verbal order due to etco2 is 73 (End-tidal CO2, ETCO2 values exceeding 50 mmHg is considered respiratory depression, greater than 70 mmHg is categorized as [MEDICAL CONDITION]). Pt is on Cont. (continuous) pulse ox and cont Etco2. Increased 02 (oxygen) to 10L due to spo2 (blood oxygen saturation) was 76% (normal is greater than 90%). WIll continue to monitor and support. Effective Date: 8/2/2020 10:32 (AM) Type: Health Status Note Note Text: Writer received report from previous shift that resident became short of breath and was placed back on the vent. Writer notified PCP no new orders were given. VS BP (blood pressure) 108/67, RR24, Pulse 108, 02 76%. Writer notified (physician) and new order RR to 18 Tidal volume 450, and increase oxygen to 10L. Resident VS currently bp 116/60, Pulse 98, 02 Sat 96%, Co2 61-63, RR21. No s/s (signs/symptoms) of pain at this time .Author: (LPN B). Effective Date: 8/3/2020 12:58 (PM) Type: Physician Note Note Text: [MEDICAL CONDITION] medicine service: .hypercapnic resp failure required return to full vent support PCo2ET >90 over the weekend w (with) associated cyanosis, MS (mental status) Change and dyspnea (difficulty breathing).[MEDICAL CONDITION] to cuffed and vent settings adjusted. [MEDICATION NAME] has been discontinued .(R#901) with a history of ventilator dependent [MEDICAL CONDITION], acute hypoxic [MEDICAL CONDITION], clinical [MEDICAL CONDITION] .hospital admission who required intubation .hospital course included treatment for [REDACTED]. A review of R#901's Medication Administration Record [REDACTED]. The resident's MAR for August 2020 noted the resident received their 5 AM [MEDICATION NAME] dose on 8/1. The resident received [MEDICATION NAME] 10mg (Scheduled every 8 hours from 7/26/20 - 8/1/20) on the following dates and times: Administered at 5 AM on 7/28, 7/29, 7/31, 8/1; Administered at 1 PM on 7/27, 7/28, 7/29, 7/30, 7/31; and administered at 9 PM on 7/27 and 7/31. It was not given due to Vitals outside of parameters at 9 PM on 7/28 and 7/30. On 11/6/20 at 8:30 AM, LPN B was interviewed regarding R#901. LPN B indicated she had seen R#901 on 8/1/20 and the resident was lethargic. LPN B stated, The previous shift gave me regular report, when I went in there I saw the change in condition. I did notify (Physician A) because the only difference in the resident's medications was the [MEDICATION NAME]. I noticed the condition, (R#901) was lethargic, called the doctor who had ordered the [MEDICATION NAME] to get it discontinued. Once it was discontinued (R#901) started rousing and coming back a little bit. Worked on (the resident's) respiratory status as well. LPN B indicated she was not working when the [MEDICATION NAME] was originally ordered for R#901. LPN B continued and stated, The resident had been complaining of pain, basically generalized. (R#901) was on [MEDICATION NAME] I remember that. When I came back, I said, 'Why is (R#901) on this ([MEDICATION NAME])?' LPN B indicated it was not typical for her to see [MEDICATION NAME] ordered and continued, (Physician A) is the pain management doctor. That was the first or second time I've seen that ordered, not something I normally see. LPN B was asked if she believed the resident's decline and subsequent return to ventilatory support was directly related to the [MEDICATION NAME] based on what she assessed, to which LPN B answered, Yes. I feel the resident made progress, then with the [MEDICATION NAME], (R#901) went back down. Once we got the med discontinued we had to get (R#901) back up again. LPN B indicated she was not sure where Physician A documents reasoning for medication changes. LPN B was then asked if R#901 ever used [MEDICATION NAME] that she was aware of, to which she answered, No. That's why it triggered when I saw (R#901) like that. When queried about the progress note she authored for R#901 on 8/2/20, LPN B stated, You need to know your pain meds. Some pain meds mess with respiratory. I had been off work. Came back, I said this ain't right. Me and the respiratory therapist went in there and we were doing what we need to do and I got on the phone and called (Physician A). That ([MEDICATION NAME]) was the only new thing (R#901) had gotten. The only odd thing out that it could've been. They put (R#901) back on the vent when we came in then we took over. When queried regarding R#901 also having scheduled [MEDICATION NAME] ordered, LPN B stated, That's why I didn't understand the [MEDICATION NAME]. Probably should've questioned it more. But they said (R#901) saw the pain doctor and I figured they came up with a plan. My thought was why didn't they just up or schedule the [MEDICATION NAME]? (R#901) didn't decline enough to get sent out. (The resident) was de-sating, vitals down. Went back on the vent, started doing better. I did not give the resident any more pain meds until (they) came back up. On 11/6/20 at 9:51 AM, Physician A was contacted via telephone and queried regarding R#901. Physician A stated, Unless I'm there looking at the chart, I don't remember. When asked if he remembered ordering [MEDICATION NAME] for R#901, Physician A stated, Sorry, I don't remember. If I did there would be a record. Pharmacy should be able to confirm what was ordered. Physician A stated that he was not coming into the facility today. On 11/6/20 at 11:34 AM, LPN C was interviewed and queried regarding her documentation in R#901's record. When asked if she remembered calling the physician regarding the [MEDICATION NAME] order for R#901, LPN C stated, If I get a black box warning I call the physician to make sure it's okay (to administer). Can I say I remember (calling about the [MEDICATION NAME])? No. But that's what I do if I see a warning pop up, I call them. When queried if she knew why R#901's medication was changed from [MEDICATION NAME] to [MEDICATION NAME], LPN C stated, No, I really don't. Maybe because what (they were) on wasn't working. On 11/6/20 at 2:02 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were queried regarding R#901 being ordered [MEDICATION NAME] and subsequently requiring ventilatory support. The DON stated, The resident had a negative response to the [MEDICATION NAME]. Respirations decreased .Some people have a sensitivity. The NHA indicated that the physicians dictate medication orders. When queried regarding non-pharmacological interventions for pain relief, the DON stated, Positioning, pillows and wedges. Recliner in room. When queried if non-pharmacological interventions for pain relief should be documented in the medical record, the DON stated, If they are putting (a resident) in the recliner because they're having pain, then yeah. (R#901) did a lot of things on (their) own. The NHA stated, (R#901) was a busy person. It would be up to (Physician A) relating to the scheduling of the medication. When queried if R#901 had ever used [MEDICATION NAME] previously for pain control, the NHA and DON indicated they did not know. The DON stated, It didn't flag up as allergy. A review of R#901's admission documents did not reveal indication that the resident had received [MEDICATION NAME] prior to coming to the facility. A review of the facility's policy/procedure titled, Pain Control Program, rev. 1/2020, revealed, The facility, to the extent possible: .Evaluates existing pain and causes, Manages or prevents pain consistent with the assessment and plan of care, current clinical standards of practice, and the resident's goal and preferences .All residents will be screened daily each shift by the nurse .Resident who are receiving routine and/or PRN medications for pain will have premedication and post medication scoring for pain based on resident interview .completed by nurse .The resident will be evaluated by the nurse and/or physician to identify underlying causes of pain to ensure management of these conditions. The residents plan of care will be reviewed and updated with causative factors and interventions (pharmacological and nonpharmacological) that aide in pain relief measures for that individual .Nurse will document pain site, intensity, duration, situations, which worsen or improve the pain and nonpharmacological means utilized to minimize discomfort. Resident will be further interviewed regarding pain response including decline in functional abilities, changes in mood and behavior, changes in appetite, and possible effect on activity participation. All efforts to determine previous effective interventions for pain management will be considered as well as resident preference when possible .Resident will be followed on the pain assessment program for a period of 7 days after pain medications are ordered to monitor effectiveness of treatment .Care plan will reflect all nonmedical means of pain control as well as medications ordered for the resident . A review of the facility's policy/procedure titled, Unnecessary Medications Medication Regimen Review, revised 9/2020, revealed, Policy: An unnecessary medication is any medication when used: In excessive doses (including duplicate therapy); or For excessive duration; or Without adequate monitoring; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or An(y) combination of the reasons above. The resident's entire drug/medication regime must be managed and monitored to achieve the following goals and is applied to all categories of medications: [REDACTED]. Circumstances that warrant the evaluation of the resident and medication may include: Admission or re-admission; Multiple Prescribers; A clinically significant change in condition/status; A new, persistent, or recurrent clinically significant symptom or problem; A worsening of an existing problem or condition; An unexplained decline in function or cognition; A new medication order or renewal of orders; and; An irregularity identified in the pharmacist's monthly medication regime review .

This citation pertains to intake # 7. Based on interview and record review, the facility failed to identify a deteriorating condition, and transport one resident (Resident #704) that was a full code to an acute care setting timely, of two residents sampled for an acute change in condition, resulting in Resident #704 being in unnecessary prolonged pain, the need for additional pain medication, and a wound infection. Findings include: A record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #704 had been most recently admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #704 had a Brief Interview for Mental Status (BIMS) score of 08, indicating a moderate cognitive impairment. Resident #704 needed extensive to total assistance with toileting, personal hygiene, bed mobility and transfers. A record review of the Advanced Directives for Resident #704 indicated they were a full code and wanted to be hospitalized if warranted. A record review of the Progress Notes for Resident #704 revealed the following: 7/21/2020 14:14 (2:14 PM) Interdisciplinary Team (IDT) Note .Resident reviewed by IDT for skin. Resident has a healing moisture related wound to rot (sic) buttock, z-guard (a skin barrier cream utilized for intact skin) in place. wound has no drainage .Will continue to followed by wound care nurse. 8/6/2020 13:44 (1:44 PM) Interdisciplinary Team Note .Resident is reviewed by IDT for wound, wound to Rt (right) buttocks , No drainage, Continue calmocetine (a thick ointment used for open wounds), see wound nurse notes for assessment. 8/25/2020 13:47 (1:47 PM) Interdisciplinary Team Note .Nutritional status and skin issues reviewed by IDT. Wt (weight) this week is 148 lb. (pounds) Weight continues to decline. FA (food acceptance) is 25%. Family is aware . Stage 2 noted to sacral and right buttock areas. Zinc Guard Treatment remains in place. House supplement increased to QID (four times per day). Family will continue to bring in outside food .Interventions continued. Care plan reviewed and updated. 8/26/2020 13:59 (1:59 PM) Interdisciplinary Team Note .Resident 2 week review by IDT for skin. Resident has an open area to right buttock and sacrum with surface depth (thickness) w/MASD (with Moisture Associated Skin Damage-or damage to the skin related to constant moisture, such as sweat, urine or stool, irritating the skin, causing it the skin to breakdown), buttock is showing improvement, wound gel treatment in place. Supplements and low air mattress in place. Resident is a feeder (requiring assistance with feeding), pain comfort noted effective at this time, careplan reviewed. 8/27/2020 10:24 (AM) .Nutrition Weekly Note: Residents cbw (current body weight) is 148# (pounds) .has poor po (by mouth) intake consuming 25% of .foods at meals .has no diet changes is receiving house supplement 120 ml (milliliters) QID (four times per day), pudding, yogurt, ice cream, and pro-stat (a powdered supplement utilized to promote wound healing with the addition of protein) . 9/1/2020 08:23 (AM) Skin/Wound Note .Writer assisted CNA (Certified Nursing Assistant) with changing brief, writer observed resident to have a stage II open area to right buttock & gluteal fold, large, no drainage, no odor. Also observed a stage 4 (wound extending down to the bone) wound to to the sacrum, drainage observed brown (yellow, brown or gray drainage indicate signs of infection) in color with odor, sloughing (yellow dead skin tissue) observed, and also painful to touch. Writer cleansed area and dressing is currently in place. Writer then notified Unit Coordinator regarding residents wound- to follow-up with wound nurse. Resident currently in bed with wedge cushions in place, writer/CNA will turn & reposition q2hrs (every two hours). 9/1/2020 10:01 (AM) Health Status Note .Resident is having wound with black scab (Eschar-thick black dead tissue) on sacrum and more skin excoriation on Rt. buttocks. treatment changed to santyl (an ointment utilized on wounds that require debridement, or the removal of dead tissue) ointment . 9/1/2020 14:28 (2:28 PM) Health Status Note .Resident was observed by writer crying out in pain d/t (due to their) wound. Resident was turned and re-positioned throughout the day and scheduled [MEDICATION NAME] given, tolerated well but not effective. Resident refused to eat lunch d/t being in pain. Writer then notified Unit Coordinator, whom contacted resident's physician and an order for [REDACTED]. 9/2/2020 13:22 (1:22 PM) Health Status Note .Residents wound Care was completed by wound nurse, tolerated well. Pain meds given 30 min (minutes) before wound care- facial grimace and crying observed before wound care. Resident is currently on an air mattress and was turned & re-positioned throughout the day. 9/4/2020 10:42 (AM) .Nutrition Weekly Note: Resident has a poor po intake consuming 25% of .food at meals this week .requires 1:1 assist with meals. 9/5/2020 10:45 (AM) Skin/Wound Note .Writer changed resident's wound to (their) sacrum, cleansed open wound with NS (Normal Saline) and applied santyl in wound bed, packed moist gauxe (sic) and covered with 4x4 & ABD pad. Writer observed a very foul odor while changing residents wound, Malodorous drainage observed gray/ brownish color. Resident was turned and re-positioned with wedges. Writer sent residents physician a message regarding residents drainage and odor coming from residents wound. Awaiting return phone call. 9/5/2020 22:21 (10:21 PM) Health Status Note .patient received a wound culture on the sacrum.culture was picked up by lab. 9/6/2020 12:55 (12:55 PM) COMMUNICATION - with Family .Writer spoke with daughter . giving her an update on (Resident #704). Daughter informed of resident's lack of appetite, wound increasing in size and drainage and awaiting the results of wound culture . 9/6/2020 14:44 (2:44 PM) Health Status Note .Resident is AOx3 (alert and oriented to person, place and time), verbally able to make needs known. Today resident expressed pain with crying and facial grimacing- PRN (as needed) pain meds given, tolerated well. Resident refused to eat or drink at breakfast, even with encouragement resident still refused. Resident ate less than 25% at lunch time. Resident was turned and re-positioned through-out the day. Dressing to sacrum & right buttocks was completed by writer, pt/ (patient) tolerated well. The wound continues to decline and increase in size. Fol (sic) Odor continues to be present, still awaiting culture. Resident is currently in bed resting with positional wedges in places. 9/6/2020 18:51 (6:51 PM) Health Status Note .patient has a wound on (their) right buttocks and sacrum that is declining. Patient was expressing verbally that (Resident #704) was having pain. Afternoon nurse gave patient PRN pain medication for wound pain. Cleaned wound and changed dressing. Patient family brought dinner. Patient ate dinner. 9/7/2020 07:33 (AM) Health Status Note .Resident c/o (complaints of ) pain during the midnight shift even after writer gave resident prn pain meds. Coccyx wound bandage was changed. Wound had some leakage (drainage seeping through dressing). Specimen was sent in to lab by prior nurse. 9/7/2020 09:58 (AM) Skin/Wound Note .Seen by surgical wound care team for worsening wound to sacral region. This site presents with significant tissue damage, 4x4cm (centimeters)opening with undermining (tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edges) up to 4 cm essentially ATC (around the center), slightly malodorous. Areas of DTI (deep tissue injury-usually caused from prolonged pressure to the area) across bilateral buttocks. Wound culture obtained and sent to lab, daily treatment orders changed to dakin's 1/2 strength for wound filling, zinc based barrier cream applied to buttocks. ID (Infectious Disease) consulted. 9/7/2020 Physician's note- .Examination of .sacral area shows extensive necrotic foul-smelling decubitus ulcer with gray drainage. Laboratory evaluation White count (indicating infection) is 17,000 (normal is under 11,000) .I understand that cultures have been obtained but are not available at this time .Infected necrotic sacral decubitus ulcer that is quite extensive .Recommendation: I believe the patient requires debridement of the decubitus ulcer and needs to be evaluated by wound care. And Dakin's solution recommended. I also believe that (Resident #704) should be on systemic antibiotic therapy .Follow-up on pending cultures and adjust antibiotics accordingly. The patient may require hospitalization if wound does not improve or if debridement cannot be done and in this facility. A review of the Situation, Background, Assessment, Recommendation (SBAR) noted that Resident #704 was transferred to the hospital on [DATE] for wound infection, dehydration, and elevated white blood cells. On 9/22/2020 at 2:48 PM, an interview was completed with Confidential Witness Avia phone. According to Confidential Witness A, Resident #704 was transported to the hospital. When Confidential Witness A visited Resident #704 at the hospital on [DATE], he was notified by the hospital staff Resident #704 required surgery to debride the wounds because of the extent of tissue damage. According to Confidential Witness A, Resident #704 was still in the hospital and had a huge wound that covered their whole buttocks region. Confidential Witness A explained that Resident #704 was emaciated and was placed on artificial nutritional support and was on [MEDICATION NAME] every four hours causing nausea and was groggy but, needed it for the pain that the wound was causing. On 9/22/2020 at 3:22 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed in regard to Resident #704's deterioration (specifically from 9/1/2020-9/8/2020) while in the facility. The DON and NHA explained that Resident #704 was being monitored by their staff and Doctor's and felt that the resident could be treated within the facility. When questioned about the on going pain and increased drainage of the wound, the NHA further explained that the resident was placed on [MEDICATION NAME] and [MEDICATION NAME] and was followed by an Infection Control Physician while in the facility. When the NHA was questioned as to why the resident was not more aggressively treated before the severity of the situation, an explanation was not provided. A review of the facility policy titled, Changes in Resident Condition reviewed 8/2020 revealed the following: ACOC's (Acute Change of Condition) may occur suddenly, or over a period of several hours to several days and may present as a physical change, or changes in functional status, mood, behavior, or cognitive status. In the long term care setting .The facility staff must recognize an ACOC and identify its nature, cause, and severity to effectively assess, treat, and monitor the ACOC. The resident, attending physician, and personal representative are notified when changed in condition or certain events occur. Communication with the interdisciplinary team and caregivers is also important to ensure that consistency and continuity are maintained for the residents benefit.

This citation pertains to intake 1. Based on observation, interview, and record review, the facility failed to complete and document PEG tube (feeding tube) site care per order for two sampled residents (R500, R509) of fifteen reviewed, resulting in and the potential for infection and hospitalization . Findings include: On 7/10/20 at 3:02 PM, Confidential Witness Z was interviewed regarding R500's care in the facility. Witness Z stated that recently, R500 was hospitalized due to a PEG tube (feeding tube directly into stomach from abdomen) site infection and was now under hospice care at the facility. On 7/14/20 at 1:40 PM, Unit Manager (UM) K was asked if R500's PEG tube site could be observed. UM K indicated the resident was no longer utilizing the PEG tube for feedings and had been terminally weaned off of it. UM K also indicated that the site had been infected. Upon lifting up the resident's gown, the dressing on the PEG tube insertion site was saturated with brown/yellow colored drainage and had the date 7/11/20 written on it. The drainage had saturated the drain sponge as well as the ABD pad (absorbent gauze pad) that laid on top. UM K was asked if the dressing was supposed to be changed every day and responded, Yes. The resident's skin had a small open area (approximately the size of the head of a pencil eraser) with reddened base just below the insertion site, and a smaller open area with reddened base to the right of the site in the fold of the stomach. The resident attempted to itch at the area multiple times after the dressing had been removed. A review of the resident's Treatment Administration Records (TARs) for the months of April, May, June, and July 2020. The following was revealed for the order Change PEG site dressing every shift and as needed and monitor for signs/symptoms of infection every shift: No documentation present as completed on day shift on 4/3, 4/4, 4/7, 5/25, 5/30, 6/8, 6/16, and 6/27. The dressing was marked as changed on day shift on 7/11, 7/12, and 7/13, however, the observation of the dressing on 7/14/20 revealed a dressing dated 7/11/20 that was saturated with drainage. No documentation present as completed on night shift on 4/1, 4/3, 4/5 through 4/7, 4/11, 4/15, 4/20, 4/21, 4/25, 4/29, 4/30, 5/1, 5/5, 5/7, 5/9, 5/12, 5/14, 5/17, 5/18, 5/21 through 5/26, 5/29 through 5/31, 6/2 through 6/11, 6/14 through 6/20, 6/22 through 6/24, 7/6 through 7/8, and 7/10 through 7/13. A review of R500's progress notes revealed the following: 3/1/2020 18:46 Health Status Note: Resident .Peg patent and has no drainage at the site . 5/10/2020 11:14 Health Status Note: Resident .peg site clean and dry. 6/19/2020 22:37 Health Status Note: Redness and warmth noted to abd (abdomen). Physician informed new order consult with infectious disease doctor. New order .[MEDICATION NAME] (antibiotic) 100 mg (milligrams) BID (twice a day) x 7 days . 6/22/2020 11:22 Health Status Note: Writer received order for stat abdominal x-ray for peg tube placement. Resident currently on ABT (antibiotic therapy) for infection in the site. Feeding stopped due to formula coming from around peg tube . 6/24/2020 17:39 Nutrition/Dietary Note: Follow up visit reveals current route of nutrient administration is compromised AEB (as exhibited by): PEG site infection/malfunction s/s redness, swelling and drainage . 6/24/2020 infectious disease note: .Patient was noted to have redness around PEG site and also leakage. This has progressed over the last 3 or 4 days .Abdomen with significant [DIAGNOSES REDACTED] (skin redness) and induration (from inflammation) around PEG site there is significant also amount of leakage and I understand from the nursing staff that whatever is administered in the PEG tube comes out around it . The progress notes revealed the resident was transferred on 6/25/20 to an acute care hospital for PEG tube replacement. 7/11/2020 15:24 Health Status Note: .Peg tube site continues with drainage site cleaned ABD pad applied . A review of R500's documents from their hospitalization on [DATE] revealed: SNF (skilled nursing facility) to ED (emergency department) Handoff Form, dated 6/25/20 at 11:30 AM signed by Unit Manager K that included, Peg tube malfunction/infection, Reason(s) for transfer: Peg tube replacement - possible hospice w/ (with) terminal wean. IM (internal medicine) History and Physical - Date: 6/26/2020 .admitted : 6/25/2020 .admitted from ECF (extended care facility) for PEG tube malfunction and site infxn (infection) .was unable to receive any po (oral pill form) meds and was hypertensive (had high blood pressure) upon arrival. Infxn (infection) was treated with Doxy at facility .Review of the PEG site raised concern for surrounding [MEDICAL CONDITION] and was started on Vanc ([MEDICATION NAME]) .BP (blood pressure) has been high overnight at times .complaining of pain .Principal Problem: PEG tube malfunction .PEG site infection/[MEDICAL CONDITION]: There is some questionably purulent discharge with surrounding [DIAGNOSES REDACTED] and tenderness around PEG tube .on IV (intravenous) Vanc right now and (superficial cultures) are pending . On 7/16/20 at 8:43 AM, the Director of Nursing (DON) was queried regarding the missing documentation for PEG tube site care on R500's TARs. The DON reviewed R500's TARs for PEG tube site care and stated, There should not be blank spots in the TAR. It should be carried out as ordered. When queried regarding R500's PEG tube site dressing change observed on 7/14/20 with UM K, the DON stated, That is not the expectation. It should not be saturated and not changed. When queried regarding the site having been infected, the DON provided no further information. A review of R500's medical record revealed that the resident was admitted into the facility on [DATE] and most recently re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was moderately cognitively impaired and required total assistance from staff for bed mobility, transfers, dressing, toileting and hygiene. R509 On 07/16/20 a review of the clinical record for R509 revealed: R509 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition and total dependence on one or two persons for Activities of Daily Living including eating. A review of the Treatment Administration Records revealed: For July 2020: Change PEG site dressing every shift and as needed and monitor of signs and symptoms of infection. Start date 06/24/20. The treatment was not documented as done (left blank) for the afternoon shift on 7/1, 7/2, 7/4, 7/6, 7/8, 7/12 and 7/13; For May 2020: Change PEG site dressing every shift and as needed and monitor of signs and symptoms of infection. Start date 04/13/20. The treatment was not documented as done (left blank) for the afternoon shift on 5/1, 5/2, 5/3, 5/6, 5/7, 5/11, 5/13, 5/14, 5/15, 5/17, 5/18, 5/22, 5/25, 5/28, 5/29, 5/30, 5/31; For April 2020: Change PEG site dressing every shift and as needed and monitor of signs and symptoms of infection. Start date 04/13/20. The treatment was not documented as done (left blank) for the afternoon shift on 4/15, 4/20, 4/21, 4/25, 4/27 and 4/29. A review of the facility's policies titled, Tube Feedings, and Enteral Tube Feedings and Medication Administration, reviewed/revised 9/19, did not reveal instructions specific to PEG tube site care and dressing changes. A review of the facility's policy titled, Preventative Skin Care and Documentation, dated 9/19, did not reveal instructions specific to PEG tube site care and dressing changes.

This citation pertains to intake 4. Based on interview and record review, the facility failed to obtain an X-Ray per physician order for [REDACTED]. On 7/10/20 at 3:02 PM, Confidential Witness Z was interviewed regarding R500's care in the facility. Witness Z explained that on 1/9/20, the resident had leg pain and an X-Ray of their femur was ordered. Witness Z stated that facility did not inform them at the time of the ordered X-Ray, and stated they thought the X-Ray had been negative but was not sure. Witness Z then stated that R500 was sent out to the hospital around January 22nd for an unrelated matter and was found to have a fractured femur and had surgery to repair it. Witness Z explained that the facility told them they were investigating the matter but never got back to them about it. A review of R500's medical record revealed the following progress note: 1/9/2020 14:57 (2:57 PM) Health Status Note Note Text: Resident was seen by (doctor) and new order X-ray of left femur. Notify (doctor) with results. Will continue to monitor. Written by Licensed Practical Nurse (LPN) L. No documentation was found indicating the resident's Guardian/Responsible Party/Emergency Contact was contacted regarding the X-Ray order. No corresponding assessments for the 1/9/20 progress note were noted to be present in the resident's medical record. Further review revealed the following order: Xray of left femur. Notify (doctor) with results. No directions specified for order. Diagnostic. ordered on [DATE], discontinued on 1/14/20. On 7/14/20 at 12:52 PM, the Nursing Home Administrator (NHA) was asked to provide any incident/accident (I/A) reports for R500 from January 2020. No I/A's from that time were received prior to survey exit. On 7/15/20 at 9:08 AM, LPN L was interviewed via phone and queried regarding R500's X-Ray order on 1/9/20 and corresponding progress note. LPN L stated, What happened was (R500's) leg looked to be broken. I called (the doctor) and got an order to get an X-Ray of the leg. They ended up sending (R500) out on a different shift for something else. I don't know what happened with the results but I did order it. When queried if it is facility protocol to call the resident's responsible party (RP) when an X-Ray gets ordered, LPN L stated, Yes. I can't remember if I called (R500's RP) or not. And usually we call them after we get the results and let them know. I can't remember if I did or not. When queried if the facility investigated why the resident's leg looked broken, LPN L stated, Not to my knowledge. We didn't find out that it was actually broken until (R500) was transferred out and came back. When asked about the results of the ordered X-Ray, LPN L stated, Not sure, never saw any results. R500's medical record did not include any results or notes from the X-Ray ordered on [DATE]. Further review revealed the resident was transferred to the hospital at 1:00 AM on 1/22/20 for .Blood transfusion hemoglobin 6.2. (R500 family) notified via phone, and would be informed when (R500 is) being transferred . The resident's leg or X-Ray order was not addressed again in the progress notes after 1/9/20 and before the hospital transfer on 1/22/20. A review of R500's Medication Administration Record [REDACTED]. The medication was noted as given on the following dates with corresponding pain scores on a 0 to 10 scale, with 0 being no pain and 10 being severe pain: 1/1 through 1/3 - no administrations 1/4/20 - administered for pain 5/10 1/5/20 - administered for pain 0/10 1/7/20 - administered for pain 9/10 1/8/20 - administered for pain 6/10 1/9/20 - given once for pain 4/10 and again for pain 6/10 1/11/20 - administered for pain 8/10 1/12/20 - administered for pain 0/10 1/15/20 - administered for pain 6/10 1/17/20 - administered for pain 2/10 1/18/20 - given once for pain 7/10 and again for pain 6/10 1/19/20 - given once for pain 8/10 and again for pain 7/10 1/20/20 - given once for pain 8/10 and again for pain 7/10 1/21/20 - administered for pain 8/10. On 7/15/20 at 9:30 AM, The NHA was asked for the diagnostic test results for R500's X-Ray that was ordered on [DATE]. The NHA stated, According to the Unit Coordinator - the X-Ray did not get done so we had no report. When asked if the documentation of why it was not done be in the resident's medical record, the NHA provided no response. The next entered progress note after 1/22/20 in R500's medical record was dated 2/10/20 and read, 2/10/2020 18:43 (6:43 PM) Admission Summary .admitted from the hospital .With the [DIAGNOSES REDACTED]. A review of R500's re-admission hospital documents revealed the following: Operative Report, Documentation Date: January 31, 2020, Preoperative Diagnoses: [REDACTED].Procedures: .Open reduction internal fixation of left femoral shaft fracture with retrograde intramedullary (IM) rod. Initial Evaluation PT (Physical Therapy) Entered On: 2/1/2020 .General Info: .Pt (patient) initially presented to the ED (emergency department) on 1/22 .was sent in from (nursing home) for abnormal labs. Pt was found to have low hemoglobin .Pt was also c/o (complaining of) LLE (left lower extremity) pain and was found to have L (left) femur fracture, subsequently Ortho (orthopedic) service has been consulted and being diagnosed as Left Femoral Shaft Fracture and underwent ORIF (IM rodding) on 1/31/20. On 7/15/20 at 10:13 AM, the NHA and Director of Nursing (DON) were interviewed. When queried as to why the ordered X-Ray on 1/9/20 was not completed, the NHA stated, I found out that the Unit Secretary hadn't put the order through so it did not get done. Then the resident went out to the hospital with a low hemoglobin. The resident had pain that one day but then it wasn't significant after that. The DON added, They started giving (R500) [MEDICATION NAME] on 1/18. When asked to review the MAR for January 2020, the DON acknowledged that [MEDICATION NAME] was given to the resident prior to 1/18 with corresponding pain scores. The DON provided no further information. When queried if a resident's responsible party is to be notified of an X-Ray that is ordered, the DON stated, Any time there's a change in condition we try to notify family. At 10:24 AM, Unit Manager K joined the interview and confirmed that the X-Ray order for R500 on 1/9/20 was not carried out. A review of R500's medical record revealed that the resident was admitted into the facility on [DATE] and most recently re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was moderately cognitively impaired and required total assistance from staff for bed mobility, transfers, dressing, toileting and hygiene. A review of the facility's policy titled, Changes in Resident Condition, revised 5/2020, revealed: Information: An acute change of condition (ACOC) is a sudden, clinically important change from a resident's established/documented baseline in physical, cognitive, behavioral, or functional status . a primary goal of identifying ACOC's is to facilitate staff evaluation and management of the residents at the facility, and avoiding a transfer to the hospital or emergency room . The facility staff must recognize an ACOC and identify its nature, cause, and severity to effectively assess, treat, and monitor the ACOC. The resident, attending physician, and personal representative are notified when changed in condition or certain events occur. Communication with the interdisciplinary team and caregivers is also important to ensure that consistency and continuity are maintained for the residents benefit .2. For non-life threatening events - the License nurse will begin an SBAR assessment located in PCC. The Licensed nurse will complete the full assessment .This assessment includes a head-to-toe physical assessment .The physician will be contacted with assessment findings and licensed nurse is to proceed with orders .Staff will document resident status at least every 2 hours showing evidence of monitoring. The resident's personal representative will be contacted and informed of status .Depending upon outcome of the SBAR findings, if the resident remains at the facility for further evaluation, the resident will be placed on the 24hour report. The unit manager or supervisor will be made aware of the resident's status. Each preceding shift will complete another SBAR assessment making comparisons to the previous. The attending physician will be contacted if changes occur from one assessment to the next. This will continue every shift until the ACOC resolves or resident is transferred from the facility. The resident will remain on the 24 hour report for the duration. There will be evidence of a complete assessment and follow up by each preceding nurse. A review of the facility policy titled, Diagnostic Services, revised 9/2019, revealed: STANDARD: Clinical laboratory and radiology services are provided. POLICY: The following diagnostic services are available twenty-four hours a day, seven days a week: .Radiology . A review of the facility policy titled, Physician Order Policy and Procedure, revised 3/6/2020, revealed: e. Laboratory and other diagnostic tests: Schedule per policy. 10. The licensed nurse notifies the family of the new order and initials the square on the physician order for [REDACTED]. Quality Assurance Measure: Each day the Unit Managers will bring copies of all new orders to morning report and review them with the team. The Unit Manager will then complete a double check to assure that the order was properly transcribed.

This citation pertains in part to MI 421, MI 425 and MI 440. Based on observation, interview and record review, the facility failed to ensure an environment free from sexual abuse for one sampled Resident (R502) of five sampled residents reviewed for abuse, resulting in an Immediate Jeopardy (IJ) which began on 12/07/19, when R501 was found in bed on top of R502, both undressed from the waist down, R501 with an erect penis thrusting on R502, with the curtains drawn, resulting in the likelihood of non-consensual vaginal penetration and additional unwelcome sex acts with the likelihood for serious physical and psychosocial injury and harm. In addition the facility failed to ensure residents were free from physical and or sexual abuse for four sampled residents (R503, R509, R510, R511) of four additional residents reviewed for abuse, resulting in and the potential for unwelcome physical and sexual abuse and or sexual contact. Findings include: The Immediate Jeopardy (IJ) started on 12/07/19 and was identified on 12/10/19. The Administrator was notified of the Immediate Jeopardy on 12/10/19 and was asked for a plan to remove the immediacy. The IJ was removed on 12/11/19, based on the facility's implementation of the removal plan as verified on site on 12/11/19. Although the immediacy was removed, the facility's deficient practice was not corrected and remained at a pattern with actual harm that is not immediate jeopardy. Findings include: On 12/10/19 at 8:50 AM, a review of an anonymous complaint revealed: (R501) was found Saturday 12/07/19 at 7:15 PM on top of (R502) with no pants on. This resident (R501) is known to have inappropriate behaviors. (R502) was sent to the hospital to have a rape kit done. (R502) is not mentally able to make (their) own decisions. (R501) also lifts up the shirt of (R503) and sucks on (R503's) nipples and has been seen fingering (R503). A review of the hospital record physician note dated 12/07/19 indicated R502 was admitted into the emergency room after reported a sexual assault at a nursing home and was observed to be crying. On 12/10/19 at 9:00 AM, a review of the MIACTS (form facility uses to report incidents to the state agency) report dated 12/07/19 revealed: On 12/7/2019 at approximately 7:15 PM, Certified Nursing Assistant (CNA C) was walking down the hall of (R501). (CNA C) noted when passing (the) room (of R501) that a brief was on the floor and the curtain was partially closed .When (CNA C) entered the room, (CNA C) observed (R502) lying in the bed with (R502's) head at the foot of the bed. (R501) was observed lying on top of (R502). (CNA C) described (R501) as pumping on (R502). (CNA C) noted that both residents were naked from the waist down. (CNA C) immediately yelled at (R501) 'Get off (R502)' and got no response. (CNA C) remained in the room and yelled from the doorway that (they) needed help. (CNA D) was in the dayroom and immediately went to (the room of R501). (CNA D) states that (R501) was getting out of the bed, pants were down and noted (R501) had an erection as (CNA D) entered the room. A review of the witness statement from CNA C revealed: On 12-7-19 at around 7:10 PM to 7:15 PM as I was doing my rounds, I noticed a blue brief on the floor in (the room of R501) and I also noticed that the curtain was pulled around (R501's) bed and that's not usual so I immediately went to check on (R501) because you have to everyday because (R501) is usually trying to lure other residents, specifically women into (R501's) room. That's when I noticed the resident (R502) lying in (R501's) bed on (their) back with (their) head at the foot of the bed, with no pants or brief on with (R501) on top of (R502) with no pants or brief on, (R501's) penis had an erection and (R501) was penetrating (R502). A review of the witness statement from CNA D revealed: On 12-7-19 (at) 7:15 PM, I heard (CNA C) yelling for someone to come and assist (them) in the room of (R501). When I made it down to see what was wrong, I observed (R501) climbing off (R502) with (R501's) pants completely down and (R501's) penis had an erection. I went and notified (Nurse E) .(R501) (has) inappropriate sexual behaviors often to the point (R501's) kissing, touching and trying to put (their) mouth on resident's breast(s). I've also caught (R501) sticking (their/R501's) hand down inside female resident's briefs. A review of the statement dated 12/08/19 by CNA F revealed: .I have observed (R501) staring and watching female residents, when they walk by, (R501) would reach out (their) hand to touch them .I have seen (R501) attempting to lift (the) shirt/gown up to touch resident's breast, (and) attempting to bend over toward (their) breast. I have seen (R501) ambulate down the low hall looking for female resident's room(s). On 12/10/19, a review of the facility video for 12/07/19 revealed: On 12/07/19, Saturday at 6:31 PM, R502 was directed out of a room next door to R501 by a CN[NAME] R502 walked out of the room and stopped at the doorway of their own room. At 6:52 PM the door to R501's room was shown closed. R502 was in the hallway walking down away from the room stopped in the doorway of the room next door. A CNA walked down the hall at 6:53 PM and retrieved a [NAME]et, went back up the hall and passed R501 at 6:54 PM. The CNA did not interact with R501. At 6:54 PM while standing in the doorway of their room, R501 was shown reaching out to touch a female resident seated in a wheelchair on their shoulder as the resident passed by R501. At 6:54, PM R501 is shown standing alone at the left corner of the day room, looking into the day room. Female residents were present. R501 is in front of the doors to the hallway. No staff are seen sitting in or standing around in the day area. At 6:55 PM R502 was shown walking up the hall wearing a dress and socks. At 6:56 PM R502 enters from the hallway behind R501 and pauses behind R501. R501 turns toward R502 and walks R502 through the doorway to the hall. R501 is shown with their hand at the buttock of R502 as they enter R501's room. The hand moves up toward the shoulder of R502 as they both pass through the doorway to R501's room. Between the time of R501 and R502 entering the room of R501 a resident in a wheelchair is shown to pause for a moment and look into the room. At 7:16 PM a CNA walks down the hall passing the room of R501 and then walked back up the hall into the shower room. At that time a second CNA discovers R501 and R502 and enters the room of R501. At 7:17 PM a staff member can be seen standing at the door way of R501's room making a thrusting motion with their hips. At 7:18 PM another CNA entered and at 7:19 PM, a Nurse entered. Facility shift change for the nursing staff occurred during this time which left R501 without staff supervision for approximately 20 minutes. A review of the facility record for R501 revealed R501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented moderately impaired cognition with a nine out of fifteen Brief Interview for Mental Status (BIMS) score. R501 was 66 inches tall and 198 pounds. A review of the MDS assessments Section [NAME] indicated the facility did not document any behaviors affecting others. A review of the care plan revealed the facility did not document any sexual or inappropriate behaviors in the care plan nor interventions to mitigate them. The MDS dated [DATE], completed at a prior facility, indicated in section E, R501 had physical behaviors affecting others 1-3 days in the look back period. A review of the facility record for R502 revealed R502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition with a four out of fifteen BIMS score. R502 was 62 inches tall and 142 pounds. On 12/10/19 at 9:05 AM, R501 was observed to be dressed and seated on the edge of their bed. R501 reported no concerns with other residents and stated No to questions for concerns about care or treatment by staff. R501 was asked if they had any incidents, altercations, or problems with any residents and shook their head No. On 12/10/19 at 9:12 AM, CNA G was asked about R501 and R502 and stated, (R502) is an affectionate resident. (R502) is a walker, but I've never seen (R502) go into nobodys room or interact with anybody. (R501) throws kisses. I had not seen (R501) with (R502). On 12/10/19 at 9:23 AM, Nurse H was asked about R501 and R502 and stated, (R501) has history of behaviors. I reported this back in July. (R501) physically touches residents as well. My resident in particular (R503), (R501) lifted (another female resident's) shirt and put hands on their breast. We were sitting in the day room charting and I looked up and this was going on. I told the Unit Manager at the time. I was informed that it was not considered inappropriate and was adult sexual behavior and to stop saying it was abuse. (R501) also tries to hold the hand or kiss (R510). I separated them. (R502) wants to hold your hand or lay their head on you. When asked about enough staff for supervision Nurse H stated, We have four aides and two nurses. The floor calls for six or seven CNAs. On a good day we have five CNAs. Staff complain, one CNA is afraid to work with (R501) alone. Nurse H further noted weekends are tough and Sundays are the roughest as contingent staff don't pick up enough shifts. On 12/10/2019 at 9:42 AM, CNA Q was interviewed regarding the behaviors of R501 and stated, R501 would blow kisses and touch us and try to touch the women's breasts. I would separate them and tell the nurse. I worked that day, I did not see any increased behavior by (R501). It happened after I left that day. On 12/10/19 at 9:52 AM, Housekeeping Staff I reported resident to resident fights are an everyday thing. On 12/10/2019 at 9:52 AM, CNA R was interviewed regarding R501's behaviors and stated, (R 501) never did that before. (R501) would grab at us and some of the female residents. We would just pull them away from each other. On 12/10/19 at 9:58 AM, Nurse J was asked about recent incidents and reported, I heard two residents were having sex. (R501) has always been flirtatious and blows kisses to the nurse and CN[NAME] (R502) is pretty affectionate too, but not in the same demeanor. (R502) will lay their head on your shoulder. I heard that when (R501) first came (R501) was watching porn. Nurse J was asked if this was all care planned and reported they were not sure. When asked if Nurse J thought other staff were aware of R501's or 502's behaviors, Nurse J stated, Just those that work with (them) directly. When asked about R503, Nurse J reported they had seen R503 lift their shirt around R501 and R501 attempt to kiss R503's breasts. Nurse J was asked about shift change and stated, CNA's do not overlap. Nurses do rounds CNAs don't. Some CNAs leave before the next CNA arrives. Nurse J was asked about the Saturday of the incident between R501 and R502 and reported, We were short. There was three CNAs working. We need five CNAs per the amount of behaviors. Nurse J also reported they had two CNAs this morning because of call offs until one got pulled to the unit. On 12/10/2019 at 11:14 AM, CNA C was contacted by phone and interviewed about the incident between R501 and R502 and stated, They would wander. They didn't talk to each other. It happened at shift change. (R501) would blow kisses and try to touch female residents often. I reported them to the nurses. That was the first time (R501) ever did anything like that. (R501) was on top of (R502) and had an erection. (R502) was lying there and looked scared. (R502) has dementia and doesn't know what's going on around (them). (R502) needed redirection every ten minutes and never had sexual behavior. (R502) would wander up and down the hall all night. On 12/10/19 at 11:16 AM, the Director of Nursing (DON) was asked about R501 and R502 and stated, We knew (R501) liked the ladies. Per the interviews it was just that (R501) liked the ladies. When asked about other resident contact the DON reported that Just one noted back in the summer (July 2019 with R503). They broke them up. It was not reported, because it happened in the day room and it was felt this was welcomed touching. It was immediately stopped. Staff said (R501) was touching people (females) and would rub arms and kiss their hands. The DON reported they were told this during the interviews that were done after the recent sexual incident with R501 and R502. The DON further reported there were concerns from a nurse that their charting about the behaviors by R501 had been deleted from the electronic record. On 12/10/19 at 11:18 AM, Social Worker (SW) L and the Social Work/Resident Services Director (SW) B were asked if they were aware of any sexual concerns with R501 such as blowing kisses or groping residents and SW L replied they had not been aware and SW B stated, I was in shock about everything they knew and didn't tell. They didn't tell anybody and this had been going on at least a few months prior, per the interviews. When asked if the social worker should be aware SW B stated, Yes. We could have put interventions in place, for staff to redirect and possibly have psych see them for other interventions. Staff were knowledgeable of them. I think they thought they were handling it. SW B was asked if they reviewed the care plan and Kardex (care guide for CNAs) for R501's sexual behaviors and stated, Yes. There was nothing in the care plan so there was nothing in the Kardex. It would have been important and appropriate to put in the care plan. You put in the resident to resident concerns, the intervention, educate staff and monitor and document. SW B further reported they had done interviews with the staff after the incident between R501 and R502 and reported most, but not all staff on the unit of R501 were aware of R501's sexual behaviors. On 12/10/19 at 1:23 PM, Staff M stated, I have observed (R501) sexually inappropriate with a lot of women. I have seen (R501) and (R502) in the hallway following each other. On 12/10/19 at 1:29 PM, CNA N was asked about R501 and stated, (R501) may try to get (their) hand in and grope another resident and we have to try to get (R501) away. I did not know this about (R501) when I first started. I did see (R501) sitting next to a resident (R511), groping (them) around the breast. Maybe last week or before. I thought I reported it to the nurse, but I am not sure (when). On 12/10/2019 at 1:35 PM, CNA D was contacted by phone and interviewed regarding the incident between R501 and R502 and stated, They didn't have a relationship. When we get there (R501) is usually in (R501's) room, and (R502) would wander up and down the hall. If you go up to (R502) and hold (their) hand (R502) would follow where ever you go. When (R501) was up (R501) frequently needed to be redirected from touching the female residents and the staff. (R501) would stop at the first command every time. We had three staff that night, but it runs better with four. (CNA C) was the first one in the room and screamed for help. When I got there (R501) got up and and pulled up (their) pants. (R 501's) pants were wet, but I don't know if that was semen or urine. Neither of them were wearing briefs. Then we helped (R502) out of the bed who seemed weak; It took both of us to help (R502). On 12/10/19 at 1:49 PM, R509 reported, Around Thanksgiving, a resident came up and hit me in the shoulder. R509 rolled up their sleeve to reveal a yellow and brown bruise on the outside of the left upper arm. On 12/10/2019 at 1:52 PM, Nurse F was contacted by phone and interviewed regarding the incident between R501 and R502 and stated, I would observe both of them in the day room. (R502) was a night time wanderer. We'd find (R502) in other rooms sleeping in their bed. We'd wake (R502) up and lead (R502) back to (R502's) room. (R501) would watch the women and when they passed (R501) tried to grab their hands. We would have to redirect them a lot. We would have to redirect (R501) to stop. (R501) would stop, but we had to redirect (R501) frequently from trying to touch us and the female residents and we had to redirect (R502) frequently from wandering into other residents rooms. They weren't friendly with each other. (R502) was not cognizant of what's going on, but (R501) seemed to know what was was going on. I wondered why they would put (R501) in here (locked dementia unit) with residents with Dementia and Alzheimer's because (R501) came from two west because of an incident there. And I remember (R501) was seen trying to suck on one of my female resident's breast and we had to redirect them away from each other. On 12/10/19 at 2:10 PM, R501 was asked about sexual behaviors at the facility and denied having sex with or touching any resident on their breast or vagina. R501 did nod yes when asked if they had ever thought about doing these things. On 12/10/2019 at 3:16 PM, Nurse [NAME] was contacted by phone and interviewed regarding the incident between R501 and R502 and stated, We had just got there, me, another nurse and four CNAs. Four CNAs is the norm, but it's still heavy. (R502) is a dementia resident and doesn't know what is going on. (R502) wanders all night. (R501) was quiet, never talked, and was not aggressive. (R501) was touchy-feely with the female residents. We observed it often. I remember that when I first started on that floor, I would go to take (R501's) blood sugar and (R501) tried to touch me. I told (R501) that was inappropriate and (R501) never did it again. When we nurses get there, we count the carts, get report and make rounds on the residents. When the evening CNAs get there, the day CNAs leave. They only give report on anything new that is going on. The CNAs start by rounding on their residents. (CNA C) went into (R 501's) room around 7:10 (PM) and when I got there it was 7:15 (PM). When I got to the room, I observed (R501) putting pants on and there was a wet spot on the front of the pants the size of a fist. (R502) was on the bed. (R502's) night gown was pulled up and the brief was on the floor. I do not believe it was consensual. We have a 24 hour report board and we notify the shift supervisor too. On 12/10/19 at 4:21 PM, CNA O was asked about staffing on the unit of R501 on 12/07/19 and stated, Lately we work with four. You can't keep watch on everybody with four on any floor. When asked about shift change CNA O stated, I was leaving off, once a person reports then you can go. You have to stay until somebody comes. Normally someone is sitting in the day room. I can't remember if there were enough (CNAs) to sit on Saturday. On 12/11/19 at 8:15 AM, during a phone conversation with the Administrator, the Administrator stated, We knew when we reported this that it would be an I[NAME] The police were called and a one to one was started. On 12/11/19 at 10:30 AM, R510 was asked if they were touched in an unwelcome way or had been subject to inappropriate touching, kissing by another resident and nodded their head yes, pointed down the hall and said, The man down the hall. When queried if this was R501, R510 paused and declined to discuss the incident further. On 12/11/19 at 10:45 AM, Nurse H was asked about the bruise to the shoulder of R509 and reported they were not aware of any altercation nor the bruise to the left shoulder. Upon review of assessments and incident reports for Thanksgiving, Nurse H noted one resident to resident incident, but it did not indicate R509 as one of the residents involved. On 12/11/19 at 1:13 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the facility Quality Assurance meetings and indicated many items were discussed at the meeting and included [MEDICAL CONDITION] medications, weight loss, wounds, tracheostomies and behaviors (including sexual behaviors). The DON further reported these items were also discussed in weekly and daily staff meetings and should also address any new concerns. The DON reported they should have known about it at the weekly behavior meetings. The DON was asked about the investigation of the incident for R501 and R502. The DON stated, That night we looked at video and for a period of time staff weren't able to watch (R501) during report as they were behind the wall or at the desk. This gave (R501) opportunity to escort (R502) into (R501's) room. The DON was asked about staffing for the unit R501 resides on and stated, We have four aides and two nurses on today plus the one to one. We try to staff (CNAs) at six on days and four on nights. When asked about the overlap for nurses and not CNA's, the DON stated any change in overlap would be a corporate decision. The DON was asked about the lack of a care plan regarding behavior and specifically sexual behaviors for R501 and stated, There wasn't one. The DON was asked about any incidents with R510 and brought up a concern about throwing coffee. The DON was unaware of a concern with unwelcome sexual advances by R501 toward R510. When asked about R503 and their involvement with R501's fondling and kissing the breasts of R503 and ongoing incidents of the resident lifting their shirt, the DON reported they were unaware until the interviews with staff after the 12/07/19 incident with R501. The DON was asked if they were aware of the incident where staff saw R501 grab the breast of R511 and reported. No one had told me me about that. I feel should have been told. This is part of reporting. The DON was asked if they should have been made aware of these incidents and stated, Yes. They would have come to Q[NAME] We should have known about it at the weekly behavior meetings. So we should have known, but it was not brought up. It should have been. On 12/11/19 at 1:45 PM, the Administrator was asked about the incident of sexual abuse by R501 and stated, There was no incident report made on 7/24 (2019-incident of sexual contact between R501 and R503). We didn't make out an incident report. Now we find out after the fact. If we had completed an incident report it would have come to Q[NAME] We would have caught it. Which is why we report so we can make an appropriate plan. We didn't know about the incident (on 7/24/19) until Saturday when we were going through notes. I said, 'They didn't do an incident report'. Staff should have filled out an incident report. There is no question we would have caught this and this would not have happened. A review of the facility record for R503 revealed R503 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition. R503 was 61 inches tall and 190 pounds. A review of the facility record for R509 revealed R509 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated moderately impaired cognition. A review of the facility record for R510 revealed R510 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated moderately impaired cognition with an eight out of fifteen BIMS score. R510 was 62 inches tall and 147 pounds. A review of the facility record for R511 revealed R511 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition. R511 was 66 inches tall and 101 pounds. A review of the facility Sexual Abuse Policy revealed Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area, all types of sexual assault or battery, such as rape, sodomy or coerced nudity .This would include nudity, fondling , and or intercourse involving a resident. Generally, sexual contact is nonconsensual if the resident either appears not to want the contact to occur, but lacks the cognitive ability to consent, does not want contact to occur. All suspected cases of sexual abuse must be reported immediately to the Administrator and Director of Nursing. Capacity and Consent: 1. Any investigation of resident sexual abuse must start with a determination of whether the sexual activity was consensual on the part of the resident. A resident's apparent consent to engage in sexual activity in not valid if it is obtained from a resident lacking the capacity to consent or consent is obtained through intimidation, coercion or fear .Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered abuse. 2. Determination of capacity will be made through an psychologist/psychiatrist. A review of the facility Abuse Prevention Policy and Procedure revealed, Policy Statement It is the policy of (Facility Name) HCF to maintain an environment free of abuse and neglect. Abuse is 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. Instances of abuse of all residents, irrespective of any mental or physical condition, can physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse, neglect, or misappropriation of personal property by anyone. These are defined as: Sexual Abuse: includes, but is not limited to sexual harassment, sexual coercion or sexual assault. Physical Abuse: is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Mental Abuse: includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. This includes taking or using photographs or recordings in any manner that would demean or humiliate a resident Exploitation: Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion Neglect: means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. Mistreatment: Means inappropriate treatment or exploitation of a resident Involuntary seclusion: is defined as separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's legal representative. Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, or mistreatment. It is the responsibility of all staff to provide a safe environment for the residents. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative. The subject of abuse should be routinely and openly discussed. Staff members, volunteers, family members, and others should be encouraged to report incidents of abuse and suspected abuse, and should be assured that they will be protected against repercussions. Abuse can be resident-to-resident, staff-to-resident, family-to-resident, visitor-to-resident etc. 4. The facility will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur including an analysis of: a) areas in the facility where abuse is more likely to occur in secluded areas. b) the distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff assigned have knowledge of individual care needs. c) the supervisor of staff will identify inappropriate behavior such as using derogatory language, rough handling, ignoring residents during care d) residents exhibiting needs and behaviors that predispose them to have conflict with others or subject to neglect by staff such as: residents with history of aggressive behaviors; residents who enter other residents rooms; residents with self-injury behaviors; residents with communication disorders; residents requiring extensive or total nursing care. 5) Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation, or neglect of a resident shall be reported to the Administrator immediately. 6) The facility will identify and investigate all suspicions or allegations of abuse such as suspicious bruising or residents, unusual occurrences, patterns and trends that may constitute abuse and will determine the direction of the investigation. a) The Administrator or designee shall thoroughly investigate all allegations. This investigation shall be complete within five (5) days of receipt of the allegation or suspicions. b) The Administrator or designee will take steps to ensure and prevent further potential abuse while investigation is in process. c) If the alleged perpetrator is an employee of the facility, he/she will be suspended - and not permitted contact with any resident - until the investigation has been completed. If the alleged perpetrator is a resident or resident's roommate, the individuals will be immediately separated and the rights of the residents-at-large will be protected. d) The Director of Nursing or designee will complete an assessment of resident or residents and document findings in the medical record and interdisciplinary care plan. e) An incident report will be completed. 7) If the incident or allegation involves criminal activity, including but not limited to assault, sexual abuse, homicide, forgery, or wanton neglect, the Administrator immediately notifies law enforcement meeting the requirements of the Elder Justice Act a) If there is a possible rape, the charge nurse will preserve the evidence by not changing the resident's clothes or bathing the resident) and notify the physician immediately requesting an examination at the emergency room . A review of the facility policy Policy and Procedure for Reporting Suspected Crimes under the Federal Elder Justice Act revealed: Reporting Obligation of the Covered Individual: Please note that these reporting requirements are in addition to those required by state law and those required by Medicare and Medicaid certification: 1. The EJA's reporting obligations of crimes themselves fall on covered individuals, not the facility as an entity. Each covered individual shall report to the Secretary and 1 or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime (as defined by the law of the applicable political subdivision) against any individual who is a resident of, or is receiving care from, the facility. The law does not specify that only covered individuals with first-hand knowledge must report. The law states that each covered individual must report any suspicions. 2. reasonable suspicion of a crime against a resident of a long term care facility. 3. Timing: Reporting requirements are based on real (clock) time, not business hours. If the events that cause the suspicion result in serious bodily in

This citation pertains in part to MI 421, MI 425 and MI 440 Based on interview and record review, the facility failed to report incidents of physical and or sexual abuse for three sampled Residents (R503, R510, R511) of five sampled residents reviewed for abuse, resulting in the sexual abuse of R502 and the potential for ongoing non-consenual sexual acts by a known perpetrator (R501). Findings include: On 12/10/19 at 8:50 AM, a review of an anonymous complaint revealed: (R501) was found Saturday 12/07/19 at 7:15 PM on top of (R502) with no pants on. This resident (R501) is known to have inappropriate behaviors. (R502) was sent to the hospital to have a rape kit done. (R502) is not mentally able to make (their) own decisions. (R501) also lifts up the shirt of (R503) and sucks on (R503's) nipples and has been seen fingering (R503). On 12/10/19 at 9:00 AM, a review of the MIACTS (form facility uses to report incidents to the state agency) report dated 12/07/19 revealed: On 12/7/2019 at approximately 7:15pm, Certified Nursing Assistant (CNA C) was walking down the high hall (of R501). (CNA C) noted when passing (the) room (of R501) that a brief was on the floor and the curtain was partially closed .When (CNA C) entered the room, (CNA C) observed (R502) lying in the bed with (R502's) head at the foot of the bed. (R501) was observed lying on top of (R502). (CNA C) described (R501) as pumping on (R502). (CNA C) noted that both residents were naked from the waist down. (CNA D) states that (R501) was getting out of the bed, pants were down and noted (R501) had an erection as (CNA D) entered the room. A review of the witness statement from CNA C revealed: On 12-17-19 at around 7:10 PM to 7:15 PM as I was doing my rounds, I noticed a blue brief on the floor in (the room of R501) and I also noticed that the curtain was pulled around (R501's) bed and that's not usual so I immediately went to check on (R501) because you have to everyday because (R501 is) usually trying to lure other residents specifically women into (R501's) room. That's when I noticed the resident (R502) lying in (R501's) bed on (their) back with (their) head at the foot of the bed, with no pants or brief on with (R501) on top of (R502) with no pants or brief on, (R501's) penis had an erection and (R501) was penetrating (R502). A review of the witness statement from CNA D revealed: (R501) (has) inappropriate sexual behaviors often to the point (R501's) kissing, touching and trying to put (their/R501's) mouth on resident's breast(s). I've also caught (R501) sticking (R501's) hand down inside female resident's briefs. A review of the statement dated 12/08/19 by CNA F revealed: .I have observed (R501) staring and watching female residents, when they walk by (R501) would reach out (their) hand to touch them .I have seen (R501) attempting to lift (the) shirt/gown up to touch resident's breast, (and) attempting to bend over toward (their) breast. I have seen (R501) ambulate down the low hall looking for female resident's room. A review of the facility record for R501 revealed R501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented moderately impaired cognition with a nine out of fifteen Brief Interview for Mental Status (BIMS) score. A review of the MDS assessments Section [NAME] indicated the facility did not document any behaviors affecting others. A review of the care plan revealed the facility did not document any sexual or inappropriate behaviors in the care plan nor interventions to mitigate them. The MDS dated [DATE] indicated in section [NAME] behavior affecting others 1-3 days in the look back period. A review of the CNA Task Monitor documented 11 episodes of sexually inappropriate behavior from 11/12/19 through 12/08/19. A review of the facility record for R502 revealed, R502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition with a four out of fifteen BIMS score. , A review of the facility record for R503 revealed, R503 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition. A review of the CNA Task Monitor documented zero episodes of sexually inappropriate behavior from 11/12/19 through 12/08/19. A review of the facility record for R510 revealed, R510 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated moderately impaired cognition with an eight out of fifteen BIMS score. , A review of the facility record for R511 revealed R511 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition. On 12/10/19 at 9:05 AM, R501 was observed dressed and seated on the edge of their bed. R501 reported no concerns with other residents and stated No to questions for concerns about care or treatment by staff. R501 was asked if they had any incidents, altercation, or problems with any residents and shook their head No. On 12/10/19 at 9:23 AM, Nurse H was asked about R501 and R502 and stated, R501 has a history of behaviors. I reported this back in July. R501 has touched me in the private areas. Nurse H reported that the touch was intentional by R501. (R501) physically touches residents as well. My resident (R503) in particular, (R501) lifted their shirt and put hands on their breast. I told the Unit Manager at the time. I was informed that it was not considered inappropriate and was adult sexual behavior and to stop saying it was abuse. (R501) also tries to hold the hand or kiss (R510). On 12/10/19 at 9:58 AM, Nurse J was asked about recent incidents and reported, (R501) has always been flirtatious and blow kisses to the nurse and CN[NAME] When asked about R503, Nurse J reported they had seen R503 lift their shirt around R501 and R501 kiss and fondle the breasts of R503. On 12/10/19 at 11:16 AM, the Director of Nursing (DON) was asked about R501 and R502 and stated, We knew (R501) liked the ladies. Per the interviews it was just that (R501) like the ladies. When asked about other resident contact the DON reported that Just one noted back in the summer (with R503). They broke them up. It was not reported, because it happened in the day room and it was felt this was welcomed touching. It was immediately stopped. Staff said (R501) was touching people (females) and would rub arms and kiss their hands. The DON reported they were told this during the interviews done after the incident on 12/07/19 with R501 and R502. The DON further reported there were concerns from a nurse that their charting had been deleted from the electronic record. On 12/10/19 at 11:18 AM, Social Worker (SW) L and the Social Work/Resident Services Director (SW) B were asked if they were aware of any sexual concerns with R501 such as blowing kisses or groping residents and SW L replied they had not and SWD B stated, I was in shock about everything they knew and didn't tell. They didn't tell anybody and this had been going on at least few months prior per the interviews. When asked if the SW should be aware SW B stated, Yes. We could have put interventions in place, for staff to redirect and possibly have psych see them for other interventions. Staff were knowledgeable of them. I think they thought they were handling it. SW B further reported they had done interviews with the staff post the incident between R501 and R502 and reported most but not all staff on the unit of R501 were aware of R501's sexual behaviors. On 12/10/19 at 1:23 PM Staff M stated, I have observed (R501) sexually inappropriate with a lot of women. On 12/10/19 at 1:29 PM, CNA N was asked about R501 and stated, (R501) may try to get (their) hand in and grope another resident and we have to try to get (R501) away. I did not know this about (R501) when I first started. I had not seen (R501 and R502) together before. I did see (R501) sitting next to a resident (R511), groping (them) around the breast. Maybe last week or before. I thought I reported it to the nurse, but I am not sure (who/when). On 12/10/19 at 2:10 PM, R501 was asked about sexual behaviors at the facility. Resident R501 paused and denied having sex with or touching any resident on their breast or vagina. R501 did nod yes when asked if they had ever thought about doing these things. On 12/10/19 at 4:21 PM, CNA O was asked about R503 and CNA O reported they had seen interactions between R503 with R501 in the hallway or day area, four different times over the last two months. On 12/11/19 at 10:30 AM, R510 was asked if they were touched in an unwelcome way or had been subject to inappropriate touching or kissing by another resident and nodded their head yes, pointed down the hall and said, The man down the hall. When queried if this was R510, R504 paused and declined to discuss the incident further. On 12/11/19 at 1:13 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the facility Quality Assurance meetings and indicated many items are discussed at the meeting and include behaviors (including sexual behaviors). The DON further reported these items are discussed in weekly and daily staff meetings and should address any new concerns. The DON was asked about any incidents with R510 and brought up a concern about throwing coffee. The DON was unaware of a concern with unwelcome kissing or touching by R501 toward R510. When asked about R503 and their involvement with R501's fondling and kissing the breasts of R503 and ongoing incidents of the resident lifting R503's shirt, the DON reported they were unaware until the interviews with staff after the incident on 12/07/19 between R501 and R502. The DON was asked if they were aware of the incident where staff saw R501 grab the breast of R511 and reported, No one had told me about that. I feel I should have been told. This is part of reporting. The DON was asked if they should have been made aware of these incidents and stated, Yes. They would have come to Q[NAME] We should have known about it at the weekly behavior meetings. So we should have known, but it was not brought up. It should have been. On 12/11/19 at 1:45 PM, the Administrator was asked about the cause of the incident between R501 and R502 and stated, There was no incident report made on 7/24 (2019) (incident with R503). We didn't make out an incident report. Now we find out after the fact. If we had an incident report it would come to Q[NAME] We would have caught it. Which is why we report, so we can make an appropriate plan. We didn't know about the incident (on 7/24/19) until Saturday when we were going through notes. I said, 'They didn't do an incident report'. Staff should have filled out an incident report. There is no question we would have caught this. A review of the facility Sexual Abuse Policy revealed Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area, all types of sexual assault or battery, such as rape, sodomy or coerced nudity .This would include nudity, fondling , and or intercourse involving a resident. Generally, sexual contact is nonconsensual if the resident either appears not to want the contact to occur, but lacks the cognitive ability to consent, does not want contact to occur. All suspected cases of sexual abuse must be reported immediately to the Administrator and Director of Nursing. Capacity and Consent: 1. Any investigation of resident sexual abuse must start with a determination of whether the sexual activity was consensual on the part of the resident. A resident's apparent consent to engage in sexual activity in not valid if it is obtained from a resident lacking the capacity to consent or consent is obtained through intimidation, coercion or fear .Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered abuse. 2. Determination of capacity will be made through an psychologist/psychiatrist. A review of the facility Abuse Prevention Policy and Procedure revealed, Policy Statement It is the policy of (Facility Name) HCF to maintain an environment free of abuse and neglect. Abuse is 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. Instances of abuse of all residents, irrespective of any mental or physical condition, can physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse, neglect, or misappropriation of personal property by anyone. These are defined as: Sexual Abuse: includes, but is not limited to sexual harassment, sexual coercion or sexual assault. Physical Abuse: is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Mental Abuse: includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. This includes taking or using photographs or recordings in any manner that would demean or humiliate a resident Exploitation: Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion Neglect: means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. Mistreatment: Means inappropriate treatment or exploitation of a resident Involuntary seclusion: is defined as separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's legal representative. Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, or mistreatment. It is the responsibility of all staff to provide a safe environment for the residents. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative. The subject of abuse should be routinely and openly discussed. Residents will be educated concerning the commitment of the facility to deal quickly and effectively with abuse or suspected abuse incidents on admission and annually thereafter. Staff members, volunteers, family members, and others should be encouraged to report incidents of abuse and suspected abuse, and should be assured that they will be protected against repercussions. Abuse can be resident-to-resident, staff-to-resident, family-to-resident, visitor-to-resident etc. 4. The facility will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur including an analysis of: a) areas in the facility where abuse is more likely to occur in secluded areas. b) the distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff assigned have knowledge of individual care needs. c) the supervisor of staff will identify inappropriate behavior such as using derogatory language, rough handling, ignoring residents during care d) residents exhibiting needs and behaviors that predispose them to have conflict with others or subject to neglect by staff such as: residents with history of aggressive behaviors; residents who enter other residents rooms; residents with self-injury behaviors; residents with communication disorders; residents requiring extensive or total nursing care. 5) Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation, or neglect of a resident shall be reported to the Administrator immediately. 6) The facility will identify and investigate all suspicions or allegations of abuse such as suspicious bruising or residents, unusual occurrences, patterns and trends that may constitute abuse and will determine the direction of the investigation. a) The Administrator or designee shall thoroughly investigate all allegations. This investigation shall be complete within five (5) days of receipt of the allegation or suspicions. b) The Administrator or designee will take steps to ensure and prevent further potential abuse while investigation is in process. c) If the alleged perpetrator is an employee of the facility, he/she will be suspended - and not permitted contact with any resident - until the investigation has been completed. If the alleged perpetrator is a resident or resident's roommate, the individuals will be immediately separated and the rights of the residents-at-large will be protected. d) The Director of Nursing or designee will complete an assessment of resident or residents and document findings in the medical record and interdisciplinary care plan. e) An incident report will be completed. 7) If the incident or allegation involves criminal activity, including but not limited to assault, sexual abuse, homicide, forgery, or wanton neglect, the Administrator immediately notifies law enforcement meeting the requirements of the Elder Justice Act a) If there is a possible rape, the charge nurse will preserve the evidence by not changing the resident's clothes or bathing the resident) and notify the physician immediately requesting an examination at the emergency room . A review of the facility policy Policy and Procedure for Reporting Suspected Crimes under the Federal Elder Justice Act revealed: Reporting Obligation of the Covered Individual: Please note that these reporting requirements are in addition to those required by state law and those required by Medicare and Medicaid certification: 1. The EJA's reporting obligations of crimes themselves fall on covered individuals, not the facility as an entity. Each covered individual shall report to the Secretary and 1 or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime (as defined by the law of the applicable political subdivision) against any individual who is a resident of, or is receiving care from, the facility. The law does not specify that only covered individuals with first-hand knowledge must report. The law states that each covered individual must report any suspicions. 2. reasonable suspicion of a crime against a resident of a long term care facility. 3. Timing: Reporting requirements are based on real (clock) time, not business hours. If the events that cause the suspicion result in serious bodily injury, the individual must report suspicions that: a. Result in serious bodily injury, the individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion; and b. do not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion.

This citation pertains in part to MI 421, MI 425 and MI 440. Based on observation, interview and record review, the facility failed to provide sufficient staff to supervise and monitor a known sexual perpetrator (R501) affecting one sampled Resident (R502) of five sampled residents reviewed for abuse, resulting in the likelihood of non-consensual vaginal penetration and additional unwelcome sex acts with the likelihood for serious physical and psychosocial injury and harm. Findings include: On 12/10/19 at 8:50 AM, a review of an anonymous complaint revealed: (R501) was found Saturday 12/07/19 at 7:15 PM on top of (R502) with no pants on. This resident (R501) is known to have inappropriate behaviors. (R502) was sent to the hospital to have rape kit done. (R502) is not mentally able to make (their) own decisions. On 12/10/19 at 9:00 AM, a review of the MIACTS (form facility uses to report incidents to the state agency) report dated 12/07/19 revealed: On 12/7/2019 at approximately 7:15pm, Certified Nursing Assistant (CNA C) was walking down the high hall of (R501). (CNA C) noted when passing (the) room (of R501) that a brief was on the floor and the curtain was partially closed .When (CNA C) entered the room, (CNA C) observed (R502) lying in the bed with (R502's) head at the foot of the bed. (R501) was observed lying on top of (R502). (CNA C) described (R501) as pumping on (R502). (CNA C) noted that both residents were naked from the waist down. (CNA C) immediately yelled at (R501) Get off (R502) and got no response. (CNA C) remained in the room and yelled from the doorway that (they) needed help. (CNA D) was in the dayroom and immediately went (the room of R501). (CNA D) states that (R501) was getting out of the bed, pants were down and noted (R501) had an erection as (CNA D) entered the room. A review of the witness statement from CNA C revealed: On 12-17-19 at around 7:10 PM to 7:15 PM as I was doing my rounds, I noticed a blue brief on the floor in (the room of R501) and I also noticed that the curtain was pulled around (R501's) bed and that's not usual so I immediately went to check on (R501) because you have to everyday because (R501 is) usually trying to lure other residents specifically women into (R501's) room. That's when I noticed the resident (R502) lying in (R501's) bed on (their) back with (their) head at the foot of the bed, with no pants or brief on with (R501) on top of (R502) with no pants or brief on, (R501's) penis had an erection and (R501) was penetrating (R502). A review of the witness statement from CNA D revealed: On 12-7-19 (at) 7:15 PM, I heard (CNA C) yelling for someone to come and assist (them) in the room of (R501). When I made it down to see what was wrong, I observed (R501) climbing off (R502) with (R501's) pants completely down and (R501's) penis had an erection. A review of the statement dated 12/08/19 by CNA F revealed: .I have observed (R501) staring and watching female residents, when they walk by (R501) would reach out (their) hand to touch them .I have seen (R501) attempting to lift (the) shirt/gown up to touch resident's breast, (and) attempting to bend over toward (their) breast. I have seen (R501) ambulate down the low hall looking for female resident's room. On 12/10/19, a review of the facility video for 12/07/19 revealed: On Saturday 12/07/19, at 6:52 PM the door to R501's room was shown closed. At 6:54 PM R501 was shown reaching out to touch a resident in a wheelchair on their shoulder. R501 then walks out and is shown standing alone at the left corner of the day room, looking into the day room. R501 is in front of the doors to the hallway. No staff are seen sitting in or standing around in the day area. A CNA walked up from the hall behind R501 and passed R501, but did not interact with R501. At 6:55 PM R502 was shown walking up the hall wearing a dress and socks. At 6:56 PM, R502 enters from the hallway behind R501 and pauses behind R501. R501 turns toward R502 and walks R502 through the doorway to the hall. R501 is shown with their hand at the buttock of R502 as they enter the R501's room. The hand moves up toward the shoulder of R502 as they both pass through the doorway to R501's room. At 7:16 PM a CNA walks down hall with linen in their hands and then back up the hall into the shower room. At that time a second CNA enters the hallway, discovers R501 and R502 and enters the room of R501. At 7:17 PM a staff member can be seen standing at the door way of R501's room making a thrusting motion with their hips. At 7:18 PM another CNA enters and at 7:19 PM, a Nurse entered. Facility shift change for the nursing staff occured during this time which left R501 without staff supervision for approximately 20 minutes. A review of the facility record for R501 revealed, R501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented moderately impaired cognition with a nine out of fifteen Brief Interview for Mental Status (BIMS) score. A review of the MDS assessments Section [NAME] indicated the facility did not document any behaviors affecting others. The MDS dated [DATE] indicated in section [NAME] behavior affecting others 1-3 days in the look back period. A review of the clinical record revealed a progress note dated 07/24/19 which indicated (R501) observed suckling the breast of another resident, while the other resident held (their) shirt up, in the day room. A review of the facility record for R502 revealed, R502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition with a four out of fifteen BIMS score. On 12/10/19 at 9:12 AM, CNA G was asked about R501 and R502 and stated, We do a lot at change of shift. R502 is a walker but I've never seen (them) go into nobodys room or interact with any body. R501 throws kisses. I had not seen (R501) with (R502). On 12/10/19 at 9:23 AM, Nurse H was asked about R501 and R502 and stated, R501 has history of behaviors. I reported this back in July. (R501) physically touches residents as well. My resident in particular, (R501) lifted their shirt and put hands on their breast. We were sitting in the day room charting and I looked up and this was going on. I told the Unit Manager at the time. I was informed that it was not considered inappropriate and was adult sexual behavior and to stop saying it was abuse. (R501) also tries to hold the hand or kiss (R510). I separated them. When asked about enough staff for supervision Nurse H stated, We have four aides and two nurses. The floor calls for six or seven CNAs. On a good day we have five CNAs. Staff complain, one CNA is afraid to work with (R501) (alone). Nurse H further noted weekends are tough and Sundays are the roughest as contingent staff don't pick up enough shifts. On 12/10/19 at 9:52 AM, Housekeeping Staff I reported resident fights are an everyday thing. On 12/10/19 at 9:58 AM, Nurse J was asked about recent incidents and reported, I heard two residents were having sex. (R501) has always been flirtatious and blow kisses to the nurse and CN[NAME] (R502) is pretty affectionate too, but not in the same demeanor. (R502) will lay their head on your shoulder. I will try to keep her with a CNA or with me as (R502's) a fall risk. They had a recent fall and had stitches behind the ear. I heard that when (R501) first came (R501) was watching porn. When asked if Nurse J thought other staff were aware of R501's or 502's behaviors, Nurse J stated, Just those that work with (them) directly. Nurse J was asked about shift change and stated, Nurses report off and do the (narcotic) count. CNA's do not overlap. Nurses do rounds CNAs don't. Some CNAs leave before the next CNA arrives. I have seen CNAs at the time clock waiting to leave. Nurse J was asked about the Saturday of the incident between R501 and R502 and reported, We were short, There was three CNAs working. We need five CNAs per the amount of behaviors. Nurse J also reported they had only two CNAs because of call offs this morning until one got pulled from another unit. On 12/10/19 at 11:16 AM, the Director of Nursing (DON) was asked about the incident between R501 and R502 and stated, We knew (R501) liked the ladies. On 12/10/19 at 1:23 PM, Staff M stated, I have observed (R501) sexually inappropriate with a lot of women. I have seen (R501) and (R502) in the hallway following each other. On 12/10/19 at 1:29 PM, CNA N was asked about R501 and stated, (R501) may try to get (their) hand in and grope another resident and we have to try to get (R501) away. CNA N reported thay have sitting times to make sure someone is in the day room. When asked about shift change CNA N stated, At shift change we report to other aides. Sometimes they don't come on time. On 12/10/19 at 2:10 PM, R501 was asked about sexual behaviors at the facility and denied having sex with or touching any resident on their breast or vagina. R501 did nod yes when asked if they had ever thought about doing these things. On 12/10/19 at 4:21 PM, CNA O was asked about staffing on the unit of R501 and stated, Lately we work with four. You can't keep watch on everbody with four on any floor. When asked about shift change on 12/07/19 and CNA O stated, I was leaving off, once a person reports then you can go. You have to stay until somebody comes. Normally someone is sitting in the day room. I can't remember if there were enough to sit on Saturday. On 12/11/19 at 7:47 AM CNA P was asked about staffing and the ablity to meet the care needs of residents and stated, We are short staffed. We work with three to four aides with about 14 residents a piece. Sometimes we can't get showers done or can't change as often as every two hours. You can't help feeders right away. Every time I work I feel we work short. On 12/11/19 at 1:13 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the facility Quality Assurance meetings and indicated many items are discussed at the meeting and include behaviors (including sexual behaviors). The DON further reported these items are discussed in weekly and daily staff meetings and should address any new concerns. The DON was asked about the investigation of the incident for R501 and R502 and reported they were called along with the Administrator and the police. The DON stated, That night we looked at video and for a period of time staff weren't able to watch (R501) as they were behind the wall or at the desk. This gave (R501) opportunity to escort (R502) into (R501's) room. The DON was asked about staffing for the unit R501 resides on and stated, We have four aides and two nurses on today plus the one to one. We try to staff (CNAs) at six on days and four on nights. When asked about the overlap for nurses and not CNA's, the DON stated any change in overlap would be a corporate decision. On 12/11/19 at 1:45 PM, the Administrator was asked about the cause of the incident between R501 and R502 and stated, There was no incident report made on 7/24 (2019). We didn't make out an incident report. Now we find out after the fact. If we had an incident report it would come to Q[NAME] We would have caught it. Which is why we report so we can make an appropriate plan. We didn't know about incident (on 7/24/19) until Saturday when we were going through notes. A review of the facility Sexual Abuse Policy revealed Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area, all types of sexual assault or battery, such as rape, sodomy or coerced nudity .This would include nudity, fondling , and or intercourse involving a resident. Generally, sexual contact is nonconsensual if the resident either appears not to want the contact to occur, but lacks the cognitive ability to consent, does not want contact to occur. All suspected cases of sexual abuse must be reported immediately to the Administrator and Director of Nursing. Capacity and Consent: 1. Any investigation of resident sexual abuse must start with a determination of whether the sexual activity was consensual on the part of the resident. A resident's apparent consent to engage in sexual activity in not valid if it is obtained from a resident lacking the capacity to consent or consent is obtained through intimidation, coercion or fear .Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered abuse. 2. Determination of capacity will be made through an psychologist/psychiatrist. A review of the facility Abuse Prevention Policy and Procedure revealed, Policy Statement It is the policy of (Facility Name) HCF to maintain an environment free of abuse and neglect. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Residents will not be subjected to abuse, neglect, or misappropriation of personal property by anyone. Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, or mistreatment. It is the responsibility of all staff to provide a safe environment for the residents. 4. The facility will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur including an analysis of: a) areas in the facility where abuse is more likely to occur in secluded areas. b) the distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff assigned have knowledge of individual care needs. c) the supervisor of staff will identify inappropriate behavior such as using derogatory language, rough handling, ignoring residents during care d) residents exhibiting needs and behaviors that predispose them to have conflict with others or subject to neglect by staff such as: residents with history of aggressive behaviors; residents who enter other residents rooms; residents with self-injury behaviors; residents with communication disorders; residents requiring extensive or total nursing care. e) An incident report will be completed.

This citation pertains in part to MI 421, MI 425 and MI 440. Based on observation, interview and record review, the facility failed to supervise and monitor a known sexual perpetrator (R501) affecting one sampled Resident (R502) of five sampled residents reviewed for abuse, resulting in the likelihood of non-consensual vaginal penetration and additional unwelcome sex acts with the likelihood for serious physical and psychosocial injury and harm. Findings include: On 12/10/19 at 8:50 AM, a review of an anonymous complaint revealed: (R501) was found Saturday 12/07/19 at 7:15 PM on top of (R502) with no pants on. This resident (R501) is known to have inappropriate behaviors. (R502) was sent to the hospital to have rape kit done. (R502) is not mentally able to make (their) own decisions. On 12/10/19 at 9:00 AM, a review of the MIACTS (form facility uses to report incidents to the state agency) report dated 12/07/19 revealed: On 12/7/2019 at approximately 7:15pm, Certified Nursing Assistant (CNA C) was walking down the high hall of (R501). (CNA C) noted when passing (the) room (of R501) that a brief was on the floor and the curtain was partially closed .When (CNA C) entered the room, (CNA C) observed (R502) lying in the bed with (R502's) head at the foot of the bed. (R501) was observed lying on top of (R502). (CNA C) described (R501) as pumping on (R502). (CNA C) noted that both residents were naked from the waist down. (CNA C) immediately yelled at (R501) Get off (R502) and got no response. (CNA C) remained in the room and yelled from the doorway that (they) needed help. (CNA D) was in the dayroom and immediately went (the room of R501). (CNA D) states that (R501) was getting out of the bed, pants were down and noted (R501) had an erection as (CNA D) entered the room. A review of the witness statement from CNA C revealed: On 12-17-19 at around 7:10 PM to 7:15 PM as I was doing my rounds, I noticed a blue brief on the floor in (the room of R501) and I also noticed that the curtain was pulled around (R501's) bed and that's not usual so I immediately went to check on (R501) because you have to everyday because (R501 is) usually trying to lure other residents specifically women into (R501's) room. That's when I noticed the resident (R502) lying in (R501's) bed on (their) back with (their) head at the foot of the bed, with no pants or brief on with (R501) on top of (R502) with no pants or brief on, (R501's) penis had an erection and (R501) was penetrating (R502). A review of the witness statement from CNA D revealed: On 12-7-19 (at) 7:15 PM, I heard (CNA C) yelling for someone to come and assist (them) in the room of (R501). When I made it down to see what was wrong, I observed (R501) climbing off (R502) with (R501's) pants completely down and (R501's) penis had an erection. A review of the statement dated 12/08/19 by CNA F revealed: .I have observed (R501) staring and watching female residents, when they walk by (R501) would reach out (their) hand to touch them .I have seen (R501) attempting to lift (the) shirt/gown up to touch resident's breast, (and) attempting to bend over toward (their) breast. I have seen (R501) ambulate down the low hall looking for female resident's room. On 12/10/19, a review of the facility video for 12/07/19 revealed: On 12/07/19, Saturday at 6:31 PM, R502 was directed out of a room next door to R501 by a CN[NAME] R502 walked out of the room and stopped at the doorway of their own room. At 6:52, PM, the door to R501's room was shown closed. R502 was in the hallway walking down away from the room stopped in the doorway of the room next door. A CNA walked down the hall at 6:53 PM and retrieved a [NAME]et, went back up the hall and passed R501 at 6:54 PM. The CNA did not interact with R501. At 6:54 PM while standing in the doorway of their room, R501 was shown reaching out to touch a female resident seated in a wheelchair on their shoulder as they passed by R501. At 6:54 PM R501 is shown standing alone at the left corner of the day room, looking into the day room. R501 is in front of the doors to the hallway. No staff are seen sitting in or standing around in the day area. At 6:55 PM R502 was shown walking up the hall wearing a dress and socks. At 6:56 PM R502 enters from the hallway behind R501 and pauses behind R501. R501 turns toward R502 and walks R502 through the doorway to the hall. R501 is shown with their hand at the buttock of R502 as they enter R501's room. The hand moves up toward the shoulder of R502 as they both pass through the doorway to R501's room. Between the time of R501 and R502 entering the room of R501 a resident in a wheelchair is shown to pause for a moment and look into the room. At 7:16 PM a CNA walks down the hall passing the room of R501 and then walked back up the hall into the shower room. At that time a second CNA discovers R501 and R502 and enters the room of R501. At 7:17 PM a staff member can be seen standing at the door way of R501's room making a thrusting motion with their hips. At 7:18 PM another CNA entered and at 7:19 PM, a Nurse entered. Facility shift change for the nursing staff occured during this time which left R501 without staff supervision for approximately 20 minutes. A review of the facility record for R501 revealed, R501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented moderately impaired cognition with a nine out of fifteen Brief Interview for Mental Status (BIMS) score. A review of the MDS assessments Section [NAME] indicated the facility did not document any behaviors affecting others. The MDS dated [DATE] indicated in section [NAME] behavior affecting others 1-3 days in the look back period. A review of the clinical record revealed a progress note dated 07/24/19 which indicated (R501) observed suckling the breast of another resident, while the other resident held (their) shirt up, in the day room. A review of the facility record for R502 revealed, R502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition with a four out of fifteen BIMS score. On 12/10/19 at 9:12 AM, CNA G was asked about R501 and R502 and stated, We do a lot at change of shift. R502 is a walker but I've never seen (them) go into nobodys room or interact with any body. R501 throws kisses. I had not seen (R501) with (R502). On 12/10/19 at 9:23 AM, Nurse H was asked about R501 and R502 and stated, R501 has history of behaviors. I reported this back in July. (R501) physically touches residents as well. My resident in particular, (R501) lifted their shirt and put hands on their breast. We were sitting in the day room charting and I looked up and this was going on. I told the Unit Manager at the time. I was informed that it was not considered inappropriate and was adult sexual behavior and to stop saying it was abuse. (R501) also tries to hold the hand or kiss (R510). I separated them. When asked about enough staff for supervision Nurse H stated, We have four aides and two nurses. The floor calls for six or seven CNAs. On a good day we have five CNAs. Staff complain, one CNA is afraid to work with (R501) (alone). Nurse H further noted weekends are tough and Sundays are the roughest as contingent staff don't pick up enough shifts. On 12/10/19 at 9:52 AM, Housekeeping Staff I reported resident fights are an everyday thing. On 12/10/19 at 9:58 AM, Nurse J was asked about recent incidents and reported, I heard two residents were having sex. (R501) has always been flirtatious and blow kisses to the nurse and CN[NAME] (R502) is pretty affectionate too, but not in the same demeanor. (R502) will lay their head on your shoulder. I will try to keep her with a CNA or with me as (R502's) a fall risk. They had a recent fall and had stitches behind the ear. I heard that when (R501) first came (R501) was watching porn. When asked if Nurse J thought other staff were aware of R501's or 502's behaviors, Nurse J stated, Just those that work with (them) directly. Nurse J was asked about shift change and stated, Nurses report off and do the (narcotic) count. CNA's do not overlap. Nurses do rounds CNAs don't. Some CNAs leave before the next CNA arrives. I have seen CNAs at the time clock waiting to leave. Nurse J was asked about the Saturday of the incident between R501 and R502 and reported, We were short, There was three CNAs working. We need five CNAs per the amount of behaviors. Nurse J also reported they had only two CNAs because of call offs this morning until one got pulled from another unit. On 12/10/19 at 11:16 AM, the Director of Nursing (DON) was asked about the incident between R501 and R502 and stated, We knew (R501) liked the ladies. On 12/10/19 at 1:23 PM, Staff M stated, I have observed (R501) sexually inappropriate with a lot of women. I have seen (R501) and (R502) in the hallway following each other. On 12/10/19 at 1:29 PM, CNA N was asked about R501 and stated, (R501) may try to get (their) hand in and grope another resident and we have to try to get (R501) away. CNA N reported thay have sitting times to make sure someone is in the day room. When asked about shift change CNA N stated, At shift change we report to other aides. Sometimes they don't come on time. On 12/10/19 at 2:10 PM, R501 was asked about sexual behaviors at the facility and denied having sex with or touching any resident on their breast or vagina. R501 did nod yes when asked if they had ever thought about doing these things. On 12/10/19 at 4:21 PM, CNA O was asked about staffing on the unit of R501 and stated, Lately we work with four. You can't keep watch on everbody with four on any floor. When asked about shift change on 12/07/19 and CNA O stated, I was leaving off, once a person reports then you can go. You have to stay until somebody comes. Normally someone is sitting in the day room. I can't remember if there were enough to sit on Saturday. On 12/11/19 at 7:47 AM CNA P was asked about staffing and the ablity to meet the care needs of residents and stated, We are short staffed. We work with three to four aides with about 14 residents a piece. Sometimes we can't get showers done or can't change as often as every two hours. You can't help feeders right away. Every time I work I feel we work short. On 12/11/19 at 1:13 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the facility Quality Assurance meetings and indicated many items are discussed at the meeting and include behaviors (including sexual behaviors). The DON further reported these items are discussed in weekly and daily staff meetings and should address any new concerns. The DON was asked about the investigation of the incident for R501 and R502 and reported they were called along with the Administrator and the police. The DON stated, That night we looked at video and for a period of time staff weren't able to watch (R501) as they were behind the wall or at the desk. This gave (R501) opportunity to escort (R502) into (R501's) room. The DON was asked about staffing for the unit R501 resides on and stated, We have four aides and two nurses on today plus the one to one. We try to staff (CNAs) at six on days and four on nights. When asked about the overlap for nurses and not CNA's, the DON stated any change in overlap would be a corporate decision. On 12/11/19 at 1:45 PM, the Administrator was asked about the cause of the incident between R501 and R502 and stated, There was no incident report made on 7/24 (2019). We didn't make out an incident report. Now we find out after the fact. If we had an incident report it would come to Q[NAME] We would have caught it. Which is why we report so we can make an appropriate plan. We didn't know about incident (on 7/24/19) until Saturday when we were going through notes. A review of the facility Sexual Abuse Policy revealed Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area, all types of sexual assault or battery, such as rape, sodomy or coerced nudity .This would include nudity, fondling , and or intercourse involving a resident. Generally, sexual contact is nonconsensual if the resident either appears not to want the contact to occur, but lacks the cognitive ability to consent, does not want contact to occur. All suspected cases of sexual abuse must be reported immediately to the Administrator and Director of Nursing. Capacity and Consent: 1. Any investigation of resident sexual abuse must start with a determination of whether the sexual activity was consensual on the part of the resident. A resident's apparent consent to engage in sexual activity in not valid if it is obtained from a resident lacking the capacity to consent or consent is obtained through intimidation, coercion or fear .Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered abuse. 2. Determination of capacity will be made through an psychologist/psychiatrist. A review of the facility Abuse Prevention Policy and Procedure revealed, Policy Statement It is the policy of (Facility Name) HCF to maintain an environment free of abuse and neglect. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Residents will not be subjected to abuse, neglect, or misappropriation of personal property by anyone. Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, or mistreatment. It is the responsibility of all staff to provide a safe environment for the residents. 4. The facility will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur including an analysis of: a) areas in the facility where abuse is more likely to occur in secluded areas. b) the distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff assigned have knowledge of individual care needs. c) the supervisor of staff will identify inappropriate behavior such as using derogatory language, rough handling, ignoring residents during care d) residents exhibiting needs and behaviors that predispose them to have conflict with others or subject to neglect by staff such as: residents with history of aggressive behaviors; residents who enter other residents rooms; residents with self-injury behaviors; residents with communication disorders; residents requiring extensive or total nursing care. e) An incident report will be completed.

This citation pertains to intake # 7. Based on observation, interview and record review, the facility failed to implement effective interventions to prevent weight loss for one (Resident #702) of two residents reviewed for weight loss, resulting in a forty three pound weight loss for a resident on a bolus tube feeding (liquid nutrition that is infused through a tube that is anchored to the inside of the stomach and extends to the outside of the body), and the likelihood for continued weight loss with declining health. Findings include: On 11/19/19 at 6:24 PM, an interview via telephone was completed with Family Member C. Family Member C explained that she was concerned with the weight loss of Resident #702. Family Member C stated, I lost my brother, so I had not been in to see (Resident #702) in a while, when I came in I was shocked, (Resident #702) looked like they lost weight. I used to take care of (Resident #702) at home. They always were around 178 pounds (#). They never lost weight at home. I would bolus feed them because they are very active and did not want to be connected to a tube all day. They never fought or refused being fed through the tube. I would come into the facility and there would be tube feeding formula spilled all over the place (verified via pictures attached to the intake). I wondered if (Resident #702) was even getting the formula. On 11/20/19 at 9:15 AM, Resident #702 was observed dressed and in their wheelchair. Resident #702 was queried in regards to the tube feeding that they received. Resident #702 lifted up their shirt to reveal a white abdominal binder in which a tube was observed underneath it, the resident appeared thin. Resident #702 was confused but did explain that they were unable to eat by mouth. Resident #702 was queried in regards to weight loss and stated, I have lost some weight, but I am not sure why. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #701 had been admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #702 had a Brief Interview for Mental Status (BIMS) score of 11, indicating a mild cognitive impairment. A record review of the weights for Resident #702 revealed the following: 2/6/19 176# 2/13/19 172# 2/20/19 167# 2/27/19 166# 3/27/19 161# 4/25/19 156# 5/30/19 155# 6/26/19 154# 7/25/19 147# 8/28/18 145# 9/25/19 144# 10/29/19 135# 11/5/19 133# A record review of the physician orders revealed the following order for Resident #702: Bolus Two Cal HN 1 can at 9 AM, 1 PM, 5 PM, 9 PM and 12mn (midnight) dose completion 960 cc initiated 3/25/19. A record review of the Medication Administration Record [REDACTED]. A record review of the progress notes from Septemeber through present revealed no refusals of the bolus feedings by Resident #702, or documentation from the doctor regarding the weight loss. A record review of the care plan for Resident #702 revealed the following: Focus- Resident requires a tube feeding .r/t (related to) dysphagia (difficulty swallowing) .HT (height) 72 inches WT (weight) 173# WT LOSS 166# 2/26/19 change to pump 2/27/19 4/4/19 .down 3# .feeding via bolus now 8/18/19 wt down 1# 145# .stable 10/15/19 review wt down 1# activity has increased adding fifth can for +calories According to MAR, the resident had been receiving five cans since (MONTH) 2019, there were no additions of more calories documented. On 11/20/19 at 2:27 PM, an interview was completed with Registered Dietician (RD) B regarding Resident #702's weight loss. RD B stated, (Resident #702) was very irritated, we were trying a modified [MEDICATION NAME] swallow (MBS), we want them to eat but the family couldn't go at first. We will try to reach out to them again. When (Resident #702) first came in, I wanted them on a (continuous) pump (instead of a bolus feeding), and (Resident #702) would pull it, the formula would be all over. So, I started the bolus on (MONTH) 22 (2019). (Resident #702) was getting cans of [MEDICATION NAME] in February, it was changed to Two Cal. RD B was asked to show any new additional orders made in regards to the continued weight loss once Resident #702 was changed to the bolus feedings and was unable to provide any information but stated, (Resident #702) is getting more than what they should need. I am not sure what is going on. The weight should not be going down. I question if the nurses are giving it (the bolus feeding). On 11/20/19 at 5:15 PM, an interview was completed with the Director of Nursing (DON) in regards to Resident #702's weight loss. The DON had explained that she felt the resident had a possible underlying condition causing their weight loss and also stated, We want to try to get the MBS completed so they can eat. We want them to eat. The Administrator was not present during the survey. A review of the facility policy titled, Weight Loss Policy and Procedure revised 9/2019 revealed the following: Objective: To maintain each resident's acceptable parameters of nutritional status, unless the resident's condition demonstrates that this is not possible; to assure each resident receives a therapeutic intervention in the event of unintended weight loss. 11. The Nutritional Services staff assess targeted residents and plans appropriate interventions and follow-up. All appropriate documentation is found in the plan of care. A tube feeding policy was reviewed but did not address weight changes.

Based on observation, interview and record review, the facility failed to implement interventions to prevent the development and/or worsening of pressure ulcers (wounds caused by pressure) for 3 (#'s 109, 169 and 179 )of fourteen Residents reviewed for pressure ulcers resulting in pressure ulcer worsening, the development of multiple stage three and four pressure ulcers, unnecessary pain, and increased likelihood for decline in overall health status. In addition, the facility failed to assess, monitor, and document pressure ulcers and failed to implement interventions per professional standards of practice for 3 (#'s 19, 177, and 227) of fourteen residents reviewed for pressure ulcers resulting in lack of pressure reduction interventions, unnecessary pain, and the likelihood for decline. Findings include: Resident 109 On 9/9/19 at 12:20 PM, Resident #109's call light was noted to be on from the hallway of the facility. On 9/9/19 at 12:30 PM, a contact isolation precaution sign was noted outside of Resident #109's room revealing Personal Protective Equipment (PPE) of gown and gloves were to be worn upon entry to the room. Family Member II was present in the room and standing in the doorway wearing a gown. When asked, Family Member II indicated they were looking for staff and stated, (Resident #109) hasn't been repositioned since I got here. When asked what time they arrived at the facility, Family Member II replied, 9:30 (AM). Upon donning PPE and entering the room, Resident #109 was observed laying in their bed, positioned on their back with their heels directly on the mattress. A dressing was observed on the Resident's right ear. The Resident had an air mattress in place on their bed. The air mattress controller as set to alternating air, max/350 pound weight. An interview was conducted with Family Member II at this time. With further inquiry regarding the Resident not being repositioned, Family Member II stated, I have to put the light (call light) on from them (staff) to come turn (Resident #109). When asked about the dressing covering Resident #109's right ear, Family Member II stated, It's a sore, (Resident #109) got there from them not turning them. (Resident #109) has sores all along their back from not being turned too. I would be so scared if I was not here every day. The CNAs (Nursing Assistants) are not on it and the weekends are scarce. Turning (the Resident) has always been a problem here. With further inquiry, Family Member II indicated they relocated closer to the facility in order to visit the Resident daily and ensure they are being cared for and turned. At 12:35 PM on 9/9/19, Nursing Assistant JJ and Nursing Assistant KK entered the Resident's room. Nursing Assistant JJ and Nursing Assistant KK repositioned the Resident by placing foam wedges on both of the Resident's sides with the Resident's spine directly on the mattress. Nursing Assistant JJ and Nursing Assistant KK did not check the Resident's brief for incontinence while they were in the room. An interview was conducted with the Assistant Director of Nursing (ADON) on 9/9/19 at 4:00 PM. When queried regarding what the air mattress settings are supposed to be set at, the ADON stated, Their (the Residents weight). An observation of Resident #109's air mattress and settings were completed with the ADON at this time. The air mattress was set at max/350 pounds. The ADON changed the settings. When queried, the ADON indicated the air mattress do not provide proper pressure reduction when not set correctly. Record review on 9/10/19 revealed Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required total assistance to perform Activities of Daily Living (ADLs). Review of Resident #109's care plans on 9/10/19 revealed the following care plans: Resident is at Risk for pressure injury r/t (related to): Incontinence, Limited Mobility. admitted with ABD surgical wound, skin injury to (Left) ischium area. 5/1/19 IDT review 5/10/19 IDT review, new skin breakdown noted to back, tx (treatment) ordered .6/16/19 DTI (Deep Tissue Injury) noted to back and (L) ischium. 6/26/19 IDT review UTD to back (debrided), (L)ischium & coccyx . (Initiated: 4/15/19; Revised: 8/9/19). Care plan interventions included: -Check for incontinence Q (every) 2 hours/PRN (as needed) (Initiated: 4/15/19) -Elevate extremities . (Initiated: 4/15/19) -Provide peri-care/protective cream with each incontinent episode (Initiated: 4/15/19; Revised: 8/30/19) -Turn/reposition Q (every) 2 hours/PRN (as needed) (Initiated: 4/15/19; Revised: 8/30/19) -[MEDICATION NAME] solution to (L) ischium and back areas (Initiated: 6/16/19) The resident has actual impairment to skin integrity of the (Abdomen, (L) ischium r/t fragile skin, recent surgery, nutritional concerns AEB (As Evidenced By) (L)ischium stg (stage) III and Abdominal incision dehisced . (Initiated: 4/18/19; Revised: 5/2/19). Care plan interventions included: -Assess skin daily with ADLs/ report changes (Initiated: 4/18/19) -Monitor/document location, size and treatment of [REDACTED]. to MD (Initiated: 4/18/19) On 9/10/19 at 10:31 AM, Resident #109 was observed in their room. The Resident was in bed positioned slightly on their right side. The right side of the Resident's head was positioned down and a wound dressing was noted under the Resident's head. On 9/11/19 at 5:20 AM, Resident #109 was observed laying in their bed, positioned on their back. The Resident's heels were noted to be directly on the mattress and the Resident had a dressing in place on their right ear. On 9/11/19 at 6:47 AM, Resident #109 was observed in their bed. The Resident was positioned on their back with their heels on the mattress. The Resident's head was turned to the right, with their right ear down. The dressing covering the Resident's right ear remained visible. An interview was conducted with Wound Care Nurse U on 9/11/19 at 10:46 AM. When queried regarding Resident #109's pressure ulcers, Nurse U indicated the Resident had multiple pressure ulcers with wet to dry dressings. When asked if the pressure ulcers were facility acquired, Nurse U revealed all the pressure ulcers were facility acquired. Wound care observation for Resident #109 was completed with Wound Care Nurse U and Nursing Assistant GG on 9/11/19 at 10:52 AM. Upon entering the room, Resident #109 was observed positioned directly on their back with their heels placed on the mattress. The Resident's head was turned to the right with their right ear placed downward. Nurse U proceeded to remove the dressing covering Resident's right ear. The outer cartilage of Resident #109's right ear was dusky and dark gray in color with an open area approximately one centimeter (cm) in length noted on the mid distal aspect of the outer cartilage. Nurse U then reapplied the dry ABD dressing previously in place over the Resident's ear. Nurse U then uncovered the Resident to complete the dressing changes on their back pressure ulcers. When they uncovered the Resident, a raised, fluid filled blister was observed on the Resident's right, upper thigh. When asked, Nurse U revealed the blister was new and had not been reported to them. Nurse U measured the blister at this time and stated, It's 1 (cm) by 0.9 (cm). Nurse U and Nursing Assistant GG then rolled the Resident on their right side. Nurse U removed the dressings covering the Resident's back. The wound was located directly over the Resident's spine was red and white in color with visible depth. The tissue directly surrounding the wound bed was pale white in color. Nurse U measured the wound bed at this time and stated, It's 11 (cm) by 1.3 (cm). Nurse U did not measure the depth of the wound bed. Resident #109 had another pressure ulcer, located just below and to the left of the pressure ulcer on their spine. The center of the wound bed was black and gray in color surrounding by pale, white tissue. Nurse U measured the pressure ulcer and stated, It's 5 (cm) by 1.5 (cm) and unstageable. Nurse U then proceeded to remove the dressing from Resident #109's coccyx/sacral pressure ulcer. The removed dressing had a moderate amount of odorous, pale colored drainage noted. The wound was approximately the size of a softball in width. The wound edges were unattached and there was visible undermining. The base of the wound bed was red and white in color with brown/gray colored tissue noted on the proximal edge of the wound. Nurse U measured the wound at this time and stated, 7 (cm) x 11 (cm) X 3 (cm) with 3.5 (cm) tunneling. After reapplying a dressing, Nurse U removed the dressing on the Resident's left ischium pressure ulcer. The wound was irregularly shaped and approximately the size of a softball in width. The wound edges were unattached, and the base was red, white, and pink in color with visible undermining and tunneling. Nurse U measured the wound at this time and stated, It's 6 (cm) by 11 (cm) X 2.5 (cm) with 2.4 (cm) undermining from the 11 to two o'clock positions. Nurse U then reapplied a dressing to the wound bed. Nurse U and Nursing Assistant GG then repositioned the Resident to complete the dressing change on the Resident's right ischium pressure ulcer. When Nurse U removed the dressing covering the Resident's right ischial pressure ulcer, a foul odor was noted. The wound was irregularly shaped and approximately the size of a baseball. The wound bed was black and brown in color with a scaly appearance. Nurse U measured the wound and stated, It's 6 (cm) by 6 (cm). When queried regarding the Resident's heels, Nurse U indicated the Resident's heels were intact. When asked to view the skin on their heels, Nurse U proceeded to remove the Resident's socks. A dark purple colored area was observed on the Resident's left heel. When asked about the area, Nurse U assessed the area and said, The area surrounding the purple is non-blanchable. It's a new DTI (Deep Tissue Injury). Nurse U then measured the pressure injury on the Resident's heel and stated, It's 2 (cm) by 3 (cm). When queried regarding interventions to prevent Resident #109 from developing pressure ulcers including pressure ulcers on their heels, Nurse U indicated the Resident used to have heel boots but did not return to the facility with them after they were hospitalized . With further inquiry regarding prevention, Nurse U indicated the Resident had an air mattress and was turned. When queried regarding observations of the Resident in the same position, Nurse U and Nursing Assistant GG did not provide an explanation. Review of Resident #109's documentation in the Electronic Medical Record (EMR) on 9/12/19 revealed the Resident was admitted with a pressure ulcer on their left buttocks. A detailed review of skin/wound documentation further revealed Resident #109 developed multiple pressure ulcers while at the facility. The skin/wound documentation included the following: -4/12/19: Admit/Readmit Screener . Left Buttocks . Type: Pressure .Length: 3 cm (centimeter) . Width: 3 cm . -4/17/19: Skin Assessment . (L) ischium . Type: Pressure . Length: 1 cm . Width: 1.5 cm . Depth 0.1 cm Stage: III . -4/24/19: Skin Assessment . (L) ischium . Type: Pressure . Length: 3 cm . Width: 1.5 cm . Depth 0.1 cm Stage: III . 5/1/19: Skin Assessment . (L) ischium . Type: Pressure . Length: 2 cm . Width: 2 cm . Depth 0.1 cm Stage: IV (Four) . -5/10/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure Stage: I (one) . (L) ischium . Type: Pressure . Length: 2 cm . Width: 1 cm . Depth 0.1 cm Stage: III . -5/21/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure Stage: I (one) . (L) ischium . Type: Pressure . Length: 2 cm . Width: 1 cm . Depth 0.1 cm Stage: IV (Four) . -5/27/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure Stage: I (one) . (L) ischium . Type: Pressure . Length: 2 cm . Width: 1.3 cm . Depth 0.1 cm Stage: IV (Four) . -6/9/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure Stage: I (one) . (L) ischium . Type: Pressure . Length: 2 cm . Width: 1 cm . Depth 0.1 cm Stage: III . -6/16/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure . Length 10 cm . Width . 6 cm . Stage: Unstagable . (L) ischium . Type: Pressure . Length: 4 cm . Width: 5 cm . Depth UTD (Unable to Determine) . Stage: Unstageable . -6/23/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure . Length 13 cm . Width . 6 cm . Depth UTD (Unable to Determine) . Stage: Unstageable . (L) ischium . Type: Pressure . Length: 5 cm . Width: 5 cm . Depth UTD (Unable to Determine) . Stage: Unstageable . Bilateral Buttocks . Type: Pressure . Length: 5 cm . Width: 7 cm . Depth UTD (Unable to Determine) . Stage: Unstageable . -6/23/19: Skin/Wound Note . Seen by surgical team for multiple skin injuries. Coccyx, (L)ischium and bilateral are 100% necrosis, current treatment appropriate for sites, future debridement pending. Also surgical site on ABD is clean and healing . -6/26/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure . Length 15 cm . Width 8 cm . Depth 5 cm . Stage: IV (four) . (L) ischium . Type: Pressure . Length: 5 cm . Width: 7 cm . Depth UTD (Unable to Determine) . Stage: Unstageable . Bilateral Buttocks . Type: Pressure . Length: 5 cm . Width: 7 cm . Depth UTD (Unable to Determine) . Stage: Unstageable . -6/26/19: Skin/Wound Note . Seen by surgical wound care team for debridement and assessment to large back skin injury . large eschar tissue removed from back area to expose full thickness wound exposing muscle tissue, heavy pockets of serosanguineous drainage noted . 15 x 8 x 5 cm skin injury under care . -7/2/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure . Length 12.5 cm .Width 4 cm . Depth 3 cm . Stage: IV . (L) ischium . Type: Pressure . Length: 8 cm . Width: 8 cm . Depth 3 cm . Stage: IV . -7/8/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure . Length 11.5 cm . Width 5 cm . Depth 3 cm . Stage: IV . Coccyx .Type: Pressure . Length: 6 cm . Width: 6.5 cm . Depth UTD . Stage: Unstageable . (L) ischium . Type: Pressure . Length: 10 cm . Width: 8 cm . Depth 0.4 cm . Stage: IV . -7/11/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure . Length 10 cm . Width 5 cm . Depth 3 cm . Stage: IV . Coccyx .Type: Pressure . Length: 6 cm . Width: 7 cm . Depth UTD . Stage: Unstageable . (L) ischium . Type: Pressure . Length: 10 cm . Width: 8 cm . Depth 0.5 cm . Stage: IV . -7/14/19: Skin/Wound Note . The patient has 3 wounds which we have addressed . This wound measures 10.5 x 3 cm . stage IV into the muscle. The patient has a sacral decubitus ulcer which is unstageable measuring 6 x 7 cm with necrotic eschar. There is an 8 x 9 cm left ischial decubitus ulcer which is mostly clean but with some [MEDICATION NAME] exudate at the level of the ischial periosteum. This is stage IV . -7/18/19: Skin Assessment . Coccyx .Type: Pressure . Length: 7 cm . Width: 7 cm . Depth UTD . Stage: Unstageable . Back . Type: Pressure . Length 10 cm . Width 4 cm . Depth 0.3 cm . Stage: IV . (L) ischium . Type: Pressure . Length: 7.5 cm . Width: 8.5 cm . Depth 1 cm . Stage: IV . -7/21/19: Skin Assessment . Coccyx .Type: Pressure . Length: 7 cm . Width: 8 cm . Depth 1 cm . Stage: IV . Back . Type: Pressure . Length 10 cm . Width 4 cm . Depth 0.1 cm . Stage: IV . (L) ischium . Type: Pressure . Length: 6 cm . Width: 7 cm . Depth 1 cm . Stage: IV . -8/6/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure . Length 12 cm . Width 4.5 cm . Depth 0.3 cm . Stage: IV . Right Ear .Type: Pressure . Length: 3 cm . Width: 0.5 cm . Depth 0.1 cm . Stage: III . Coccyx .Type: Pressure . Length: 8 cm . Width: 9.5 cm . Depth 0.3 cm . Stage: IV . (L) ischium . Type: Pressure . Length: 8 cm . Width: 6.5 cm . Depth 0.3 cm . Stage: IV . -8/11/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure . Length 12 cm . Width 4.5 cm . Depth 0.3 cm . Stage: IV . Right Ear .Type: Pressure . Length: 3 cm . Width: 0.5 cm . Depth 0.1 cm . Stage: III . Coccyx .Type: Pressure . Length: 6.5 cm . Width: 8 cm . Depth 0.5 cm . Stage: IV . (L) ischium . Type: Pressure . Length: 8 cm . Width: 8 cm . Depth 0.4 cm . Stage: IV . -8/26/19: Admit/Readmit Screener . Sacrum . Sacrum stage 4, Left/Right ischium left/right lateral heel red and boggy right ear superior back . No measurements were contained in the assessment. -9/6/19: Skin Assessment . Vertebrae (upper-mid) . Type: Pressure . Length 8 cm . Width 1.2 cm . Depth 0.2 cm . Stage: IV . Right Ear .Type: Pressure . Length: 0.2 cm . Width: 0.3 cm . Depth 0.0 cm . Stage: III . Coccyx .Type: Pressure . Length: 6 cm . Width: 11 cm . Depth 1 cm . Stage: IV . Right Back . Type: Pressure . Length 3 cm . Width 1 cm . Depth UTD . Stage: Unstageable . Mid back area . Type: Pressure . Length 5 cm . Width 1 cm . Depth UTD cm . Stage: Unstageable . (R) ischium . Type: Pressure . Length 6 cm . Width 6 cm . Depth UTD . Stage: Unstageable . (L) ischium . Type: Pressure . Length: 7 cm . Width: 11 cm . Depth 2 cm . Stage: IV . On 9/12/19 at 11:37 AM, Resident #109 was observed in their room. The Resident was positioned with pillows on both of their sides, directly on their back. Resident 169 Record review on 9/10/19 revealed Resident #169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required total assistance to perform Activities of Daily Living (ADLs). Review of Resident #169's care plans on 9/9/19 revealed a care plan entitled, Resident has pressure injury . (Initiated: 7/30/19; Revised: 8/15/19). Care plan interventions included: -Provide peri-care/protective cream with each incontinent episode (Initiated: 7/30/19) -Turn/reposition Q 2 hours/PRN (Initiated: 7/30/19) -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (Initiated: 7/30/19) On 9/10/19 at 10:32 AM, Resident #169 was observed in their bed. The Resident was laying in bed and positioned slightly on their left side. The Resident had a tracheotomy and was receiving mechanical ventilation. When spoke to, the Resident would make eye contact, nod, and smile but was unable to verbally respond to questions. Both of the Resident's legs were bent at the hips and knees and their left wrist was bent inward. When asked if they were able to move their legs and left wrist, the Resident nodded to indicate no. The Resident's legs and feet were positioned directly on the bed with their legs and ankles crossed. On 9/11/19 at 6:20 AM and 10:19 AM, Resident #169 was observed in their bed, positioned slightly on their left side. The Resident's legs and feet were positioned directly on the bed with their legs and ankles crossed. Review of Resident #169's wound documentation on 9/11/19 revealed the following: -7/30/19: Admit/Readmit Screener . Left lower leg (front) . Type: Pressure . Length: 2.5 cm . Width: 2 cm . Stage II (two) . Left ankle (outer) . Type: Pressure . Length: 1.5 cm . Width: 1 cm . Stage II (two) . Left heel . Type: Pressure . Stage: N/A . -8/6/19: Skin Assessment Wound Nurse . Coccyx .Type: Pressure . Length: 4 cm . Width: 3.5 cm . Depth: 0.3 cm . Stage IV (four) . (L) lateral leg . Abrasion . --8/14/19: Skin Assessment Wound Nurse . Coccyx .Type: Pressure . Length: 3.5 cm . Width: 3 cm . Depth: 0.2 cm . Stage IV (four) . (L) lateral leg . Abrasion . -8/22/19: Skin Assessment Wound Nurse . Coccyx .Type: Pressure . Length: 4.2 cm . Width: 2 cm . Depth: 0.4 cm . Stage IV (four) . Right Buttocks . Type: Pressure . Length: 1 cm . Width: 1 cm . Depth: 0.1 cm . Stage III . Right Ankle (outer) . Type: Pressure . Length: 1.5 cm . Width: 1 cm . Depth: UTD . Stage: Unstageable . -8/30/19: Skin Assessment Wound Nurse . Coccyx .Type: Pressure . Length: 4 cm . Width: 2 cm . Depth: 0.3 cm . Stage IV (four) . Right Buttocks . Type: Pressure . Length: 1 cm . Width: 1 cm . Depth: 0.1 cm . Stage III . Right Ankle (outer) . Type: Pressure . Length: 1.5 cm . Width: 1 cm . Depth: UTD . Stage: Unstageable . An interview was conducted with Wound Care Nurse U on 9/11/19 at 10:20 AM. When queried regarding Resident #169's skin and wounds, Nurse U stated, (Resident #169) was admitted with a pressure ulcer and they have a facility acquired stage three on their ankle. Wound care observation for Resident #169 was completed at this time. The Resident was observed to be in bed and positioned slightly on their left side. The Resident's legs and feet were positioned directly on the bed with their legs and ankles crossed. Upon uncovering and repositioning the Resident to complete wound care, a raised, fluid filled area was observed on the Resident's left, lateral lower leg proximal to their ankle and where their leg had been directly on the mattress. When queried, Nurse U indicated the area was new. Nurse U measured the area at this time and stated, It's 1 (cm) by 1.9 (cm). When asked if the area was a pressure injury, Nurse U replied, Yes. Nurse U then removed the dressing on the Resident's left lateral (outer) ankle. The wound was irregularly shaped and approximately the size of a half dollar. The wound bed was red in color with pale white surrounding tissue. Undermining was visible. Nurse U measured the wound at this time and stated, It's 1.7 (cm) by 2 (cm) by 0.4 (cm). Nurse U then applied a 4 x 4 gauze covered with a [MEDICATION NAME] dressing over both areas. After completed the dressing change on the Resident's ankle, Nurse U proceeded to complete the dressing change on the Resident's coccyx pressure ulcer. The removed dressing had a moderate amount of thick, brown colored, odorous drainage. The wound was oblong shaped with irregular and unattached edges. The wound bed was red with white colored tissue and visible tunneling and undermining. Nurse U measured the wound at this time and stated, It's 4 (cm) by 2.5 (cm) by 1 (cm). After wound care was completed, Resident #169 was positioned slightly on their left side with their legs touching each other and their lower extremities placed directly against the mattress. When queried regarding pressure reduction and the development of a new pressure ulcer, Nurse U indicated they would inform the Physician. When asked about documentation indicating the Resident had pressure ulcers on their right lower extremity when their wounds were on the left, Nurse U was unable to provide an explanation. When asked why the last documented wound assessment was completed on 8/30/19, Nurse U revealed they were the only wound nurse for the facility and have modified their working hours due to returning to school. Nurse U stated, I do my best but I can't be everywhere. No further explanation was provided. When queried regarding interventions to prevent pressure, Nurse U indicated wound treatments are changed as deemed necessary and the Resident has an air mattress in place. Resident 179 On 9/9/19 at 10:37 AM, during the initial tour, Resident #179 was observed lying in bed on their back with their legs pointed to the right side. Resident #179's heels were observed to be lying against the mattress with no foot protection devices in place. A sign above their bed read, Make sure heel protectors are on while in bed. Resident #179 was able to answer a few yes or no questions but unable to be interviewed regarding their care. On 9/9/19 at 2:22 PM, Resident #179 was observed lying in bed with their legs pointed to the right and was still on their back with no heel protectors on. On 9/10/19 at 8:35 AM, 9:38 AM, and 10:05 AM, Resident #179 was observed lying in bed on their back with their legs pointed to the right side. Resident #179 did not have heel protectors in place and their heels were touching the mattress. On 9/10/19 at 10:28 AM, morning care was for Resident #179 was observed with Nurse Z and Certified Nursing Assistant (CNA) DD. Resident #179 was observed to be lying on their back with their legs pointed toward the right side. A positioning wedge was on the right side of the resident and Resident #179 did not have heel protectors in place. Morning care was completed with Resident #179 without difficulty. The resident was unable to turn themselves in bed but was able to help hold themselves on their side using a grab bar while staff performed care. The resident was compliant with care as CNA DD explained each step. Upon finishing the care, CNA DD placed the positioning wedge back under #179's right side, and the resident's legs pointed toward the right. No heel protectors were placed on the resident's feet before staff left the room. On 9/10/19 at 12:27 PM, 2:26 PM, 2:54 PM, 3:10 PM, 3:25 PM, and 3:37 PM, Resident #179 was observed lying in bed with their legs pointed toward the right side with no heel protectors in place. On 9/11/19 at 6:10 AM, 6:41 AM, 7:20 AM, 8:25 AM, 8:43 AM, 9:12 AM, 10:45 AM, and 11:12 AM, and 12:00 PM, Resident #179 was observed lying in bed with their legs pointed toward the right side with no heel protectors in place. On 9/11/19 at 12:06 PM, a wound care observations for Resident #179 was conducted with Wound Care Nurse (WCN) U and Nurse Z. When queried regarding Resident #179's coccyx pressure ulcer, WCN U stated, I had ordered [MEDICATION NAME] not that long ago and it (the wound) was almost healed. (Nurse Z) saw the wound (this past) Saturday and wrote new orders. There was slough (yellow/gray/cream colored dead tissue) present and it had opened back up. When queried regarding expectation for turning and repositioning residents in bed, WCN U stated, Anyone bed bound should be turned every two hours or more frequently if needed. Thank goodness (Nurse Z) caught that it worsened, honestly. You can't make people do their job. It is a standard of practice and they know that. The last order for the wound was [MEDICATION NAME] and it was a tiny spot. When queried regarding Resident #179 having heel protectors on while in bed, WCN U nodded at the sign above the resident's bed and stated, Yes, they are supposed to have heel protectors on. When queried regarding Resident #179 being observed in the same position in bed since 6:10 AM, WCN U stated, They know (Resident #179) is supposed to be turned. I will have a talk with the manager. It is just unacceptable. Wound care for Resident #179's coccyx wound was then observed. WCN U looked at the wound and stated, This has worsened. It's good (Nurse Z) changed the treatment order and assessed the change. It's now 3.5 centimeters (cm) (length) by 2.2cm (width). It's unstageable with necrotic dark slough. I can't determine the depth. On 9/12/19 at 8:19 AM, the Director of Nursing (DON) was interview and queried regarding the facility's policy/procedure for turning and repositioning residents in bed. The DON stated, Every two hours or more often if necessary, staff should be turning and repositioning for those that are bed bound. When asked what the expectation is for turning and repositioning a resident in bed who has a pressure ulcer, the DON stated, I would expect someone with a bed sore to be turned and repositioned so it doesn't get worse. When queried regarding expectation for carrying out orders for pressure ulcer prevention, such as heel protectors, the DON stated,If there is an order, it should be carried out, unless the patient refuses. But refusals should be documented. A review of Resident #179's skin assessments revealed the following: Admission: 03/06/2019 Date: 03/26/2019 Coccyx Pressure 5cm (length) 2.5cm (width) 0.2cm (depth) III (stage). (Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling.) Date: 05/07/2019 Coccyx Pressure 3.5cm 1cm 0.2cm III Date: 06/05/2019 Coccyx Pressure 0.4cm 0.1cm 0.1cm III Date: 07/03/2019 Coccyx Pressure 0.8cm 0.6cm 0.1cm III Date: 07/10/2019 Coccyx Pressure 0.8cm 0.5cm 0.1cm III Date: 07/19/2019 Coccyx Pressure 0.5cm 0.5cm 0.1cm III Date: 08/07/2019 Coccyx Pressure 0.4cm 0.5cm 0.1cm III Date: 08/16/2019 Coccyx Pressure 0.4cm 0.4cm 0.1cm III Date: 9/8/2019 SKIN OBSERVATION TOOL - (Licensed Nurse) Observed coccyx wound to have some black necrotic areas to the wound bed, no drainage observed, foul odor observed- alerted weekend supervisor for wound nurse to follow to start new tx (treatment) regimen. Date: 9/9/2019 Sacrum 4cm x 4cm x 0.5cm skin injury noted. Approximately 90% slough, 10% necrosis. A review of Resident #179's progress notes revealed the following: 8/16/19 12:03 (PM) Type: Interdisciplinary Team (IDT) Note Note Text: Reviewed by IDT for healing skin injury to coccyx area. This site is clean less than 0.5cm diameter, partial thickness skin loss site. [MEDICATION NAME] dressing applied and changed Q3days (every three days) continues to be an effective treatment regime at this time. Supplements given at med pass to aid skin healing. Followed by wound care weekly. Author: (WCN U). 8/29/19 14:32 (2:32 PM) Type: Interdisciplinary Team Note Reviewed by IDT r/t (related to) skin injury, treatment continued to coccyx/sacral see wound assessment for measurements, area continues to stabilize, no changes to treatment at this time, wound care will continue to follow. 9/8/19 14:31 (2:31 PM) Type: Skin/Wound Note Note Text: Writer went to change residents dressing to coccyx d/t (due to) being soiled with BM (bowel movement) per CNA, removed residents [MEDICATION NAME] dressing dated for 9/8/19 observed black necrotic tissue to wound bed, no drainage observed at the time, foul odor coming from wound, no bleeding observed. Writer cleansed wound with Normal Saline, patted dry, applied a wet to dry dressing with 4X4 and ABD Pad, applied wedge cushion so resident remains on side, tolerated well. Resident to be turned & repositioned Q2hrs. Writer notified Supervisor in order for wound nurse to follow resident and start a new tx (treatment) regimen .Author: (Nurse Z). A review of Resident #179's orders revealed the following: Cleanse coccyx wound with NS (Normal Saline), apply [MEDICATION NAME] dressing every 3 days and PRN (as needed) 6/5/19. Heel protectors to bil (bilateral) feet 3/6/19. A review of Resident #179's care plan revealed the following: BED MOBILITY: The resident requires extensive to total assistance of (2) staff for repositioning and turning in bed as necessary Date Initiated: 06/22/2015 Revision on: 03/14/2017. Focus: The resident has impairment to skin integrity r/t (related to) fragile skin,occasional incontinence of bowel and bladder, DX (diagnosis) of [MEDICAL CONDITIONS], hx (history) of ulcers, decline in nutritional status 3/6/19 readmit skin injury present . 3/13/19 ([MEDICATION NAME]) and 3/19 [MEDICATION NAME] .4/25/19 .UTD (unstageable) to coccyx, treatment changed 4/30/19 coccyx area impr(TRUNCATED)

Based on observation, interview and record review, the facility failed to operationalize a Restorative Nursing Program to prevent development of a contracture for one (# 191) of 10 Residents reviewed for limited Range of Motion (ROM), resulting in a lack of the provision of Restorative Nursing Services and development of bilateral foot drop (ankle contractures). Additionally, the facility failed to implement and operationalize a Restorative Nursing Program to maintain level of functioning and/or prevent contractures for four (#'s 109, 121, 169, and 201) of 10 Residents reviewed for limited Range of Motion (ROM), resulting in a lack of assessment of ROM, Residents with contractures and impaired mobility not receiving Restorative Nursing services, and the likelihood of pain and increased limitations in ROM. Findings include: Record review on 9/9/19 revealed Resident #191 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required total assistance to perform Activities of Daily Living (ADLs). The MDS additionally indicated the Resident had no functional limitations in ROM. Review of Resident #191's care plans on 9/9/19 revealed a care plan entitled, The resident has an ADL self-care performance deficit r/t (related to) Limited Mobility, Limited ROM (Revised: 1/25/19). The care plan did not include interventions pertaining to ROM. Another care plan entitled, The resident is ventilator dependent r/t ALS (1/12/19) included the intervention, Maintain muscle strength with active/active assuasive/passive ROM and prevent contractures with use of splints (Initiated: 1/12/19). On 9/9/19 at 2:47 PM, Resident #191 was observed in their room, positioned on their back in bed. The Resident had a tracheotomy and was receiving mechanical ventilation. An interview was conducted with the Resident at this time. When speaking, the Resident's voice was hoarse and quiet and they would often mouth words. The Resident's toes were pointed down, away from their head and fingers on both hands were noted to be bend inward. When asked if they were able to move their hands, Resident #191 indicated they were stiff and stated, My (spouse) tries to straighten them out. They like them straight. When asked if they were receiving Restorative Nursing services for ROM, Resident #191 stated, No. Two hand/arm splints were observed on a stand in the corner and two heel boots were noted on a stand under the Resident's TV. On 9/10/19 at 10:11 AM, Resident #191 was observed in their room. The Resident was laying in bed, positioned on their back. The two hand/arm splints were in the same place in the room in the corner on a stand and the heel boots were on the stand under the TV. When asked about the hand/wrist braces, Resident #191 revealed staff rarely put them on. On 9/10/19 at 4:07 PM, an interview was conducted with the Assistant Director of Nursing (ADON). When asked if Resident #191 was recieving Restorative Nursing Services, the ADON reviewed the Restorative log documenation and stated, They are not on Restorative at this time. Review of Resident #191's Restorative Therapy Program Recommendations (Dated 2/20/19) on 9/11/19 revealed, To maintain PROM- BLE PROM exercises 20 reps five times a week for 12 weeks . Review of provided Restorative task documentation at this time revealed the following: -March: Received Restorative 11 times during the month -April 2019: Received Restorative 14 times during the month -May 2019: Received Restorative 10 times during the month -June 2019: Received Restorative 10 times during the month An interview was conducted with the Assistant Director of Nursing (ADON) on 9/11/19 at 1:03 PM. When queried regarding Restorative documentation revealing Resident #191 did not receive five times per week as ordered, the ADON stated, I don't have staff to do that (Restorative five times per week). The ADON then stated, We are working on getting a real Restorative program going. It needs work, I know that. We need more staff. An interview was conducted with the Director of Nursing (DON) on 9/12/19 at 8:52 AM, When queried regarding Restorative Nursing not being completed as ordered, the DON did not provide an explanation. When asked about Resident #191 not currently receiving restorative, the DON replied, The floor staff should be doing it. It should be a task. The DON reviewed Resident #191's medical record at this time and stated, It is not on there, not on the care plan. I will have to talk to MDS. An interview was conducted with Nursing Assistant PP on 9/12/19 at 11:47 AM. When queried regarding the hand/wrist braces observed in Resident #191's room and when they are applied, Nursing Assistant PP revealed they do not apply the braces. An interview was conducted with the Assistant Director of Nursing (ADON) on 9/12/19 at 12:48 PM. When queried regarding Resident #191's MDS indicating the Resident had no limitations in ROM, observation of limitations, and assessment of ROM, the ADON provided PT Evaluation and Plan of Treatment documentation. Review of the documentation revealed the following: -PT Evaluation and Plan of Treatment . Certification Period: 1/14/19 -3/12/19 . RLE ROM=WFL (Within Functional Limits) (PROM=WFL); LLE ROM=WFL (PROM=WFL) . -OT (Occupational Therapy) Evaluation and Plan of Treatment . Certification Period: 9/9/19-11/7/19 . RUE (Right Upper Extremity) ROM= Impaired (PROM); LUE (Left Upper Extremity) = Impaired (AAROM) . RUE pain upon movement . -PT Evaluation and Plan of Treatment . Certification Period: 9/9/19-11/7/19 . RLE ROM = Impaired (Stiffness towards the end of ROM and bilateral foot drop); LLE ROM = Impaired . Patient has had a significant decline from PLOF (Previous Level of Functioning) . When queried regarding the documentation indicating Resident #191 developed limitation in ROM including bilateral foot drop, the ADON did not provide further explanation. On 9/9/19 at 12:30 PM, Resident #109 was observed in their room. The Resident was in their bed, positioned on their back with their heel directly on the mattress. When asked questions, the Resident would attempt to respond but had difficulty speaking. Family Member II was present in the room and an interview was conducted at this time. When asked about Resident #109's ROM and if they were receiving Restorative nursing services, Family Member II indicated the Resident is unable to move themselves and stated, They (Restorative staff) come in maybe two times a week. Record review on 9/10/19 revealed Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required total assistance to perform Activities of Daily Living (ADLs). The MDS further indicated the Resident had functional limitations in ROM in both their upper and lower extremities. Review of Resident #109's care plans on 9/10/19 revealed a care plan entitled, The resident has an ADL self-care performance deficit r/t (related to) Limited Mobility, Limited ROM . (Initiated: 4/13/19; Revised: 8/27/19). The care plan did not include interventions pertaining to Passive Range of Motion (PROM) and/or Active Range of Motion (AROM). An interview was conducted with the Assistant Director of Nursing (ADON) on 9/9/19. When queried regarding Restorative Nursing documentation, the ADON indicated documentation is completed on paper forms which are maintained in a separate binder. When asked if Resident #109 was receiving restorative, the ADON reviewed their documentation and indicated they were. Review on 9/11/19 of Resident #109's Restorative Program dated 4/17/19, revealed, Type of Device: B (Bilateral) hand rolls to prevent contractures. Instructions: Provide B (Bilateral) UE (Upper Extremity) ROM and gentle stretching as tolerated. Notify Therapy/Nursing Staff if signs of contracture is noticed in Bilat hands or wrists. Review of Restorative task documentation revealed the following: -April 2019: No Restorative documentation provided -May 2019: Restorative received six times -June 2019: Restorative received 10 times -July 2019: Restorative received 10 times -August 2019: Restorative received 10 times -September 2019: Restorative received 2 times An interview and record review of Resident #109's PT Evaluation and Plan of Treatment Documentation occurred with the ADON on 9/11/19 at 1:03 PM. Documentation review revealed the following: -Certification Period: 4/14/19-6/7/19 . RLE ROM = Impaired (Hip/knee- PROM Ankle planterflexed with deformity); LLE ROM = Impaired (Hip/knee- PROM Ankle planterflexed with deformity) . -Certification Period: 9/9/19-9/9/19 . RLE ROM = Impaired (reduced for all 3 joints); LLE ROM = Impaired (Reduced for all LE joints) . When queried regarding Resident #109's decline in mobility function from (MONTH) to (MONTH) 2019 and not receiving Restorative as ordered, the ADON indicated indicated the facility does not have always have staff to provide Restorative because the Restorative Aides get pulled to the floor when the facility needs staff and are not able to provide Restorative services. Record review on 9/9/19 revealed Resident #169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required total assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident had function limitation in ROM in one side of their upper extremities and one side of their lower lower extremities. Review of Resident #169's care plans on 9/9/10 revealed a care plan entitled, The resident has an ADL self-care performance deficit r/t [MEDICAL CONDITION] (one sided paralysis), Impaired balance, Limited Mobility, Limited ROM (Initiated: 7/30/19). The care plan did not include interventions pertaining to PROM and/or AROM. An interview was conducted with the Assistant Director of Nursing (ADON) on 9/9/19. When queried if Resident #169 was receiving Restorative Nursing Services, the ADON reviewed their documentation and indicated the Resident was not on the Restorative caseload. With further inquiry, regarding the Resident having limitations in mobility, the DON revealed Restorative Nursing is initiated after a referral is completed by Therapy Services. On 9/10/19 at 10:32 AM, Resident #169 was observed in their bed. The Resident was laying in bed and positioned slightly on their left side. The Resident had a tracheotomy and was receiving mechanical ventilation. When spoke to, the Resident would make eye contact, nod, and smile but was unable to verbally respond to questions. Both of the Resident's legs were bent at the hips and knees and their left wrist was bent inward. The Resident's hips were bent at approximately a 70 degree angle and their knees were bent at approximately a 40 degree angle. When asked if they were able to move their legs and left wrist, the Resident nodded to indicate no. An interview was conducted and observation of Resident #169 was completed with Nurse U and Nursing Assistant GG on 9/11/19 at 10:20 AM. The Resident was observed to be in bed and positioned slightly on their left side. The Resident's legs and feet were positioned directly on the bed with their legs bent and their ankles crossed. The Resident's left wrist was bent inward. When queried regarding Resident #169's mobility, Nursing Assistant GG indicated the Resident was only able to move one wrist normally. An interview was conducted with the ADON on 9/11/19 at 1:03 PM. When queried regarding observation of Resident #169's contactures, not receiving restorative nursing services to prevent further decline and limitations in mobility, and the Resident's baseline mobility upon admission including facility policy/procedure to assessment and monitor ROM to prevent additional and/or worsening contractures, the ADON replied, I will have to look. Review of Resident #169's progress note documentation in the Electronic Medical Record (EMR) on 9/11/19 did not reveal any documentation pertaining to contractures and/or ROM assessment. Review of Resident #169's Admit/Readmit Screener assessment, dated 7/30/19, at this time did not reveal any documentation of limitations in ROM. On 9/12/19 at 12:53 PM, an interview was completed with the ADON. When queried regarding Resident #169, the ADON stated, (Resident #169) was evaluated by PT (Physical Therapy) on 9/5/19. When asked why the Resident was not evaluated until 9/5/19 when they were admitted on [DATE], the ADON replied, I'm not sure. Record review of provided PT Evaluation and Plan of Treatment (dated 9/5/19) at this time revealed, Reason for Referral: Per nsg (nursing) staff, Resident is getting still in BLE (Bilateral Lower Extremities) so at risk of developing further contracture . at risk of developing pressure sore with braces so PT will manage the BLE contractures by stretching . RLE ROM= Impaired . LLE ROM= Impaired . With further inquiry regarding the observations and staff statements pertaining the the Resident's upper extremity also having impaired mobility and not being included in the assessment, the ADON was unable to provide an explanation. Record review of facility policy entitled, Rehabilitation Program- Nursing Rehab and Restorative (Revised 8/2018) revealed, The departments of therapy and nursing services provide a program of preventive rehabilitative, restorative, and supportive care . Rehabilitative, Restorative and support services include: Proper body position and alignment . Ambulation . Active and passive range of motion . Splint/brace application . On 9/9/19 at 12:57 PM, Resident #129 was observed in bed and did not respond to the knocking on the door or the greeting. On 9/10/19 at 5:20 AM, 6:30 AM, and 9:40 AM, Resident #129's limbs remained in the same position and appeared contracted. On 9/12/19 at 12:09 PM, Certified Nurses Aide (CNA LL) was asked about Resident #129's Range of Motion (ROM) and stated, They've been contracted a long time. I do Passive Range of Motion (PROM) with care and the Restorative aide sees (R#129) too. On 9/12/19 at 12:16 PM, Restorative CNA S was asked to provide documentation of Resident #129 receiving restorative therapy and stated, (R#210) receives treatment three times a week, but I'm pulled to the floor a lot. Review of restorative therapy documentation revealed that Resident #129 received restorative therapy twice between (MONTH) 2nd and (MONTH) 8th, twice between (MONTH) 30th and (MONTH) 6th, twice between (MONTH) 21st and (MONTH) 21st, twice between (MONTH) 22nd and (MONTH) 28th, twice between (MONTH) 5th and (MONTH) 11th, once between (MONTH) 26th and (MONTH) 1st, twice between (MONTH) between (MONTH) 2nd and (MONTH) 8th, and none at all from (MONTH) 9th and (MONTH) 14th. Record review of Resident #129's Electronic Health Record (EHR) revealed R#129 was admitted into the facility on [DATE] readmitted on [DATE] with [DIAGNOSES REDACTED]. A recent Minimum Data Set (MDS) dated , 7/10/19 revealed Resident #129 had a severely impaired cognition and was totally dependent on staff for Activities of Daily Living (ADLs). Section G0400 (the assessment of ROM) of the MDS revealed had impaired ROM of both lower extremities. On 9/9/19 at 1:21 PM, Resident # 201 was observed lying in bed and did not respond to the knocking on the door or being greeted. R#201 appeared to have both legs pulled up towards their abdomen and chest. On 9/11/19 at 11:49 PM, Resident #201 was observed up in a rolling recliner near the day/dining room. Resident #201's legs were observed to be pulled up towards their abdomen and chest. On 9/12/19 at 12:09 PM, Certified Nurses Aide (CNA R) was asked about Resident #210's Range of Motion (ROM) of the legs and stated, I do passive ROM when I give a bed bath. (Resident #201)'s Hospice and they give the showers. On 9/12/19 at 12:16 PM, Restorative CNA S was asked to provide documentation of Resident #210 receiving restorative and stated, They are not on my list. When Physical Therapy (PT) is done they give me a paper, they did not give me a paper. On 9/12/19 at 12:35 PM, PT manager (PTM T) was asked about Resident #201 receiving Restorative therapy and stated, (Resident #201) is hospice. (Resident #201) had PT in (YEAR) and Restorative works with them for three months then discontinues the treatment. Record review of Resident #201's Electronic Health Record (EHR) revealed that Resident #201 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum (MDS) data set [DATE] revealed R#210 had severely impaired cognition and required extensive assistance with Activities of Daily Living (ADLs) including bed mobility and transfers. Section G0400 (the assessment of ROM) of the MDS revealed had impaired ROM of both lower extremities. A review of the facilities policy titled, Rehabilitation Program-Nursing Rehab & Restorative, dated 8/2018, revealed, Standard: The departments of therapy and nursing services provide a program of preventive rehabilitative, restorative, and supportive care. The restorative coordinated and evaluates progress .

This citation pertains to intake # 9 Based on interview and record review, the facility failed to effectively monitor a change in condition, and provide prompt acute care following a fall for one resident (R902) of two residents reviewed for falls resulting in the resident waiting eight hours in pain with a [MEDICAL CONDITION] and bruising to the face. Findings include: On 5/21/19 at 8:33 AM, confidential family member A was interviewed regarding R902's fall. They stated that they were notified that R902 fell at approximately 11:30 PM on 4/11/19, and that they had sustained slight bruising to the face. Confidential Family Member A stated that it wasn't until 7:30am the following morning that they were notified that R902 was being sent to the hospital. Upon arrival to the hospital, Confidential Family Member A stated that R902's face had massive black and blue bruising, a lump on their cheek and a [MEDICAL CONDITION]. Confidential Family Member A further stated that R902 was due to be discharged from the facility in two days however, as a result of the [MEDICAL CONDITION], R902 is currently in rehabilitation at another facility, and still has bruising to the face from the fall. A review of R902's medical record revealed that they were admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed the following progress notes written by Nurse C: 4/12/2019 23:44 (11:44pm) Health Status Note-Writer doing rounds Resident observed lying on floor on right side. ROM (range of motion) done limited ROM to right leg small abrasion on right lower arm. C/O (complain of) right leg pain. Assisted back to bed with four person and blanket. Supervisor, family, and physician aware. Slight swelling to right cheek. Xray ordered. 4/12/2019 03:00 (3:00am) Health Status Note Late Entry: Xray result received linear lucency in right lesser trochanter compatible with acute non displaced fracture ([MEDICAL CONDITION]) versus artifact Message left for physician. Awaiting return call at this time. 4/12/2019 03:07 (3:07am) Health Status Note: Received X-ray report. Supervisor & physician aware. Awaiting for return call. WCTM (will continue to monitor). 4/12/2019 05:46 (5:46am) Health Status Note: Resident resting in bed at this time.c/o pain on R/t (right) leg while turning. Tylenol given as ordered. Bruise on R/T side of face & (and) orbit area.R/t side of face slight swollen. Ice pack applied. Physician notified about the x-ray report. Waiting for return call. Neuro (neurological) check in progress. Supervisor aware. WCTM. The medical record progress notes showed no indication that the Director of Nursing (DON) was aware of R902's fall and fracture, or that the on-call physician was spoken to regarding R902's x-ray results. Further review of the medical record revealed the following progress notes written by Nurse B. 4/12/2019 07:46 (7:46 AM) Health Status Note: Upon during (doing) walk thru at approx.(approximately) 0615 (6:15am) writer noticed that resident was asleep with facial bruising red in color, right eye swollen shut. Writer awakened resident to find out what happened, (R902) stated (R902) rolled (out) of bed a few hours before. States my whole right side is in pain right now. Writer spoke with the night nurse whom states resident x-ray results just came in showing a non-displaced trochanter FX (fracture). to the right side, per night (Nurse C) messaged physician with no response. Writer immediately notified ADON (Assistant Director of Nursing) given permission to transport to ER (emergency room ). Writer then notified (Doctor) at approx. 0704 (7:04am) via phone and was given orders to transport to (local hospital) via Med-star transport. Residents daughter & resident (R902) notified. Secretary called notified Medstar- per transport they will be here within the hour. Staff cleansed and prepped resident for pick-up, awaiting Med-star. 4/12/2019 10:43 (10:43am) Discharge Summary Note: Med-Star arrived at approx 0804 (8:04am) to transport resident to the hospital. Resident left at approx. 0820 (8:20am) via stretcher to (local hospital), resident alert & aware of what's going on at the time of transfer . At time of transfer skin assessed, resident has a blackened eye which is swollen shut. Red & dark blue bruising to the entire right side of her face, some pain & swelling to the right hip area, otherwise skin intact. Resident had a low-grade temp of 99.2 Now (new) order of [MEDICATION NAME] 650mg (milligrams) was given & tolerated well . On 5/21/19 at 1:20 PM, an interview was completed with Nurse B regarding R902's fall. Nurse B stated, I was doing my morning rounds and I looked in R902's room and I could see bruising to (R902's) face. It actually scared me because it was dark and I could see it, and the midnight nurse hadn't told me what happened. I asked (R902) what happened, and (R902) stated that they fell out of bed. I pulled back the covers and I could instantly see that something was out of place. (R902) stated that their entire body hurt. I was unable to complete range of motion. I called the ADON and had (R902) sent to the hospital. Nurse B was asked the procedure that they follow when they are unable to get in contact with the physician to obtain an order to send a resident to the hospital. Nurse B stated, I contact the Director of Nursing. On 5/21/19 at 1:19 PM, Nurse C was attempted to be reached by phone for an interview to no avail. Message left however, no return phone call was received by the end of the survey. On 5/21/19 at 2:29 PM, an interview was conducted with Unit Manager (UM D ) who completed the incident and accident report for R902. UM D was asked if they knew what occurred. UM D explained that they weren't working that night, but the midnight shift nurse stated that R902 reported that they were dreaming and fell out of bed. UM D was asked what the procedure is for sending a resident to the hospital when the physician can't be reached. UM D stated, The DON's phone number is available for anyone to contact if the physician cannot be reached. On 5/21/19 at 3:00 PM, the DON was interviewed regarding R902's fall and the delay in them being sent to the hospital. The DON explained that if (R902) was resting comfortably and not complaining of pain then they may not have sent them. The DON was asked the facility's procedure for staff when they are unable to reach the physician when a resident needs to be sent to the hospital. The DON stated, They should be calling me, and then I'll call the on-call physician, and if they don't answer, I'll contact the medical director. On 5/21/19 at 4:00 PM, during the exit conference, preliminary concerns were discussed with the Administrator and the DON. In regards to R902 not being provided with timely acute care, the Administrator stated, (R902) was going to be more comfortable here than at the hospital. Orto (Orthopedic) wouldn't have seen (R902) in the middle of the night. A review of the facility's policy, Changes in Resident Condition outlines the following, An acute change of condition (AC[NAME]) is a sudden, clinically important change from a resident's established/documented baseline in physical, cognitive, behavioral or functional status. Examples (not all-inclusive) mental status change, bleeding, chest pain, combative/aggressive behavior, decrease oral intake, depressed mood/reactive depression, [MEDICAL CONDITION], significant change in physical or mental baseline the facility staff must recognize an AC[NAME] and identify its nature, cause, and severity to effectively assess, treat, monitor the AC[NAME]. The facility's Emergency Transfer to Acute Care Hospital policy outlines the following, Resident will be safely transferred to an acute care hospital to provide emergency or necessary care that is unavailable at the long term care facility.

Based on observation, interview and record review, the facility failed to provide and document interventions to prevent the worsening of an existing pressure ulcer for one (#16) of four residents reviewed for pressure ulcers, resulting in the worsening of an existing pressure ulcer and the likelihood for further wound decline and possible infection. Findings include: A review of R#16's Minimum Data Set (MDS) assessment dated [DATE] revealed the following: R#16 was admitted into the facility on [DATE] and most recently readmitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident's cognitive skills for daily decision making were severely impaired, and required extensive-to-total assistance from staff for activities of daily living (ADLs). Further review of R#16's medical record and, Wound Care Progress Note, dated, 11/20/18, revealed the following: History of Present Illness: It has a history of a stage III ulcer to the coccyx which is unstageable today. Nursing notes indicate wound declined approximately 3 days ago. Patient continues to have limited cognition and limited mobility incontinent. (R#16) also continues on tube feedings .Skin: Toxic ucler was a Stage III but now is unstageable. This ulcer shows a severe decline since I seen (R#16) 1 week ago. The wound measures 9 cm (centimeters) in length by 9 cm in width with a depth UTD (Unable to Determine). Wound base is now 100% necrotic (dead tissue) and dark with surrounding excoriation and minimal serosanguineous (thin, pale red drainage) .Plan: Coccyx ulcer is now unstageable . At this time, further review revealed a, Wound Care Progress Note, dated, 11/13/2018, with the following documentation: History of Present Illness: Chronic stage 3 ulcer to coccyx. Patient has limited cognition. (R#16) continues to be incontinent .is full care .Skin: Patient's coccyx ulcer stage III shows improvement again this week. This wound is nearly closed again .does have a history of this wound closing in the past and reopening. Today the wound measures 0.3 cm in length by 0.3 cm in width with a depth of 0.1 cm. Wound is very shallow with pink granular (healing) tissue and only scant serous (thin, clear) drainage. Periwound area (skin surrounding open wound) is slightly moist as (R#16) is incontinent of urine but there is no erythemia no induration no maceration. (R#16) is debilitated and nonambulatory .is on tube feedings .has very limited cognition .Plan: Patient is doing very well with the current treatment and the wound is nearly closed again .Maintain good skin hygiene and incontinence care . On 11/29/18 at 1:31 PM, an observation was made of wound care for R#16's pressure ulcer with Nurse F. When queried regarding R#16's wound, Nurse F stated, (R#16) was readmitted here from the hospital with this wound. Two weeks ago it was very small, the last couple of weeks it has increased in size. It went from almost closed to 9 cm x 9 cm, unstageable. They should be turning, checking, and changing (the resident) every two hours. I am concerned about the decline over about six days. The resident was then turned on their side and their cloth incontinence brief was un-snapped to expose the wound on the residents coccyx area. Two blue cloth transfer pads were observed under the resident. Upon opening the brief, the material in the middle, extending to the back, was noted to be soaked in yellow urine, and the resident's skin appeared moist. When queried regarding the saturated brief, Nurse F indicated they did not believe the resident was changed 30 minutes prior to wound care as they had requested. Nurse F indicated the decline of the wound was potentially related to moisture, and stated, Sometimes when they are supposed to have seven CNAs (Certified Nursing Assistant) on the unit and they are running with four, priority things like this don't get done like they should. It's frustrating to have it almost healed and then come back and see it opened like this. R#16 was observed to have an open area with slough (yellow/white dead tissue) on the left buttock. The edges of the wound appeared fragile, moist, and white-ish, and the skin surrounding the wound appeared fragile, moist, and pink. On 11/29/18 at 2:03 PM, R#16's assigned nurse, Nurse Y was approached and queried about the observations made of the resident's brief prior to the wound care observation. Nurse Y stated, No, (R#16) was not changed. (Nurse F) showed me, and that was not changed 30 minutes before the wound care like it was supposed to be. Nurse Y was then asked about their familiarity with R#16's wound decline and stated, I saw it on the 16th (of (MONTH) (YEAR)) and then didn't work that weekend. It was worse when I came back after the weekend, I'm not sure if just pee caused all the breakdown. I do know one thing, (that wound) was almost healed. On 11/29/18 at 2:27 PM, Unit Manager and Nurse AA (UM AA) was asked to review R#16's electronic medical record (EMR) for documentation of turning, repositioning, and incontinence care. R#16's, Documentation Survey Report v2, for (MONTH) (YEAR) was reviewed in the EHR with UM AA and revealed the following: The system response, -97-not applicable, was entered into the, Turn/Reposition Q (every) 2 hours/PRN (as needed), intervention/task for R#16 on Saturday, (MONTH) 17th at 8:00 AM, 10:00 AM, 12:00 PM, and 2:00 PM. Lack of documentation (blank areas) under the, Turn/Reposition Q2 hours/PRN, intervention/task was noted for the following dates and times: Saturday, (MONTH) 17th at 4:00 PM and 6:00 PM; Sunday, (MONTH) 18th at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, and 6:00 PM; and Monday, (MONTH) 19th at 12:00 AM, 2:00 AM, 4:00 AM, and 6:00 AM. Lack of documentation (blank areas) under the B&B - Bowel and Bladder Elimination, intervention/task and Peri-care with protective cream after each incontinence, intervention/task was noted for the following: Friday, (MONTH) 16th Day shift (0700-1500), Sunday, (MONTH) 18th Day shift (0700-1500), and Monday, (MONTH) 19th Night shift (2300-0700). UM AA acknowledged the gaps in the documentation but provided no further explanation. On 11/29/18 at 2:41 PM, Nurse F was interviewed and asked to review the wound care documentation for R#16. Nurse F reviewed their treatment and skin records and stated the following while reviewing them, On 10/8, (R#16's pressure ulcer) was 1 cm x 1.9 cm and it was granular. On 10/16, moisture affected areas extended to the buttocks but the wound was still granulation and (the wound measured) 1.5 cm x 1 cm. On 10/23, it was 1.2 x 1.2 cm, improvement was noted with granulation and mild periwound [DIAGNOSES REDACTED], but the moisture affected areas from the previous week looked better. On 11/7, it was 0.4 cm x 0.5 cm, I told (R#16's family member) we were going to have it healed soon, I was excited! Then on 11/13 it was 0.3 c, x 0.4 cm, and I was like, 'Yes! Okay!' Then on 11/20, it was 9 cm x 9 cm and unstageable. That was the entire wound area and the open area definitely had a significant increase. All I could think was, 'What happened?' At this time, the above mentioned gaps in R#16's intervention/task documentation were reviewed with Nurse F and they responded, I thought maybe (R#16) had a bad week. That might be where my gap is though. It makes sense that's where the gaps are, because that's the time in question before the decline. I know that if a wound heals fast, it can break down fast. I wish I had more answers. On 11/30/18 at 11:51 AM, CNA BB was interviewed via phone and queried about caring for R#16 anytime between 11/16/18 and 11/19/18. CNA BB stated, I think that's one of the days we were short. I think we had 3 or 4 aides. I was only able to get some charting done, not all. CNA BB then explained that they knew which tasks were to be completed for R#16, such as turning, repositioning, and using a cloth brief. When asked if CNA BB was able to complete those tasks during the time period in question, CNA BB stated, I don't remember. I don't remember specifically. I don't know if the resident was turned and repositioned. I don't remember seeing the wound. I do remember when they were talking about the wound after, they said it had gotten bigger. On 11/30/18 at 11:56 AM, an interview was conducted with the Director of Nursing (DON). When asked if they were aware of the status of R#16's pressure ulcer, the DON replied, I know (R#16) had one week where (they) were doing really well and then there was a decline. (R#16) has a history of healing and reopening pressure ulcers. I know they have cloth briefs on (R#16) because the plastic ones would make things worse. The DON then reviewed the gaps in the above mentioned intervention/task documentation. The DON acknowledged the gaps and stated,I see day shift didn't document on the 18th, I see on the 19th . The DON then was asked to review the wound care documentation for R#16 from 11/13/18 compared to 11/20/18. The DON was asked about the gaps in intervention/task documentation and the documented decline in the resident's pressure ulcer and stated, I see what you're saying. I have no other thoughts on that. A review of R#16's care plan revealed the following: Focus: Resident is incontinent of B & B Cognitive impairment .Interventions: Check AND CHANGE every two hours and as needed; Peri-care/protective cream after each incontinence . Focus: The resident has actual impairment to skin integrity r/t (related to) fragile skin,incontinent of bowel and bladder,needs assistance with bed mobility .Interventions: Keep skin clean and dry; Turn/Reposition Q 2 hours/PRN . A review of facility document titled, Wound Care Policy, dated 8-16, revealed the following: .Prevention: .2. Repositioning is a common effective intervention for residents at risk for development of pressure injuries. Residents who are at risk will be repositioned in their bed or chair a minimum of every two hours. An increase in scheduled repositioning will be adjusted for those residents who have a pressure injury or who are deemed higher risk due to previous pressure ulcers or multiple risk factors .3. Management of moisture due to urine and fecal incontinence will be managed for each resident .Use of protective ointments/creams after incontinent episodes will be implemented for those residents found to be at high risk .

Based on observation, interview and record review, the facility failed to safely transfer one (#172) of six sampled residents reviewed for accidents, resulting in the resident obtaining a fall with a left femur fracture. Findings include: On 11/27/18 at 9:55 AM, during the initial tour of the facility R#172 was observed and was queried on any falls that had occurred at the facility. R#172 stated, I fell and broke my leg, it is all healed up now. On 11/29/18 at 4:07 PM, a review of an incident report involving R#172 indicated the following: Date: 8/4/18 at 9:30 AM, Incident Description: Writer informed by resident that they fell . Resident stated, 'I fell yesterday on my knee.' Immediate Action Taken: Writer assessed resident, no swelling or bruising noted. Resident (complained of) c/o pain to left knee. X-Ray ordered. Witnesses: Certified Nursing Assistant (CNA W) stated, The resident was lowered to the floor. On 11/29/18 at 4:15 PM, a review of a progress noted dated 8/4/18 at 11:33 PM, involving R#172 indicated the following, Type: Transfer to Hospital Summary. Note Text: Resident transferred to (emergency room ) ER (Local Hospital) due to left knee xray result with a fracture on left femur . On 11/29/18 at 4:23 PM, a review of R#172's Care Plan indicated the following, Focus: The resident has an ADL self-care performance deficient (related to) r/t Limited Mobility, Impaired balance, Poor Safety Awareness, generalized weakness, obesity, [MEDICAL CONDITION]. Date Initiated: 5/12/2017. Revision Date: 5/22/2017. Interventions: Transfer: The resident requires Mechanical Lift (Hoyer) with (2) staff assistance for transfers. Date Initiated: 5/20/2016. Revision: 5/28/2016. On 11/29/18 at 4:27 PM, a review of R#172's Kardex indicated the following, Transfer: The resident requires Mechanical Lift (Hoyer) with (2) staff assistance for transfers. On 11/29/18 at 4:35 PM, a review of a document titled Employee Counseling Form dated 8/9/18 regarding CNA W involving R#172 and the incident which occurred on 8/3/18, indicated the following: Problem: Failure to follow Resident Plan of care and Facility Policy regards to incident on resident .Resulting in injury to resident (FX). Employee Approach: Met with CNA on 8/9/18 at 7 AM, no comment. Department Head Comment: Termination. On 11/30/18 at 8:00 AM, a review of R#172's medical record indicated, an admission to the facility on [DATE] and a readmission on 8/10/18 with [DIAGNOSES REDACTED]. A review R#172's Minimum Data Set (MDS) assessment dated [DATE], indicated an intact cognition with extensive to total assistance for activities of daily living (ADLs). On 11/30/18 at 8:15 AM, R#172 was queried on the incident involving them which occurred on 8/3/18. R#172 stated, Staff attempted to transfer me and dropped me. R#172 indicated that they could not remember the name of the staff who was attempting to transfer them. On 11/30/18 at 8:25 AM, Nurse S was queried regarding the incident which occurred involving R#172 on 8/3/18. Nurse S stated, The resident reported the fall to me the next day and I called the doctor. Nurse S was queried on the transfer status for R#172 and stated, The resident is a hoyer lift transfer. On 11/30/18 at 8:30 AM, Nurse T was queried regarding the incident which occurred involving R#172 on 8/3/18. Nurse T stated, I was off during that time but I heard about it. Nurse T was queried on the transfer status for R#172 and stated, Hoyer lift transfer. On 11/30/18 at 8:35 AM, CNA U was queried on the incident which occurred involving R#172 on 8/3/18. CNA U stated, I was on medical leave during that time. CNA U was queried on the transfer status for R#172 and stated, The resident is a two person hoyer lift transfer. On 11/30/18 at 8:45 AM, CNA V was queried on the incident which occurred involving R#172 on 8/3/18. CNA V stated, I'm contingent, I was not on the floor. CNA V was queried on the transfer status for R#172 and stated, It's a two person hoyer lift. On 11/30/18 at 9:17 AM, the incident report dated 8/4/18 involving R#172 was reviewed with the Assistant Director of Nursing (ADON). The ADON stated, CNA W did not follow the care plan and was terminated. On 11/30/18 at 10:15 AM, a phone call was attempted to CNA W regarding the incident which occurred involving R#172 on 8/3/18. The individual who answered the phone stated, You have the wrong number. On 11/30/18 at 11:23 AM, CNA X was queried on the incident which occurred involving R#172 on 8/3/18. CNA X stated, I was working with another resident and was told by the nurse to go help CNA W with a transfer of R#172 into their wheelchair. The resident was nervous. We did a two person transfer with the resident to their wheelchair, the resident slipped, we put them down, and then picked them up again and put them in the wheelchair. CNA X was queried on if R#172 should have been transferred using a hoyer lift. CNA X stated, Yes, they are a two person assist with a hoyer lift. CNA X admitted that she did not look at R#172's kardex or care plan before transferring the resident. CNA X indicated that she typically looks at a resident's care plan and/or kardex before transferring a resident. CNA X stated, I was in a rush. They were not my resident. Sorry about that. On 11/30/18 at 11:57 AM, the Director of Nursing (DON) was queried regarding the incident which occurred involving R#172 on 8/3/18. The DON stated, CNA W did not check the kardex, CNA W was trying to get the transfer done quickly. I fired her. CNA W did not dispute that she did not check the resident's kardex. On 11/30/18 at 12:20 PM, a facility policy titled Responsibilities of Direct Care Staff with a review date of 9/2016 indicated, 2. Review plan of care on Kiosk for resident specific needs.

This citation pertains to Intake # MI 653. Based on observation, interview and record review, the facility failed to take immediate action upon finding a resident who had not returned from a smoking break on 8/29/18 at 7:40 PM, for one resident (R#503) of three residents sampled for elopement risk, from a total sample of five residents. An Immediate Jeopardy (IJ) arose when the facility identified that R#503 had eloped on 8/29/18 and the staff were unaware of the whereabouts of the Resident. R#503 walked to a gas station located one half mile from the facility and was transported to the hospital by the local police department and was seen by a physician on 8/30/18 at 12:49 AM. This had the likelihood to cause serious harm, injury, or death. The Administrator was notified of the IJ on 9/11/18 at 2:43 PM and a plan of correction was requested to remove the immediacy. The IJ started on 8/29/18 and was identified on 9/11/18. The IJ was removed on 8/30/18 based on the facility's implementation of the plan of removal as verified onsite. Findings include: On 9/11/18 at 8:45 AM, the Director of Nursing (DON) was asked about the facility reported incident involving the elopement of R#503, and provided the following timeline, On 8/29/18 at 7:40 PM, (R#503) went outside to smoke, telling the receptionist that 'I'll be back in 15 minutes.' The receptionist went to the offices to turn the machines and lights off and lock the doors. When finished, (the receptionist) went outside to see if any residents were still outside, didn't see anyone and locked the front doors. The DON was asked for the Investigation and Accident report (I&A), the facility's policy and procedures for smoking, and elopement. On 9/11/18 at 9:00 AM, record review of R#503's medical record was conducted. R#503 was admitted into the facility on [DATE] and readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed that the Brief Interview for Mental Status (BIMS) was not conducted. However the facility's Mental Status Questionnaire dated, 8/28/18 revealed R#503 scored four out of 11 points indicating Severe [MEDICAL CONDITION]. Section G of the MDS revealed R#503 was independent and required no supervision with eating, transfers, and ambulation (walking). Further review of R#503's record revealed that an elopement risk assessment and elopement care plan had not been entered into the Electronic Medical Record (EMR). On 9/11/18 at 9:25 AM, the I&A was reviewed. Events prior to the missing resident. 7:00 PM, the CNA saw the resident in the TV room properly dressed and wearing shoes prior to the CNA's lunch break. Upon return around 7:45 the resident was not in the room, this was not unusual as the resident was a heavy smoker, the CNA looked in the room again at 9:45 PM, R#503 was not there and assumed the resident was out smoking and did not look. At 7:30 the Charge Nurse saw the resident in the TV room, gave the resident medications and did not see the resident after that. At 7:40 PM the receptionist saw the resident leaving and said the doors will be locked at 8:00 PM, R#503 said, 'I'll be back in 15 minutes.' The receptionist did her closing routine , checked the smoking areas around the building, assumed R#503 entered the building while (the receptionist) was not at the desk. At 10:00 PM the Charge Nurse, started the shift, was interrupted by staff to discuss the assignment and did not make initial rounds. The Charge Nurse was made aware R#503 was not in the room by a CNA taking vital signs at 11:20 PM. Review of the facility's policy and procedure titled Elopement dated as Revised 8/30/18, reflected the changes made after R#503 eloped on 8/29/18, as did the policy and procedure titled Smoking Policy dated as Revised 8/30/18. On 9/11/18 at 12:02 PM, the DON was asked for R#503's Elopement Assessment and care plan for elopement and stated, We didn't do one, by history he didn't need one. On 9/12/18 at 10:30 AM, a tour of the exterior of the facility was conducted. It was observed that video cameras were mounted at the main entrance, the ambulance entrance, the north entrance (for employees only) and the east entrance. After the tour the DON was asked if there was video recording of R#503 leaving the facility's property and stated, No. On 9/12/18 at 12:49 PM, the Receptionist was asked about R#503's elopement and stated, I saw (R#503) leaving at 7:40 for a cigarette. I went to turn off the lights in the offices and lock the doors. I have to lock the patio doors, (R#503) was not outside when I locked the front doors, so I locked the doors and left. On 9/12/18 at 10:02 AM, the facility provided the following removal plan for the immediate jeopardy regarding the failure to prevent the elopement of R#503 on 8/29/18. The IJ removal plan: Element 1 Following facility and neighborhood search, the resident was found at the hospital unharmed. The resident did not return to the facility. Element 2 The processes that lead to this occurrence have been identified that the staff responsible for this resident did not properly perform walking rounds and ensure the residents safety. On 8/30/18 the IDT has completed a review of the Wandering risk assessments on all residents and completed any that were missing and updated others to assure that these reflected the resident's current status. This includes the risk of wandering away from the building and plans of care updated for those residents designated as high risk. All assessments and care plans were completed on 8/31/2018. This risk assessment will be added to the assessments completed on admission/ readmission as well as with every quarterly, annual and significant change of status assessment. If risk scores increase, care plan interventions will be adjusted to reflect the change. Element 3 The Administrator and DON immediately reviewed and updated the Elopement policy to include a sign in/out sheet at the front desk implemented at 8:00am 8/30/2018. Residents are being required to sign out and in when they go outside to ensure that their whereabouts can be accounted for in an emergency. If the resident has not signed back in and is not outside, the receptionist will contact the nursing unit to ensure the resident is back on the unit. The Receptionist will check the list at mealtimes as well as prior to the end of her shift at 8:00pm. All receptionists and relief staff have been educated on this process by the DON by 8/31/2018. On 8/30/2018, Resident services staff began education with all residents who smoke as well as those who go outside unattended. The receptionist assisted with education as residents came to the lobby to go outside requiring them to sign out and in. Residents are being educated on an ongoing basis. Residents intending to go off the facility grounds will still be required to sign out at the nurse's station in the LOA book. The Smoking Policy was reviewed and updated by the IDT led by the NHA and DON on 8/30/2018 at 1:30pm. This policy now includes those residents requesting to smoke after 8:00pm must do so on the one east patio and must be accompanied by a staff member or family member. The doors to this area are alarmed and staff will be required to re-alarm. Once the receptionist leaves at 8:00pm, no resident will be allowed to smoke in front of the building. Resident Services staff is having all smokers sign receipt of the updated policy. This education was completed started on 08/30/18 and completed on 09/04/2018. Evidence was entered into the resident's medical records. The NHA and DON reviewed the policy on walking rounds on 8/30/18. They deemed it appropriate. Education has been provided to nursing staff. As of 9/12/2018, 85% of the staff signed acknowledgments of the education excluding those on planned leaves and this will continue until all nursing staff have signed the acknowledgement. The DON / designee educated the licensed nurses on proper report including LOA's and appointments, policy changes, and immediate notification of LNHA and DON if a resident is suspected missing. The nurses signed acknowledgement of the requirement for these actions. The NHA had the revised smoking policy and the information about the required signing out and in with receptionist when going outside added the admission packet on 8/31/2018. The DON educated the admissions staff and nursing supervisors on the changes and the need to communicate these during the admission process. This will include signing for receipt of the policies. This education was complete on 08/31/2018. Element #4 The Director of Nursing will audit all new/readmissions weekly to ensure that wandering risk assessments have been completed and care plans appropriately implemented beginning (MONTH) 4, (YEAR). These audits will be forwarded to the QA committee. The Director of Resident Services will be reviewing the education provided to the residents by her staff members RE: smoking policy and sign out/in requirements Daily audits initiated on 8/31/2018 where a staff member will take the sign out book outside and verified that all who are out there have signed out. This will be completed prior to meals, as well as at random times throughout the shift. This will be continued until determined unnecessary by the IDT. The Administrator is responsible for sustained compliance.

This citation pertains to intake # . Based on interview and record review, the facility failed to prevent verbal and/or physical abuse for 2 (#'s 701 and 703) of 3 sampled residents from abuse from a total sample of three residents, resulting in the mental anguish,anger and fear of dependent residents that reside in the facility. Findings include: Resident #701 On 1/17/18 at 9:20 a.m., a record review of the Minimum Data Set (MDS) assessment and face sheet for Resident #701 revealed that the resident was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that Resident #701 had a Brief Interview of Mental Status (BIMS) of 8, indicating that Resident #701 had a moderately impaired cognition. The MDS also revealed that Resident #701 required extensive assist with toileting and was incontinent of bowel and bladder. On 1/17/18 at 9:30 a.m., a review of the Activity of Daily Living (ADL) care plan created on 5/27/17 contained the intervention under, Toilet Use: The Resident requires extensive assistance by (1) staff for toileting. This intervention was initiated on 6/23/15. On 1/17/18 at 9:35 a.m., Resident #701 was observed up in the wheel chair dressed and groomed. Resident #701 was interviewed and had clear speech, knew that he was in a nursing facility, knew what city he lived in and thought it was year 2017. Resident #701 was asked if he recalled an incident of being struck by a staff member that helped take care of him. Resident #701 replied, Yes. Resident #701 was able to re-call the name of the Certified Nurse Assistant (CNA A). Resident #701 stated, I remember he (CNA A) hit me and swore at me. Resident #701 was asked where he was struck and pointed he to his left chest area. Resident #701 lifted his shirt to reveal his left chest, no abnormal findings during the observation was noted. Resident #701 was asked if he knew why (CNA A) had swore at him and hit him and stated, I don't remember why but it hurt. It made me nervous. That was the first time (CNA A) hit me but he has swore at me before. On 1/17/18 at 9:40 a.m., an interview was completed with the Director of Nursing (DON) in regards to CNA A 's employment history. The DON stated, This broke my heart. We had to fire him (CNA A). He was always an outstanding employee. He had no disciplines in his file. He had outstanding attendance .if he would have just admitted to it, if he had just snapped, but he denied it. He was an employee here for [AGE] years. We called the police twice but they never came. We did report his (CNA A) license to the CNA registry. On 1/17/18 at 10:15 a.m., during a tour of the unit that CNA A was responsible for, Assistant Director of Nursing (ADON B) stated, It (the incident) scared the hell out of me! He (CNA A) was my go to guy. He was always calm. Everyone liked him. I don't know if this was an isolated incident. On 1/17/18 at 10:25 a.m., an interview was conducted with CNA C. According to CNA C, she regularly took care of Resident #701 on the day shift. CNA C stated, He (Resident #701) tells you what he wants and doesn't want. CNA C was asked if she was familiar with the incident that occurred between Resident #701 and CNA A. CNA C stated, I heard about it, I asked (Resident #701) about it and he told me the exact same thing he told everyone else. I was stunned. I didn't really know (CNA A) because I worked day shift and he worked afternoons. On 1/17/18 at 10:35 a.m., an interview was completed with the Administrator in regards to the employment of CNA A. The Administrator stated, I did not know him. I have 300 employees. The Administrator was queried in regards to the investigation of the allegation of CNA A striking and yelling at Resident #701. The Administrator stated, We did review the camera system and it did match up to what (CNA D) said. We had to let (CNA A) go and we called the police and reported it to the CNA registry. On 1/17/18 at 10:40 a.m., an interview was attempted via phone with CNA D who had witnessed the incident between Resident #701 and CNA A. CNA D did not answer the phone or call back. According to the DON, CNA A was in court and the facility would attempt to contact her as well but was unsuccessful by the end of the survey. On 1/17/18 at 11:15 a.m., a record review of the progress notes and skin assessments in the Electronic Medical Record (EMR) for the month of January 2018 for Resident #701 was completed. According to the EMR, there was one skin assessment completed for 1/9/18 with no significant findings. A progress noted date 1/2/18 15:44 (3:44 p.m.) stated .Small bruise noted to chest area . A progress note dated 1/2/18 16:47 (4:47 p.m.) stated, Discoloration to left side of Resident (#701) chest area after staff witnessed a confrontation with a CNA. CNA no longer works here and investigation was completed . On 1/17/18 at 11:20 a.m., an attempt to interview CNA A via phone was made. A male answered the phone and stated, You have the wrong number. The facility did not have any other phone numbers to contact the former employee with. On 1/17/18 at 11:25 a.m., a record review of the employee statements was completed in regards to the investigation of the incident between CNA A and Resident #701. The statement written by the Director of Resident Services (Employee D) was reviewed and contained an interview between Employee D and Resident #701. The statement (dated 1/2/18) stated, (CNA A) takes care of me (Resident #701) at night. Employee D asked Resident #701 if CNA A was nice to him. Resident #701 stated, Most of the time, he yells at me when I wet the bed. Resident #701 was asked what happed on the night of 1/1/18. Resident #701 stated, He (CNA A) got mad at me and punched me in the chest, pointing to a bruised area on his chest. Employee D asked Resident #701 if the above incident has ever happened before, Resident D stated, Well, yes. On 1/17/18 at 11:30 a.m., a record review of the document titled, Termination Report dated for 1/3/18 for CNA A was reviewed. On the report, the box was checked stating, Misconduct Abuse Allegation. On 1/17/18 at 11:35 a.m., a record review of the document titled, Employee Counseling Form dated 1/3/18 was reviewed and stated the following: Problem: Reported to writer Employee (CNA A) was observed striking a patient and using aggressive language. Goal: Will not strike residents. Employee Approach: (hand written and signed by CNA A) Resident need no help get in the bed and I have no problem doing my job he is a patient I care for regular. I been here [AGE] years and never had a complaint from staff/family. I have no reason to strike or use aggressive tone for any reason of my resident. On 1/17/18 at 11:40 a.m., a record review of the hand written statement signed by eye witness CNA E was completed. The document was dated for 1/2/18. The statement stated, (At 6:20 p.m.) I (CNA E) overheard (CNA A) telling a patient (Resident #701), 'Didn't I tell you to go to the toilet, You think I'm about to keep changing this[***]' Then he (CNA A) punched the man (Resident #701) twice and he told him to answer him. I was shocked and scared. I ran in a room and called my mom. After that I took a break at 6:30 (p.m.). (CNA A) got off at 10:00 p.m. I then went to check on (Resident #701). I told him that I seen and heard what happened to him. I asked why he haven't told he said he was scared. I informed him that I would. Then I looked at his chest. I didn't see a bruise. On 1/17/18 at 11:50 a.m., an interview with ADON B who had completed the interview with CNA E. ADON B stated, I rolled back the camera. I seen (CNA A and E) delivering towels to rooms. (CNA E) headed down the hallway, there was a linen cart right to the right of the doorway of (Resident #701)'s room. You can see (CNA A) reach into the cart, her face looked right into the room, she ran down the hallway very quickly in room [ROOM NUMBER] and shut the door. The next day she reported it. She was afraid to report it because she was a new CNA and he (CNA A) was a charge tech. A charge tech is a CNA that supervises other CNA's, makes out the schedule and assignments. ADON B was asked about the abuse education that CNA A and E had received. ADON B stated, They all were just inserviced on abuse back in November. ADON B was asked if CNA E was upset during the interview. ADON B stated, Oh, yes! I had no reason not to believe her. At this time the abuse inservice sign in sheets/records was requested for the nursing staff but not received by the end of the survey. Resident #703 On 1/17/18 at 10:45 a.m., a record review of Resident #703's MDS assessment and face sheet was completed. According to the face sheet, Resident #703 was admitted to the facility 7/10/17 and then readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #703 had a BIMS of 15, indicating an intact cognition. On 1/17/18 at 12:10 p.m., an interview was completed with Resident #703 who was a resident that was cared for regularly by CNA A. Resident #703 stated, I knew (CNA A). I heard him yelling and swearing in the hallway to other residents a lot. I was scared to think what he was doing to them when the door was closed. One day, when I first moved to the floor, I had decided to go to the nurse to ask her for my pills because I had not gotten them yet. Well, all the sudden I heard in a mean tone, 'Turn around, and get back to your room!' Then he repeated it, I turned around to see if he was talking to me or someone else. When I realized he was talking to me I told him he didn't need to talk to me like that. He then told me that I was wasting my time and there was no nurse up at the nursing station. Another time I had my light on and I heard him outside my room say, 'I have to help this junkie.' I confronted him about it and he told me I couldn't prove what 'junkie' he was talking about. Resident #703 was asked if she had reported CNA A to anyone. Resident #703 stated, I told the nurse, but I don't remember her name. She told me she couldn't see (CNA A) saying that. Resident #703 was asked about whether or not she knew about about the where about of CNA A. Resident #703 stated, I heard he was fired. I am glad because I was afraid of him. He (CNA A) knew exactly how and when he could talk to residents that way (in an abusive nature), he was very manipulative. I wasn't surprised he was fired. On 1/17/18 at 4:00 p.m., a record review of the facility policy titled, Abuse, Mistreatment Neglect, Exploitation and Misappropriation of Resident Property, dated 12/2017 was completed. The policy stated the following: Policy-Residents have the right to be free from abuse This includes , but not limited to, freedom from corporal punishment . Definitions-Abuse. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse .physical abuse and mental abuse .

This pertains to intake MI 004 Based on observation, interview, and record review, the facility failed to implement safety measures for one (#501) of three sampled residents identified as being at risk for falls and reviewed for accidents from a total sample of three, resulting in a fall from a highback reclining wheelchair and sustaining facial swelling, bruising, and 14 sutures. Findings include: On 6/28/16 at 10:00 a.m., per review of the clinical record and incident reports for resident #501 (R501), the following was revealed: R501 was initially admitted into the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] noted that the resident had severe cognitive impairment, required extensive assistance for ambulation and transfers, and had unsteady balance. Fall assessment dated [DATE] documented R501 was a High Risk for Falls. Review of an incident report dated 6/10/16 indicated that, DCT (direct care technician) was called to her (R501) room, observed resident (R501)on the floor face down position. Resident (R501) unable to give (description of fall). Resident (R501) assessed. Resident (R501) was in Geri-chair. Staff was with her trying to put her in bed. Staff closed the door. Resident (R501) leaned forward and fell . Noted laceration on upper lips and face. Resident taken to hospital. Duty nurse statement: DCT (staff ), the witness of the fall; she tried to put her in bed in her room; when she closed the door resident lean forward and fell on her face. PM Nurse Supervisor statement: Arrived to room, resident observed with bleeding to nostrils, laceration above upper lip, Responsive to verbal and tactile stimuli, no complaint of blurred vision or dizziness. Neuro checks initiated. Vital signs stable at the present time. No loss of consciousness. DCT (staff ''C) statement: After I took (R501) leg rests off and locked her chair I went around her to close the room door to get her ready for bed. She leaned forward and fell on the floor. The following nursing notes documented: 6/11/16 - resident (R501) came back from the hospital, noted 14 sutures on upper lips and nose area. 6/12/16 - bruise and swelling on her face and around the eyes. Review of fall risk care plan documented, The resident is at risk for falls related to unaware of safety needs, confusion, deconditioning, gait/balance problems. Intervention: high back wheelchair while eating with chair alarm, then Rock 'n Go with alarm. On 6/28/16 at 11:30 a.m., the Acting Director of Nursing (ADON) was interviewed regarding the wheelchair used by R501. The ADON stated R501's husband visits daily and verbalized difficulty pushing the Rock and Go wheelchair his wife was presently using and requested a regular wheelchair for his wife. The ADON stated R501 was on a two week trial for the use of a regular wheelchair. Physician order [REDACTED]. Occupational Therapy note of 5/15/16 documented R501 was upgraded to a high back wheel chair from a rocker chair per family request. On 6/28/16 at 9:15 a.m., R501's husband was interviewed and stated, I received a phone call at 6:00 p.m. informing me that my wife fell and they (the facility) were waiting on an ambulance. When I got here, she had a lot of blood on her face. On 6/28/16 at 12:39 p.m. DCT staff C was interviewed via phone. Staff C stated the following: On the day of the fall, I took (R501) to her room around 5:30 p.m. to get her dressed for bed. She was in a regular wheelchair. Once I took the leg rests off the wheelchair, I went to close the door. (R501) leaned forward - like she was trying to put her feet on the floor and fell face forward on the floor. Staff stated R501 sat in the wheelchair for dinner. After dinner and before going to bed, R501 had been sitting in the wheelchair for about 30 to 40 minutes while she (staff C) prepared to get her ready for bed. Staff C further stated the way R501 was positioned in her wheelchair (sitting upright) made it unsafe. Staff ''C stated the wheelchair was not able to recline. Staff C said, No one told me that it could lean back. I would always see it upright. The wheelchair was never leaned back. On 6/28/16 at 1:31 p.m., when Unit Manager staff ''A was queried about necessary DCT training for R501's wheelchair, she said, (R501's) highback wheelchair didn't recline for positioning and improved trunk control. Because it didn't recline, there was no need to DCT's to be trained to use it. On 6/28/16 at 2:30 p.m., when the Assistant Director of Nursing (ADON) was queried about fall prevention interventions for R501, she said, (R501) has poor posture and should be reclined in her wheelchair to prevent her from falling. The Director of Nursing (DON) was interviewed via the telephone on 6/28/16 at 2:59 p.m. The DON said, At the time of her fall, (R501) was not in a reclining wheelchair. She was in a high back wheelchair and it didn't recline. Some do, but her's didn't. When queried if staff needed to be educated on positioning R501 in the highback wheelchair, the DON said, No additional education was required because it was a regular wheelchair. On 6/28/16 at 12:30 p.m., when Occupational Therapist-Registered (OTR) staff B was queried about fall prevention interventions put in place for R501 and said, The Dycem mat and reclining wheelchair position were put in place to prevent the resident from falling from her chair. Staff B was queried about the degree of recline for the reclining high back wheelchair given to R501. Staff B said, For safety, it's important to know how much to recline the resident in the chair. When we issue a reclining chair like this, it (the degree of recline) should be noted. If the degree of recline is not specified, you run the risk that someone won't know and may have the resident more upright than what is safe. I would like to believe that the people that care for (R501) know she should be reclined. Therapy progress notes were reviewed with staff B and revealed the degree of wheelchair recline wasn't specified for R501. Physical Therapy Discharge Summary dated 6/9/16 documented, Patient and Caregiver Training: Instructed nursing caregivers in compensatory strategies, positioning maneuvers, positioning/pressure relieving techniques, proper body mechanics, safety sequencing techniques, safe transfer techniques, safety precautions and use of assistive devices(s) in order to facilitate improved functional abilities, increase safety and decrease need for assistance .with 100% carryover demonstrated by primary caregivers. Facility policy titled, Accident and Incident Prevention, revised 10/2015 documented the following: Employees will be trained and inserviced related to procedures for accident/incident prevention at orientation, annually and as necessary. ( )

Based on observation, interview and record review, the facility failed to provide necessary care for identified pain, failed to notify the physician concerning pain management of a Stage III pressure sore, and failed to follow it's policy on pain management for one resident (#712) out of eight residents sampled for pain management out of a total sample of 30 residents, resulting in unrelieved and unmanaged pain. Findings include: On 1/6/15 at 9:10 a.m., during an observation of resident #712's morning care and positioning on her bed, resident #712 began to moan, clench teeth, and have facial grimacing. On 1/6/15 at 9:25 a.m., review of resident #712's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #712's cognition status was severely impaired as documented in the Five Day Minimum Data Set ((MDS) dated [DATE]. Further documentation supported that Resident #712 later developed a stage three pressure ulcer (wound that involves an open area to an affected location on the body that includes the skin and muscle tissue and is painful) to her Sacrum on 12/8/14 according to the documentation from the "Treatment Record." The "Medication Administration Record" (MAR) was also reviewed for December 2014 and January 1-8, 2015 for type of medication used to relieve pain, none was found. Review of an untitled care plan for resident #712 documented the following, "potential for pain related to Arthritis, [MEDICAL CONDITION] and Pressure Sore (no date), documented in the interventions the following: -Keep the physician informed, -Monitor for signs and symptoms of pain, -Pain screen every shift and as necessary, -Administer pain medications as ordered, -Anticipate the resident's need for pain relief and respond promptly -Monitor, record and report any signs and symptoms of non-verbal pain... The MAR indicated [REDACTED]. No documentation was found supporting non-pharmacological approaches as interventions utilized or that pain medications were offered or given . Additionally, no assessment documentation for pain observation from 7 a.m. to 7 p.m. was observed on December 26th, 30th and 31st. January 1-5, 2015, pain was identified from staff "J" in the MAR's. Furthermore, the nursing notes for the aforementioned months, did not identify any pain management. On 1/6/15 at 11:00 a.m., nurse "J" was queried regarding pain management for documented pain observations for resident #712, and if a physician order [REDACTED].#712. On 1/6/15 at 2:10 p.m., during a wound care observation with staff "N", resident #712 moaned, retracted when touched, clinched teeth, and grimaced with furrowed forehead when wound care was provided. When queried what medications for pain did the resident receive, staff "N" responded, "she has no medications for pain." On 1/6/15 at 2:40 p.m., the Certified Nursing Assistant (CNA) staff "O" was interviewed concerning resident's non-verbal expressions of pain, she responded, "She does moan with her care a lot, especially to her shoulder and buttocks." Additionally, CNA staff "P" stated, "she moans and looks like she is in pain to her arm, but that some days are more than usual." On 1/8/15 at 1:00 p.m., a review of the facility's pain policy titled, "Pain Control Program" revised 9/2009, documented that "The resident will be evaluated by the nurse and or physician to identify underlying causes of pain to ensure management of these conditions...Physician will be notified to obtain orders for pain medication if necessary." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND IMPLEMENT INTERVENTIONS TO LIMIT THE POTENTIAL FOR FALLS, FOR ONE (#407) RESIDENT OF 16 RESIDENTS REVIEWED FOR FALLS OF A TOTAL SAMPLE OF 30 RESIDENTS, RESULTING IN A FALL WITH INJURIES, REQUIRING hospitalization AND treatment for [REDACTED]. FINDINGS INCLUDE: ON 1/15/13 AT 7:30 AM, RESIDENT #407 WAS OBSERVED LYING IN BED, EYES CLOSED. RESIDENT #407 HAD RED, BLACK AND BLUE BRUISING THAT SURROUNDED THE LEFT EYE AND COVERED THE LEFT CHEEK AREA. AT 11:30 AM, RESIDENT #407 WAS OBSERVED IN HER ROOM SEATED IN A WHEEL CHAIR. RESIDENT #407 HAD STAPLES ON THE RIGHT SIDE OF THE SCALP AND A DARK RED SCAR ON THE SIDE OF HER LEFT EYE. THE LEFT SIDE OF RESIDENT #407'S FACE WAS DISCOLORED RED, BLACK AND BLUE. DURING AN INTERVIEW, RESIDENT #407 STATED, "...I fell IN THE BATHROOM WHILE FIXING MY CLOTHES..." ON 1/16/13 AT 2:00 PM, REVIEW OF THE CLINICAL RECORD REVEALED THE FOLLOWING: RESIDENT #407 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION RESIDENT ASSESSMENT INSTRUMENT FOR RESIDENT #407, DATED 8/16/12 , DOCUMENTED RESIDENT #407 REQUIRED ASSISTANCE FOR TRANSFER, HYGIENE, GROOMING AND TOILET USE. THE FALL RISK ASSESSMENT, DATED 8/10/12, DOCUMENTED RESIDENT #407 WAS AT HIGH RISK FOR FALLS. THE CARE PLAN FOR RESIDENT #407, REVISED 9/10/12 ,DOCUMENTED, "AT RISK FOR INJURY, SKIN TEARS ABRASIONS BRUISES DUE TO DECLINE IN MOBILITY, WEAKNESS, GOAL: WILL HAVE NO FALLS THIS QUARTER, APPROACH: ...ACCOMPANY RES (RESIDENT) TO TOILET AND STAY WITH (RESIDENT) UNTIL DONE..." THE NURSING NOTE, DATED 1/06/13, 01:00 AM, DOCUMENTED RESIDENT #407 WAS FOUND IN HER ROOM IN THE BATHROOM IN FRONT OF THE TOILET, THERE WAS DARK RED BLOOD ON THE FLOOR, RESIDENT #407'S GOWN, HEAD AND FACE. THERE WAS AN EIGHT CENTIMETER (CM) LACERATION TO THE SCALP AND A FOUR CM LACERATION ABOVE THE LEFT EYE. THERE WAS NO LOSS OF CONSCIOUSNESS. PER DOCTOR'S ORDERS, RESIDENT #407 WAS TRANSFERRED VIA AMBULANCE TO THE HOSPITAL. THE NURSING NOTE, DATED 1/6/13, 07:20 AM, DOCUMENTED (RESIDENT #407) HAD RETURNED FROM THE HOSPITAL VIA AMBULANCE WITH FIVE STAPLES TO THE SCALP AND FOUR STITCHES TO THE LEFT EYE BROW. ON 1/16/13 AT 2:00 PM, REVIEW OF THE ACCIDENT/INCIDENT REPORTS FOR RESIDENT #407, REVEALED THE FOLLOWING: ON "9/10/12, WHAT HAPPENED?: RESIDENT #407 WAS OBSERVED ON THE FLOOR IN THE RESTROOM (RESIDENT'S). WHY DID IT HAPPEN:? RESIDENT ATTEMPTED TO TRANSFER FROM THE TOILET SEAT TO THE WHEEL CHAIR. DIDN'T PULL THE CORD (CALL LIGHT) AS INSTRUCTED. CORRECTIVE ACTION: CP (CARE PLAN) #2, REINFORCE CALL LIGHT. THE CARE PLAN WAS UPDATED WITH THE INTERVENTION TO REMAIN WITH RESIDENT #407 WHILE IN THE BATHROOM. ON "1/06/13, WHAT HAPPENED?: RESIDENT #407 WAS OBSERVED ON THE FLOOR IN BATHROOM (RESIDENT'S). WHY DID IT HAPPEN:? PT (PATIENT/RESIDENT) STATES 'I STOOD UP TO FIX THE DIAPER AND fell ' . VISIBLE INJURY: EIGHT CM LACERATION TO TOP OF HEAD (SCALP), FOUR CM LACERATION ABOVE LEFT EYE. SUMMARY OF INVESTIGATION: VERBAL STATEMENT RECEIVED FROM DCT (DIRECT CARE TECHNICIAN/NURSE AIDE), "RES (RESIDENT)WAS ASSISTED TO TOILET AND INSTRUCTED TO USE CALL LIGHT FOR ASSIST BACK TO BED. BUT RES STOOD UP TO FIX HER UNDERGARMENT AND fell ...CONCLUSION: RES SENT TO ER (EMERGENCY) FOR POST FALL EVAL (EVALUATION) AND SUTURES PER DR ORDERS..." ON 1/16/13 AT 3:00 PM, DURING AN INTERVIEW, THE ASSISTANT DIRECTOR OF NURSING (ADON) EXPLAINED THAT ON 1/06/13, RESIDENT #407 WAS ASSISTED TO THE TOILET BY THE DCT AND THE DCT LEFT RESIDENT UNATTENDED ON THE TOILET. THE ADON CONFIRMED THAT THE INTERVENTION IN THE PLAN OF CARE TO "ACCOMPANY RESIDENT #407 TO THE TOILET AND STAY UNTIL DONE" TO LIMIT THE POTENTIAL FOR FALLS AND INJURIES FOR RESIDENT #407, WAS NOT IMPLEMENTED. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY ASSESS, DEVELOP AND IMPLEMENT TIMELY INTERVENTIONS NECESSARY TO PREVENT THE DEVELOPMENT OF NEW PRESSURE SORES FOR ONE (# 403) OF SEVEN SAMPLED RESIDENTS WHO WERE IDENTIFIED "AT RISK" FOR PRESSURE SORES FROM A TOTAL SAMPLE OF 30 RESIDENTS, RESULTING IN THE AVOIDABLE DEVELOPMENT OF FACILITY ACQUIRED PRESSURE SORES. FINDINGS INCLUDE: REVIEW OF RESIDENT #403'S NURSING ADMISSION SKIN assessment dated [DATE], DOCUMENTED THE RESIDENT HAD A BRUISE TO THE LEFT ANTECUBITAL AREA AND SEVEN STAPLES THAT WERE INTACT TO THE RESIDENT'S LEFT HIP INCISION. THERE WERE NO PRESSURE SORES OR OTHER ALTERATIONS IN SKIN INTEGRITY DOCUMENTED. REVIEW OF THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE], DOCUMENTED RESIDENT #403 HAD NO COGNITION IMPAIRMENT AND WAS PHYSICALLY DEPENDENT ON STAFF, REQUIRING TWO PLUS ASSISTANCE FOR BED MOBILITY, TRANSFERS AND ALL ACTIVITIES OF DAILY LIVING. THE MDS DOCUMENTED THAT RESIDENT #403 WAS "AT RISK" FOR PRESSURE SORES AND CODED THE RESIDENT AS NOT HAVING PRESSURE SORES AT THE TIME OF THE INITIAL ADMISSION ASSESSMENT. THE MDS CODED THE RESIDENT AS NOT HAVING ANY PRESSURE REDUCING DEVICES FOR CHAIR/BED NOR ANY TURNING/ REPOSITIONING PROGRAM DOCUMENTED. REVIEW OF THE 30 DAY SCHEDULED MDS ASSESSMENT, DATED 12/12/2012, DOCUMENTED RESIDENT #403 WAS "AT RISK" FOR PRESSURE SORES AND CODED AS HAVING A STAGE TWO (PARTIAL THICKNESS SKIN LOSS INVOLVING THE EPIDERMIS, DERMIS OR BOTH) PRESSURE SORE. THE MDS CODED THE RESIDENT AS NOT HAVING ANY PRESSURE REDUCING DEVICES FOR CHAIR/BED NOR ANY TURNING/ REPOSITIONING PROGRAM DOCUMENTED. REVIEW OF BI-WEEKLY NURSE ASSISTANT, "SKIN CHECK" SHEETS DOCUMENTED: - 11/27/12, "BUTTOCK RED". -12/1/12, "OPEN WOUND ON BOTTOM TOLD NURSE ABOUT IT." -12/5/12, (NO SKIN ISSUES DOCUMENTED). -12/8/12, "BUTTOCK IS RED." -12/12/12, "OPEN ON BUTTOCKS CREAM APPLIED." -12/15/12, "WOUND ON BOTTOM." -12/18/12, "SHOWER/WOUND DONE." -12/22/12, "OPEN ON COCCYX." -12/26/12 "OPEN AREA ON BUTTOCKS." -12/29/12, (NO SKIN ISSUES DOCUMENTED). -1/9/13, "OPEN AREA ON BUTTOCKS." -1/11/13. "WOUND DONE BY NURSE." REVIEW OF NURSING NOTES DOCUMENTED: -12/8/12, "...PER NURSE ASSISTANT SKIN INTACT . BUTTOCK RED." -12/14/12, "NOTED OPEN AREA ON COCCYX AREA 2.0 X 1.5 CM (CENTIMETERS). SUPERVISOR AWARE TREATMENT ORDERED." THERE WERE NO SKIN ASSESSMENTS OR MEASUREMENTS BY A LICENSED NURSE TO DESCRIBE THE RESIDENT'S SKIN ALTERATION OF OPEN AREAS TO CORRESPOND WITH THE RESIDENTS OPEN AREAS DOCUMENTED BY THE NURSE ASSISTANTS "SKIN CHECKS" DATED 12/1/12, UNTIL 12/8/12. (ONE WEEK AFTER THE OPEN WOUND WAS OBSERVED). -12/19/12, "WOUND CARE/ASSESSMENT DONE. COCCYX AREA PRESENTS AS STAGE III (FULL THICKNESS SKIN LOSS INVOLVING DAMAGE TO OR NECROSIS OF SUBCUTANEOUS TISSUE THAT MAY EXTEND DOWN TO, BUT NOT THROUGH, UNDERLYING FASCIA) 5. O X 3.0 X 0.2 CM...MODERATE SANGUINEOUS DRAINAGE, NO ODOR. AIR ALTERNATING MATTRESS REQUESTED TODAY..." -12/28/12, "WOUND CARE/ASSESSMENT DONE. COCCYX AREA STAGE III ULCER 4.0 X 3.0 X 0.1 CM..." (THERE WERE NO LICENSED SKIN ASSESSMENTS OR MEASUREMENTS DOCUMENTED BETWEEN 12/28/12 AND 1/12/13 (TWO WEEKS). -1/12/13, "WOUND CARE/ASSESSMENT DONE. SACRAL STAGE III 1.5 X 1.5 X 0.2 CM. MILD EXCORIATION AT LEFT ASPECT OF WOUND..." -1/16/13, "WOUND CARE/ASSESSMENT DONE. COCCYX AREA STAGE III ULCER 1.5 X 0.8 X 0.3 CM...PERIWOUND SKIN ERYTHREMIC AND EXCORIATED..." REVIEW OF PHYSICIAN ORDERS [REDACTED]. -"[MEDICATION NAME] TWICE PER DAY AND AS NEEDED TO OPEN AREAS ON TAILBONE AND RIGHT BUTTOCKS. TURN AND REPOSITION PATIENT EVERY TWO HOURS." ON 1/15/13 AT 10:00 A.M., RESIDENT #403 WAS QUERIED REGARDING THE "SORE" ON HER BOTTOM, AND STATED "IT HURT TO SIT IN THE WHEELCHAIR. ESPECIALLY WHEN THEY WOULD GET ME UP FOR THERAPY. I WOULD BE UP IN THE CHAIR WAITING FOR THERAPY TO COME AND THEN I WOULD BE SITTING IN THERAPY TOO. I HAD TO ASK THEM (REHAB STAFF) FOR A CUSHION. ONCE THEY GAVE ME A CUSHION FOR MY WHEELCHAIR THINGS WERE BETTER. I WASN'T AS SORE. I HAVE TO WAIT ON STAFF TO REPOSITION ME. THEY DON'T COME LIKE CLOCKWORK. SOMETIMES IT TAKES LONGER THAN I WOULD LIKE TO HAVE TO WAIT. WHAT CAN YOU DO?" ON 1/16/13 AT 9:55 A.M., A WOUND CARE OBSERVATION FOR RESIDENT #403 WAS CONDUCTED WITH THE TREATMENT NURSE AND THE VISITING WOUND CARE PHYSICIAN. A STAGE THREE PRESSURE SORE (FULL THICKNESS TISSUE LOSS INVOLVING DAMAGE TO OR NECROSIS OF SUBCUTANEOUS TISSUE) WAS OBSERVED ON THE RESIDENT'S COCCYX THAT MEASURED 1.5 X 0.8 X 0.3 CENTIMETERS (CM). THE WOUND BASE WAS GRAY. THERE WAS A SCANT AMOUNT OF SEROUS DRAINAGE ON THE SOILED DRESSING. THE SURROUNDING SKIN WAS REDDENED AND EXCORIATED. THE RIGHT BUTTOCK PRESSURE SORE WAS MACERATED WITH IRREGULAR GRAYISH TISSUE AND MEASURED APPROXIMATELY 1.5 CM X 1.0 CM. THERE WAS NO DRAINAGE NOTED. THE TREATMENT NURSE STATED, "THIS IS THE FIRST TIME THE WOUND DOCTOR HAS SEEN THIS RESIDENT'S WOUND. ON 1/18/13 AT 11:45 A.M., DURING AN INTERVIEW AND RECORD REVIEW WITH THE WOUND TREATMENT NURSE, SHE STATED, "THE FLOOR NURSE'S ARE SUPPOSE TO TAKE CARE OF THE RESIDENT'S SKIN ASSESSMENTS AND DOCUMENT IN THE NURSES NOTES. THE FLOOR NURSES ARE RESPONSIBLE FOR MINOR TREATMENTS FOR 'REDNESS, TEARS OR BLISTERS'. I SEE THE RESIDENT'S FOR STAGE II ULCERS. I CONSULT THE WOUND PHYSICIAN FOR STAGE III ULCERS. THE NURSE'S ARE RESPONSIBLE FOR UPDATING AND INITIATING RESIDENT CARE PLANS. I UPDATE 'SKIN' CARE PLANS ONLY IF I SEE THE RESIDENTS." THE WOUND TREATMENT NURSE WAS UNABLE TO EXPLAIN WHY THE RESIDENT HAD TO ASK FOR A WHEELCHAIR CUSHION FOR COMFORT FOR HER "SORE BOTTOM", AND WHY AN ANTI-PRESSURE MATTRESS WAS NOT ORDERED AND PLACED ON RESIDENT #403 UNTIL AFTER THE ONSET OF THE STAGE III PRESSURE SORE ON 12/19/12, WHEN THEIR POLICY DOCUMENTED "ALL AT-RISK RESIDENTS WOULD BE PLACED ON ANTI-PRESSURE MATTRESS. AND ADDITIONALLY PRESSURE REDUCTION DEVICES AND MATTRESSES WERE TO BE ASSESSED FOR THE RESIDENT'S NEEDS INDIVIDUALLY. ON 1/18/13 AT 11:55 A.M., DURING AN INTERVIEW AND RECORD REVIEW WITH UNIT MANAGER "P", SHE STATED, "THERE IS NO SCHEDULE FOR TURNING RESIDENTS. WE TELL THE NURSE ASSISTANTS VERBALLY WHAT THE RESIDENT'S NEED." HOWEVER, THERE WERE NO UPDATES TO THE RESIDENT'S CARE PLAN TO TURN THE RESIDENT EVERY TWO HOURS, NOR WERE THERE UPDATES TO ENSURE THE RESIDENT HAD A WHEELCHAIR CUSHION IN PLACE WHEN UP IN THE WHEELCHAIR. REVIEW OF THE FACILITY'S "WOUND CARE" POLICY, DATED SEPTEMBER 2012, DOCUMENTED: "PREVENTION- #1. ALL RESIDENT WHO RESIDE IN THE FACILITY DETERMINED AT RISK FOR SKIN BREAKDOWN WILL HAVE INTERVENTIONS IN THEIR CARE PLAN AIMED AT PREVENTION OF DEVELOPMENT OF SKIN BREAKDOWN. THESE INTERVENTIONS WILL BE INDIVIDUALIZED BASED ON THE RISK ASSESSMENT. #4. PRESSURE REDUCTION METHODS WILL BE UTILIZED FOR THE RESIDENTS AT RISK FOR DEVELOPMENT. ANTI-PRESSURE MATTRESSES WILL BE UTILIZED FOR ALL RESIDENTS AT RISK. ADDITIONAL PRESSURE REDUCTION DEVICES AND MATTRESSES WILL BE ASSESSED FOR NEED ON AN INDIVIDUAL BASIS." ( )

This citation pertains to MI 99. Based on interview and record review, the facility failed to prevent a significant medication error in 1 of 2 residents (Resident #101) who had eye drops ordered by a physician, from a total of 4 sampled residents, resulting in a left eye infection. Findings include: In a telephone interview, on 3/16/12 at 8:45 AM, complainant #1 told this Surveyor that Resident #101 had left cataract surgery on 1/31/12, that the eye drops and instructions, written by the eye surgeon #10, for post-surgical use, were given to the nurse assigned to Resident #101 when Resident #101 returned from the surgery on 1/31/12. Complainant #1 stated that the eye drops were to be started immediately but no drops were given for 4 days, resulting in Resident #101 developing an infection and subsequent [MEDICAL CONDITION] in the left eye. Per the "Minimum Data Set", dated 1/25/12, Resident #101 was admitted to the facility on [DATE] from an acute care hospital, scored 11/15 on "Cognitive Patterns" (indicated she had problems with her memory), indicated it was somewhat important to have books, newspapers, and magazines to read, had [DIAGNOSES REDACTED]. Review of Resident #101's medical record revealed a "Release of Responsibility for Leave of Absence "Cataract Surgery", dated 1/31/12. Review of Resident #101's medical record revealed there were no Nurses' Notes dated 1/31/12 (the date Resident #101 left and returned to the facility for cataract surgery of the left eye), no physician orders from the facility's attending physician dated 1/31/12, and no instructions or consults from the eye surgeon #27 dated 1/31/12. Per "Physician" orders, dated 2/02/12, "1.) Instill [MEDICATION NAME] 0.09% solution in (left) eye daily x 4 wks ( once a day for four weeks); 2.) Instill [MEDICATION NAME] 1 gtt (drop) in (left eye) TID (three times a day) x 4 wks; 3.) Instill [MEDICATION NAME] drops 1 gtt om (left) eye QID (four times a day) x 4 wks; 4.) Wear eye shield on L eye x 4 days...V.O. (verbal order/attending doctor/ LPN #13)". "[MEDICATION NAME] after a certain type of eye surgery (cataract surgery). belongs to a class of drugs known as nonsteroidal anti-[MEDICAL CONDITION] (to reduce swelling) drugs. It works by blocking the effects of certain natural substances (prostaglandins) that cause pain and inflammation...Your doctor may direct you to start using this medication the day before or the day after your surgery. Place 1 drop into the affected eye as directed by your doctor, usually once or twice a day for 2 weeks. Carefully follow your doctor's specific directions." (http://www.webmd.com/drugs/drug- 0-[MEDICATION NAME]+Opht.aspx?drugid= 0&drugname=[MEDICATION NAME]+Opht) "[MEDICATION NAME] is a fluoroquinolone antibiotic that kills sensitive bacteria by stopping the production of essential proteins needed by the bacteria to survive...Use [MEDICATION NAME] eye drops exactly as directed by your doctor. If you do not understand these directions, ask your pharmacist, nurse, or doctor to explain them to you." (http://www.drugs.com/[MEDICATION NAME].html) "[MEDICATION NAME] is a steroid medicine. It prevents the release of substances in the body that cause inflammation. [MEDICATION NAME] is used to treat eye swelling caused by surgery." (http://www.drugs.com/[MEDICATION NAME].html) Review of Resident #101's "Medication Administration Record" revealed that the administration of the prescribed post-surgical eye drops ([MEDICATION NAME], and [MEDICATION NAME]) was not started until 2/03/12. In an interview, on 3/15/12 at 2:15 PM, Licensed Practical Nurse (LPN) #13 stated she had been a nurse for 5 years, had worked at the facility for the past 3 years, and was Resident #101's nurse from 7:00 AM -7:00 PM on 3/31/12. LPN #13 said she remembered Resident #101 returning from the cataract surgery with her daughter #29, but could not remember what time it was when they returned. LPN #13 stated, "(Resident #101's daughter #29) said the patch was supposed to be on for 3 days and some drops...one was for 3 times a day and the other was for 4 times a day, were supposed to start the next day. We got the order that night and put it in action" When asked who "we" were, LPN #13 stated LPN #14 and herself. LPN #13 also stated, "To be honest, I can't even remember if I charted on her. When asked if why the instructions from the eye surgeon #27 were not in Resident #101's medical record, she stated, "It could have been misfiled". When asked what she did with the eye drops that Resident #101's daughter brought back, LPN #13 stated, We put them in the med cart with her name on them". When asked why the post-surgical eye drops were not started until 2/3/12 (3 days after the surgery), LPN #13 responded, "There was a paper for the eye drops. We didn't get to transcribe the order until then". When asked who "we" were, LPN #13 stated, "(Registered Nurse/RN #17) was there that day". When asked if she thought she had made a medication error, LPN #13 stated, "Not to my knowledge. No, Ma'am!" In an interview, on 3/15/12 at 2:47 PM, LPN #14 stated she would have remembered if she had been given Resident #101's eye drops and the instructions from the eye surgeon #27. LPN #14 said, "I have (the other end of the hall)". LPN #14 stated, "After (cataract) surgery, the eye drops start that night". In a telephone interview, on 3/16/12 at 8:13 AM, RN #17 stated she did not receive the orders for Resident #101's eye drops on 3/31/12. RN #17 stated, "I'm a nurse. I could write an order myself. (ADON #1) took me up there (third floor) to see her eye when it was swollen...I don't think I was the Unit Manager (of the third floor) at that time...If I get a consult, I do all the work. I think I've seen some changes in (LPN #13)...That's definitely a medication error (not making sure the post-surgical eye drops are ordered and instilled after cataract surgery)". A "Report of Consultation" written by the "Retina Consultant #28", dated 2/13/12, was found in Resident #101's medical record. The document read, "Endophthalmitis (see definition below) left eye. Recommendations: continue all drops as directed. continue to monitor vitals periodically. Get WBC (white blood count) tomorrow. Use [MEDICATION NAME] (eye drops) bid OS (twice a day in left eye). Will call in (prescription). Will call (Resident #101) later. May add/move drops". "Endophthalmitis is an inflammation of the internal coats of the eye. It is a dreaded complication of all intraocular (inside the eye) surgeries, particularly cataract surgery, with possible loss of vision and the eye itself. Infectious etiology (origin) is the most common and various bacteria and fungi have been isolated as the cause of the endophthalmitis..." http://en.wikipedia.org/wiki/Endophthalmitis) Per a consultation letter (presented as evidence by complainant #1) to Resident #101's Eye Surgeon #27, dated 2/14/12, from the "Retina Consultant #28", "Impression: endophthalmitis in left eye. the [MEDICATION NAME] sample is growing may be Strep viridans (infection) that was susceptible to the [MEDICATION NAME] (antibiotic) which was injected (into the eye). I am recommending we monitor her over the next few days. She (Resident #101) may require reinjection if there is any sign of recurrent infection, but hopefully this will take care of it. I advised them to monitor her at her nursing home for evidence of fevers, and to take a white blood cell count tomorrow looking for signs of systemic infection..." ( )

This citation pertains to MI 99. Based on observation, interview, and record review, the facility failed to assure that the monitoring of residents needs met professional standards for 2 of 4 Sampled residents (Resident #101 and Resident #102), from a total of 4 Sampled residents; resulting in negative outcomes (significant medication error for Resident #101 and potentially avoidable falls for Resident #102). Findings include: "Nurses may initiate treatments or carry out interventions initiated by other authorized healthcare providers. Nurses are coordinators of care as well as caregivers." (Nursing's Social Policy Statement: Second Edition. 2005). Nursing assessment is the "deliberate and systematic collection of data" of the residents' health and functional status and is the first step in Nursing Process. The data obtained in the assessment is communicated to other care givers and health professionals and is used to diagnose the problem and plan and implement care (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). Nursing assessment is the "deliberate and systematic collection of data" of the residents' health and functional status and is the first step in Nursing Process. The data obtained in the assessment is communicated to other care givers and health professionals and is used to diagnose the problem and plan and implement care (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). "...For a few days after surgery, your doctor may ask you to use eyedrops to help healing and decrease the risk of infection. Ask your doctor about how to use your eyedrops, how often to use them, and what effects they can have. You will need to wear an eye shield or eyeglasses to help protect your eye. Avoid rubbing or pressing on your eye...Problems after surgery are rare, but they can occur. These problems can include infection, bleeding, inflammation (pain, redness, swelling), loss of vision, double vision, and high or low eye pressure. With prompt medical attention, these problems can usually be treated successfully". (http://www.nei.nih.gov/health/cataract/cataract_facts.asp#4h) According to Law Every Nurse Should Know , (Creighton, H., 5th Edition, pg 98), "Nurses must obey the orders of the physician in charge of a patient, unless an order would lead a reasonable person to anticipate injury if it were carried out", Resident #101 An unannounced investigation was conducted 3/15/12-3/16/12. Resident #101 no longer resided at the facility at the time of the investigation. In a telephone interview, on 3/16/12 at 8:45 AM, the complainant told this Surveyor that Resident #101 had left cataract surgery on 1/31/12, and that the eye drops and instructions, written by the ophthalmologist/eye surgeon #27, for post-surgical use, were given to the nurse assigned to Resident #101 when Resident #101 returned from the surgery on 1/31/12. The complainant further stated that no drops were given for 4 days, resulting in Resident #101 developing an infection and subsequent [MEDICAL CONDITION] in the left eye. Per the "Minimum Data Set", dated 1/25/12, Resident #101 was admitted to the facility on [DATE] from an acute care hospital, scored 11/15 on "Cognitive Patterns" (indicated she had problems with her memory), indicated it was somewhat important to have books, newspapers, and magazines to read, had [DIAGNOSES REDACTED]. Review of Resident #101's medical record revealed a "Release of Responsibility for Leave of Absence" form, dated 1/31/12, revealed that Resident #101 left the facility for "Cataract Surgery". Review of Resident #102's "Patient Care Plan(s)", revealed there were no care plans or interventions related to the potential for infection or pain related to cataract (clouding of the eye's lens) surgery. Review of Resident #101's medical record revealed it contained no Nurses' Notes dated 1/31/12 (the date Resident #101 left and returned to the facility for cataract surgery of the left eye), no physician orders from the facility's attending physician dated 1/31/12, and no instructions or consults from the eye surgeon #27 dated 1/31/12. Per "Physician" orders, dated 2/02/12, "1.) Instill [MEDICATION NAME] 0.09% solution in (left) eye daily x 4 wks (once a day for four weeks); 2.) Instill [MEDICATION NAME] 1 gtt (drop) in (left eye) TID (three times a day) x 4 wks; 3.) Instill [MEDICATION NAME] drops 1 gtt om (left) eye QID (four times a day) x 4 wks; 4.) Wear eye shield on L eye x 4 days...V.O. (verbal order/attending doctor/ LPN/Licensed Practical Nurse #13)". Review of Resident #101's "Medication Administration Record" revealed that the prescribed post-surgical eye drops were not started until 2/03/12. In an interview, on 3/15/12 at 2:15 PM, LPN #13 stated she had been a nurse for 5 years, had worked at the facility for the past 3 years, and was Resident #101's nurse from 7:00 AM -7:00 PM on 3/31/12. LPN #13 said she remembered Resident #101 returning from the cataract surgery with her daughter #29, but could not remember what time it was when they returned. LPN #13 stated, "(Resident #101's daughter #29) said the patch was supposed to be on for 3 days and some drops...one was for 3 times a day and the other was for 4 times a day, were supposed to start the next day. We got the order that night and put it in action" When asked who "we" were, LPN #13 stated LPN #14 and herself. LPN #13 also stated, "To be honest, I can't even remember if I charted on her. When asked if why the instructions from the eye surgeon #27 were not in Resident #101's medical record, she stated, "It could have been misfiled". When asked what she did with the eye drops that Resident #101's daughter brought back, LPN #13 stated, " We put them in the med cart with her name on them". When asked why the post-surgical eye drops were not started until 2/3/12 (3 days after the surgery), LPN #13 responded, "There was a paper for the eye drops. We didn't get to transcribe the order until then". When asked who "we" were, LPN #13 stated, "(RN #17) was there that day". When asked if she thought she had made a medication error, LPN #13 stated, "Not to my knowledge. No, Ma'am!" In an interview, on 3/15/12 at 11:15 AM, this Surveyor requested all incident reports and medication error reports for Resident #101 from DON/Director of Nursing #2. In an interview, on 3/16/12 at 8:55 AM, DON #2 stated there were no incident reports related to Resident #101 and said, "We didn't know about it (an incident regarding Resident #101) until just now". In an interview, on 3/15/12 at 2:47 PM, LPN #14 stated she would have remembered if she had been given Resident #101's eye drops and the instructions from the eye surgeon #10. LPN #14 said, "I have (the other end of the hall)". When asked if she had ever taken care of a resident that had had cataract surgery, LPN #14 said she remembered a few residents at the facility that had had the surgery, and said she had it done herself. LPN #14 stated, "After (cataract) surgery, the eye drops start that night". In a telephone interview, on 3/16/12 at 12:11 PM, RN #6 stated he worked the 7:00 AM - 7:00 PM shift, and he spoke to this Surveyor regarding Resident #101's left eye after the cataract surgery. RN #6 stated, "I was upset because there was so much crusting (dried drainage) on (Resident #101's) left eye...an extremely large amount...the eye was reddened...it was obvious someone from night shift wasn't cleaning the eye...I was there, in the (Resident #101's) room when the daughter (#29) told me (Resident #101) was blind in the eye. I passed it (the information that she was blind in the eye) on to the afternoon supervisor sometime between 5:00 PM - 7:00 PM. She (Resident #101) had bruising (to the left eye)...I filled out an incident report. I know I did. Some of the nurses laughed at me (for filling out an incident report)". On 3/16/12 at 12:26 PM, this Surveyor asked DON #2 if she was sure there were no incident reports or medication error reports for any time during Resident #101's stay at the facility, and she stated, "No, there weren't". On 3/16/12 at 12:30, DON #2 presented this Surveyor with and "Accident/Incident Report", dated 2/10/12 regarding Resident #101 that read, "(Resident #101) returned from eye doctor's appointment with hematoma below (right) eye...2/29/12, Reviewed in QA (Quality Assessment)". In a telephone interview, on 3/16/12 at 8:13 AM, RN #17 stated, "They were already putting drops in her eyes when it was brought to my attention. That's definitely a medication error (not making sure the post-surgical eye drops are ordered and instilled after cataract surgery)". ( ) Resident #102 During the course of the investigation, it was revealed that information regarding Resident #102's fall risk, fall history, and implementation of fall prevention assessments, and appropriate fall prevention devices and adequate supervision were not communicated or implemented effectively between facility staff when Resident #102 moved from the 3rd floor to the 1st floor, and staff did not take the initiative to make sure they were properly informed. Per "Accident/Incident Report", dated 2/08/12 at 7:30 AM, Resident #102 was, "observed on floor, in bathroom...transfer without assist...Corrective Action: w/c (wheelchair) alarm...How could it be prevented: Resident can ask for assistance". Per "Accident/Incident Report", dated 2/08/12 at 9:30 PM, Resident #102 9:30 PM, "observed on floor, in her room. Why did it happen? Resident transfer without any assist...How could it be prevented: patient needs bed alarm". Per "Interdisciplinary Progress Notes", dated 2/20/12, "Resident (#102) transferred from 3rd floor. Alert and verbally responsive with some confusion". Per "Accident/Incident Report", dated 2/21/12 at 10:20 AM, Resident #102 "slipped to floor, in bedroom...How could it be prevented: Shoes on & light used for assist". Per "Accident/Incident Report", dated 3/02/12 at 1:45 AM, Resident #102 was "observed on floor, resident's room. Why did it happen: self transfer. How could it be prevented: use call light for assistance". Resident #102's fall prevention care plan, (added prior to 3/02/12) read, "Potential for injury r/t (related to) fall risk secondary to generalized weakness, need for excessive cardiac needs, Diabetes, new meds...(9). alarms to bed and wheelchair". LPN #16 updated the same care plan on 3/02/12 with: (11). Reorientate to call light use prn (as needed). (12). Contact RS (Resident Services) regarding issues with roommate". In an interview, on 3/16/12 at 10:00 AM, nurse aide #20 stated she didn't remember Resident #102 falling but stated, "( Resident #102) made me take the alarm off..." When asked if she reported the incident to the charge nurse, nurse aide #20 stated she charted it. When asked to provide the charting, nurse aide #20 stated the facility did not keep that type of charting. In an interview, on 3/16/12 at 9:04 AM, the Director of Therapy #19 stated, "(Resident #102) still needs supervision" because her "safety decisions are not complete". Director of Therapy #19 said, "We (the facility staff) have an obligation to make sure...alarms on...We (Therapy Department) did not recommend the cane". In an interview, on 3/16/12 at 9:10 AM Physical Therapist #18 stated that a "Level II Evaluation" is to be ordered by nursing after a resident has 3 falls, "but, we didn't get one...(Resident #102) needs stand by assist with all activity". In a telephone interview, on 3/16/12 at 12:11 PM, RN #6 stated, "We (staff) would have to watch (Resident #102). She would try to get up and walk alone". In an interview, on 3/16/12 at 10:04 AM, LPN #21 stated she had worked with (Resident #102) two days ago, and said, "(Resident #102) is not steady at all. That's why she uses a cane and walks behind her wheelchair a lot". LPN #21 stated she was the nurse caring for Resident #102 when she was found on her floor on 2/21/12, and stated, "I wasn't aware she had previous falls. No alarms were going off. Her alarm was sitting on her dresser, but it wasn't hooked up. I didn't think about it. Later, she was up walking around. (The alarm) remained on the dresser. I didn't know much about her and neither did the nurse I got report from. She had just transferred to our floor (first floor) the day before". When asked how she could have learned about whether Resident #102 was at risk for falls LPN #21 replied, "I would just have to get the feel for what she was like. No one told me she was a fall risk. If I was informed, I would tell them (the nurse aides)...Maybe we should hook up her cardiac chair with the alarm". When asked how Resident #102 made her needs known, LPN #21 stated, "(Resident #102's) she's up walking around by herself all the time. She (Resident #102) doesn't use the call light; she just comes and tells me what she wants". LPN #21 stated the nurse aides could find out whether a resident was a fall risk by looking at the electronic care guide. Review of the nurse aides' electronic care guide, dated 3/16/12, for Resident #102 revealed there were no alerts regarding history of falls, alarms, or increased supervision; it read: "Needs assistance with ADL (activities of daily living), Monitor for proper footwear, Attends therapy, Notify nurse of increased shortness of breath, will put lotion/ointment on feet - monitor for same". Review of LPN #21's "Interdisciplinary Progress Notes" regarding Resident #102, revealed that she wrote, "Resident is alert, responsive, makes needs known" on 2/22/12, 3/06/12, 3/08/12, 3/09/12, 3/13/12, and 3/14/12. In addition, on 3/06/12 LPN #21 also wrote: "Up ambulating ad lib (at her own pleasure) in bed room with cane; on 3/13/12: "(Resident #102) can ambulate ad lib with cane or wheelchair", and on 3/14/12: "(Resident #102) up ambulating ad lib with cane or walking behind w/c (wheelchair)". In an interview, on 3/16/12 at 12:27 PM, SW/Social Worker #23 stated she was the Social Worker for all the residents on the first floor (the floor that Resident #102 resided on since 2/20/12). SW #23 stated that Resident #102 was alert, oriented, and had no confusion. SW #23 stated she was not aware that Resident #102 had fallen twice on 2/08/12, when she resided on the third floor. When asked why there was no behavioral care plan in place for noncompliance regarding the call light, alarms, and use of the cane, SW #23 stated, "I knew about one fall. I should be notified when a resident is not compliant with stand by assist and when noncompliance (causes) falls. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO (1) CONSISTENTLY ASSESS, AND IMPLEMENT TIMELY INTERVENTIONS TO PREVENT AN AVOIDABLE FALL FOR ONE RESIDENT (#515) OUT OF 10 RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 30 RESIDENTS, RESULTING IN INJURIES THAT INCLUDE A SPRAIN, LACERATION AND FRACTURE, AND (2) ENSURE THAT THREE VIALS OF INSULIN IN CURRENT USE WERE SECURELY STORED IN A LOCKED MEDICATION CART. FINDINGS INCLUDE: ON 4/19/11 AT 10:00 AM, RECORD REVIEW REVEALED THAT RESIDENT #515 WAS ORIGINALLY admitted INto the facility on [DATE] AND REadmitted on [DATE], WITH [DIAGNOSES REDACTED]. RESIDENT #515'S MOST RECENT QUARTERLY MINIMUM DATA SET ((MDS) dated [DATE], ASSESSED THE RESIDENT AS BEING COGNITIVELY INTACT, TOTALLY DEPENDENT ON STAFF FOR BATHING AND TRANSFERS WITH TWO PERSONS PHYSICAL ASSIST, EXTENSIVE ASSISTANCE FOR DRESSING, HYGIENE, AND THE USE OF THE TOILET WITH ONE PERSON PHYSICAL ASSISTANCE. THE ASSESSMENT ALSO INDICATED THAT THE RESIDENT HAD A FALL IN THE PAST 30 DAYS. AN ADMISSION FALL RISK assessment dated [DATE], DOCUMENTED A SCORE OF (16) AND ON 3/8/11, THE SCORE WAS (14). A "TOTAL SCORE OF (10) OR ABOVE REPRESENTS A HIGH RISK" FOR FALLS. THE ASSESSMENT ALSO INDICATED THAT RESIDENT #515 HAD 1-2 FALLS IN THE PAST 3 MONTHS, DECREASED MUSCULAR COORDINATING/JERKING MOVEMENTS, PSYCHOTROPIC MEDICATION, AND UNDERLYING HEALTH CONDITIONS THAT MAY PREDISPOSE RESIDENT #515 TO FALLS. RESIDENT #515'S INITIAL FALLS CARE PLAN, DATED 9/15/10, INDICATED THE RESIDENT WAS AT RISK FOR FALLS DUE TO SELF CARE DEFICIT RELATED TO DECREASED MOBILITY, OBESITY, GENERAL WEAKNESS, ALTERED CARDIAC STATUS, AND GOUT. FURTHER REVIEW OF THE CARE PLAN REVEALED RESIDENT #515 WAS A POTENTIAL FOR INJURY RELATED TO A HISTORY OF FALLS, USE OF MECHANICAL LIFT, "MULTI RX", AND AMBIEN AT BED TIME. ON 4/19/11 AT 11:35 A.M., DURING A LUNCH MEAL OBSERVATION, RESIDENT #515 WAS OBSERVED SITTING IN A WHEELCHAIR WITH HER LEFT ARM BANDAGED WHILE EATING HER LUNCH. AT 12:10 P.M., CHARGE NURSE "F" WAS ASKED WHAT HAPPENED TO RESIDENT #515'S ARM. CHARGE NURSE "F" STATED THE "TECH" WAS GETTING THE RESIDENT READY, AND "WHEN HE ROLLED HER OVER, SHE MISSED THE ASSIST BARS AND LANDED ON THE FLOOR, HIT HER ARM, AND HAD TO GET STITCHED." ON 4/19/11 AT 12:15 P.M., RESIDENT #515 WAS INTERVIEWED REGARDING HER LEFT ARM AND STATED, THAT DIRECT CARE TECH (DCT) "I" WAS GETTING READY TO WASH HER UP, ROLLED HER OVER ON HER SIDE AND SAID "STAY THERE." "HE WENT INTO THE BATHROOM TO GET SOMETHING AND I fell on THE FLOOR. I HAVE 23 STITCHES, A BROKEN BABY FINGER, SPRAINED ANKLE, AND BRUISES ON MY KNEES AND LEGS." RESIDENT #515 WAS FURTHER QUERIED WHETHER THERE WERE ANY ASSIST BARS ON HER BED. RESIDENT #515 STATED, "I DID NOT HAVE ANY ASSIST BARS ON MY BED." THERE WERE NO ASSIST BARS OBSERVED ON RESIDENT #515'S BED AT THE TIME OF THE INTERVIEW. RESIDENT #515'S POWER OF ATTORNEY WAS VISITING AT THE TIME OF THIS INTERVIEW AND STATED, "IT SHOULD HAVE BEEN TWO PEOPLE ASSISTING HER." ON 4/20/11 AT 2:30 P.M., REVIEW OF THE INTERDISCIPLINARY PROGRESS NOTES DATED 4/12/11 AT 1:00 P.M., REVEALED, "RESIDENT WAS BEING CLEANED IN BED AND LOST HER GRIP AND ROLLED OUT OF BED. RESIDENT WAS SAFELY ASSISTED BACK TO BED. resident sustained [REDACTED].#515'S FALL AND SHE WAS TRANSFERRED TO A LOCAL HOSPITAL AT 1:00 P.M." RESIDENT #515 RETURNED to the facility on [DATE] AT 11:05 P.M., WITH [DIAGNOSES REDACTED]. COMPLAINT (C/O) OF PAIN VOICED WITH FLEXION AND EXTENSION TO 4TH AND 5TH FINGERS. SLIGHT EDEMA TO (L) FINGERS, SPRAIN (L) ANKLE, C/O PAIN VOICED WITH ROM (RANGE OF MOTION)." FURTHER REVIEW OF THE INTERDISCIPLINARY PROGRESS NOTES DATED 4/13/11 AT 5:30 P.M., REVEALED "RECEIVED X-RAY RESULTS. (L) OBLIQUE FX (FRACTURE OF THE 5TH METACARPAL), NO DISLOCATION, FX OF THE (L) HAND, WRIST WITH FINGERS. ON 4/21/11 AT 11:10 A.M., DURING AN INTERVIEW WITH DCT "I", WHEN QUERIED HOW MANY PEOPLE SHOULD ASSIST RESIDENT #515 WITH ADL'S (ACTIVITIES OF DAILY LIVING), HE STATED, "USUALLY I DO IT BY MYSELF. DCT "I" FURTHER STATED, I TURNED HER (RESIDENT #515) ON HER SIDE AND SHE HELD ONTO THE NIGHT STAND. I ASKED HER IF SHE HAD IT, AND SHE SAID 'YES'. HER LEGS JUST TOOK OVER HER BODY, AND SHE fell . I JUST COULD NOT CATCH HER." ON 4/21/11 AT 2:00 P.M., DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) STATED, RESIDENT #515 HAD TWO PERSON ASSIST WITH TRANSFERS. HOWEVER, DURING CARE ON 4/12/11, THERE WAS ONLY ONE PERSON THAT ASSISTED RESIDENT #515 WITH CARE. ON 4/22/11 AT 2:30 P.M., REVIEW OF THE FACILITY'S POLICY "ACCIDENT AND INCIDENT PREVENTION" REVISED 2/2011, DID NOT ADDRESS ASSISTANCE WITH CARE. ( ) ON 4/19/11 AT 4:45 P.M., DURING THE MEDICATION PASS OBSERVATION, NURSE "B" WAS OBSERVED LEAVING THREE OPENED INSULIN VIALS ON TOP OF THE MEDICATION CART. THE MEDICATION CART WAS OBSERVED IN THE HALLWAY OUT OF NURSE'S"B" SIGHT. DURING AN INTERVIEW ON 4/19/11 AT 5:00 P.M., NURSE "B" OFFERED NO EXPLANATION WHY SHE LEFT THE OPENED VIALS ON THE MEDICATION CART. ( )