Every finding on record at Avista Nursing and Rehabilitation

Based on observations, interviews and record review, the facility failed to 1) Ensure that hand hygiene was practiced between residents while serving food in the dining room, 2) Ensure the sanitary handling of clean food plates during transporting from the kitchen to the dining room, 3) Ensure urinary catheters for 2 residents (Resident #2 and Resident #3) were not on the floor, 4) Ensure that the multi-use shower bed was cleaned and sanitized between residents' use, 5) Ensure that contact precautions were followed for 1 resident (Resident #94), 6) Ensure that a barrier was used and sanitation was done with use of a Glucometer for one resident (Resident #50), and 7) Ensure that appropriate Personal Protective Equipment (PPE) was worn during care for 1 resident (Resident #2) of 32 residents reviewed for infection control practices. Findings Include: Resident #3: On 6/22/26 at 11:55 AM, a Contact Precaution Isolation Sign was present on the outside of Resident #3's room door. The Resident was not present in their room. On 6/22/26 at 12:44 PM, Resident #3 was observed in the dining room. The Resident was sitting in a wheelchair in close (touching) proximity to two other residents. On 6/22/26 at 1:36 PM, Resident #3 was observed in their room, lying in bed. An indwelling urinary catheter drainage bag was on the side of the bed. An interview was completed at this time. When queried regarding the reason they were admitted to the facility, Resident #3 replied, UTI (Urinary Tract Infection) and kidneys. Resident #3 was asked how long the indwelling urinary catheter had been in place and replied, Over two months. When queried if they still had a UTI and if they were receiving treatment, Resident #3 replied, Getting pills for UTI but I told them it don't work. Record review revealed Resident #3 was most recently admitted on [DATE] with diagnoses which included diabetes mellites, chronic respiratory failure, bipolar disorder, anxiety, chronic kidney disease (CKD), Bardet-Biedl syndrome (BBS- rare genetic disorder characterized by obesity, kidney abnormalities, and vision loss), and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate assistance with toileting and bathing. The MDS further detailed the Resident had an indwelling urinary catheter and was receiving an antibiotic. Review of Resident #3's Electronic Medical Record (EMR) revealed a urine culture and sensitivity (C & S) report dated as collected on 6/17/26 with the final culture results dated 6/20/26. The (C&S) was dated as printed on 6/22/26 with handwritten documentation indicating the results were reviewed by facility staff on 6/22/26. The urine culture C &S revealed the Resident had ESBL (Extended-Spectrum Beta-Lactamase- antibiotic resistant) Escherichia coli (bacteria normally found in the intestines) and was a Multi-Drug Resistant Organism (MDRO). Review of Resident #3's EMR revealed the care plan, I have an active infection I am receiving prophylactic ABX (antibiotic) r/t (related to) frequent UTIs. I have an active UTI. (Initiated: 5/21/26; Revised: 6/25/26). The care plan included the intervention, Contact Precautions (Initiated: 6/21/26). On 6/23/26 at 2:56 PM, Resident #3 was observed sitting in the hallway, near the nurses' station and close the Therapy door, in their wheelchair. Their urinary catheter drainage bag was under their wheelchair and dragging on the floor. At 2:57 PM, a female staff member approached, spoke to and hugged/touched the Resident but did not address their catheter. The female staff member did not perform hand hygiene after walking away from the Resident. At 3:04 PM on 6/23/26, Resident #3 moved their wheelchair in the hall to be closer to the wall. Their urinary catheter drainage bag was observed dragging along the floor as they self-propelled themselves in their wheelchair. An interview was completed at this time. When asked how they were doing, Resident #3 verbalized they were having pain in their left kidney and had not received their pain medication at 1:00 PM. When queried, Resident #3 revealed they propelled themselves from activities in their wheelchair back to the unit to get their pain medication. Resident #3 was asked if any facility staff had adjusted or emptied their urinary catheter drainage bag and the Resident revealed that staff had not adjusted and/or emptied the drainage bag since they had been sitting in their wheelchair. After Resident #3 received their pain medication, the Resident was observed self-propelling themselves down the hallway and back to the Activity/Dining room of the facility with their urinary catheter drainage bag dragging on the floor. An interview was completed with Licensed Practical Nurse (LPN) GG on 6/23/26 at 3:29 PM. When queried why Resident #3 was placed in contact precautions, LPN GG revealed they were not sure and would need to review the Resident's EMR. LPN GG reviewed the diagnoses in Resident #3's EMR and verbalized the Resident was diagnosed with gram negative sepsis. When queried regarding the location and specific organism was related to the need for contact precautions, LPN GG replied, I don't know. LPN GG reviewed Resident #3's EMR further and stated, The only see I am thinking is that she has a wound on the pubis and buttocks. When asked if the Resident also a wound on their heel, LPN GG confirmed they did but was unable to provide the source and location of the infection. LPN GG was informed of Resident #3's urine C &S indicating the Resident had ESBL in their urine. An interview was completed with Infection Control (IC) Registered Nurse (RN) A on 6/23/26 at 3:52 PM. When queried regarding the facility policy/procedure related to residents exiting their room who are on contact precautions, IC RN A replied, Can't force them to stay in their room. When queried how the facility was protecting other residents from potential spread of infection and MRDOs, IC RN A responded they educate residents who are on contact precautions on infection prevention topics including isolation, distancing, and hand hygiene. IC RN A was asked how they educate residents and stated, I haven't had anyone to educate recently. When queried regarding Resident #3 being on contact precautions, IC RN A indicated the Resident was recently placed on contact and verbalized they had not provided infection prevention education to them. When queried regarding the source of Resident #3's infection necessitating contact precautions, IC RN A confirmed the Resident had ESBL in their urine. IC RN A was informed of observation of Resident #3 sitting in close proximity to other residents in the dining room and staff touching/hugging without Personal Protective Equipment (PPE). When queried regarding the lack of PPE and potential spread of infection, IC RN A responded that the infectious organism was contained in the Resident's urine and in their urinary catheter drainage bag. When asked if urinary drainage bags should be directly on the floor, IC RN A responded that they should not. IC RN A was then asked why Resident #3's urinary catheter drainage bag on the floor and dragging along on the floor when the Resident was propelling themselves throughout the facility and was unable to provide an explanation. When queried where and what would be considered contaminated, IC RN A replied, Wherever foley bag is touching. When asked, IC RN A confirmed understanding of the concern. Resident #50: Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses which included right below knee amputation (RBKA), peripheral vascular disease, and diabetes mellitus. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required total assistance to complete all ADLs with the exception of eating. On 6/24/26 at 8:27 AM, an observation of LPN II checking Resident #50's blood glucose level was completed. LPN II removed the glucometer (device to check blood glucose level) from the medication cart along with an alcohol pad and a glucometer testing strip (strip inserted into the glucometer where blood sample is applied). LPN II entered Resident #50's room and sat the glucometer (used for multiple residents) directly on the Resident's overbed table. LPN II then donned gloves without performing hand hygiene first. LPN II wiped Resident #50's finger with an alcohol pad, allowed it to dry, and then used a lancet to poke their finger to obtain a blood sample. LPN II wiped the first drop of blood with a new alcohol pad and then immediately applied the next drop of blood to the glucometer strip in the glucometer. After the glucometer test result was obtained, LPN II exited the room and placed the glucometer directly on top of the medication cart without a barrier. An interview was completed with LPN II on 6/24/26 at 8:40 AM. When queried if barriers are supposed to be used under the glucometer, LPN II replied, Yes. An interview was conducted with the Director of Nursing (DON) on 6/25/26 at 1:50 PM. When queried regarding the procedure for glucometer use, the DON verbalized the procedure which included use of a barrier with the glucometer. The DON was informed of observations of LPN II checking Resident #50's blood glucose level and placing the glucometer directly on the Resident's over bed table without a barrier, the DON stated that was Not okay. Upon request for a policy/procedure pertaining to blood glucose monitoring and glucometer use, the facility provided a policy/procedure entitled, Blood Glucose Monitor Decontamination (Reviewed: 1/26). The provided policy/procedure did not include the procedure for using the glucometer. Observations done on 6/22/26, of Dining Room: On 6/22/26 at 12:01 p.m., observations made in the main dining room are as follows: -A total of 7 staff were passing resident's food trays out:, 5 of 7 staff did not sanitize their hands between resident's. Staff were observed setting up the resident's meals, putting clothing protectors on several resident's then going directly to the food serving line to get another resident's food without sanitizing their hands. There was a total of 3 wall hand sanitizers available. -A Nursing Assistant/CNA was observed carrying resident's food [NAME] and her long pink thumb nail was touching the food on the plates. The same CNA had long curly hair that was not pulled back, every time she bent over with the plate of food, her hair dropped down by the residents face and their food. -A housekeeper also had long hair that was not pulled back and she was delivering plates of food with her hair dropping down as she bent down to set the plate down. This same housekeeper was going table-to-table and putting clothing protectors on the resident's without sanitizing her hands between resident's or tables. -A CNA had bright pink nails that were no less then 1 inch above the tips of her fingers; she was serving food and did not sanitize her hands between resident's. -A kitchen food servers went into the kitchen to get more clean white plates; she carried them back to the tray line held against her right side of her clothing, contaminating the plates. -Resident #2's urinary catheter drainage bag was resting on the floor under his wheelchair as he ate his meal. Observations of Dining Room on 6/23/26: -The CNA with the long bright pink nails was serving resident's food with no gloves on, and her nails touched several food items on the plates as she carried them. -Two CNA's still had the long hair that was not pulled back, as they bent over to place the resident's plates of food their hair dropped down toward the residents face and food plate. During an interview done on 6/23/26 at approximately 9:30 a.m., the Director of Nursing/DON stated Nails can't be more then a quarter of an inch, I have looked at the policy. Review of the facility Catheter Care, Urinary policy dated 10/2025, stated Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility Hand Hygiene policy dated 9/2025, stated Use an alcohol-based hand rub before and after direct contact with residents; after contact with a residents intact skin; after removing gloves. Review of the facility Dress Code and Personal Hygiene policy dated 5/2019, stated All employees dress and groom in a manner that is appropriate to their working conditions; keeping fingernails clean and trimmed; arranging hair so that it does not interfere with work assignments or direct contact with residents. Observation of resident #2 with Enhanced Barrier Precautions/EBP: -An observation was done on 6/22/26 at 2:00 p.m., of a CNA doing peri care in resident #2's room with only purple gloves on; there was EBP signage on the outside of his door. Review of the facility Transmission-based precautions policy dated 9/2025, stated [NAME] required PPE prior to resident contact. Shower Room: Observation done on 6/23/26 at 5:00 p.m., of the main shower room revealed the following: -The blue shower mat on top of the white shower bed had an excessive amount of dirt, old dried skin, and debris on the top, sides and underneath. -The floor had papers and dirt on it; the corners were very dusty. -On the inside of the shower door was an area of dried white drippings. Observation done on 6/24/26 at 9:12 a.m., accompanied by Housekeeping Supervisor AA, revealed the following: -The blue shower mat on top of the shower bed was still full of dead skin, dirt-like and debris; no one had cleaned it. -The floor was dirty with dirt and papers, and also a soiled purple medical glove was on the floor by the toilet. -The inside door still had the white dried drippings on it. During an interview done on 6/24/26 at 9:37 a.m., Housekeeping Supervisor AA stated The CNA (Nursing Assistant) is supposed to clean it (the shower room, including the blue shower mat). During an interview done on 6/24/26 at 9:43 a.m., CNA Z stated (The) CNA who gave the shower, who ever uses the bed, cleans it right after. Resident #94 (R94): A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R94 was admitted to the facility on [DATE] with diagnoses that include: subacute osteomyelitis (infection in bone), Methicillin Susceptible Staphylococcus Aureus (MSSA/ infection), Proteus Mirabilis Morganii (multi-resistant drug organism – MDRO), Extended Spectrum Beta Lactamase (ESBL/ antibiotic resistant infection), peripherally inserted central catheter (PICC/ for long term IV antibiotic use), diabetes mellitis (DM), heart failure, acute respiratory failure and DM retinopathy (effecting blood vessels of the eyes). The MDS assessment dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. On 06/22/2026 at 11:19 AM, Observed contact precaution sign on room door of R46, after personal protective equipment (PPE) was donned, the resident was observed resting in bed and had an IV antibiotic running, a urinary catheter with light yellow urine draining, and reported that he had an infectious wound on his bottom. R94 was agreeable to observation of care as it was to occur throughout the day. Nurse M was present and said R94 was due to have IV antibiotics administered, the PICC dressing changed, wound and catheter care done on her shift. On 06/22/2026 at 1:43 PM, Nurse M said she was ready to administer IV medication, change the PICC dressing, perform wound care and urinary catheter care. After gathering supplies from the hall, Nurse M donned (applied) gown and gloves, she decided that she did not have enough or correct supplies and removed gloves and exited the room in gown to retrieve purple top wipes and reentered the room in same gown, applied a new set of gloves – no hand hygiene in between. Nurse M had a wad of gloves (not in box) that she had brought in with her and placed them on the bedside table with supplies while she cleaned the over bed table with wipes – no barrier was used. Nurse M changed gloves – no hand hygiene then transferred the supplies to the over bed table – no barrier used. During the PICC line dressing change Nurse M removed the barrier sheet from the kit and placed it to the side and then applied the sterile gloves. Nurse M changed the PICC line dressing and decided she needed to grab extra PICC line change kit for the split gauze and occlusive cover that had gotten improperly stuck from the first kit. Nurse M removed her gloves and wore her gown into the hall to the treatment cart to retrieve a new kit, Nurse M reentered the room same gown opened the new kit removed the barrier cloth and set it to the side unused and applied sterile gloves then preceded with the split gauze and occlusive dressing application. Nurse M at no time during PICC line dressing change performed hand hygiene, used a barrier or changed her gown. Nurse M changed gloves (no hand hygiene) and administered IV antibiotics. Nurse M changed gown and gloves to perform wound care, no hand hygiene between. Nurse M reached under PPE gown and pulled a pair of bandage scissors out of her pocket (not cleaned before use) and placed them along with dressing supplies on the over bed table (no barrier). During wound care Nurse M opened each gauze, calcium algonate pad and wound coverings and sat them on top of each of the outside packaging that they came in. Nurse M cleaned the wound, applied Medi honey to calcium algonate pad and packed the wound, the Medi honey cap was top down on the over bed table and the tube open and laid on the tabletop. Nurse M had the wrong size external covering and removed her gloves, left in the gown to go to the treatment cart in the hall and get a bigger sacrum sized covering (she did not remove/change gowns nor perform hand hygiene upon her return). Nurse M opened the covering and placed it on top of outside the package while she repositioned R94 to place it. Nurse M changed gown and gloves (no hand hygiene) then performed catheter care without further incident. Nurse M was interviewed after care and asked if it was ok to leave the room in a gown with no reply. Nurse M was asked if the outside of packaging was clean, and she said no it was not. Nurse M was asked about hand hygiene when she change her gloves, no response except ok. Nurse M was asked about cleaning of her scissors, and she said she cleaned them with purple wipes in between uses (observed that she did not clean them once removed from her pocket before use). Nurse M was unaware when asked what the barrier sheets were for that she pulled out and put to the side of the PICC kit. According to a record review of R94's orders revealed: Dated 06/13/2026: contact precautions. Dated 06/20/206- 06/26/2026: Vancomycin HCl Intravenous Solution Reconstituted 1.5 GM. (glycopeptide antibiotic) Dated 06/16/2026-06/26/2026: Zerbaxa Intravenous Solution Reconstituted1.5 (1-0.5) GM. (Cephalosporin/B-lactamase antibiotic) Dated 06/16/2026: Wound: right buttocks: Wash wound and pat dry. Apply Medi honey to wound bed, place calcium alginate to fill wound. Cover with bordered foam dressing; one time a day. According to a record review of R94's care plan revealed: Focus: I have an active infection r/t Wound infection, Sepsis Date Initiated: 06/13/2026 with Interventions: Contact Precautions. and; Focus: I have a PICC line to my right upper arm. Date Initiated: 06/13/2026 with Interventions: Change IV dressing per order AND as needed for soiling or break in integrity. and; Focus: I am at risk for MDRO infection r/t: Hx. (history of) MDRO, Skin, Foley, PICC. Date Initiated: 06/13/2026. With Intervention: Educate on Hand hygiene; Enhanced Barrier Precautions: SKIN, FOLEY, PICC Staff will wear PPE (gown and gloves) while engaged in high contact activities. On 06/24/2026 at 9:47 AM, Observed CNA J enter the doorway of R94 room, she put on a gown then took it back off, rolled it up and stuffed it in the door (PPE holder), she walked down the hall and got the tray cart and pulled it toward R94's room. CNA J put that rolled up gown on with gloves and went in R94 room. Observed CNA J remove R94's breakfast tray and she exited the room with gloves and gown on placed the tray in the cart that was in the hallway. CNA J then re-entered the room wearing the same gloves and gown and closed the door. On 06/25/2026 at 11:52 AM, during an interview with CNA N she was asked about resident precautions. CNA N said they are trained on each type and when asked about contact she said that gown and gloves were to be donned at the resident's door before entering and removed and discarded in the room before exiting, and hand hygiene was performed. CNA N confirmed that it was not appropriate to leave the room in any PPE and/or return to the room in the same PPE. On 06/25/2026 at 11:59 AM, during an interview with the wound care nurse (WC Nurse) E was asked about contact precautions and said hand hygiene then don gown and gloves before entry to residents in contact precautions rooms. WC Nurse E said any break in contact during care with resident hand hygiene and gloves are changed at every step. WC Nurse E said always use a barrier and a wiped surface was not adequate. WC Nurse E said it was not acceptable to walk outside of a room wearing the PPE, he said PPE was disposed of in the residents room and that the process of hand hygiene, gown, gloves etc. would need to be performed before reentry to the residents room and said it was part of the infection control standards. When queried, WC Nurse E said the outside of packaging was not an appropriate or clean barrier. On 06/25/2026 at 12:17 PM, during an interview with infection control preventionist (ICP) A was advised on observations of R 94's provision of care with no hand hygiene between gloves changes, PPE that was worn in/out of room, no use of barrier with care, PPE that was donned (applied) /doffed (removed) and reused, use of bandage scissors stored in pockets / unsanitary and contamination of clothing under PPE to access them, gloves used from a wad not straight from a box. ICP A said it was not acceptable to leave and renter a room in PPE no matter the reason. ICP A said that hand hygiene should be performed before, during care when gloves were changed and after care before the resident's room was exited. ICP A agreed it was never appropriate to don doff then redon (reapply) the same PPE. When queried, ICP A said that wound wash should be dedicated to the resident in contact precaution and not placed back in stock and bandage scissors should not be stored in staff pockets and a resident in contact precautions should have dedicated equipment. ICP A said that none of the observations mentioned followed protocols and it is not the performance she expected from the staff. ICP A said she does monthly audits and training on infection control practices. According to a record review of the facilities policy titled Hand Hygiene revealed: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections. And Policy interpretation and implementation: 2. All personnel shall follow the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; 9. Use an alcohol-based hand rub containing at least 62% alcohol for the following situations: Before and after direct contact with residents; Before preparing or handling medications; Before performing any non-surgical invasive procedures; Before and after handling an invasive device (e.g., urinary catheters, IV access sites); Before donning sterile gloves; Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, etc.; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; After removing gloves; Before and after entering isolation precaution settings; 10. Hand hygiene is the final step after removing and disposing of personal protective equipment;11.The use of gloves does not replace hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. With Procedure: Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves; 1. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. According to a record review of the facilities policy titled Isolation- categories of transmission based precautions revealed: Policy Statement: Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. and; Contact Precautions:1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment; 2. Contact precautions are used for residents infected or colonized with MDROs in the following situations: a. When a resident has wounds, secretions, or excretions that are unable to be covered or contained .; 6. Staff and visitors wear gloves (clean, non-sterile) when entering the room; a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage); b. Gloves are removed and hand hygiene performed before leaving the room; c. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed; 7. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include:On 06/22/2026 at 9:15AM during the initial kitchen tour, the drain line to ice machine was observed sitting directly inside the drain. On 06/22/2026 at 9:18AM the cap to the atmospheric vacuum breaker was observed partially unscrewed and loose on the water line to the garbage disposal. On 06/22/2026 at 9:26AM an attached hose with a chemical feeder downstream of an atmospheric vacuum breaker was observed at the utility sink in the kitchen. During this observation, Dietary Manager BB stated she was familiar with wasting [NAME] and knew that the utility sink needed one. On 06/22/2026 at 11:42AM during lunch observation, diced tomatoes stored behind the steam table in the kitchen were temped using a thermometer probe at 51 F. During this observation, Dietary Manager BB was interviewed on the proper temperature requirement for cold holding, and she stated cold holding should be at 40 degrees or lower. On 06/22/2026 at 11:45AM the diced tomatoes were temped using a thermometer probe at 52 F stored in the refrigerated seasoning table in the dining room serving area. On 06/22/2026 at 11:48AM the shredded cheese was temped using a thermometer probe at 47 F stored in the refrigerated seasoning table in the dining room serving area. On 06/22/2026 at 11:51AM the sour cream was temped using a thermometer probe at 44 F stored inside the refrigerated seasoning table in the dining room serving area. On 06/22/2026 at 11:53AM Dietary Manager BB removed the shredded cheese, diced tomato, and other cold items from the refrigerated seasoning unit and placed them in the freezer to cool down. According to the 2022 FDA Food Code, 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.According to the FDA 2022 Food Code, 5-205.15 System Maintained in Good Repair, A plumbing system shall be: repaired according to law.and maintained in good repair.According to the State of Michigan's 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).According to the State of Michigan's 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.According to the FDA 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5 C (41 F) or less.Record review of email communication from Support Dietician CC on 06/25/2026 on 1:42PM, noted: In regards to discarding food after service, we do not hold food for longer than 4 hours so we do not record discard time. Meals last approximately 1 hour and food is discarded after service.

The facility failed to ensure a safe and sanitary shower room for 1 of 2 shower rooms and that shower curtains were maintained without holes. Findings include: Observation done on 6/23/26 at 5:00 p.m., of the main shower room revealed the following: -The blue shower mat on top of the white shower bed had an excessive amount of dirt, old, dried skin, and debris on top, on sides and underneath.-There were 2 large holes in the top of the shower curtain.-The floor had papers and dirt on it; the corners were very dusty.-There was a area on the inside of the main door of a dried white substance. Observation done on 6/24/26 at 9:12 a.m., accompanied by Housekeeping Supervisor AA, revealed the following: -The blue shower mat on top of the shower bed was still full of dead skin, dirt-like and debris; no one had cleaned it.-The floor was dirty with dirt and papers, and also a soiled purple medical glove was on the floor by the toilet.-The inside door still had the white dried drippings on it. During an interview done on 6/24/26 at 9:37 a.m., Housekeeping Supervisor AA stated The CNA is supposed to clean it (the shower room, including the blue shower mat). During an interview done on 6/24/26 at 9:43 a.m., CNA Z stated (The) CNA who gave the shower, whoever uses the bed, cleans it right after. During an interview done on 6/24/26 at 12:01 p.m., Infection Control Nurse A stated My staff should let me know when they see it (the shower in poor condition and dirty). Review of the facility walkthrough (dated daily with facility rounds), revealed no documentation of a shower room; no space to write in observations of the shower room was found. Review of the Infection Control Education Attendance Record dated 3/16/26, revealed staff had been educated on cleaning the shower room.

Based on observation, interview and record review, the facility failed to ensure that residents were treated in a respectful and dignified manner for 12 residents (#2, #3, #6, #7, #9, #10, #13, #17, #30, #46, #50 and #69) of 12 residents reviewed, resulting in call lights not being in reach, residents wandering and sleeping in other residents' beds, lack of timely assistance with care, uncovered urinary catheter drainage bags, and Resident #6 being told to urinate in their brief. Findings include: Resident #6: On 6/22/26 at 10:20 AM, Resident #6 was not in their room. A strong, foul urine odor was present in their room. An interview was completed with Resident #6 on 6/22/26 at 12:05 PM. The Resident was in their room in bed, and the strong urine odor remained. Resident #6 was pleasantly confused and smiled but did not respond to all questions asked. Review of Resident #6's face sheet revealed the Resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart failure, right hip replacement, depression, dementia, and anxiety. The face sheet further detailed Resident #6 had an activated Durable Power of Attorney (DPOA) for medical decision making. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact and required maximum to total assistance to complete ADLs. Review of progress note documentation in Resident #6's Electronic Medical Record (EMR) revealed the Resident's cognitive status and level of alertness varied from being alert and orientated to self only to being alert and orientated X three (person, place, and time) with confusion. Health Care Provider documentation also detailed the Resident was alert but unable to communicate well with periods of confusion. On 6/22/26 at 1:56 PM, an interview was completed with Resident #6, Family Member Witness JJ and Family Member Witness KK. When queried regarding Resident #6's care at the facility, Witness JJ stated, (Resident #6) has depends on instead of (facility staff) getting (the Resident) up to go to the bathroom. When asked if they knew when they needed to use the restroom, Resident #6 responded that they did. Witness KK then stated, They tell (Resident #6) to go in their pants and indicated that upset that even more then the staff not assisting Resident #6 to use the bathroom. When queried, Resident #6 stated, Yes, they tell me to just go in my pants. When asked if there was a specific staff member who told them to go in their pants, Resident #6 stated, Just one or two but one more than the other. When asked the names of the staff members, Resident #6 responded that they did not know their names. Witness JJ added that the facility staff do not introduce themselves or wear name tags, so it is hard to know what their names are. When queried if the staff told them to urinate or have a bowel movement, Resident #6 indicated it was both but started with bowel movements because they had an indwelling urinary catheter. Witness JJ revealed they did not find out that staff had told Resident #6 that until they took them to the urologist appointment outside of the facility. Witness JJ stated, (Resident #6) told the nurse there (at urologist office). When queried how it made them feel when the staff told them to go in their pants, Resident #6 looked down and shrugged their shoulders but did not provide a verbal response. Resident #6 was asked again how it made them feel and did not look up but responded in an apathetic monotone that they just did it because they didn't have another option. Witness JJ and Witness KK both verbalized that Resident #6 is not a person who normally complains. Witness JJ then stated, I talked to the Social Worker (Social Services Designee [SSD] B) here about it. When queried what happened when they spoke to SSD B, Witness JJ responded that SSD B told them they would look into it. Review of Resident #6's EMR revealed a care plan entitled, I use a medication for cognitive support. My cognition fluctuates from a BIMS (Brief Interview Mental Status score) of 8 (moderately cognitively impaired) to 14 (cognitively intact) (Initiated: 3/27/26; Revised: 6/24/26). A second care plan entitled, I have an ADL self-care performance deficit related to. decreased strength and endurance, Impaired balance, decreased fine motor skills, Alzheimer's, dementia. (Initiated: 3/27/26; Revised: 6/24/26). The care plan included the intervention, Toilet Use: I require assistance by (2) staff for toileting (Initiated: 3/27/26). Further review of Resident #6's care plans in the EMR revealed the Resident had a discontinued care plan for a Urinary Tract Infection (UTI) from 6/2/26 to 6/8/26 as well as an active care plan related to recurrent UTIs. Review of Resident #6's Medication Administration Record (MAR) in the EMR confirmed Resident #6 was treated with an antibiotic for a UTI for 5 days from 6/3/26 to 6/7/26. An interview was completed with SSD B on 6/25/26 at 12:14 PM. When queried if they were aware of a concern related to staff telling Resident #6 to go in their brief rather than assisting them to the bathroom, SSD B responded, The family came to me regarding if staff are taking (the Resident) to the bathroom. SSD B was asked if Family Member JJ spoke to them regarding staff telling the Resident to go in their pants, SSD B confirmed they were aware. An interview was conducted with Unit Manager K on 6/25/26 at 12:30 PM. When asked if they were aware of a concern brought forth by Resident #6's family that facility staff had told the Resident to go in their pants, Unit Manager K replied, That was brought up in one of our morning meetings. When asked, Unit Manager K stated, That is absolutely not okay. That is what causes UTIs. Unit Manager K was then asked if Resident #6 had developed a UTI while at the facility and indicated they would need to review the Resident's EMR. After reviewing Resident #6's EMR, Unit Manager K confirmed the Resident developed a UTI while at the facility. Unit Manager K stated it was negotiable as to the etiology of the UTI being related to the Resident being told to go in their pants by staff due to the Resident having a catheter. When queried how they would feel if they were told to urinate or have a bowel movement in their brief by the people they depend on for assistance, Unit Manager K indicated they would be very upset and hurt. An interview was completed with the Director of Nursing (DON) on 6/25/26 at 1:47 PM. When queried if they were aware of staff telling Resident #6 to go in their pants rather than assisting them to the bathroom, the DON responded they were not but stated that was not okay. When queried regarding other staff being aware and stating the concern had been brought up in the facilities morning meeting, the DON responded that they had been on vacation. No further explanation was provided. Resident #3: On 6/22/26 at 10:11 AM, an interview was completed with Resident #3 in their room. When queried regarding the care they receive at the facility, Resident #3 stated that the staff are rude. When queried how the staff are rude, Resident #3 responded that the staff don't change them when they ask to be changed and revealed that they feel like the staff brush them off. When queried if there were any specific staff that were rude or made them feel disregarded, Resident #3 responded that there were. Resident #3 was then asked the names of the staff and revealed they did not know their names because the staff do not introduce themselves. Record review revealed Resident #3 was most recently admitted on [DATE] with diagnoses which included diabetes mellites, chronic respiratory failure, bipolar disorder, anxiety, chronic kidney disease (CKD), Bardet-Biedl syndrome (BBS- rare genetic disorder characterized by obesity, kidney abnormalities, and vision loss), and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate assistance with toileting and bathing. The MDS further detailed the Resident had an indwelling urinary catheter and was receiving an antibiotic. Resident #17: An interview was completed with Resident #17 in their room on 6/22/26 at 10:30 AM. The Resident was in their room, in bed positioned on their back. An unknown substance was present on the Resident's pillow. When queried if the facility staff treat them with dignity and respect, Resident #17 responded that some staff are disrespectful. Resident #17 was asked how the staff are disrespectful to them and responded that they just are. Resident #17 was asked for an example and stated, An Aide threw my clothes at me and left when they needed assistance. When queried if the Aide said anything to them, Resident #17 did not provide a response but stated they don't like that. With further inquiry, Resident #17 revealed they do not feel that staff are respectful when they talk to them. Resident #17 verbalized that not all staff were disrespectful. Resident #17 was unable to provide specific staff names when asked. Record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction (stroke) with resulting dysphagia (difficulty swallowing), convulsion disorder with seizures, and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively intact and required moderate to total assistance to complete ADLs. Resident #50: On 6/22/26 at 9:43 AM, Resident #50 was observed in their room. The Resident was laying on their back in bed. The Resident was unshaven and their hair had a greasy appearance. On 6/23/26 at 9:07 AM, Resident #50 was observed in their room. The Resident was laying on their back in bed. The Resident was unshaven and their hair had a greasy appearance. When queried how they are treated by staff at the facility, Resident #50 replied, Some of the staff are not worth the effort. When asked what that meant, Resident #50 repeated that some are not worth the effort. When asked if they meant the staff were rude or not nice to them, Resident #50 stated, It is more how they say it than what they say. Resident #50 indicated some of the staff have poor attitudes which makes them not worth the effort. Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses which included right below knee amputation (RBKA), peripheral vascular disease, and diabetes mellitus. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required total assistance to complete all ADLs with the exception of eating. Call Light Placement and Response: Resident #2: Review of facility Electronic Medical Record/EMR revealed, Resident #2 was [AGE] years old, alert and was admitted to the facility o During an interview done on 6/22/26 at 1:30 p.m., Resident #2 stated It use to be 6 or 7 minutes (for staff to answer call light), but now it about a half an hour. I asked them what the problem was and they (staff) said it's my break, I said that's not my problem, It's not right. Resident #9: Review of the facility EMR revealed, Resident #9 was [AGE] years old, alert and was admitted to the facility on [DATE]. During an interview done on 6/23/26 at 8:37 a.m., Resident #9 stated They (staff) don't come right away, it takes at least 30 minutes (to answer call light), mostly on days, when I have pain it's a long time before I get my pain med. Resident #30: Review of the facility EMR revealed, Resident #30 was [AGE] years old, interviewable with confusion (Dementia) and admitted to the facility on [DATE]. During an interview done on 6/22/26 at 11am Family Member #1 stated They (staff) don't answer the call light sometimes on days and weekends; it takes 20 to 30 minutes maybe even longer. Resident #69: Review of the facility EMR revealed, Resident #69 was [AGE] years old, alert with confusion (history of mental health disorder) and was admitted to the facility on [DATE]. Observation was made on 6/22/26 at 10:18 a.m., Resident #69 was in bed, when asked if she could reach her call light, she was unable to locate it. The residents call light was clipped to the right upper part of her pillow, out of sight and reach. Review of the facility Resident Rights handout (in the admission packet, un-dated) revealed all resident's were to be treated with dignity and respect; which includes placing the call light within reach and answering call lights in a timely manner. Dignity Resident #7: A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated that Resident #7 was admitted to the facility on [DATE] with diagnoses: History of a stroke, weakness, diabetes, heart disease, hypertension, kidney disease, and peripheral vascular disease. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with care. On 6/22/2026 at 1:55 PM, Resident #7 was observed in his room sitting in a wheelchair and he was very upset, as there was another resident lying in his bed. He told the other resident to get out of his bed, and the other resident began to reach for Resident #7's cane that was leaning against the end of the bed. Resident #7 began swinging a reacher stick at the other resident and yelled Don't touch my cane!. A nurse aide was in the room during the incident and separated the two residents and assisted the other back across the hall to his room. The Nurse Aide told Resident #7, He can't help it. On 6/23/2026 10:47 AM, Resident #7 was observed sitting in a wheelchair in his room, when asked how he was doing that day, he said Ok now. Resident #7 said the resident across the hall was in his room again the prior evening and Resident #7 was upset about it. On 6/25/2026 at 12:35 PM, the Unit Manager EE was interviewed about the incident between Resident #7 and the resident across the hall. She said she had not been notified of the incident and did not know the other resident was wandering into other residents rooms and sleeping in their beds. She said she should have been notified of the incident; and a care plan should have been initiated. Confidential group of residents:During an interview with a confidential group of residents four of the seven residents reported that call light responses regularly took over an hour, and one of the seven residents reported that the staff often turned off the call light and did not provide the requested care and did not return to perform care without an additional request. Resident #13 (R13): A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R13 was admitted to the facility on [DATE] with diagnoses that include: congestive heart failure (CHF / decreased ability of heart to pump blood), atherosclerotic heart disease (ASHD / hardening of arteries), chronic obstructive pulmonary disease (COPD/ progressive lung disease), diabetes mellitus (DM), stage 2 chronic kidney disease (CKD), anxiety and history of falls. A record review of Orders revealed R13 was admitted to hospice services on 05/11/2026. The MDS assessment dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. On 06/22/2026 at 10:15AM, during an interview with R13 he reported that he had recently moved rooms in the facility, R13 reported that when he moved room that he went the afternoon and evening without water provided, that he did not receive assistance and that his call light was not answered. He said he felt very disrespected and like he could not get anyone to help him. R13 said that he talked to the lady about it because he was upset, he could not recall the name of who he had reported the complaint to. On 06/23/2026 at 1:18 PM, during a follow up interview R13 said he remembered the lady had spoken to about the complaint was Unit Manager (UM) K. On 06/25/2026 at 8:56AM, during an interview with UM K she was asked if she had received a complaint from R13 about his feelings of disrespect, lack of water and response to care when he changed rooms. UM K said that she had talked to R13 about his concerns a couple of days after he changed rooms, she said he told her it was just the one day that he did not get water or his call lights answered. UM K was asked if that was acceptable care even for 'one day' and she stated No, absolutely not. UM K said she had talked to the staff on his unit and made sure they were aware of R13's room change so that they checked on him and provided care. UM K said she had made additional rounds to check on R13 because of his concerns. A record review of R13'S care plan revealed: Focus: I have Peripheral Vascular Disease r/t (related to) Diabetes, Heart disease . with Interventions: Encourage good nutrition and hydration. and Focus: I have a behavior problem- I am behavioral at baseline. with Interventions: Anticipate and meet my needs. Resident #46 (R46): A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R46 was admitted to the facility on [DATE] with diagnoses that included: Parkinson diseases (progressive neurological disorder), rhabdomyolysis (breakdown of muscle), adult failure to thrive, anxiety and dementia. The MDS assessment dated [DATE] indicated the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12/15 and required assistance with care. On 06/22/2026 at 10:00 AM, observed R46 breakfast tray on her over bed table, R46 said her breakfast tray has been sitting there since 8 AM and no one had been back to get it, she said that was typical. R 46 said that the staff act bothered if she asked for anything and it took up to 40 minutes for her call light to be answered. R46 said that at times staff were on their phones when they were in her room, and she thought that was rude. Observed CNA I enter R46's room and ask if resident needed something, R46 said yes that she wanted her breakfast tray removed. R46 was told by CNA I that CNA J would pick it up on her rounds. Observed CNA J approach the door of R46, CNA I told CNA J that R46 was ready for her breakfast tray to be removed, CNA J rolled her eyes, turned around and made a noise (which indicated she was not going to do it) then CNA J shook her head and walked the other way down the hall. CNA I took R46's breakfast tray and exited the room. On 06/24/2026 at 9:12 AM, observed R46's call light tucked high up under her pillow and out of reach. When R46 was asked she said she can not reach it with her condition (Parkinson's disease- has tremors). R 46's roommate/husband said he often will press his call light for her if she needs assistance because she cannot reach hers, he said that he was gone most of the day on Mondays, Wednesdays and Fridays at dialysis and that she can not get help on those days if the call light is not pinned where she can easily reach it. R46 was asked if that happened often and she stated yes, more than I care for. R46 said that one time she slid out of bed and had to holler for half an hour before someone came to help her because she was unable to reach her light. On 06/25/2026 at 9:00 AM, during an interview with UM K was asked about R46 and she said R46 was anxious but easy to redirect. When queried about the call light response time and accessibility especially on her husband dialysis days, she said she noticed R46 was more anxious when her husband was gone to dialysis. UM K said no one should be on the phone in a resident's room and that CNA could perform resident's requested care when she was asked. On 06/25/2026 at 9:07 AM, during a walk-through visit to R46's room with UM K, both the resident and husband verbalized the concern that R46 call light was often out of her reach and was unable to call for help when he was not there. UM K said she would add R46 to her rounds on the floor and re-educate her staff on responding and placement of call light. Resident #13 (R13): A record review of R13'S care plan revealed: Focus: I am at risk for falls related to: Parkinson's, Rhabdomyolysis, Dementia. with Interventions: educated to use her call button and ask for help; Reinforce the need to call for assistance. and Focus: I have an ADL self-care performance deficit related to Debility. with Interventions: AMBULATION: I do not walk at this time; LOCOMOTION: I required assistance by (1) staff.; EATING: I require set up assistance to eat; PERSONAL HYGIENE/ORAL CARE: I require assistance by (1) staff with personal hygiene and oral care; DRESSING: I require assistance by (1) staff to dress; TOILET USE: I require assistance by (2) staff for toileting; TRANSFER: I require assistance by (2) staff to move between surfaces; BED MOBILITY: I require assistance by (1) staff to turn and reposition in bed; BATHING/SHOWERING: I require assistance by (1) staff with bathing/showering. andFocus: I have impaired cognitive function/dementia. with Interventions: Keep My routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. According to a review of the facilities policy titled Resident rights revealed: Policy statement: Employees shall treat all residents with kindness, respect, and dignity. With Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity. According to a review of the facilities admission packet given listed under resident's rights revealed: Residents have the right to. Dignity and respect: you have the right to be treated with respect and dignity. and Safe environment: you have a right to safe, clean, comfortable and homeless environment, including but not limited to receiving treatment and supports for daily living safely. According to a review of the facilities policy titled call lights, use of revealed: Purpose: to respond promptly to residents call for assistance. with Procedure: 1. Facility personnel must be aware of call lights; 2. Answer call lights in a prompt, calm, courteous manner; 4. When providing care to residents be sure to position the call light conveniently for the resident to use.; 7. Please call a on the bed or preferred location stated by the resident prior to leaving the room.

Based on observation and interview, the facility failed to ensure that the results of the most recent federal or state survey were kept in an area that was readily accessible for review to residents, family members and resident representatives for a confidential group of residents reviewed.Findings include: On 06/23/2026 at 1:33 PM, during an interview with a confidential group of residents, seven of seven residents reported that they did not have access to the state survey results for the facility and were unaware of how to gain access to the information. On 06/23/2026 at 2:35 PM, during an interview with CNA O who worked at the front reception desk was queried where the survey results were kept CNA O said she was unsure and needed to ask the DON for assistance. On 06/23/2026 at 2:37 PM, during an interview with the DON she was asked to locate the last survey results that is for the residents and family to review. The DON said she was not sure and that she thought it was in the NHA's office and needed to ask. After the DON texted an unknown staff member, she said the binder was at the reception desk. The DON was made aware that CNA O who was at the reception desk that day (06/23/2026) had been asked where the survey results were located and CNA O had reported that she was unaware of the location. The DON approached the reception desk and after she reviewed several binders behind the desk (an area only accessible by staff), she pulled out one of the binders and stated, here it is. An observation of the binder revealed a binder in a bright floral pattern and labelled with a clear background with black lettering placed over the floral pattern on the spine of the binder and was difficult to see. The DON was asked why the binder was not accessible to the residents or families without the need to ask for it and she did not have an answer. The DON said she would place it on the table in the lobby, so it would be accessible.On 06/23/2026 at 3:13 PM, during an interview with the NHA she was asked about the survey results location, and she said she had spoken to the DON was aware they were not out and accessible and she was unsure why they were kept behind the desk and not out on the table in the lobby. According to a review of the admission packet given listed under residents' rights: Residents have the right to: Examine the results of the most recent survey of the facility conducted by federal or state surveyors and any plan of correction in effect with respect to the facility.

Based on interview and record review, the facility failed to ensure that a Registered Nurse was on duty for eight consecutive hours a day, seven days a week, resulting in the potential for inadequate coordination of routine or emergent care. Findings Include: Staffing: A record review of the daily posted nurse staffing data sheets from June 2025 to June 2026 indicated there were 15 days with documented 0 for Total Number of Staff and Total Scheduled Hours for RN/Registered Nurse hours: 9/15/2025, 10/8/2025, 12/30/2025, 3/16/2026, 4/10/2026, 4/20/2026, 4/21/2026, 4/26/2026, 5/20/2026, 6/2/2026, 6/5/2026, 6/6/2026, 6/7/2026, 6/20/2026, and 6/21/2026. Upon further review of the Nursing Hours posted document, the facility did not identify 8 hours of RN coverage in a 24 hour period for the identified days. The resident Census for the identified days ranged from 81- 90. On each days document, LPN/Licensed Practical Nurse hours were listed, but each RN hour said 0. On 5/20/2026 there were no RN's listed and 2 LPN's listed on the 7:00 PM to 7:00 AM shift for a census of 82 residents. On 3/16/2026 there were 3 LPN's listed on the 7:00 PM to 7:00 AM shift with no RN's for a Census of 82. The staffing documents identified there were usually 4 Nurses on the 7:00 PM to 7:00 AM shift. A review of the Facility Assessment dated March 2026 identified the following: . RN coverage of 8 hours is sufficient as there are very few duties that an LPN cannot complete in our home in the case that duty must be completed not within the 8 hours that an RN is scheduled a nurse manager who is an RN will be called in to complete the duty. There was no identification on the daily posted nurse staffing sheets that an RN Unit Manager was added for the day. On 6/25/2026 at 2:19 PM, the staffing sheets were reviewed with the Administrator. The 0's for RN hours in a 24 hour period were reviewed and the Administrator said she thought the documents were copies. Reviewed they were copies of the original documents and should have the same documentation as each original document for the specified day. There was no additional information as to the lack of RN hours on the posted documents.

Based on interview and record review, the facility failed to 1) Provide and document education on vaccine side effects for Coronavirus Disease (COVID-19) immunization, and 2) Provide current COVID-19 vaccine education sheet for 4 residents (Resident #2, Resident #9, Resident #10 and Resident #94) of 4 residents reviewed for vaccine education, resulting in misinformation and a lack of full disclosure regarding the COVID-19 vaccine. Findings Include:Resident COVID-19 Vaccine Consent Review: Resident #2: Review of facility Electronic Medical Record/EMR revealed, Resident #2 was [AGE] years old, alert and was admitted to the facility on [DATE]. Review of Resident #2's facility Vaccine Consent dated 6/16/26, revealed no documentation of education for Coronavirus Disease/COVID-19 side effects, with documentation stating I have been offered or received the Michigan Department of Health & Human Services/Centers for Disease Control and Prevention Vaccine Information Sheet. Review of the facilities current Healthcare Personnel Vaccination Recommendations handout dated 7/22, revealed it was not current with Centers for Disease Control Center's/CDC vaccine recommendations. The facility was currently using outdated vaccine recommendations for all resident's; this information sheet was given to all resident's upon admission to the facility. Also, in the facility Resident's admission Packet (un-dated), revealed a COVID-19 vaccine information sheet dated 10/19/23, also outdated. During an interview done on 6/25/26 at approximately 3:00 p.m., the resident said he was not given information on the COVID-19 vaccine, stating I can't remember getting any. Resident #9: Review of the facility EMR revealed, Resident #9 was [AGE] years old, alert and was admitted to the facility on [DATE]. Review of Resident #9's facility Vaccine Consent dated 3/16/26, revealed no documentation of education for COVID-19 side effects, with documentation stating I have been offered or received the Michigan Department of Health & Human Services/Centers for Disease Control and Prevention Vaccine Information Sheet. During an interview done on 6/22/26 at 10:15 a.m., the resident denied he had received any vaccine information upon admission. Resident #10: Review of the facility EMR revealed, Resident #10 was [AGE] years old, confused, and was admitted to the facility on [DATE] with a re-admission on [DATE]; he resident was no table to be interviewed due to cognitive decline and confusion. Review of Resident #10's facility Vaccine Consent dated 6/23/26, revealed no documentation of education for COVID-19 side effects, with documentation stating I have been offered or received the Michigan Department of Health & Human Services/Centers for Disease Control and Prevention Vaccine Information Sheet. Resident # 94: Review of the facility EMR revealed, Resident #94 was [AGE] years old, alert and was admitted to the facility on [DATE]. Review of Resident #94's facility Vaccine Consent dated 6/16/26, revealed no documentation of education for COVID-19 side effects, with documentation stating I have been offered or received the Michigan Department of Health & Human Services/Centers for Disease Control and Prevention Vaccine Information Sheet. Throughout the survey (6/22/26 through 6/25/26), several attempts were made to interview the resident; during all attempts he said he could not recall if he was given any vaccine information from facility staff. During an interview done on 6/24/26 at 9:28 a.m., the Director of Nursing/DON stated I do not do all the immunization consents with all the new residents because it's electronic now; I use the information in their admission packet. I do not up-date the vaccine information, did not know I had too. During an interview done on 6/24/26 at 8:55 a.m., Admissions Director U stated I make up the packages for the nurses to go over with the resident or POA (Power of Attorney) or Guardian (vaccine information). Admissions Director U said she does not change or up-date the vaccine information sheet, she was not aware of it being out-of-date. During several interviews done on 6/22/26, 6/23/26, 6/24/26 and 6/25/26, (from 10:00 a.m., to 4:00 p.m.) Infection Control Nurse, RN A, revealed she was unaware the vaccine information sheet's that was being handed out to all new resident's was not current with CDC up-to-date recommendations, and she did not go over the information regarding side effects of COVID-19 with resident's. IC Nurse A also said she was unaware vaccine side effects were not documented on the facility resident vaccine consent form. Review of the facility Coronavirus Disease (COVID-19)-Vaccination of Residents policy (un-dated), stated Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. The resident (or representative) is provided with the most current vaccine information statement (VIS) prior to vaccine administration. COVID-19 vaccine education, documentation, and reporting are overseen by the infection preventionist and coordinated by their designee.

Based on interview and record review, the facility failed to 1) Provide and document education on vaccine side effects for influenza (flu) and pneumovax (pneumonia) immunizations, and 2) Provide current vaccine education sheets for 4 residents (Resident'#2, Resident #9, Resident #10 and Resident #94) of 4 residents reviewed for vaccine education, resulting in misinformation and lack of full disclosure regarding influenza and pneumovax vaccines. Findings Include:Resident Vaccine Consent Review: Resident #2: Review of facility Electronic Medical Record/EMR revealed, Resident #2 was [AGE] years old, alert and was admitted to the facility on [DATE]. Review of Resident #2's facility Vaccine Consent dated 6/16/26 (after re-admitted from hospital), revealed no documentation of education regarding Influenza or Pneumococcal side effects, with documentation stating I have been offered or received the Michigan Department of Health & Human Services/Centers for Disease Control and Prevention Vaccine Information Sheets. Review of the facilities current Healthcare Personnel Vaccination Recommendations handout dated 7/22, revealed it was not current with Centers for Disease Control Center's/CDC vaccine recommendations. The facility was currently using outdated vaccine recommendations for all resident's; this information sheet was given to all resident's upon admission to the facility. Also, in the facility Resident's admission Packet (un-dated), revealed a CDC Influenza/Flu vaccine information sheet dated 8/6/2021. and a CDC Pneumococcal Polysaccharide/PPSV23 vaccine information sheet dated 10/30/2019, both outdated. During an interview done on 6/25/26 at approximately 3:00 p.m., the resident said he was not given information on the Flu or Pneumovax vaccines, stating I can't remember getting any. Resident #9: Review of the facility EMR revealed, Resident #9 was [AGE] years old, alert and was admitted to the facility on [DATE]. Review of Resident #9's facility Vaccine Consent dated 3/16/26, revealed no documentation of education regarding Influenza or Pneumococcal side effects, with documentation stating I have been offered or received the Michigan Department of Health & Human Services/Centers for Disease Control and Prevention Vaccine Information Sheets. During an interview done on 6/22/26 at 10:15 a.m., the resident denied he had received any vaccine information upon admission. Resident #10: Review of the facility EMR revealed, Resident 310 was [AGE] years old, confused, and was admitted to the facility on [DATE] with a re-admission on [DATE]; he resident was no table to be interviewed due to cognitive decline and confusion. Review of Resident #10's facility Vaccine Consent dated 6/23/26, revealed no documentation of education for Influenza or Pneumococcal side effects, with documentation stating I have been offered or received the Michigan Department of Health & Human Services/Centers for Disease Control and Prevention Vaccine Information Sheets. Resident # 94: Review of the facility EMR revealed, Resident #94 was [AGE] years old, alert and was admitted to the facility on [DATE]. Review of Resident #94's facility Vaccine Consent dated 6/16/26, revealed no documentation of education for Influenza or Pneumococcal side effects, with documentation stating I have been offered or received the Michigan Department of Health & Human Services/Centers for Disease Control and Prevention Vaccine Information Sheets. Throughout the survey (6/22/26 through 6/25/26), several attempts were made to interview the resident; during all attempts he was unable to recall if he was given any vaccine information from facility staff. During an interview done on 6/24/26 at 9:28 a.m., the Director of Nursing/DON stated I do not do all the immunization consents with all the new resident's because it's electronic now; I use the information in their admission packet. I do not up-date the vaccine information, did not know I had too. During an interview done on 6/24/26 at 8:55 a.m., Admissions Director U stated I make up the packages (admission packet including immunization education sheets) for the nurses to go over with the resident or POA (Power of Attorney) or Guardian (vaccine information). Admissions Director U said she does not change or up-date vaccine information sheets, she was not aware of them being out-of-date. During several interviews done on 6/22/26, 6/23/26, 6/24/26 and 6/25/26, (from 10:00 a.m., to 4:00 p.m.) Infection Control Nurse, RN A, revealed she was unaware the vaccine information sheet's that was being handed out to all new resident's was not current with the CDC up to date recommendations, and she did not go over the information regarding side effects of Influenza or Pneumovax with resident's. IC Nurse A also said she was unaware vaccine side effects were not documented on the facility resident vaccine consent form. Review of the facility Pneumococcal Vaccine policy dated 2001, stated All resident's are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The resident (or representative) is provided with the most current vaccine information statement (VIS) prior to vaccine administration. Administration of the pneumococcal vaccine is made in accordance with current Advisory Committee on Immunization Practices and Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the facility Influenza Vaccine Resident and Staff policy dated 9/25, stated Prior to the vaccination, the resident (or residents legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Administration of the influenza vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

Based on observation, interview and record review, the facility failed to 1) Ensure that medications were secured, including a pill on the floor for Resident #79 and that opened medications were properly labeled and dated, and 2) Maintain medication and treatment carts in a clean and sanitary condition, identified for two of four medication carts and two of four treatment carts reviewed for medication storage. Findings include: Medication Storage and Labeling: A record review of the electronic medical record indicated Resident #79 was admitted to the facility on [DATE] with diagnoses: Hypertension, hypothyroidism, arthritis, and bipolar disorder. On [DATE] at 11:06 AM, during a tour of the facility a small round white pill was found on the floor of Resident #79's room. The pill was located on the floor near the bed wheel at the foot of the bed; a clear medication cup was also on the floor nearby. On [DATE] at 11:15 AM, Nurse DD came into the room and was asked about the white pill lying on the floor by the resident's bed. The Nurse identified the white round pill with EP 116 stamped on it as Lasix 20 mg, per an online Drug identification resource. Resident #79 was asked about the pill and pill cup on the floor, and she said she thought she lost a pill but wasn't sure. Nurse DD said she usually threw the medication cup away and she did not know the pill was on the floor. She was unsure when that happened. Nurse DD disposed of the pill. A review of the physician orders for Resident #79 indicated she received Lasix 20 mg twice a day. A review of Resident #79's Medication Administration Record/MAR for [DATE] revealed Lasix 20 mg was signed as given that morning and twice a day each day for the month. Observations of Medication Carts 1-A and 1-B: Observations made on [DATE] at 7:33 a.m., accompanied by the Director of Nursing/DON of medication 1-A are as follows: -x2 loose pills found in second and third drawers, -Lispro Insulin open [DATE] with a written expiration date of [DATE] (expired). During an interview done on [DATE] at 7:20am Nurse, LPN L stated it (Lispro Insulin) should be 30 days to expiration. -House stock of RestRe Liquid protein was found with drippings on all sides, and the top was full of sticky partly dried medication. Observations made on [DATE] at 8:17 a.m., accompanied by the Director of Nursing/DON of medication cart 1-B are as follows: -House stock of RestRe Liquid protein was found with drippings on all sides, and the top was full of sticky partly dried medication. During an interview done on [DATE] at 8:19 a.m., the DON stated, I see it (liquid protein bottle), it's dirty. -In the top drawer, an opened and partly used container of Ventolin 90 mcg (for treatment of asthma) with no expiration date and per manufactured guidelines on the box, it was expired. -In the second and third drawers was found a total of 7 loose pills, and an extensive amount of small pieces of paper, dust and crushed medications in the bottom corners. During an interview done on [DATE] at 9:00 a.m., the DON stated, I told them (Nursing staff) to clean them (the med carts) yesterday. During an interview done on [DATE] at 11:14 a.m., the DON stated, The nurse's clean the med (medication) carts, the ones who are responsible for the cart. Review of the facility Storage of Medications policy dated 5/26, stated The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. ON [DATE] at 1:59 PM, during an observation of Treatment Cart 1B there was a box of triamcinolone cream (topical steroid) labeled with resident's name and date, the tube of medication inside was opened and unlabeled and no open dated. Observed one packaged 20-gauge needle with the expiration date of [DATE], the date was verified by Nurse R who disposed of it. Observed 2 triple antibiotic creams and one hydrocortisone cream (topical steroid) all opened without opened dates, Nurse R said they were stock medications, so no name needed. Observed three tubes of prescribed sodium fluoride toothpaste with resident label and date on the box, no label or date on the opened tubes. Observed one tube of Santyl collagenase ointment (enzymatic debridement medication) with resident's name and open date on box, no name or label on the opened tube inside. Observed one tube of betamethasone cream (topical steroid) box labeled with resident and open date, no name or date on opened tube inside box. One stock bottle of wound wash opened and undated. Nurse R was asked if the tube was outside of the box how staff could identify who it belonged too, and she replied it could not be identified for certain if it were out of the box. On [DATE] at 2:45 PM, during an observation of Treatment Cart 2 there were two tubes of Santyl collagenase ointment (enzymatic debridement medication) with resident's names and open date on box, no names or labels on the opened tubes inside. Observed one tube of Diclofenac gel (topical anti-inflammatory) with no name or label on the opened tube and no box, Nurse S was asked who it belonged to and she said she threw the box away, so she was not sure. Observed one opened tub of Silvadene cream open with resident label, no open date. Observed one opened tube of triamcinolone cream with resident label and date on box, no label or date on the tube inside. Observed one opened tube of Calomoseptine cream (topical menthol/zinc oxide) not labeled or dated and no box. Observed 2 opened bottles of prescription AM lactic lotion 12 % (topical alpha hydroxy lotion) not dated or labeled. Observed One stock bottle of wound wash opened and undated. Nurse S was asked about if staff would be able to identify the medications outside of the box, or if they had no label at all and she said she understood the point of labelling the actual medications and not just the boxes. On [DATE] at 4:37 PM, Observed Treatment Cart 1B unlocked and unattended in the hallway, all the drawers with medication and supplies were easily assessable. UM K observed the access by SA and walked over and locked the cart, verified it should not be readily accessible. According to a record review of the facilities policy labelled Storage of medications reveled: Policy statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. With Policy interpretation and implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper; temperature, light, and humidity controls; 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing; 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use.; 9. Unlocked medication carts are not left unattended; 12. Only persons authorized to prepare and administer medications have access to locked medications.

Based on observation, interview and record review the facility failed to ensure clinical staff postings were accurately completed for several days in 2025 and 2026, resulting in several missed days and incomplete documents. Findings Include: On 6/24/2026 at 10:20 AM, the Director of Nursing was interviewed and staffing documents were requested. She said the facility Scheduler kept the documents in her office. A record review of the daily posted nurse staffing data sheets from June 2025 to June 2026 indicated there were several days that the documents were missing: 5/21/2026 and 6/16/2026. In addition, there were 2 documents for 5/29/2026 and none for 5/30/2026. There was also a staffing document dated January but did not include a day or year. There were several days with missing information on the form including 12/30/2025; the RN Total Scheduled Hours for the 7:00 AM to 7:00 PM shift was blank and the RN hours Actual Hours Worked was blank. The Total Number of Staff for RNs was listed as 0. On 6/25/2026 at 2:20 PM, the Administrator was interviewed about the daily posted nurse staffing sheets. Reviewed with her that there were some days that were missing, and some of the documents had missing information and blanks. She said she thought the documents were copies. Confirmed the documents were copies and should reflect the original documents for accuracy.

Based on interview and record review, the facility failed to ensure that the drug/medication regimen reviews were completed, dated and in the medical record monthly, for 3 residents (Resident #8, Resident #12 and Resident #84) of five residents reviewed for medications, resulting in the potential for each resident to receive unnecessary medications and develop adverse effects. Findings Include: Medication Regimen Review Resident #8: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #8 was admitted to the facility on [DATE] with diagnoses: Dementia, Pulmonary hypertension, diabetes, history of falls, back pain, history of a stroke, auditory hallucinations, depression, peripheral vascular disease, cataracts, and hypertension. The MDS assessment dated [DATE] had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 9/15 and the resident needed some assistance with care. On 6/23/2026 at 2:38 PM, a review of the electronic medical record/emr identified a progress note dated 6/22/2026 at 10:51 AM, IDT Note: MRR completed- no recommendations. On 6/23/2026 at 3:30 PM, the Director of Nursing/DON was interviewed about the Medication Regimen Reviews/Pharmacy reviews that were to be completed monthly by the pharmacist for each resident. She said the pharmacy reviews were on a paper list in her office. The DON said all of the residents were listed together on one paper if the pharmacist completed the monthly review and did not have any recommendations related to the resident's medications. She said if there were recommendations by the pharmacist, they would be in the electronic medical record/emr under the Document tab in the Pharmacy section for each resident. The DON was asked if the monthly Pharmacy reviews were in the residents medical record and she said if there was a recommendation from the pharmacist, that document should be in the medical record. Upon further review of the medical record for Resident #8, the resident did not have any other reviews or recommendations for the past year in the medical record. On 6/24/2026 at 10:00 AM, paper copies of the June 2025-June 2026 pharmacy reviews for Residents #8, were received. The reviews were listed as Resident names and the date a review was completed by the pharmacist; all residents were listed on the document. There was no additional information. Resident #8 had one recommendation titled, Consultant Pharmacist Recommendation to Physician for September 2025 related to a Risperdal (antipsychotic medication) Gradual Dose Reduction/GDR. The resident had received the medication since April 2025. The recommendation was signed by the pharmacist and there was no response written on the form from the physician or other provider. The recommendation was not located in the resident's medical record. Resident #12: A record review of the electronic medical record and MDS assessment indicated Resident #12 was admitted to the facility on [DATE] with diagnoses: Dementia, schizophrenia, diabetes, kidney disease, anemia and hypertension. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss with a BIMS score of 12/15 and needed some assistance with care. A review of the medical record progress notes for Resident #12 identified a note dated 6/22/2026 indicating a pharmacy review was completed. On 6/24/2026 at 11:30 AM, the DON provided a copy of a monthly pharmacy recommendation dated 12/15/2025 for Resident #12. The recommendation was related to the antidepressant medication Mirtazapine/Remeron and asked about a GDR as the resident had received the medication since June 2025. The pharmacy recommendation was signed by the pharmacist and there was no documentation from the physician or provider on the document. It was not located in the medical record. There were no additional pharmacy reviews or recommendations in Resident #12's medical record for the past year. Resident #84:A record review of the Face sheet and MDS assessment indicated Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's Dementia, diabetes, epilepsy, heart failure, urinary retention, history of falls with fracture left leg, peripheral vascular disease, anxiety, psychosis, weakness, hypothyroidism, and hypertension. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a BIMS score of 5/15 and needed assistance with care.A review of the medical record for Resident #84 identified a progress note dated 6/22/2026 at 10:51 AM, IDT Note: MRR completed- no recommendations. There were no additional pharmacy reviews/MRR's in the resident's medical record for the past year.On 6/24/2026 at 11:12 AM, the Director of Nursing provided one pharmacy recommendation for Resident #84 for March 12, 2026, related to Fluphenazine/Prolixin dose 5 mg, (an antipsychotic medication). The pharmacist asked about a GDR for the medication, as the resident had received the medication since March 2025 without a GDR. The pharmacy recommendation was signed by the pharmacist, but the physician or provider had not documented or signed to acknowledge the recommendation. The pharmacy recommendation was not in the resident's medical record. Residents #8, #12 and #84 did not have monthly pharmacy reviews identified in their medical records or pharmacy recommendations over the past year. The documents received from the DON were obtained from the pharmacy for surveyor review.

Based on observation, interview and record review, the facility failed to ensure that the communication process was implemented, and documentation was readily available reflecting coordination of a resident's care, for one resident (Resident #13) of one resident reviewed for hospice services. Findings include:Resident #13 (R13):A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R13 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF / decreased ability of heart to pump blood), atherosclerotic heart disease (ASHD / hardening of arteries), chronic obstructive pulmonary disease (COPD/ progressive lung disease), diabetes mellitus (DM), stage 2 chronic kidney disease (CKD) and history of falls. A record review of Orders revealed R13 was admitted to hospice services on 05/11/2026. The MDS assessment dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. On 06/22/2026 at 10:15AM, during an interview with R13 he reported that he was on hospice services but said he remained independent in most of his care, R13 said staff assisted him with showers. A record review of R13'S care plan revealed: Focus: have a terminal prognosis r/t (related to) congestive heart failure. On services with (provider name) Hospice. with Interventions: June Hospice Calendar: 06/02 LPN, CNA; 06/04 CNA, RN; 06/05 SW; 06/08 CNA; 06/09 LPN, CH; 06/11 RN, CNA; 06/15 CNA; 06/16 LPN; 06/18 CNA, RN; 06/22 CNA; 06/23 LPN; 06/25 CNA, RN, CH; 06/27 SW; 06/29 CNA; 06/30 LPN Date Initiated: 05/15/2026 Revision on: 06/22/2026. And Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.On 06/24/2026 at 9:27 AM, during an interview with CNA I she was asked where the hospice communication binder for R13 was located and she produced 2 binders located at the nurse's station desk on the unit of R13. A record review of R13's hospice binders for May and June revealed: monthly visit schedules, hospice agreement, hospice care plan and a total of four communications, three of the communications were from Chaplin visits in May and one dated 06/11/2026 was from the nurse. No other communications / coordination of care visits were present in the binder. On 06/24/2026 at ~(approximately) 9:30 AM, Nurse L on R13's unit was asked about the communication in the hospice binders and observed and confirmed the lack of documentation. Nurse L said she was new to the unit and she was not sure why there was scant documentation compared to the calendar visits. On 06/24/2026 at 10:03 AM, during an interview with the DON she said the binders were a thing of the past and not used. The DON said that social services (SS) B handled the hospice care. The DON said she was unsure where the communication/documentation was in the chart. On 06/24/2026 at 10:25 AM, during a follow up interview with the DON she said after she spoke with SS B that there should be some information from each visit documented in the binder and that SS B had called the hospice company to advise them it was not done. The DON was asked to review the binders and agreed there was scant documentation, with only one nurse visit documented. The DON said that the interdisciplinary team (IDT) met monthly and that information was in care conference notes in the EMR. A record review of R13's electronic medical record (EMR) revealed no care conference since documented since January 16th, 2026. A further record review of the documents in EMR revealed no hospice communication outside of the consent for care. The consent for hospice care was signed on 05/11/2026. On 06/24/2026 at 12:06 PM, During an interview with SS B she produced a stack of warm copies of hospice visit/coordination for R13. When SS b was asked why they were not available in the chart she replied, Because, I have 80 residents. SS B was asked why there was no communication in the hospice binders on the unit she said they should be signing off on visits in there. On 06/24/2026 at 12:30 PM, during an interview with the NHA she was asked what a reasonable amount of time was to upload records for coordination of care, the NHA said she would have to look at the policy, but she thought one business day would be enough. The NHA looked at R13's EMR and said Well, I see the stack of hospice notes she (SS B) gave you are in there; I can also see that they were just uploaded today. The NHA confirmed that there was not a care conference documented for R13 since January in the EMR and could not confirm if one was completed and said SS B would be the one who completed it. The NHA agreed to call SS B to the interview. On 06/24/2026 at 12:35 PM, during an interview with the NHA and SS B the SS B confirmed R13 was enrolled in hospice on 05/11/2026. When SS B was asked why there was no care coordination accessible for R13's hospice care in the uploaded documents, SS B stated I didn't know there was a timeframe on uploading them and said it sometimes takes a few weeks to get them in the chart. When asked if 7 weeks was acceptable, she had no reply. SS B acknowledged that the hospice binder was not up to date and had not been properly utilized by the hospice staff and that she had called them about it today (06/24/2026). SS B was asked if a care conference had been completed for R13 since the last documented on in January 2026, she said yes but she had not put it in the computer yet and looked at the NHA and stated, I put it on my PIP (performance improvement plan) for May. The NHA agreed that the documents were not uploaded and available timely in the residents' records for coordination. According to a record review of the facilities policy titled Hospice program revealed: Policy interpretation and guidelines: 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with Hospice representative and ensure the level of care. d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. According to a record review of the facilities policy titled Coordination of medical care revealed: Policy interpretation and guidelines: 2. Coordination of medical care includes. d. Coordinating and monitoring the provision of medical care; e. Establishing a framework of expectations for healthcare practitioners; f. Monitoring practitioners, providing feedback, and interviewing when necessary.; g. Functioning as a liaison between attending physicians and facility staff to address areas of concern.

Based on interview and record review, the facility failed to ensure that accurate and comprehensive informed consent was provided prior to initiation of psychotropic medications for one resident (Resident #12) of five residents reviewed for unnecessary medications. Findings include:Resident #12: Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, psychosis, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required supervision to maximum assistance to complete Activities of Daily Living (ADLs) with the exception of eating. The MDS further detailed the Resident was taking psychotropic medications. Review of Resident #12's Medication Administration Record (MAR) for June 2026 revealed the Resident was currently receiving the following psychotropic medications: - Fluphenazine Decanoate (Prolixin- long lasting antipsychotic medication with a black box warning for use in elderly) Intramuscular (IM) Injection - 25 mg milligrams (mg)/milliliter (mL) every 14 day(s) for psychosis. - Divalproex Sodium (Depakote- medication used to treat seizures and as a mood stabilizer associated with bipolar disorder with black box warning) Delayed Release (DR) 250 mg twice a day for Major neurocognitive. with behavioral disturbance. An interview was completed with Social Services Designee (SSD) B on 6/23/26 at 1:42 PM. When queried regarding facility procedure related to obtaining consents for psychotropic medications, SSD B stated, I get the consents. When asked if they monitor and track all psychotropic medication use in the facility, SSD B replied, Yes. Resident #12's psychotropic medication consents were requested from SSD B. The following consents were received and reviewed with SSD D: - A consent for Fluphenazine Decanoate dated 2/18/26- A consent for Depakote (not Depakote DR) dated 10/2/25. When queried why the consent for Depakote did not specify Depakote DR, SSD B reviewed the consent, indicated the consent was incorrect, and stated, It should say DR. SSD B was then asked if they review the side effects of the psychotropic medications with the Resident and/or their guardian, SSD B stated, No and indicated they have a nurse review the potential medication side effects. When asked why they sign the informed consent form if they are not reviewing the potential side effects of the medication, SSD B stated, I see what you're saying. I understand. With further inquiry, SSD B stated, Should probably have them (nursing staff) sign it (informed consent form). On 6/24/26 at 10:46 AM, an interview was completed with Resident #12's Legal Guardian Witness LL. When queried regarding Resident #12's psychotropic medication consents including what information is reviewed with them when obtaining consent, Witness LL responded that the facility does not go over side effects of medications when they contact them to obtain consent. With further inquiry regarding their understanding of Resident #12's psychotropic medications and potential side effects of medication use, Witness LL responded, I go with what they (facility staff) say because I am not clinical in regard to medication recommendations. An interview was completed with the Director of Nursing (DON) on 6/25/26 at 1:50 PM. When queried regarding the facility policy/procedure related to informed consent for psychotropic medication use, the DON indicated a consent form is completed and obtained for each psychotropic medication. When queried if the form should have the correct formulation of the medication, such as DR versus not, the DON responded that it should. The DON was then asked if the possible side effects and risks/benefits of the medications should be reviewed with the resident/resident representative prior to initiation of therapy and confirmed they should. When queried regarding Resident #12's having a consent for Depakote, not Depakote DR, and SSD B confirming they made an error, the DON did not provide further explanation. When queried regarding SSD B stating they obtained and signed the consent forms but did not review the potential side effects, the DON verbalized understanding of the concern.Review of facility policy/procedure entitled, Psychotropic Medication Use (Reviewed: 1/26) revealed, Informed Consent or Refusal: 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the Practitioner/physician will review the following with the resident/representative prior to obtaining documented consent or refusal: a. non-pharmacological alternatives; b. the indications and rationale for the recommendation c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and d. the resident's/representative's right to accept or decline the treatment.

Based on interview and record review, the facility failed to 1) Ensure the resident's right to formulate an Advanced Directive for one resident (Resident #3) and 2) Ensure that a resident was competent to sign an advance directive/Code Status for one resident (Resident #43), of 3 reviewed for Advance Directives, resulting in the potential for the residents' lack of informed knowledge related to options for code status and miscommunication of code status. Findings Include: Resident #3: Record review revealed Resident #3 was most recently admitted on [DATE] with diagnoses which included diabetes mellites, chronic respiratory failure, bipolar disorder, anxiety, chronic kidney disease (CKD), Bardet-Biedl syndrome (BBS- rare genetic disorder characterized by obesity, kidney abnormalities, and vision loss), and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate assistance with toileting and bathing. A review of Resident #3's Electronic Medical Record (EMR) revealed the Resident was a full code status indicating the wanted to be resuscitated in case of a medical emergency. Advance Directive documentation such as Durable Power of Attorney (DPOA) was not noted in the EMR. A form entitled, Advance Directive/Medical Treatment Decisions was present in Resident #3's EMR. The form specified, This is to acknowledge that I have been informed in writing. of my right. to make decisions concerning medical care. and the right to formulate and issue Advance Directives to be followed should I become incapacitated. The option checked on the form was, I have chosen to formulate and issue the following Advance Directives. There was no further information checked regarding formulation of Advance Directives, such as a DPOA, selected on the form. The form was dated and signed by the Resident on [DATE]. An interview was completed with Social [NAME] Designee (SSD) B on [DATE] at 1:15 PM. When queried regarding Resident #3's Advance Directive form indicated the Resident chose to formulate and issue an Advance Directive but not having Advance Directive documentation in the EMR, SSD B stated, They clicked the wrong one. (Resident #3) wants to be to a full code. When asked what choosing to formulate and issue and Advance Directive means, SSD B responded that it meant code status. When asked if Advance Directives also referred to advanced care planning such as setting up a DPOA, SSD B replied, Yeah, I guess. We talk to them (residents) about that. When queried if they spoke to Resident #3 about an Advance Directive, SSD B did not provide a response. An interview was completed with Resident #3 on [DATE] at 2:56 PM. When queried if facility staff had discussed formulating an Advance Directive, such as a PDOA, with them, Resident #3 responded that they would like to get something in place and that the facility staff have not offered to assist them. When asked if they would need assistance, Resident #3 revealed they would as they are unsure about the options and what would need to be completed. An interview was completed with the Director of Nursing (DON) on [DATE] at 1:58 PM. When queried regarding Resident #3's Advance Directive form indicating the Resident wanted to formulate an Advance Directive, not having an Advance Directive in their EMR, and interviews completed with SSD B and Resident #3, the DON stated, I don't know what to tell you. A review of the facility policy titled, Advance Directives/Advance Care Planning, dated reviewed 1/2026 provided, Policy Statement: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. 14. In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: a. Advance Directive — a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated. Advance Directives Resident #43: A record review of the Face sheet and Minimum Data Set/MDS indicated Resident #43 was admitted to the facility on [DATE] with diagnoses: History of a stroke, history of a myocardial infarction (heart attack), weakness right lower leg, diabetes, liver disease, history of liver transplant, lung disease, dementia, depression, anxiety, chronic kidney disease, and gout. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 8/15 and the resident needed some assistance with care. On [DATE] at 11:12 AM, during a review of the Advance directives/Code status document for Resident #43, the document was checked that the person did not wish to formulate advance directives and appeared unsigned. A staff member signed the form on [DATE]. Further review of the progress notes for Resident #43 identified the following: [DATE] at 9:20 AM, a Social Services note Called (the resident's friend) and let her know that we need her to come up and sign documents for the guardianship. [DATE] at 4:40 PM, a Nursing/Clinical Note: Resident admitted to facility via stretcher via EMS (emergency medical services). Upon assessment, resident is alert and oriented x1 (person/himself- he is not oriented to place or time). A record review of a Psychiatric Evaluation & Consultation dated [DATE] identified the following, . Social Work reports significant behavioral concerns including a recent incident in which (Resident #43) struck his son with his cane and was subsequently evicted from his apartment, which is a clinically significant disclosure reflecting behavioral dyscontrol in the context of severe cognitive impairment and dementia. Cognitive impairment is severe with orientation 1 out of 4. On [DATE] at 3:15 PM, Social Services Staff B was interviewed and asked about Resident #43's Advanced Directives. She showed the resident's Advance Directives form and she said he signed the Advance Directives for wanting CPR on [DATE] the day of admission. During the interview with Social Services B on [DATE] at 3:15 PM, she said she completed Resident #43's initial BIMS for the MDS dated [DATE] and the score was 8/15 (moderate cognitive loss) and she said on [DATE] the Psychologist completed the next BIMS, and the score was 3/15 (severe cognitive loss). Social Services B was asked if the resident was competent to legally sign documents and she provided 2 documents that indicated the resident was declared incompetent to make his own decisions on [DATE] by Physician F and [DATE] by Psychologist HH. Physician F documented . unable to understand complex medical (and financial) decision making. Psychologist HH documented, . lacks insight and judgement into medical and financial decision making. During the interview with Social Services B on [DATE] at 3:15 PM, she said she was told the resident had to sign no matter what when they were admitted . She said there was no mention of the residents 'competence and she said it was their facility policy to make sure it was signed. She said the resident's girlfriend was seeking guardianship, as the resident was not able to make his own decisions. A review of the facility policy titled, Advance Directives/Advance Care Planning, dated reviewed 1/2026 provided, Policy Statement: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3.) If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive care plan for one resident (Resident #43) of 23 residents reviewed, resulting in Resident #43 lacking Care Plan interventions related to wandering into other residents' rooms. Findings Include: Resident #43: A record review of the Face sheet and Minimum Data Set/MDS indicated Resident #43 was admitted to the facility on [DATE] with diagnoses: History of a stroke, history of a myocardial infarction (heart attack), weakness right lower leg, diabetes, liver disease, history of liver transplant, lung disease, dementia, depression, anxiety, chronic kidney disease, and gout. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 8/15, and the resident needed some assistance with care. On 6/22/2026 at 1:55 PM, Resident #43 was observed lying in another residents' bed (Resident #7) across the hall from Resident #43's room. Resident #7 was very upset when he found Resident #43 lying in his bed. He told Resident #43 to get out of his bed and Resident #43 began to reach for Resident #7's cane that was leaning against the end of the bed. Resident #7 began swinging a reacher stick at Resident #43 and yelled Don't touch my cane!. On 6/23/2026 at 10:47 AM, Resident #7 was interviewed and said the resident across the hall (Resident #43) was in his room again the prior evening and Resident #7 was upset about it.On 6/24/2026 at 4:45 PM, Certified Nursing Assistant/CNA H was observed in the hallway near Resident #43's room. When asked about the resident, she said that he would wander in the hallway. The MDS assessment for Resident #43 dated 6/4/2026 Section E, question 0900 Wandering- Presence & Frequency was checked for 2. Behavior of this type occurred 4 to 6 days. A review of a Psychosocial Evaluation for Resident #43 dated 6/3/2026 provided, . Hospital records indicate that he has a previous diagnosis of Dementia and struck his son with his cane and was agitated and aggressive leading to his admission to the hospital. A record review of the Care Plans for Resident #43 on 6/24/2026 indicated there was no mention of Resident #43 wandering into other resident's room and lying down in their beds. On 6/25/2026 at 12:35 PM, the Unit Manager EE was interviewed about the incident between Resident #43 and another. She said she had not been notified of the incident and did not know Resident #43 was wandering into other residents' rooms and sleeping in their beds. She said she should have been notified of the incident; and a care plan should have been initiated.

The facility failed to provide adequate supervision, and develop, enact and evaluate interventions for repeated wandering into other residents' rooms for one resident (Resident #43). Findings include: Resident #43: A record review of the Face sheet and Minimum Data Set/MDS indicated Resident #43 was admitted to the facility on [DATE] with diagnoses: History of a stroke, history of a myocardial infarction (heart attack), weakness right lower leg, diabetes, liver disease, history of liver transplant, lung disease, dementia, depression, anxiety, chronic kidney disease, and gout. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 8/15, and the resident needed some assistance with care. On 6/22/2026 at 1:55 PM, Resident #43 was observed lying in another resident's bed (Resident #7) in the wrong room (across the hall from Resident #43's room). Resident #7 was very upset when he found Resident #43 lying in his bed. He told Resident #43 to get out of his bed and Resident #43 began to reach for Resident #7's cane that was leaning against the end of the bed. Resident #7 began swinging a reacher stick at Resident #43 and yelled Don't touch my cane!. A nurse aide was in the room during the incident and separated the two residents and assisted Resident #43 back across the hall to his room. The Nurse Aide told Resident #7, He can't help it Resident #43 didn't say anything and walked with the Nurse Aide back to his room. On 6/23/2026 10:47 AM, Resident #7 was observed sitting in a wheelchair in his room, when asked how he was doing that day, he said Ok now. Resident #7 said the resident across the hall (Resident #43) was in his room again the prior evening and Resident #7 was upset about it.On 6/24/2026 at 4:45 PM, Certified Nursing Assistant/CNA H was observed in the hallway near Resident #43's room. When asked about the resident, she said that he wandered in the hallway. CNA H said Resident #43 would usually sleep from early afternoon until about 5:30 PM every day. She said he would get up and start walking up and down the hall; sometimes he would ask to use the phone. The CNA was asked if she had seen him sleep in other resident's beds and she said she had seen him go into other residents' rooms. A record review of the electronic medical record for Resident #43 identified a Nursing Assessment Admission date 5/28/2026 and lock date 5/29/2026. Section P. Elopement Risk was marked Yes for Dementia and the other questions were marked No. The MDS assessment dated [DATE] Section E, question 0900 Wandering- Presence & Frequency was checked for 2. Behavior of this type occurred 4 to 6 days. A record review of the Care Plans for Resident #43 on 6/24/2026 indicated there was no mention of Resident #43 wandering into other resident's room and lying down in their beds. A record review of the progress notes for Resident #43 revealed there was no note related to the resident wandering, entering other residents' rooms or lying down in their beds. A review of a Psychosocial Evaluation dated 6/3/2026 provided, . Hospital records indicate that he has a previous diagnosis of Dementia and struck his son with his cane and was agitated and aggressive leading to his admission to the hospital.A record review of the Kardex for Resident #43, reviewed on 6/24/2026, did not mention the resident was wandering into other residents' rooms. The Safety section did not mention the resident wandering or that he could be aggressive.On 6/25/2026 at 12:35 PM, the Unit Manager EE was interviewed about the incident between Resident #7 and the resident across the hall Resident #43. She said she had not been notified of the incident and did not know Resident #43 was wandering into other residents rooms and sleeping in their beds. She said she should have been notified of the incident; and a care plan should have been initiated. During the interview with Unit Manager EE on 6/25/2026 at 12:40 PM, she was asked how staff would be notified if a Resident had a history of wandering. She said there was an Elopement book at the front desk and Resident #43 should be listed in the book. A review of the Elopement book at the front desk revealed Resident #43 was not included.

Based on interview and record review the facility failed to ensure that nurses completed yearly competencies and training for one nurse (Nurse A) of 1 nurse reviewed for education and competencies. Findings Include: On 06/25/2026 at 9:30 AM, Regional Human Resources/HR Director T was interviewed about staff education. She said the completed education documents were stored in the staff files in the HR office. A yearly competency was requested to be reviewed for Nurse A. On 6/25/2026 at 11:29 AM, the HR Director T was interviewed, and she said she did not have a competency evaluation for Nurse A. A review of the Facility Assessment dated March 2026 identified the following: Training, Competencies- Annual and on hire, in person and Show me. On 6/25/2026 at 2:40 PM, the Administrator was interviewed about the absence of a competency for Nurse A and said the staff were looking into it.

Based on interview and record review, the facility failed to ensure that 4 of 5 Certified Nursing Assistants (CNA), reviewed for the mandatory 12 hours of yearly training, had the required training. Findings Include: On 06/25/2026 at 9:30 AM, Regional Human Resources/HR Director T was interviewed about staff education. She said the completed education documents were stored in the staff files in the HR office and the 12 hour Certified Nursing Assistant/CNA training was able to be downloaded from the training cite on the computer. At that time the HR Director T was asked to see the 12 hour CNA training for 4 CNA's I, V, X, and Y. The HR Director was not able to locate the proof of training. On 6/25/2026 at 11:29 AM, the HR Director T was interviewed and she provided several pages of training documents for CNA X equaling 10.91 hours. She also provided 75 minutes/1 hour 15 minutes of training for CNA I. She said there was no additional training for CNA's Y and V and that was all of the information she could locate. Only CNA X had training on Abuse Neglect and Dementia Care. On 6/25/2026 at 2:40 PM, the Administrator was interviewed about the lack of required 12 hour CNA education for CNA's I, V, X and Y and said the staff were looking into it.

based on interview and record review, the facility staff failed to follow and update timely a fall care plan for one resident (Resident #101) resulting in missed interventions necessary for care and services not being care planned with a likelihood of unmet care needs. Findings include: Resident #101:Record review of Resident #101's fall incident report dated 4/2/2026 at 6:00AM revealed that the aide requested nursing assistance in the weight room across from the therapy office. Upon arrival the writer noticed resident alert and oriented laying up against the wall in the weight room. Aide reported resident lost his footing on the weight scale as resident was assisted back to his wheelchair. Aide stated resident did not (hit) his head. This writer assessed resident for bruising & injuries, none noted. Resident reported he lost his step on his weaker side as the aide was assisting him back in his wheelchair. There was no mention of resident footwear at the time of the incident. Incident report noted no witness statements found.In an interview on 4/15/2026 at 2:30PM with the Director of Nursing (DON) related to Resident #101's fall on 4/2/2026 at 6:00AM, the DON stated that the facility did not wake up residents at that time just for weights. The DON stated that she talked to the nurse and investigated the incident, no notes or witness statements were made, we followed the plan of care. It was not a huge investigation. The resident had no appointments that day. Record review of resident weight log revealed weight at 5:51 Am and as a standing weight. Why was this aide to get the weight at that time of the morning? The DON stated that the facility has staff that do weights, so that it is consistent, weights can be done anytime. Daily weights we do them in the morning depending usually on day shift which is 6am to 6pm. He has history of left foot drop and left side weakness to left leg/arm. The resident was just mad that the nurse left the Certified Nurse Assistant (CNA) and him in the weight room. He said that his knees gave out. No, I did not talk to the CNA or resident, just the nurse.Record review of Resident #101's medical record revealed admission on [DATE] from the hospital setting. Medical diagnoses included: heart disease, occlusion and stenosis of right carotid artery, hemiplegia and hemiparesis post intracerebral hemorrhage affecting the left non-dominant side, diabetes, depression, anxiety disorder, hypothyroidism, orthostatic hypotension, anemia, moderate protein-calorie malnutrition, mitral valve insufficiency, tricuspid valve insufficiency, and cardiomyopathy.Record review of Resident #101's care plans page 1 through 27, revealed the resident needed assistance with ambulation per one person with 2 wheeled walker and left foot orthosis, received physical therapy for gait training and neuro-muscular re-education. Transfer: Resident requires assistance by one staff to move between surfaces, allow increased time secondary to dizziness at times. Record review of Fall care plan dated 3/3/2026 related to recurrent falls, history of left hip fracture, debility, cardiovascular accident (CVA) with left hemiplegia, diabetes, anemia, dizziness, fatigue, orthostatic hypotension, and potential medication side effects. Interventions included: Transfer and change positions slowly, left side of bed at wall. On 4/6/2026 new intervention of: Use seated scale when obtaining weights, was added 4 days post fall.Record review of the facility 'Care Plans- Baseline' policy dated 9/2025 was the only care plan policy received when requested, revealed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. the baseline care plan includes instructions needed to provide effective, person-centered care of the resident the meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident

based on observation, interview and record review, the facility failed to prevent a fall/accident and ensure that a left foot Ankle Foot Orthosis (AFO) device and gait belt were applied prior to standing for one resident (Resident #101) of 4 sampled residents, resulting a fall with likelihood for repeat falls, pain and serious injury. Findings include: Resident #101:Record review of Resident #101's fall incident report dated 4/2/2026 at 6:00AM revealed that the aide requested nurse assistance in the weight room across from the therapy office. Upon arrival the writer (Nurse) noticed resident #101 was alert and oriented laying up against the wall in the weight room. Aide reported resident lost his footing on the weight scale as resident was assisted back to his wheelchair. Aide stated resident did not (hit) his head. This writer assessed resident for bruising & injuries, none noted. Resident reported he lost his step on his weaker side as the aide was assisting him back in his wheelchair. There was no mention of resident footwear at the time of the incident. Incident report noted no witness statements found.In an interview on 4/15/2026 at 2:30PM with the Director of Nursing (DON) related to Resident #101's fall on 4/2/2026 at 6:00AM, the DON stated that the facility did not wake up residents at that time just for weights. The DON stated that she talked to the nurse and investigated the incident, no notes or witness statements were made, we followed the plan of care. It was not a huge investigation. The resident had no appointments that day. Record review of resident weight log revealed weight at 5:51 AM and as a standing weight. The surveyor asked why was this aide to get the weight at that time of the morning? The DON stated that the facility has staff that do weights, so that it is consistent, weights can be done anytime. Daily weights we do them in the morning depending usually on day shift which is 6am to 6pm. He has history of left foot drop and left side weakness to left leg/arm. The resident was just mad that the nurse left the Certified Nurse Assistant (CNA) and him in the weight room. He said that his knees gave out. No, I did not talk to the CNA or resident, just the nurse.Record review of Resident #101's medical record revealed admission on [DATE] from the hospital setting. Medical diagnoses included: heart disease, occlusion and stenosis of right carotid artery, hemiplegia and hemiparesis post intracerebral hemorrhage affecting the left non-dominant side, diabetes, depression, anxiety disorder, hypothyroidism, orthostatic hypotension, anemia, moderate protein-calorie malnutrition, mitral valve insufficiency, tricuspid valve insufficiency, and cardiomyopathy.Record review of Resident #101's care plans page 1 through 27, revealed the resident needed assistance with ambulation per one person with 2 wheeled walker and left foot orthosis, received physical therapy for gait training and neuro-muscular re-education. Transfer: Resident requires assistance by one staff to move between surfaces, allow increased time secondary to dizziness at times. Record review of Fall care plan dated 3/3/2026 related to recurrent falls, history of left hip fracture, debility, cardiovascular accident (CVA) with left hemiplegia, diabetes, anemia, dizziness, fatigue, orthostatic hypotension, and potential medication side effects. Interventions included: Transfer and change positions slowly, left side of bed at wall. On 4/6/2026 new intervention of: Use seated scale when obtaining weights, was added 4 days post fall.Observation and interview on 4/15/2026 at 8:20AM of Resident #101 while lying in bed with no covers on, the resident was awake. Resident #101 stated that his left foot is getting better, he has a calf/leg/shoe device (AFO-Ankle Foot Orthosis) that helps his leg, and he stated when asked about his right foot that it was fine and had no injury or pain. Observation of residents' bare feet bilaterally noted no bruising, sore or skin injuries noted, to the feet while in the bed. He stated that he is doing therapy services and that he is getting more strength and feels like he is making progress. Observation on 4/15/2026 at 10:25AM of Resident #101 was seated up in wheelchair in therapy session, with right ankle weight on and exercises in progress, right arm 3 lb. weight for arm strengthen. Resident #101 stated that he had a massive stroke and had left side weakness and foot drop. The surveyor Observed left leg/foot Ankle Foot Orthosis (AFO) in place to left shoe. Resident #101 did state that he had a lidocaine patch to his left knee for pain. In an interview on 4/15/2026 at 11:20AM with Resident #101 revealed he had left foot drop and the splint thing (AFO) to stand/walk. On that night (4/2/2026) at 4AM in the morning 2 nurses came into his room to weigh him. They got him up at 4:00AM, and he refused. Resident #101 stated that he was sat up and he told them that he needed to sit for 10 minutes or so or his blood pressure would drop. It was a big-sized nurse, she was wide and a skinny young girl that was told to get me up to be weighed. The big-sized girl was snotty and picked me up under my arm pits and put me in the wheelchair. The skinny girl took me to the weight room across from the therapy. Resident #101 stated that he usually goes to the chair weight scale on the other end of the hallway. They (staff) had no gait belt on him and he was barefoot, he did not have any socks on, they just got him out of bed. The skinny girl stood the resident up and he started to black out and went down. The resident #101 stated that there was only one handrail in the room, it was on the back of the scale. He fell backwards and landed on his left foot/leg and hurt his knee. The skinny aide was only about 90 pounds, and she went to get the big-sized girl. Resident #101 stated that his left big toe was bleeding. The large-sized girl didn't do anything. Resident #101 stated that he had a fall at home and broke his hip in December/January. Resident #101 stated that his toe healed up and there's nothing to look at there. Resident #101 stated that he usually gets weighed on the sitting chair scale and for some reason that night they changed to a wheelchair scale but made him stand up, he knows the wheelchair weighs 27 pounds and they subtract that from the total weight. Observation on 4/15/2026 at 11:35AM Observation of the weight room/closet across from the therapy office, revealed a white room with tiled walls, with a wheelchair platform scale with one handrail and scale head plugged in to the wall. There were no other handrails noted in the room. Observation on 4/15/2026 at 11:38AM on Unit 2 revealed a Chair scale with black plastic seat with bilateral arm rest with scale head noted located in the courtyard entry way. In a phone interview on 4/15/2026 at 12:27PM with Certified Nurse Assistant (CNA) J revealed that the Licensed Practical Nurse (LPN) I asked her to get a weight on resident #101 so she went to his room and asked him to get up, she stated that it was like 4:00AM in the morning and she had to wake him up. CNA J stated that she felt bad about waking him, but the nurse told her to get his weight. The resident stated that he was tired and did not want to get up, so we moved slowly, he sat up at the edge of the bed and got in the wheelchair eventually. CNA J stated she took the resident to the weight room across from the therapy office and had him stand up to get weighed. The resident was very upset he had to get weighed at 4AM. We had to get him up just for the weight. CNA J stated that she works 3rd shift and that was the first resident weight she had gotten since she was hired in October 2025, because it's her first CNA job. The resident #101 started to fall backwards against the wall. CNA J could not lift the resident herself, while the resident was on the floor, she had to go get the nurse LPN I to help get the resident up into the wheelchair. When asked the CNA J stated that the resident did not have socks on and she did not put his leg splint (AFO) or used a gait belt on the resident. Record review of Resident #101's Occupational and physical Therapy notes dated 3/3/2026 through 4/1/2026 noted hemiplegia and hemiparesis affecting the left side, orthostatic hypotension and muscle weakness generalized and diagnoses for therapy. In an interview on 4/15/2026 at 12:40pm with Physical Therapy Assistant (PTA) M revealed the PTA worked with the resident #101 most days. PTA M revealed that Resident #101 had left foot drop on admission and left leg AFO/splint and needed the left leg AFO/splint to stand and a gait belt. In a phone interview on 4/15/2026 at 1:01PM with Licensed Practical Nurse (LPN) I recalled the event of Resident #101's fall int the weight room on 4/2/2026. LPN I stated that Resident #101 fell in the weight room on the edge of the scale because he missed placed his footing and fell. He was weak on standing, he said he could stand. After he fell, she recommended that he use the weight chair scale instead. The surveyor asked why was the weight done so early in the morning? LPN I stated the resident needs daily weights. He needed to be weighed that morning. He didn't want to get up out of bed, and she stated that she explained that he would end up back in the hospital and the severity of not getting weighed. LPN I stated the Resident #101 slipped on the scale, and the CNA J came and got her. Resident #101 was on the floor, and she did an assessment, Vital signs, and skin assessment, the resident had no complaints of pain. Left knee pain? No, he did not say anything about left knee pain. When we were in his room I educated him and he sat up on the edge of the bed and I went back out of the room to the CNA, and she went into the resident's room and got him up and weighed him. He had yellow gripper socks on I believe, our practice is to have gripped socks or shoes on when weighing. Record review of Resident #101's left knee x-ray dated 4/4/2026 revealed clinical information of pain with 2 views. Impression: Mild osteoarthritis of the knee joint.Record review of the facility 'Fall and Fall Risk Management' policy dated 11/2025, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A fall is defined as unintentionally coming to rest on the ground, floor or other lower level. Medical factors that contribute to the risk of falls include Arthritis, heart failure, anemia, neurological disorders and balance and gait disorders.

Based on interview and record review, the facility failed to prevent the development of an unstageable right ankle pressure ulcer for one resident (Resident #301) of three residents reviewed for pressure ulcers, resulting in a device-related, facility-acquired unstageable pressure ulcer, pain, and infection requiring intravenous antibiotics. Findings include: On 9/16/20, at 4:00 PM, a record review of Resident #301's electronic medical record revealed a readmission on 4/16/20 after a hospitalization for an Open Reduction Internal Fixation of their right femur due to a fall. A review of the Minimum Data Set assessment dated [DATE] revealed severely impaired cognition and that Resident #301 required extensive assistance with two or more persons assistance for Activities of Daily Living (ADL's.) A review of Nursing Assessment Admission/Readmission/Quarterly Date 4/16/2020 18:04 revealed . Entered From Acute hospital . Skin . Site Other R (right) Hip fx (fracture) Type Surgical incision . wrapped with ace wrap and immobilizer . A review of Discharge Summary . 4/15/2020 revealed . Keep immobilizer on for all activity. Including when in the transfer lift - the immobilizer should be opened TID (three times a day) and as needed for skin checks and skin care . A review of IDT Note 5/10/2020 revealed . resident encouraged to turn more often . A review of IDT Note 5/20/2020 revealed . Skin assessment complete following areas noted: right outer ankle: pressure unstageable covered in yellow slough measuring 5 cm (centimeters) x (by) 4.5 cm x UTD (unable to determine) odor present . New orders to culture the ankle . A review of Wound Evaluation Date 5/21/2020 revealed . Wound Pain . Pain Number: 5/10. A review of Nursing/Clinical Note revealed Rt outer ankle culture came back with Moderate Escherichia coli. Dr updated and ordered [MEDICATION NAME] with pharm (pharmacist) to dose . [MEDICATION NAME] 65mg (milligrams) IV (intravenous) q (every) 8 hours for 10 days . A review of Resident #301's Braden skin assessment Date: 4/24/2020 revealed Score 14 . Moderate Risk . Activity . Chairfast: Ability to walk severely limited or non-existent . A review of Resident #301's care plans revealed the following: I have an ADL self-care performance deficit and limited physical mobility due to decreased mobility,[MEDICAL CONDITION](stroke) with right side weakness . Date Initiated: 06/07/2019 . Interventions/Tasks . BED MOBILITY: I require extensive assist of (1) staff for repositioning and turning in bed. Date Initiated: 06/07/2019 . Kydex PRO (pressure reducing orthotic) for right heel/foot. Remove q shift for skin inspection Date Initiated: 02/11/2020 . I have limited physical mobility due [MEDICAL CONDITION] right side weakness . Date Initiated: 06/07/2019 . I have altered skin integrity or risk of altered skin integrity . further unavoidable declines anticipated r/t (related to) refusal of treatments to be done by staff and basic care and repositioning . Float my heels using pillows or specialty boots Date Initiated: 06/07/2019 . Turn and reposition q 2 h (hour) Date Initiated: 06/07/2019 . I am at risk for alteration in skin integrity related to: normal disease progression w/unavoidable decline . impaired mobility . Interventions/Tasks Air mattress put on resident bed . Date Initiated: 05/10/2020 . A review of Order Summary revealed Send to . ER to eval & treat Order Date 06/01/2020. On 9/17/20, at 3:45 PM, Unit Manager A was asked why Resident #301 developed their pressure ulcer injury on their ankle and Unit Manager A stated that the resident had an immobilizer on to help keep the knee straight. Unit Manager A further offered that the knee immobilizer went from the ankle to the middle of their thigh. There was Velcro up the middle and there were medal stays on either side. Unit Manager A was asked why they felt the pressure ulcer developed on the ankle and Unit Manager A stated, it was from the brace. We did get her a new one because it kept sliding down. On 9/17/20 , at 4:00 PM, a record review of the Medication Administration Record [REDACTED]. AVOID director to the distal femur. IMMOBILIZER in place all times. SKIN check to be complete my LICENSED nurse every 6 hours. WOUND covered with sterile with dry dressing. DO NOT remove until follow up with surgeon. Every 6 hours for assessment -Start Date- 04/16/2020 1800 -D/C Date-06/02/2020 . There were check marks with nurses initials with no additional detailed charting on how the skin appeared under the immobilizer. On 9/17/20, at 5:15 PM, a record review of the facility provided policy Prevention of Pressure Ulcers/Injuries Revised 12/2019 . review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable . Mobility/Repositioning . Choose a frequency for repositioning . At least every hour, reposition residents who are chair-bound . A review of the facility provided policy Assistive Devices and Equipment Revised July 2017,November 2019) revealed . the following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment . Appropriateness for resident condition . Personal fit . Device condition .

Based on interview and record review, the facility failed to prevent a fall with hip fracture for 1 (Resident #3) of 7 sampled Residents, resulting in Resident #3 sustaining a fall from her bed during resident care, and sustaining a fracture to the left hip. Findings include: Record review of facility 'Falls Program-Allegra Nursing and Rehab', dated 2/2017, provided by the facility as their fall program, revealed the purpose is to provide a safe environment for residents, modify risk factors and reduce risk of all-related injuries. If a fall occurs: Charge nurse to complete the following: Neurological assessment-completed for all falls. Record review of Resident #3's Minimum Data Set (MDS), dated [DATE], revealed a [AGE] year-old female with Brief Interview of Mental Status (BIMS) score of 12 out of 15, moderately impaired. The MDS assessment identified transfers and bed mobility as 3/3 two-person assist. Record review of Resident #3's 'Accident/Incident' report, dated 3/16/17 at 5:50 AM, revealed that Certified Nurse Assistant (CNA) called writer (of report) to the room, stating she was changing the linen on the resident's bed after using the bedpan, CNA reached down to get linen off the floor, looked up and noted resident rolled out of bed on her left side. Resident stated she rolled out of bed, while being taken care of. Immediate action taken included notifying the physician, order of x-rays, vital signs. Resident assisted into wheelchair due to resident refusing to go back to bed, complained of left leg pain, pain medication given. CNA educated on proper technique and scoop mattress ordered. There was no range of motion documented or neurological assessment, including pupil checks, noted. Record review of Resident #3's nursing progress notes, dated 3/16/17 at 7:33 AM, noted that the family member was notified of resident rolling out of bed and there was no documentation of range of motion or lower extremity rotation. Record review of Resident #3's 'Nursing Home to Hospital Transfer Form', dated 3/16/17 at 8:35 AM, revealed that Resident #3's reason for transfer: Fall An interview on 3/15/17 at 9:30 AM with Resident #3 revealed that she was in the bed and that girl (CNA L) came that morning to get me up, she turned me over, there was only one girl and she turned me fast and the next thing I knew I was on the floor. I hurt my hip, my left hip. Boy, it hurt. I had surgery and they put a pin in my hip. I went to the hospital and stayed a week. When I fell , I hit my head and it hurt a lot along with my back. I'm an old lady and when I fell there was no stopping. I don't remember exactly but they put in my wheelchair. I was scared so bad I was hollering because I hurt. She (CNA) was pulling the linens off or something. Yes, she had dressed me before, I just don't know what she was doing that day. She was in a hurry. The bed was up off the floor, she raised it up, and it was a ways up. I'm [AGE] years old and it happened a day before my birthday. An interview on 3/15/17 at 2:45 PM with Licensed Practical Nurse (LPN) J revealed that she went to the resident's room when the CNA L told her that she was taking care of the resident when she pulled the sheets while the resident was on her side facing the door away from the CNA. The Licensed Practical Nurse (LPN) Jstated that CNA L said that she bent over to put sheets on the floor when Resident #3 fell on the floor. LPN J stated that she saw the resident on the floor and the bed was up to waist high in the air. Record review of Resident #3's left hip x-ray, dated 3/16/17, revealed commuted and displaced interochanteric fracture of the left femoral neck with mild Varus angulation. Record review of Resident #3's hospital discharge summary, dated 3/22/17, revealed discharge [DIAGNOSES REDACTED]. An interview on 6/15/17 at 3:00 PM with Certified Nurse Assistant (CNA) L revealed that she was taking Resident #3 off the bedpan and set the bedpan on the floor and the Resident #3 rolled off the opposite side of the bed. CNA L stated that she got a disciplinary write up and next time to use two people and not to rush and to go side to side. CNA L revealed that the shift was short staffed and that she was hurrying and rushing to get done. Record review of Certified Nurse Assistant L employee file for disciplinary actions revealed that on December 27, 2016, the CNA had been disciplined due to Resident #3 reporting that the CNA refused to get her up in the morning. On 3/22/17 CNA L was again disciplined for the fall on 3/16/17 related to Resident #3. On 4/4/17 again CNA L was disciplined related to care issues with a different resident.

This citation pertains to intake MI 204. Based on interview and record review, the facility failed to prevent the development of a pressure ulcer, promote the healing of a pressure ulcer, and prevent infection of a pressure ulcer in 1 of 3 sampled residents (#1) reviewed for pressure ulcers, in a sample of 23 residents, resulting in Resident #1 developing an unstageable pressure ulcer to sacral/coccyx area, resulting in worsening condition of a pressure ulcer, infection (osteo[DIAGNOSES REDACTED]) to the coccyx area, and pain associated with the development of an open wound and infection. Findings include: According to the Admission Record, Resident #1 was an [AGE] year-old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), dated [DATE], Resident #1 was dependent on staff for all Activities of Daily Living (ADL) care, to include assist with bed mobility, and incontinence care, and had no score coded for the Brief Interview for Mental Status (BIMS) assessment, revealing severe cognitive impairment. The MDS also had coded under section for skin, as no pressure ulcer on admission. Review was done on 7/6/16, of E HEALTH INFO MGMT from Hospital records where Resident #1 was discharged to on 4/5/16, from the facility with admission [DIAGNOSES REDACTED]. According to History of Present Illness (hospital records) revealed that Resident #1 presented to Emergency Department with altered mental status, a wound on his buttock that was becoming black, and that the facility staff were concerned that it was necrotic and infected. Resident #1 was admitted to the hospital in guarded condition for infected decubitus ulcer. Under Physical Exam documented There is a large, black decubitus ulcer noted to his buttock with foul odor. He also has a wound on his right hip that is bandaged. Under Hospital Course revealed that Resident #1 was admitted to the hospital with [REDACTED]. A Foley catheter was placed on 4/7/16, due to coccyx ulcer and incontinence. Under Significant Diagnostic Studies: Bone Scan indicated that There is an increase uptake in the coccyx on technetium MDP (Tests used to diagnose) and indium 111 WBC scans, consistent with osteo[DIAGNOSES REDACTED]. Cultures from the coccyx wound taken on 4/9/16, revealed Staphylococcus species, and Streptococcus B species. Discharge from hospital was placed on hold for Resident #1 on 4/12/16, due to Resident #1 undergoing another wound debridement on 4/14/16, with deep cultures done. Resident #1 was discharged to another Extended Care Facility on 4/14/16, per family members request not to return Resident #1 to previous facility. Under Operative Report dated 4/17/16, with Preoperative Diagnosis documented: Stage IV decubitus ulcer sacro-coccygeal region. It is a pressure ulcer. Pre-debridement size is 7.5 x 4 x 2.3 cm (centimeters). Post debridement size is 8 x 4 x 4 cm (centimeters) with bone exposed and the fascia exposed. According to npuap.org, National Pressure Ulcer Advisory Panel (NPUAP, 2014) documents Stage III Pressure Ulcer as: full thickness skin loss, involving damage to, or necrosis of, sub cutaneous tissue that may extend down to, but not through underlying fascia (band or sheet of connective tissue beneath the skin). The ulcer presents clinically as a deep crater, with or without undermining of adjacent tissue. Stage IV Pressure Ulcer: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (tendon, joint capsule), undermining and sinus tract may also be associated with Stage IV pressure ulcer. It also documents Infected referring to: The presence of microorganisms in sufficient quantity to overwhelm the defenses of viable tissue and produce the signs and symptoms of infection. Under Prevention of Pressure Ulcers: A resident who is admitted without a pressure ulcer does not develop a pressure ulcer unless clinically unavoidable, and that a resident who has an ulcer receive care and services to promote healing, and prevent additional ulcers to include: Pre-admission skin assessment, Skin assessment documented on admission, Braden score, Skin assessment every 24 hours (if there is a change in skin condition or pressure ulcer), correct support surfaces, nutritional support, mobility status addressed, Facility Acquired Pressure Ulcers properly documented, Was skin assessed on admission, repositioning addressed, Head of bed less than 30 degree elevation, every 2 hour bed turns, every 1 hour off- loading in wheel chair. Under Evaluation of Skin Integrity and Tissue Tolerance documents that Urine and Feces contribute substances that may irritate the epidermis (skin) and may make skin more susceptible to break down. Some Studies have found that fecal incontinence may pose a greater threat to skin integrity due to acids, and enzymes of feces, irritation from prolonged exposure to urine and feces may hasten skin break down. Review was done of Clinical/Therapy Notes from the hospital dated 1/4/16, (two days prior to admission into facility) documented WOC (wound ,ostomy, continence) consulted per policy as pt, (patient) at risk for pressure issues AEB (as evidenced by) Braden score of 11. Pt. (patient) up in chair, stood with assist, removed silicone dressing, top of gluteal crease (coccyx area) moist, red, not open, drsg (dressing) hold moisture in, recommend barrier wipes. Review of Resident #1 Patient Admission/ readmission Screen (admission to the facility) dated 1/6/16, was done on 7/7/16, which documented Braden Risk Assessment score as 15 (at risk for breakdown), and bed side commode checked, bladder and bowel incontinence checked, and under Skin Assessment, existing pressure ulcer, was left unchecked for Yes or No. There was no description on the admission assessment sheet of a pre-existing pressure ulcer documented for Resident #1 on admission into the facility. Review of facility Admission Progress Notes, dated 1/6/16, (no time entry listed) documented Res (resident) admitted this afternoon via MMR. res (resident) A x 1 (alert times one) to self able to answer some questions and denies pain. Incontinent of bowel and bladder and requires assistance from staff with ADLs (Activities of Daily Living) and transfers. Res (resident) weight bearing as tolerated. Takes pills whole with applesauce. Family present at this time. There was no documentation of skin assessment completed with any open areas noted for Resident #1. On 1/10/16, at 01:20 (1:20 AM) an entry was made in progress notes Dressing remains dry and intact to left hip (surgical repair of left [MEDICAL CONDITION]).There were no other documentation notes related to Resident #1 skin integrity. On 1/22/16, at 04:38 (4:38 PM) under General Progress Notes documented He has a stage 2 pressure ulcer on his coccyx area closer to left buttocks. Progress Notes documented Late Entry for 1/26/16, 17:41 (5:41 PM) Wound rounds completed with NP (Nurse Practitioner) res (resident) has left butt excoriation measuring 4.4 cm x 1.5 cm of red tissue and approx. 75 % slough (dead tissue). Edges are red and intact. No drainage noted. On 3/4/16, at 04:37 (4:37 AM) documented His wound care done on his coccyx and a culture was taken it continues to have drainage and foul odor coming from the site. On 3/10/16, at 14:35 (2:35 PM) under General Progress notes documented under Diagnosis Excoriation to gluteal fold (buttock area) and R (right) buttock, full thickness with [MEDICATION NAME] faecalis,(bacteria found in intestinal track), check sacral x ray to rule out osteo[DIAGNOSES REDACTED] (inflammation of bone caused by infection). On 3/11/16, under General Progress Notes, at 03:46 (3:46 AM) documented Grimacing (signs of pain or discomfort) was noted in face earlier in shift when resident sitting up on coccyx in chair, remains on oral antibiotic for infection to the coccyx wound. Light brownish drainage noted from wound with foul odor. Upper right buttocks areas red, slight warm and puffy. On 3/12/16, under General Progress Notes, at 03:47 (3:47 AM) documented Resident's treatment done to coccyx area as ordered. Continues to have light brownish colored drainage with foul odor. On 3/15/16, at 14:12 (2:12 PM), under heading of Skin documented Wound rounds completed with NP. Left buttock/crease excoriation full thickness measures 3.5 cm (centimeters) x 1.5 cm x 2.5 cm. 3 cm tunneling at 1200. Small amount of purulent drainage present. Red tissue with 25 % slough/necrotic tissue. Edges rolled and necrotic. On 3/22/16, at 16:05 (4:05 PM) under heading of Skin documented Previous coccyx/excoriation reevaluated and now Stage 3 pressure ulcer measuring 3.5 cm x 2.5 cm x 1.5 cm. Tissue pink and granulating with yellow slough present on wound base On 4/5/16, at 09:06 (9:06 AM) documented under heading of Skin that Stage 3 pressure ulcer to coccyx/gluteal region measures 6 cm x 3.5 cm x 2.5 cm deep undermining present. 4 cm at 1200, 3 cm at 0100, 1 cm at 0900, 3 cm at 0300. Wound base black, moist eschar (dead tissue) with moderate amount of purulent drainage present. Right hip Stage I pressure ulcer measuring 3 cm x 1.2 cm of red unblanchable (pressure related alteration) skin. On 4/5/16, at 10:11 (10:11 AM) under General Progress Notes documented Resident has increased lethargy this A.M., wound has very foul odor, new orders to send to ER (emergency room ) for eval/tx (evaluation and treatment). Resident was sent out the facility on 4/5/16, and was admitted to the hospital. Review was done of Laboratory Services report dated 3/4/16, of wound culture of right buttock that was collected on 3/3/16, at 20:00 (8:00 PM) and verified on 3/8/16, at 08:05 (8:05 AM) documented as Final Report Many Streptococcus agalactiae (Group B), Moderate [MEDICATION NAME] faecalis. A phone Interview was conducted on 7/6/16, at 8:45 AM, with Resident #1's family member, who reported that they were in the facility almost daily, and that Resident #1 coccyx area was intact on admission into the facility, and that Resident #1 had a small red spot on his coccyx but it was not opened, and the facility was informed and were suppose to monitor the area. The family member also said that staff were not repositioning Resident #1 while they were present in the facility, and did not think he was being moved when they were not in the facility. They also verbalized that before Resident #1 was sent out, he was in so much pain that he would scream out horribly. They also verbalized that when ever the call light was turned on, it took and extremely long time for someone to respond to the call light, and there were numerous times he was not being cleaned up timely after incontinence episodes, and that when he was sent out of the facility on 4/5/16, the family did not want him to return to that facility, and was seeking placement for Resident #1 into another Extended Care Facility. Review of skin work sheets dated 1/8/16, documented Resident #1 with small area to coccyx area, circled on skin assessment sheet, with no description on the sheet other than red spots. On 1/11/16, documented refused. On 1/14/16, nothing was documented on the skin work sheet. On 1/18/16, a small circle was documented on skin worksheet with no description. On 1/21/16, the skin worksheet was documented on as wound, and circled coccyx area. On 1/25/16, the skin worksheet had a circled coccyx area and was checked normal and abnormal in the boxes at top right of the worksheet. On 2/4/16, coccyx area was circled on skin worksheet with no description. On 2/8/16, coccyx area was circled and documented open area, bad smell. On 2/11/16, and 2/29/16, the skin worksheet was blank, except for normal box checked on 2/29/16. On 3/12/16, skin worksheet had an area marked on coccyx with no description. On 3/23/16, and 3/26/16, the skin worksheet was blank. On 4/2/16, skin worksheet was documented on as refused. On 4/4/16, there was an X placed on the skin assessment worksheet over the coccyx area, and also a red area marked on right hip with measurements documented as 6.5 centimeters x 5.0 centimeters. An interview was conducted with Licensed Practical Nurse, Staff JJ on 7/6/16, at 3:30 PM who was the nurse on duty on 1/6/16, and said she did Resident #1's admission into the facility. StaffJJasked if she remembered what the area on Resident #1's coccyx area looked like. She said, Yes, it was red,not opened and we put a RepliCare on it. Staff JJ was asked why there was no documentation on the skin assessment section describing the area. StaffJJ said that would have been documented by the Unit Manager. An interview was conducted with the Director of Nursing, Staff B on 7/6/16, at 3:45 PM related to Resident #1. StaffB was asked if she remembered if Resident #1 was admitted to the facility with a pressure ulcer. Staff B said she thought so but couldn't remember the stage. Staff B was asked why the skin assessment section was left blank on admission. She did not have an answer. Another interview was conducted with Staff B on 7/11/16 at 10:30 AM, related to Resident #1. Staff B said that Resident #1 had a treatment initiated on 1/21/16, Resident #1 was having loose stools around 2/8/16, and then the treatment order was changed on 2/25/16, on 3/9/16, the treatment order was changed again, and then the treatment order was changed again on 3/23/16. Staff B was asked when his wound progressed to a Stage III why there was no Foley catheter placed into Resident #1 to help keep him clean and dry. Staff B said their facility policy doesn't specify the use of a Foley catheter. Staff B was also asked if she was aware that Resident #1 developed osteo[DIAGNOSES REDACTED] in coccyx area. She said, No, she was not aware, that the Unit Manager would have been more familiar with that. Staff B was asked how Resident #1 could have developed an infection in his wounds and she said probably from not being kept clean and dry. An phone interview was conducted on 7/11/16 at 1:20 PM, with Registered Nurse, Staff TT, who was the Unit Manager during Resident #1's admission to the facility. StaffTT was asked if she remember Resident #1's coccyx area and if she recalled him having an open area. Staff TT was unable to recall. Staff TT was able to recall that his wound progressed to a stage III, or IV before he was sent out of the facility. Staff TT was asked if Resident #1 had a Foley place in him when his wound progressed to a III or IV and she replied that he did not. Review was done of the Facility's Policy and Procedure titled Skin Practice Guide, dated 1/2013. Under Phase 1: Assess documents that Nursing Staff complete the Patient Admission/Readmission Screen and answer specific questions regarding the patient's skin status. Under the heading Phase 3: Implementation documents that the use of A fecal pouch may assist with managing fecal incontinence.( Resident #1 did not have an order or treatment for [REDACTED].

This citation pertains to MI# 526, MI# 202 Based on observation, interview and record review, the facility failed to provide adequate training to provide quality care of open skin areas and/or wound vac's for 3 (#3, #5, #19) of 3 sampled Residents from a total sample of 23, resulting in Resident #3 having skin break down with no treatment in place, Resident #5 being left wet and soiled from wound vac dressing leakage and Resident #19 verbalizing concerns of nurse training with wound vac's and dressing leakage. Findings: Record review of facility 'Skin Observation, Body Audits and Required Documentation' form, dated 6/1/2015, revealed significant new findings are validated by the licensed nurse through direct observation of the skin condition. The licensed nurse initiates evaluation of the skin condition, contacts the attending physician and family, notifies members of the wound team for additional evaluation as indicated and documents findings on the patient ' s clinical record. The licensed nurse is responsible for conducting a head to toe evaluation weekly for any patient without a pressure ulcer. Record review on 7/6/16 of facility white three ring binder of in-service ' s in house found that there were no wound vac records for in-service training of wound vac dressing changes or trouble shooting leaking dressings, suction issues. Record review of facility ' Incontinence Care' policy, dated 8/2014, revealed the purpose was to outline a procedure for cleansing the perineum and buttocks after an incontinence episode or with daily care. (11.) Apply clean linen and/or brief or other incontinent products as needed. Suggested documentation: Unusual observations and/or complaints, such as drainage or skin alterations and subsequent interventions including communications with physician. Record review of facility Policy on Abuse, dated 5/13/2013, revealed the definition of neglect: is defined as a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Examples include, but are not limited to: absence of frequent monitoring for residents known to be incontinent, resulting in being left to lie in urine or feces. Resident #3: Record review of Resident #3's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year- old female with Brief Interview of Mental status (BIMs) score of 14 out of 15, cognitively intact. Functional status for activities of daily living section G revealed that Resident #3 was 2 person assist with mechanical lift for transfers, non-ambulation and dependent for toileting on staff. Observation on 7/6/16 at 10:00 AM with CNA I of Resident #3's incontinence care (brief change and bed pan) revealed urine stained white sheets with odor noted. Observation of Resident #3's buttocks area revealed there to be an abrasion open area to the right buttocks with no dressing or barrier cream noted in place. In an interview at the time with Resident #3 revealed that there has been no treatments or dressing to the right buttocks and that it was painful when touched or wiped (cleaned). Resident #3 was asked about her sheets being dirty and she stated that they don't change them when they get wet. Record review of Resident #3's Admission nursing assessment dated [DATE] under section Skin identified a sacrum open area of 4 x 1 cm . Record review of Resident #3's Medication Administration Record [REDACTED]. Record review of nursing notes dated 6/16/16 through 7/6/16 revealed there were no notes regarding the sacrum open area at all. Observation on 7/6/16 at 10:50 AM of Resident #3's right buttocks area with Registered Nurse (RN) Y and Licensed Practical Nurse (LPN) AA revealed an area measured at 4.8 cm X 3.0 cm with inner open areas measuring 1.5 cm X 1 cm, and 0.7 X 0.4 red wound beds. Observation of the left buttocks noted a 2.0 cm X 1.6 cm blanchable area. Record review of Resident #3's Nurse Practioner's note dated 7/11/16 revealed reason for visit was a wound. The Nurse Practioner noted an open wound to right buttocks with wound care with foam dressing and [MEDICATION NAME] powder to buttocks every shift. Resident #5: Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year-old male with Brief Interview of Mental status (BIMs) score of 14 out of 15, cognitively intact. Functional status for activities of daily living section G revealed that Resident #5 was 1 person assist for transfers, non-ambulation and dependent on staff for bed mobility. Record review of Resident #5's Care Plans pages 1 through 23 of 23, revealed that there was no mention a wound vac, dressing changes or of wound site monitoring. Record review of the facility incident investigation revealed that the Resident #5 reported to nursing that his wound vac was leaking and that he needed pain medication, the nurse told him it was shift change and that they would be back. The nurse returned to the room at approximately 9:00 AM and he reminded the nurse that it (wound vac) was leaking, and she administered his medications, the nurse stated that she would be back. Resident #5 was noted by the facility investigation to stat that the nurse returned around 10:00 AM when he showed the nurse the wound vac the nurse stated I have to get my head around that: and left the room. At 11:00 AM the resident's brother came in and got the resident #5 assistance getting cleaned up, at approximately 11:30 AM when the nurse came into do the dressing change. In facility documented interviews with certified nurse assistant's in which they noted the resident's brother had concerns that the resident needed cleaned up. A CNA was noted to go to the Resident #5's room to find the 'whole bed soaked with both dried and wet areas, including the resident's gown, shorts, and briefs. Record review of Licensed Practical Nurse (LPN) YY employee file 'Staff Development Program Plan' form dated prepared 1/20/2016 revealed that the negative pressure wound therapy under the skills/technique listing was not checked off as having validation/return demonstration. In an interview on 7/7/16 at 11:40 AM with the Human Resource Staff D about wound vac in services or education for the nurses held by nursing department for nurses, revealed that there were no in-services for wound vac treatments. In an interview on 7/7/16 at 11:05 AM with Licensed Practical Nurse (LPN) AA revealed that she was just into her 90 days at the facility and that she had been sent out of town to the corporate offices to received training/orientation. LPN AA stated that she did not recall the corporate orientation discussing wound vac skills or demonstrating a dressing change. LPN AA stated that while on orientation at the facility building it was discussed with her preceptor, but that the was no demonstration on how to change a wound vac. In an interview on 7/7/16 at 2:45 PM with the Director of Nursing (DON) revealed that once it was noted by the state surveyor that there was a lack of education for the nurses that the facility would be holding an in-service to educate the licensed nurses on the skills/techniques of wound vac dressing changes. The DON stated that there was no in-house formal education on wound vac's given to nurses prior to the state surveyors request for in-servicing education. Record review of the manufacture ' V.A.C. Therapy Clinical Guidelines' a reference source for clinicians, dated 12/2012, pages 1 through 68 reviewed. On page 21, 'Ensuring dressing Integrity' noted if you find that the seal is broken and the V.A.C. drape has become loose, trim away any loose or moist edges, ensure the skin is dry and then apply new drape strips. Note: If a leak source is identified, patch with additional drape to ensure seal integrity. Resident #5 was discharged to the hospital on [DATE] and chose not to return the facility and that the spouse had called the facility with concerns about the lack of supplies per the 'Red Worksheet for discharged Patients to Hospital' form and 'Concern Form'. Resident #19: Record review of supplemental Resident #19's Minimum Data Set (MDS), dated [DATE], revealed a [AGE] year-old female with Brief Interview of Mental status (BIMs) score of 15 out of 15, cognitively intact. In an interview on 7/7/16 at 12:10 PM with Resident #19, who had a wound vac dressing in place to the abdomen, revealed that the wound vac dressing has leaked several times and that she has to call the nurse to the room to fix it, then waits for 2-3 hours or more with the drainage in her bed and clothes. Resident #19 stated that the nursing staff just don't have the knowledge of wound vac's and that she had to educate them on how to do the dressing changes. Resident #19 stated that the staff are nice people, but they are over worked, under staffed and just don't know what to do. Resident #19 stated that the drainage from her wound vac is acidic and hen it leaks it irritates the skin and gets all over the bed. There was no packet of past non-compliance submitted by the facility during the on-site investigation. #

Based on interview and record review, the facility failed to do a complete assessment and monitor 1 (Resident #6) of 7 sampled residents reviewed for assessment and monitoring, who experienced a significant change in condition resulting in repeated vomiting, respiratory distress and who subsequently died . Findings Include: Due to the requirements of the Health Insurance Portability and Accountability Act (HIPPA), the findings in this report are limited. Review of the Face Sheet, Minimum Data Sets (MDS, resident assessment tool) dated [DATE] and [DATE], social worker, nurses and physician progress notes [REDACTED].#6 was a [AGE] year old male, admitted to the facility on [DATE], confused, severely impaired cognitively and dependent on staff for all activities of daily living (ADL's). The resident's [DIAGNOSES REDACTED]. Resident #6's code status revealed he was a full code, in which he was to be sent to the hospital if required with condition change. Per review of the resident's code status, he was a full code, including being transferred to the hospital is an acute condition change and doing CPR (cardio [MEDICAL CONDITION] resuscitation) is necessary. Review of Resident #6's MDS's (dated [DATE] and [DATE]) revealed he had a BIMS (cognitive assessment) score of 5, which indicated he was severely cognitively impaired and was unable to make his needs known to staff. Review of Resident #6's facility GI distress care plan (dated [DATE]), revealed staff were to assess, monitor and report any signs of bleeding in stools or an increase in abdominal pain. Review of Resident #6's facility Neurological care plan (dated [DATE]), revealed staff were to assess, monitor and report signs or symptoms of tremors, rigidity, dizziness, changes in level of consciousness, slurred speech. Review of Resident #6's [MEDICAL CONDITION] care plan (dated [DATE]), revealed staff were to assess, monitor and report signs of [MEDICAL CONDITION]/fluid overload, such as change in mental status, weight gain, neck vein distension, abnormal lung sounds, extremity swelling, etc. (this would include respiratory fluid overload, shortness of breath and oxygen levels). Review of Resident #6's physician History and Physical (dated [DATE]), stated advise to monitor for: N/V (nausea and vomiting), diarrhea, dizziness, uti (urinary tract infection), flatulence (gas), [MEDICAL CONDITION], recommend: orthostatic bp (blood pressure) & weight, continue monitor changes in mental status mood affect behaviors. Review of the facility Alert Charting Log (dated [DATE]), revealed Resident #6 was put on alert charting due to a change in his condition, his medical condition had decreased and staff were to assess him for [MEDICAL CONDITION] activity, behaviors, daily wts (weights), pain, inct. (incontinence), mood and monitor for-N/V (nausea & vomiting), diarrhea, dizziness, flatulence (gas), [MEDICAL CONDITION], tremors. Patients are entered on the Alert Charting Log when they are identified as requiring continued follow-up and documentation. Review of the facility Alert Charting Log policy (dated [DATE], revised [DATE]), stated the Alert Charting Log is a tracking and communication system to alert licensed nurses to changes in a patient's condition that warrants continued observation. Review of the Alert Charting Log Charting Guide revealed for Gastrointestinal concerns the nurse would assess, monitor and chart: vital signs, weights, pain, heart burn, nausea, vomiting, flatulence, stool description, bowel sounds, abdominal distention. For Respiratory concerns the nurse would assess, monitor and chart: vital signs, skin color/warmth, mental status, weakness, fatigue, pain, cough, sputum, lung sounds, restlessness, dyspnea (difficulty breathing), nutrition, hydration, oxygen, pulse Ox (level of oxygen in the blood level), lab results, x-ray. Review of the facility Daily Interdisciplinary Eagle Room Report (dated [DATE], not a part of the facility electronic charting), revealed Resident #6 had a change in condition and stated emesis x I (one) 8:20 p (p.m.) greenish sig. (significant amount) with undigested food, vomited sm (small amount) green fld. (fluid) x I (one), Abd (abdomen x-ray done-neg. Has much congestion-rales/rhonchi (abnormal breath sounds) no crackles in all lung fields esp. (especially) upper, coughing (these are signs of respiratory abnormalities). Review of Resident #6's nurses note's (dated [DATE] at 13:03, 1:03 p.m.), stated Emesis noted after breakfast x 1. (Family Member #1) notified with no new concern to reported (sic) at this time. Medication given as ordered with no behaviors reported. ,[DATE] (one-on-one staff with resident) throughout shift. The above nurse's note's (dated [DATE]) were incomplete regarding resident assessment per the residents Alert Charting Log (dated [DATE]) and the facilities Alert Charting Log policy (dated [DATE]). During an interview done on [DATE] at 1:03 p.m., staff member M (Charge Nurse) when asked by this surveyor why she did not do a complete nursing assessment (per his Alert Charting Log and the facility Alert Charting policy) on the resident after he had vomited she sated I monitored him. Review of Resident #6's nurses note's (dated [DATE] at 03:26, 3:26 a.m.), stated Resident had emesis x 1 at 8:20 p.m. emesis of green liquid with undigested food noted. No further N/V (nausea & vomiting) noted. Remained in room pacing at times. Has been cooperative with care. Incontinent care given by assist of two staff. Resting quietly in bed at this time. [MEDICAL CONDITION] of BLE (both lower extremities) noted. No [MEDICAL CONDITION] activity has been noted. The above nurse's note's (dated [DATE]) was incomplete regarding the resident assessment per the residents Alert Charting Log (dated [DATE]) and the facilities Alert Charting Log policy (dated [DATE]). Review of Resident #6's nurses note's (dated [DATE] at 15:57, 3:57 p.m.), stated Resident had a large greenish emesis. Dr (staff member T, the resident's primary Physician) paged. New order for abdominal x-ray and labs in the a.m. During an interview done on [DATE] at 1:40 p.m., staff member D (Unit Manager, RN) stated The nurse (staff member U, Charge Nurse, LPN) told me the resident had a emesis and I called doctor (staff member T, physician). When this surveyor asked staff member D (Unit Manager) what repeated emesis could mean in regards to Resident #6, she stated it can mean a bowel obstruction, bile duct obstruction, side effects of medications, it could mean different things. I put him on alert charting on [DATE] because he had behaviors, incontinent issues, [MEDICAL CONDITION] and to monitor for signs & symptoms of (a new medication). I was aware of his emesis on [DATE]. When this surveyor asked about lack of a complete assessment regarding charting on [DATE] at 1:03 p.m., staff member D stated she didn't state consistency (of the emesis) or the amount, no abdominal sounds, no palpation (of the abdomen), no dehydration monitoring, no lung sounds. When this surveyor asked staff member D if when she called and got the x-ray order (on [DATE]), if she had informed the residents physician (staff member T) of his respiratory condition per documentation on the Daily Interdisciplinary Eagle Room Report (dated [DATE], much congestion, rales, rhonchi in all lung fields, especially the upper), she stated I can't remember if I informed the doctor of his respiratory condition. Reviewing the resident's nurse's notes dated [DATE], revealed no documentation of informing staff member T (physician) of the resident's respiratory status. Staff member D (Unit Manager) stated The nursing assessments are incomplete and it is defiantly not good nursing practice, they (nursing staff) should be charting and monitoring every shift all things on the alert charting its on-going it started on [DATE], this is very inadequate care. Review of the residents Toileting record dated [DATE] through [DATE], revealed no documentation of a bowel movement on [DATE], [DATE], and [DATE]. Review of the residents Weights and Vitals documentation dated [DATE] through [DATE], revealed no vital signs (part of a complete resident assessment) were done on Resident #6 after [DATE]. During an interview done on [DATE] at 2:10 p.m., staff member J (Nurse Consultant) stated no other vital signs after [DATE]. A phone interview was done on [DATE] at 2:35 p.m., with staff member T (Primary Physician). When this surveyor asked him if he was made aware of Resident #6's respiratory condition per the Daily Interdisciplinary Eagle Room Report (dated [DATE]), he stated no, I don't recall that, the nurses did not ask me to come see him. Review of Resident #6's nurses note's (dated [DATE]), revealed no charting was done on the day shift (7:00 a.m. to 7:00 p.m.) by the residents primary nurse, staff member U (Charge Nurse, LPN). A phone interview was done on [DATE] at 2:45 p.m., with staff member U (Charge Nurse, LPN). When this surveyor asked her why she did not chart anything in Resident #6's nurse's notes on [DATE] regarding him being put on alert charting she stated he was on alert charting? I am a new nurse and I don't know about alert charting. I didn't see him having emesis, no one told me he did not have BM's (bowel movements) on the 17 th, 18 th and 19 th ([DATE], [DATE] and [DATE]). I was aware why (staff member D, Unit Manager) called and got the x-ray, I was busy I did not get out of there at a decent time, I was busy passing med's (medications). I am hardly able to chart, I am there so late. Staff member U had no documentation of any assessments done on the resident or of monitoring Resident #6 during her shift on [DATE]. During an interview done on [DATE] at 11:20 a.m., staff member N (Nursing Assistant/CNA) stated during day shift (on [DATE]), he was vomiting 2 times a lot, it was orangish/yellow with eggs in it, about 8:30 a.m. to 9:00 a.m. and the 2nd time at about 10:00 a.m. to 10:30 a.m., a little. I reported it to the nurse, I didn't do vitals or temps. During an interview done on [DATE] at 12:00 p.m., staff member P (Housekeeper), stated he had BM coming out of his nose and mouth. During an interview done on [DATE] at 11:35 a.m., staff member L (CNA) stated he (the resident) was in his bed quite tired. I didn't ' take any vitals, I wasn't given any instructions from the nurse on what to do, no nurse told me to watch him. During an interview done on [DATE] at 12:40 p.m., with staff member A (Director of Nursing/DON), she stated there should have been a full head to toe assessment, between the 17 th and 18 th ([DATE] and [DATE]) the doctor should have been questioned regarding transfer to the hospital, I wasn't ' informed of acute change of condition. Review of the Radiology Report (dated [DATE]), stated Results: There is no significant colonic dilation. Conclusion: Radiographic findings of developing small bowel obstruction. Review of the Medical Certificate of Death (dated [DATE]), revealed Resident #6 cause of death was a. Resp (respiratory) Failure, b. End Stage Dementia.

Based on interview and record review, the facility failed to document changes in condition for 1 (Residents #6) of 7 sampled residents reviewed for changes in health conditions resulting in repeated vomiting, respiratory distress and who subsequently died . Findings Include: Record review of the facility 'Documentation Guidelines for the Clinical Record' booklet dated ,[DATE] page (1.) presented to the surveyors from the corporate consultant J noted 'The patient's clinical record, is used by all members of the healthcare team to record, preserve and communicate the patient's progress and current treatment. It provides a record of the patient's health status, including observations, measurements, history, and prognosis, and serves as the primary document describing the healthcare serves provided to the patient ' Page (2.) The purpose of documentation, documenting events, occurrences, interactions and outcomes in a clinical record serves many purposes, including regulatory, clinical, financial, and administrative. The predominant purpose of the clinical record is to maintain continuity of care from caregiver to caregiver . Review of the facility Alert Charting Log policy (dated [DATE], revised [DATE]), stated the Alert Charting Log is a tracking and communication system to alert licensed nurses to changes in a patient's condition that warrants continued observation. Review of the Face Sheet, Minimum Data Sets (MDS, resident assessment tool) dated [DATE] and [DATE], social worker, nurses and physician progress notes [REDACTED].#6 was a [AGE] year old male, admitted to the facility on [DATE], confused, severely impaired cognitively and dependent on staff for all activities of daily living (ADL's). The resident's [DIAGNOSES REDACTED]. Resident #6's code status revealed he was a full code, in which he was to be sent to the hospital if required with condition change. Per review of the resident's code status, he was a full code, including being transferred to the hospital is an acute condition change and doing CPR (cardio [MEDICAL CONDITION] resuscitation) is necessary. Review of Resident #6's MDS's (dated [DATE] and [DATE]) revealed he had a BIMS (cognitive assessment) score of 5, which indicated he was severely cognitively impaired and was unable to make his needs known to staff. Review of Resident #6's facility GI distress care plan (dated [DATE]), revealed staff were to report any signs of bleeding in stools or an increase in abdominal pain. Review of Resident #6's [MEDICAL CONDITION] care plan (dated [DATE]), revealed staff were to report signs of [MEDICAL CONDITION]/fluid overload, such as change in mental status, weight gain, neck vein distension, abnormal lung sounds, extremity swelling, etc. (this would include respiratory fluid overload, shortness of breath and oxygen levels). Review of Resident #6's physician History and Physical (dated [DATE]), stated advise to monitor for: N/V (nausea and vomiting), diarrhea, dizziness, uti (urinary tract infection), flatulence (gas), [MEDICAL CONDITION], recommend: orthostatic bp (blood pressure) & weight, continue monitor changes in mental status mood affect behaviors. Review of the facility Alert Charting Log (dated [DATE]), revealed Resident #6 was put on alert charting due to a change in his condition, his medical condition had decreased and staff were to assess him for [MEDICAL CONDITION] activity, behaviors, daily wts (weights), pain, inct. (Incontinence), mood and monitor for-N/V (nausea & vomiting), diarrhea, dizziness, flatulence (gas), [MEDICAL CONDITION], tremors. Patients are entered on the Alert Charting Log when they are identified as requiring continued follow-up and documentation. Review of the facility Daily Interdisciplinary Eagle Room Report (dated [DATE], not a part of the facility electronic charting), revealed Resident #6 had a change in condition and stated emesis x 1 (one) 8:20 p (p.m.) greenish sig. (significant amount) with undigested food, vomited sm (small amount) green fld. (fluid) x I (one), Abd (abdomen x-ray done-neg. Has much congestion-rales/rhonchi (abnormal breath sounds) no crackles in all lung fields esp. (especially) upper, coughing (these are signs of respiratory abnormalities). Review of Resident #6's nurses note's (dated [DATE] at 13:03, 1:03 p.m.), documented Emesis noted after breakfast x 1. (Family Member #1) notified with no new concern to reported (sic) at this time. Medication given as ordered with no behaviors reported. ,[DATE] (one-on-one staff with resident) throughout shift. The above nurse's note's (dated [DATE]) were incomplete regarding resident documentation per the residents Alert Charting Log (dated [DATE]) and the facilities Alert Charting Log policy (dated [DATE]). During an interview done on [DATE] at 1:03 p.m., staff member M (Charge Nurse) when asked by this surveyor why she did not document a complete nursing assessment (per his Alert Charting Log and the facility Alert Charting policy) on the resident after he had vomited she sated I monitored him. But was not able to provide documentation of monitoring. Review of Resident #6's nurses note's (dated [DATE] at 03:26, 3:26 a.m.), documented Resident had emesis x 1 at 8:20 p.m. emesis of green liquid with undigested food noted. No further N/V (nausea & vomiting) noted. Remained in room pacing at times. Has been cooperative with care. Incontinent care given by assist of two staff. Resting quietly in bed at this time. [MEDICAL CONDITION] of BLE (both lower extremities) noted. No [MEDICAL CONDITION] activity has been noted. The above nurse's note's (dated [DATE]) was incomplete regarding the resident assessment per the residents Alert Charting Log (dated [DATE]) and the facilities Alert Charting Log policy (dated [DATE]). Review of Resident #6's nurses note's (dated [DATE] at 15:57, 3:57 p.m.), documented Resident had a large greenish emesis. Dr (staff member T, the resident's primary Physician) paged. New order for abdominal x-ray and labs in the a.m. During an interview done on [DATE] at 1:40 p.m., staff member D (Unit Manager, RN) stated The nurse (staff member U, Charge Nurse, LPN) told me the resident had an emesis and I called doctor (staff member T, physician). When this surveyor asked staff member D (Unit Manager) what repeated emesis could mean in regards to Resident #6, she stated it can mean a bowel obstruction, bile duct obstruction, side effects of medications, it could mean different things. I put him on alert charting on [DATE] because he had behaviors, incontinent issues, and [MEDICAL CONDITION] and to document signs & symptoms of (a new medication). I was aware of his emesis on [DATE]. When this surveyor asked about lack of a complete assessment documentation regarding charting on [DATE] at 1:03 p.m., staff member D stated she didn't state consistency (of the emesis) or the amount, no abdominal sounds, no palpation (of the abdomen), no dehydration monitoring, no lung sounds. When this surveyor asked staff member D if when she called and got the x-ray order (on [DATE]), if she had informed the residents physician (staff member T) of his respiratory condition per documentation on the Daily Interdisciplinary Eagle Room Report (dated [DATE], much congestion, rales, rhonchi in all lung fields, especially the upper), she stated I can't remember if I informed the doctor of his respiratory condition. Reviewing the resident's nurse's notes dated [DATE], revealed no documentation of informing staff member T (physician) of the resident's respiratory status. Staff member D (Unit Manager) stated they (nursing staff) should be charting and monitoring every shift all things on the alert charting its on-going it started on [DATE], this is very inadequate care. Review of the residents Toileting record dated [DATE] through [DATE], revealed no documentation of a bowel movement on [DATE], [DATE], and [DATE]. Review of the residents Weights and Vitals documentation dated [DATE] through [DATE], revealed no vital signs (part of a complete resident assessment) were done on Resident #6 after [DATE]. During an interview done on [DATE] at 2:10 p.m., staff member J (Nurse Consultant) stated no other vital signs after [DATE]. Review of Resident #6's nurses note's (dated [DATE]), revealed no documentation was done on the day shift (7:00 a.m. to 7:00 p.m.) by the residents primary nurse, staff member U (Charge Nurse, LPN). A phone interview was done on [DATE] at 2:45 p.m., with staff member U (Charge Nurse, LPN). When this surveyor asked her why she did not chart anything in Resident #6's nurse's notes on [DATE] regarding him being put on alert charting she stated he was on alert charting? I am a new nurse and I don't know about alert charting. I didn't see him having emesis, no one told me he did not have BM's (bowel movements) on the 17 th, 18 th and 19 th ([DATE], [DATE] and [DATE]). I was aware why (staff member D, Unit Manager) called and got the x-ray, I was busy I did not get out of there at a decent time, I was busy passing med's (medications). I am hardly able to chart, I am there so late. Staff member U had no documentation of any assessments done on the resident or of monitoring Resident #6 during her shift on [DATE]. During an interview done on [DATE] at 11:20 a.m., staff member N (Nursing Assistant/CNA) stated during day shift (on [DATE]), he was vomiting 2 times a lot, it was orangish/yellow with eggs in it, about 8:30 a.m. to 9:00 a.m. and the 2nd time at about 10:00 a.m. to 10:30 a.m., a little. I reported it to the nurse, I didn't do vitals or temps. Record review of the nursing documentation dated [DATE] revealed that there was only one nurse note which identified only one emesis. There was no documentation of vital signs, no auscultation or palpation of abdomen or lungs sounds noted for the dated of [DATE] by nursing caregivers. During an interview done on [DATE] at 12:00 p.m., staff member P (Housekeeper), stated he had BM coming out of his nose and mouth. During an interview done on [DATE] at 11:35 a.m., staff member L (CNA) stated he (the resident) was in his bed quite tired. I didn't ' t take any vitals, I wasn't given any instructions from the nurse on what to do, and no nurse told me to watch him. During an interview done on [DATE] at 12:40 p.m., with staff member A (Director of Nursing/DON), she said there should have been documentation of a full head to toe assessment, between the 17 th and 18 th ([DATE] and [DATE]) the doctor should have been questioned regarding transfer to the hospital, I wasn't informed of acute change of condition. Record review of Resident #6's nursing documentation dated [DATE] 'Resident had emesis x 1 at 8:20 PM. Emesis of green liquid with undigested food noted. No further N/V (Nausea/Vomiting) noted. Remained in room .' There was no documentation of the measurement of the amount of emesis noted, no auscultation or palpation of abdomen, no lung sounds, no pain assessment, and no vital signs taken or noted for the date of [DATE] by nursing caregivers. Record review of resident #6's nursing documentation dated [DATE] revealed only one entry of documentation at 9:58 AM in which the head of the bed for Resident #6 was elevated due to upset stomach (no auscultation or palpation of abdomen area noted) face is slightly ruddy (no blood pressure or vital signs which would include a temperature noted) .head of bed kept at 45 degrees. Review of the Radiology Report (dated [DATE]), stated Results: There is no significant colonic dilation. Conclusion: Radiographic findings of developing small bowel obstruction. Review of the Medical Certificate of Death (dated [DATE]), revealed Resident #6 cause of death was a. Resp (respiratory) Failure, b. End Stage Dementia. ,

This citation pertains to intake MI 238 and . Based on interview and record review, the facility failed to prevent a sexual abuse on one resident (Resident #501), who had her breast touched by another resident (Resident #502), from 1 of 4 sampled residents reviewed for sexual abuse out of a total sample of 4 residents. This deficient practice places all female residents in Immediate Jeopardy. Findings Include: Resident #502's Admission Minimum Data Set (MDS) assessment, dated 7/8/15, reflected that he was a [AGE] year-old male, who had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, reflecting that he was cognitively intact. The 24 hour report, written by LPN A and dated 8/1/15 and 8/2/15 at (time left blank) reflected that Resident #502 continued to repeatedly follow Resident #501 repeatedly, that all staff were aware and were told to watch Resident #502. According to the Minimum Data Set (MDS) assessment, dated 5/9/15, Resident #501 was an [AGE] year old female who had a Brief Interview for Mental Status score of 7 out of a possible 15, which reflected severe cognitive impairment. In an interview on 8/12/15 at 10:45 AM, LPN A explained that when she worked on 8/1/15 and 8/2/15, a Code Black was issued for severe weather from 8/1/15 through 8/2/15. During a Code Black all residents were to be in their rooms with the door closed. LPN A stated that she saw Resident #502 out of his room during the Code Black talking to Resident #501 near the doorway of Resident #502's room. Resident #502 was redirected back to his room, was told Resident #501 was unable to make decisions for herself and Resident #502 was not to be near Resident #501. During the interview, LPN A was asked if anyone else knew that Resident #502 had been out of his room and talking to Resident #501. LPN A replied everybody knew .I wrote it in the 24 hour report In an interview on 8/14/15 at between 2:30 PM and 3:30 PM, LPN A agreed that the events that she observed with Resident #502 and Resident #501 took place on Saturday 8/1/15 and changed the third statement the facility had her write, by crossing out 8/2/15 to 8/1/1, adding the word Sat. and initialing it. The 24 hour report for the East Unit, dated 8/1/15, reflected that Resident #502 was following around Resident #501. Nurses and staff were notified to keep eyes open. In a written statement, dated 8/2/15 to 8/3/15, Nurse Aide F wrote, I did work Saturday 8/1/15 and stayed over till 3 AM around 12 AM (name of Resident 502) was attempting to go into her room he got angry and started cussing at me and stated that if he could get his gun he was going to kill me. Nurse Aide F wrote a second statement, reflecting that the date of the incident was 8/2/15 to 8/3/15, but also documented Saturday 8/1/15 I worked 7 AM to 3 PM I was paged over the walkie to come and assist (name of Resident #501) back to South unit as she was on east in the hall outside his room. The police report, dated 8/6/15, reflected on 8/6/15 the Administrator and the Director of Nursing (DON) were interviewed. During this interview the Director of Nursing told the police that before the incident with Resident #501, Resident #502 had been following (name of Resident #501) around and was being 'creepy. The DON advised that because of him (Resident #502) following her (Resident #501)around or standing in her door looking in, nurses told him to stay away from Resident #501 and to leave her alone. He was told to stop following her and that he is not allowed in her room at any time. This same report also reflected that the DON advised that Resident #502 only followed Resident #501 around, no one else. In an interview on 8/11/15 at 12:30 PM, Resident #501's Durable Power of Attorney (DPOA) stated that this was their (the facility's) third offense and stated that the facility had called her twice before and informed her that Resident #501 had been groped by another resident. DPOA stated that she was not aware of who the other resident was. Resident #501's Nurse Aide Care Guide, dated 7/30/14, directed Nurse Aides to Keep resident on South/North side away from East Unit, (where Resident #502 resided) and to redirect resident away from males. In an interview on 8/14/15 at 1:35 PM, Nurse Aide J stated that she was familiar with Resident #501. Nurse Aide J stated that staff knew whenever Resident #501engaged in conversation with males; she was either inviting them to her room or some other place in the facility. Resident #501 also had a history of [REDACTED].#504 last July 2014. This made the facility aware that Resident #501 was vulnerable. According to the facility's incident report, dated 8/2/15 at 10:30 PM, Resident #502 was found in Resident #503's room with his pants, brief and shoes off and was on top of Resident #501 straddling her. Resident #502 was instantly removed off of Resident #501 and placed on one-to-one supervision. Resident #501 was assessed and sent to the emergency room for evaluation. The facility's Daily Interdisciplinary Eagle Room Report reflected Resident #501 was sent to ER (emergency room ) for assessment seen naked with naked resident over top her. The hospital emergency care center report, dated 8/3/15 and printed at 9:57 AM, reflected on 8/3/15 at 12:26 AM Patient (Resident #501) arrives via (name of transportation service) from (name of facility) after staff witnessed sexual assault of patient (#501) by another resident at the facility. Per (medical transportation service) dispatch was notified of an assault. Patient has hx (history) of dementia, oriented to person. Does not recall exact events of tonight. Patient (#501) denies pain. Asked if anyone touched her inappropriately tonight, she denies but did state, 'A male doctor was going to check me out down there to make sure I was ok, but he couldn't finish because they came in ' . The hospital care report, dated 8/3/15, reflected that the hospital spoke to facility RN D who confirmed that Resident #501 had severe dementia. RN D stated to hospital staff that a nurse aide found Resident #502 on top of Resident #501 without her brief on. RN D told the hospital staff that, when questioning Resident #501, she stated that the male resident was Only inside me a little bit, but not all the way. Resident #501 then denied the sexual encounter. The hospital emergency care center report, dated 8/3/15, reflected that when the doctor performed the SART (Sexual Assault Rape Test) exam, Resident #501 cried out in pain. Some redness/breakdown noted to inner labia. In an interview on 8/12/15 at 12:30 PM, Resident 3501's DPOA stated that the hospital had called her and reported that the rape kit had found Resident #501 had been sexually penetrated. In an interview on the morning of 8/13/15 the Administrator stated she contacted Office H and Officer H said there was no rape kit and that the result from a rape kit takes months to get. On 8/13/15 at 11:55 AM, Resident #501's Durable Power of Attorney was called and a message was left. On 8/13/15 at 12:05 PM, Resident #501's DPOA returned the call and stated she did not remember the name of the doctor, but during the evening of Resident #501's exam, the hospital doctor who completed her exam said there was evidence of sexual intercourse. On 8/13/15 at 12:10 PM, the hospital was called and a message was left for Dr. I. On 8/13/15 at 7:30 PM, Dr. I returned the call and stated she did not tell Resident #501's DPOA that there was positive evidence of sexual intercourse. She stated there was redness, but the results were inconclusive. A review of the police report, printed on 8/7/15, reflected that on 8/7/15 the Administrator called the police and advised that the facility had interviewed some other nurses and had statements. The Administrator provided the police department with statements from LPN A and Nurse Aide G. The statement with Nurse Aide G reflected that Resident #502 told her that he was in trouble because he tried to get himself some pussy. (Name of Resident #501) told (name of Nurse Aide G) that 'he went into the room he tried to close the door she said no her roommates don't like the door closed or the lights out or the curtain pulled.' (Name of Resident #502) then said '[***] it and I just got with it.' (Name of Nurse Aide G) asked him if he actually got inside of (Name of Resident #501) and (Name of Resident #502) told her 'no but I got the feel of it then the fat [***] came to the door and told everyone.' (Name of Resident #502) also said that he couldn't get the young girls because they are worried about their jobs so, 'he tried to get an old one that don't know[***] A review of the police report showed that the police conducted a separate interview with Resident #502 on 8/3/15 and reflected that Resident #502 told the police that Resident #501 wanted to have sex with him and she did. Resident #502 said he had not (had sex). He just said that because everyone in the building believes he had sex with her. The police report reflected Resident #502 admitted he touched the victims' (Resident #501) breast. Resident #502 told the police that Resident #501 did not stop him from touching her breasts. Resident #502 told the police during the interview that Resident #502 initiated everything and that she told him she wanted to have sexual intercourse with him. Resident #502 told the police Resident #501 said she wanted him to put it in me and Resident #502 advised he did not. The police report of the interview with the Director of Nursing (DON) on 8/6/15 reflected It was believed that (Resident #502) took advantage of a situation. He had gone in the room and closed the door and knew what he was doing. The facility was placed in Immediate Jeopardy (IJ) for failure to protect one cognitively impaired resident (#501) from one cognitively intact resident (#502), resulting in sexual abuse of Resident #502, which placed Resident #501 in immediate jeopardy in regard to her health and safety with the risk for significant injury or harm. The immediate jeopardy was identified on 8/12/15 at 2:45 p.m. related to the facility's incident report dated 8/2/15 at 10:30 PM, Resident's #501 and #502 were found naked from the waist down and Resident #502 was on top of #501. The immediate jeopardy began on or before 8/1/15 (no time indicated) but according to the interview with LPN (Licensed Practical Nurse) A on 8/12/15 at 10:45 AM, the incident involving Residents #501 and #502 took place after she exited the building, who indicated she left the facility between 9:00 PM and 9:45 PM on 8/1/15. According to the written statement of LPN A dated 8/1/15, Resident #502 was redirected away from Resident #501's room and (Resident #502) was told she (Resident #501) was unable to make decisions for herself. A copy of LPN A's written statement dated 8/1/15 was requested on 8/11/15 at about 3:50 PM. On the morning of 8/12/15 at 11:00 AM, the Administrator came into the conference room and stated I don't see her statement in here. The facility did not come forth with the statement written by LPN A during the week of the survey from 8/11/15 through 8/14/15. On 8/12/15 at about 10:45 AM, during a telephone interview with LPN A, she stated she confirmed she had a written statement on file with the facility, and remembered it was Saturday (8/1/15) when she was working on the back hall she heard a page for an East Hall nurse. LPN A stated she went to get him (Resident #502) away from (Resident #501's) room, and told Resident #502 he was not allowed to be by Resident #501. Resident #501 replied we were just talking. Then LPN A redirected Resident #502 back to his room and told him she (Resident #501) was not allowed to make decisions for herself. The Facility Administrator was notified of the Immediate Jeopardy related to non-complaiance with federal regulation at F223 sexual abuse on 8/13/15 at 10:50 AM. The immediate jeopardy was abated on 8/14/15 at 4:57pm, based on confirmation during observation, interviews and record review that the facility had implemented the following to remove the immediate jeopardy: The facility Quality Assessment and Assurance committee met on 8/3/2015 and 8/13/15 to resolve the alleged failure of the facility to protect one cognitively impaired resident (#501) from one cognitively intact resident (#502), resulting in the alleged rape of Resident #501, which placed Resident #501 in immediate jeopardy in regards to her health and safety with the risk for significant injury or harm. As a result the following plan of correction has been developed. Element 1. Resident #501 was immediately assessed by charge nurse on 8/2/15 with no signs or symptoms of bruising, tears, or trauma to the peri area. The charge nurse had no new findings. There were old bruises on the upper arms and old scabbed area on thighs. Resident #501 was sent to ER for evaluation, and returned with no findings that sexual assault had occurred. Resident #501 had no change in psychosocial behaviors and continued to participate in her normal daily routine. Resident #501 was discharged to another facility .on 8/6/15. Resident # 502 - Was Immediately removed from room [ROOM NUMBER]-1 and placed on 1 on 1 supervision, which Resident #502 remained on till he was discharged home on[DATE]. Element 2. On 8/3/15 the interdisciplinary team reviewed 75 residents ' clinical records to determine if they have inappropriate sexual behavior symptoms that place them at high risk for incident. The IDT identified four residents out of 75 that display behaviors that place them at high risk for inappropriate sexual behavior (2 of the 4 are the residents involved)-These additional 2 were aggressive; none of the 75 showed signs of adverse behavior. The IDT team reviewed and revised like resident ' s behavioral care plans and Kardex ' s as indicated. IDT team also did visual rounds to like residents to ensure that behavioral interventions were in place and appropriate. In addition on 8/2/15 to 8/3/15, non-interviewable residents received a full body audit with no areas of concern noted and no changes in psychosocial well-being. Interviewable residents were interviewed to determine if any inappropriate sexual behavior occurred or was observed. No concerns were noted with inappropriate sexual behavior or changes in psychosocial well-being by either category of residents. Newly admitted residents will be evaluated for inappropriate sexual behaviors that place them at high risk for incident during their admission evaluation. IDT will review new admissions and current residents for behaviors that place them at high risk for inappropriate sexual behavior and care plans and kardex's will be reviewed and revised as indicated. Element 3. On 8/3/15 ADNS began providing education to nursing staff on the process of ongoing management of residents with inappropriate sexual behaviors and on catastrophic reactions, behaviors involving residents and documentation of occurrence. Since 8/13/15 58 nursing staff were educated prior to the start of working on the floor with residents. No nursing staff worked prior to receiving the education. 20 licensed nurses have been educated and 38 CENA'S have been educated. New nursing staff hires will be educated prior to their first scheduled shift. In addition on 8/14/15 staff were re-educated on the process of ongoing management of residents with inappropriate sexual behaviors and on catastrophic reactions, behaviors involving residents and documentation of occurrence to include keeping residents safe within the facility. Staff will be educated prior to the start of working on the floor with residents. All staff currently working within the building has been educated. Element 4. DCD or designee will audit nursing notes Monday through Friday for behaviors that place a resident at high risk for inappropriate sexual behavior to ensure documentation and interventions are in place to prevent injury or harm. Concerns will be addressed at the time. The DCDs will report findings to the ADNS who will provide a summary of findings to the QAA committee weekly for any additional actions if needed. Any allegation or witnessed sexually inappropriate behavior will be immediately addressed by protecting the vulnerable residents and reported to the abuse prevention coordinator for further investigation. DCD or designee will audit nurse's notes/24 hour reports on residents in the building Monday through Friday for suspicious areas skin impairment and/or changes in psychosocial wellbeing. Concerns will be addressed at the time. The DCDs will report findings to the ADNS who will provide a summary of findings to the QAA committee weekly for any additional actions if needed. Although the immediate jeopardy was removed on 8/14/15, the facility remained out of compliance at a scope of pattern, and severity of no actual harm with the potential for more than minimum harm, pending the facilities ability to demonstrate sustained compliance as verified by the state agency. ( )

This citation pertains to intake number MI 037. Based on interviews and records review, the facility failed to provide pressure ulcer care, as ordered by the attending physician (and recommended by the consultant orthopedic surgeon), and failed to assess/document resident responses to interventions ordered/implemented for care of a right heel pressure ulcer, in accordance with accepted standards of care, for 1 of 4 residents (Resident #101) sampled for pressure ulcer care, from a total of 6 residents reviewed, resulting in a stage III pressure ulcer (full thickness tissue loss), requiring admission to a local hospital for surgical debridement (removal of dead tissue). Findings include: Resident #101 was no longer residing at the facility during the complaint investigation. The facesheet revealed Resident #101 was a [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the physician progress notes [REDACTED].#101 was "currently on [MEDICAL CONDITION] and [MEDICAL CONDITION] therapy, 5 days a week, with plans for a total of 5 weeks." Review of the Admission Nurses Note dated 2/6/2015 at 6:36 PM, revealed Resident #101 had a cast of his right lower extremity. Review of the Minimum Data Sets ((MDS) dated [DATE], identified Resident #101 as moderately cognitively impaired, and requiring extensive assistance from a facility staff member with activities of daily living (ADL's). According to the Progress Note of the orthopedic physician consultant dated 2/11/2015 (untimed), Resident #101's right lower extremity cast was removed, and he was recommended to receive application of a padded, occlusive dressing, every 72 hours, for treatment of [REDACTED]. The Physician orders [REDACTED].#101 was to receive wound care of his right heel with a dressing change, every 72 hours. Review of the Treatment Administration Record (TAR) initiated February 2015 (untimed), revealed Resident #101 received application of a dressing to his right ankle on 2/16/2015, but did not receive another dressing change until 5 days later (on 2/21/2015); there was no documentation provided on the TAR or within the nurses notes regarding the omission of the ordered treatment. Electronic Progress Notes, including nursing documentation dated 2/11/2015 through 2/25/2015 (the date of Resident #101's transfer to a local hospital), included no entries regarding Resident #101's right heel wound. Skin assessment sheets provided to the State Surveyor on 3/4/2015 at 2:50 PM by the Director of Nursing, and identified as complete, included no documentation/entries for the period 2/11/2015 through 2/25/2015 (the date of Resident #101's transfer to a local hospital), regarding assessments or the progress of care performed on Resident #101's right heel wound. The Nurses Progress note dated 2/25/2015 at 7:11 PM, revealed Resident #101 was sent out to a local hospital for a follow up appointment with the orthopedic surgeon. According to the History and Physical dated 2/25/2015 at 5:46 PM, the consultant orthopedic surgeon documented Resident #101's right heel was assessed, at the local hospital, with a "full thickness heel decubitus ulcer" for which he received surgical debridement of the wound. During an interview on 3/4/2015 at 4:15 PM, the Director of Nursing said, "There are holes (missed documentation) in the TAR for this Resident (Resident #101) for dressing changes to the right heel. I'm not sure what happened; there's no explanation given on the TAR. I'll check into this. The care should've been done." During an interview on 3/5/2015 at 3:05 PM, the Director of Nursing said she had made unsuccessful attempts to contact nursing staff regarding missed and undocumented care of Resident #101's right heel. She acknowledged it was expected that all wounds be assessed and documented in the nurses notes, on the weekly skin care/assessment sheets, on TAR/MARs.

This citation pertains to intake number MI 311. Based on interviews and record review, the facility failed to prevent falls in 1 of 4 residents reviewed for occurrence of falls (Resident #101), from a total of 4 residents reviewed for fall risk, resulting in Resident #101 experiencing a fall from a sit to stand lift with subsequent left lateral femoral condyle fracture, left knee effusion (fluid on the knee), and admission to a local hospital. Findings include: The facesheet revealed Resident #101 was a [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "Patient Transfer Screening Analysis" dated 12/6/2012 (identified by the Director of Nursing, DON, on 4/2/2014 at 11:20 AM as the Resident's most recent assessment) assessed Resident #101 as requiring use of a sit to stand lift for transfers. Review of the Minimum Data Sets ((MDS) dated [DATE] indicated Resident #101 was moderately to severely cognitively impaired, and required extensive assistance from 2 facility staff members during transfers (movements from surface to surface). The fall risk assessment dated [DATE], (identified by the Director of Nursing, DON, on 4/2/2014 at 11:20 AM as the Resident's most recent assessment) identified Resident #101 at risk for falls due to "history of falls, unsteady gait, muscle weakness, diuretic therapy, cardiovascular medications, psychotropic medication, and multiple co-morbidities." According to the Facility Investigation Report dated 3/25/2014 (untimed), Resident #101 had completed a shower in a central shower room on 3/17/2014 at 12:55 PM, when her feet slid off the sit to stand lift platform. The Resident was reported to have been lowered to the floor by 2 CNA's. Complaints of pain by the Resident later resulted in her transfer to a local hospital for evaluation; she returned to the facility on [DATE] with a knee brace and orders for follow-up appointments. During an interview on 4/2/2014 at 10:40 AM, Resident #101 said, "I had a fall in the shower. I was on the lift machine. I was standing up. There was just one person there, not two. My hands were still wet from the shower; I'd just had a shower. My left hand slipped off the grab bar, then my feet started slipping off the machine. I told the aide that my left hand was slipping off. I fell . I hit the lift machine hard." During an interview on 4/2/2014 at 11:50 AM, CNA "B" said, "I've taken care of the Resident (#101) before, quite a bit. She's over 300 pounds. She fell after a shower. We (identified as CNA "B" and CNA "C") were using a sit to stand lift to get her off the shower chair. I don't know if her hands were completely dry. We use a lift on her because she's not able to stand up. Both her hands are weak. She refused to use the leg straps that day (identified as 3/17/2014 at 12:55 PM); she'd refused them before. I'd forgotten to bring her wheelchair to the shower room. I left it down the hall and around the corner, in front of her room. We'd used a shower chair to get her to the shower room, not her wheelchair. She got agitated. The Resident just wanted to get out of that shower room and go to lunch. I went back to her room. The other CNA (identified as CNA "C") went ahead to stand the Resident up in the lift. When I came back into the shower room, CNA "C" said something like 'hurry, we need to get her in the chair.' The Resident was collapsing, butt first. I was rushing from the doorway to put the wheelchair underneath her bottom, but she was already too low. The straps were supposed to keep the Resident from wiggling. I was trained to use the lift, to use the harness and leg straps. We're also supposed to use 2 person assist with the lift; she only had one, - CNA "C." During an interview on 4/2/2014 at 1:55 PM, CNA "C" said, "I've taken care of her (Resident #101) a lot. I witnessed her fall. Two of us (identified as CNA "B" and CNA "C") took her to the shower room in a shower chair. I didn't dry her hands after her shower; not sure her hands were dry after the shower. We'd put her brief and pants on, to the level of her knees, but they weren't pulled up until we had her stand up with use of the sit to stand lift. Once her pants were up, CNA "B" left the shower room to get the Resident's wheelchair; the Resident continued to stand in the lift. The Resident's legs were weak, and she complained her knees were hurting her all the time. She'd refused to have her leg straps used. Neither of us (identified as CNA "B" and CNA "C") put the leg straps on; that was a mistake. We're supposed to use the straps, no matter what. I know that. She couldn't bear weight with her knees. Not sure if it was because of pain or her weight; she's obese. Just when the other CNA ("B") got to the doorway of the shower room, I heard the Resident say 'I'm slipping, I'm falling." The Resident's feet collapsed out and came under the weight of her body and her knees went to one side; the Resident's left side. The harness was the only thing holding her up. I used my walkie to call for help, stat. I saw her hands come off the bar. Her feet came off the lift platform. She's obese. She should've had a 2 person assist, and 2 people should've been with her when she stood up in the lift, at all times." During an interview on 4/2/2014 at 2:40 PM, Physical Therapist (PT) "D" said, "I did an evaluation of the Resident (#101) on 7/18/2013. She was unable to stand, so I couldn't assess her weight bearing status. Assessments for use of lift machines are done by nursing staff in this facility. To use a sit to stand lift, a person should be able to bear weight in the standing position while using the lift. She (Resident #101) was completely dependent on 2 persons to stand. Her left hand has a partial contracture of the thumb and pinky finger." During an interview on 4/3/2014 at 10:15 AM, RN "G" said, "I've taken care of her (Resident #101) quite a bit. Being up in a sit to stand lift she'd need to get up and down quickly. She might be able to tolerate seconds, not even minutes; her pain and her weight are issues." During an interview on 4/3/2014 at 2:30 PM, the DON said facility staff were expected to provide 2 person assist with use of the sit to stand lift, and that 2 facility staff members were to remain in attendance with all residents in lifts, at all times. The DON also said that review of the "Patient Transfer Screening Analysis" (dated 12/6/2012) by herself, a corporate consultant, and a physical therapist revealed the tool "may not be meeting residents' needs for appropriate selection of lift mechanisms." During an interview on 4/3/2014 at 2:45 PM, the Nursing Home Administrator said the facility's investigation revealed Resident #101 had not had use of the leg straps while utilizing the sit to stand lift on 3/17/2014 at 12:55 PM, at the time of her fall. He said he had not been aware that one of the CNA's (CNA "B") had left the shower room on 3/17/2014 at 12:55 PM to retrieve the Resident's wheelchair, leaving CNA "C" alone with Resident #101 in the standing position on the sit to stand lift. He said CNA "B" and CNA "C" both received one to one inservice/education on 4/2/2014 (untimed) regarding "When using SARA (sit to stand lift)/Hoyer, you must have two people assistance at all times, and you should never leave the resident once you have started using the lift. Make sure all the items needed are close by for assistance with the transfer (wheelchair);" this was documented on the "One On One Inservice Record." He said the facility had "zero tolerance of residents placed at risk for falls." Review of diagnostic testing (x-rays and CT scans) performed at a local hospital on [DATE] at 10:54 PM, revealed Resident #101 had sustained a "lateral femoral condyle fracture" and "small knee joint effusion" of her left lower extremity.

This citation pertains to MI 306. Based on interviews and record review, the facility failed to 1). do comprehensive Nursing assessments and monitor 2). follow-up in a timely manner with a STAT lab, in the extent of 1 (Resident #500) of 8 sampled Residents, from a total sample of 8 residents, resulting in resident #500 having a critical drop in hemoglobin (Hgb., red blood cells, transports oxygen) of 4.4 (normal is 14.0 to 18.0), with subsequent death. Findings Include: Review of the face sheet, minimum data set (MDS, resident assessment tool) dated [DATE] and [DATE], Physician orders [REDACTED].#500 was a [AGE] year old male, admitted to the facility on [DATE], severely cognitively impaired, non-ambulatory, had difficulty making himself understood and understanding others, was non-verbal, had a feeding tube and was totally dependent on staff for all activities of daily living (ADL's). The residents [DIAGNOSES REDACTED]. The resident was transferred to the hospital on [DATE] due to a [MEDICAL CONDITION] (GI bleed) and returned to the facility on [DATE]. The resident had a history of [REDACTED]. Review of the interdisciplinary note dated [DATE], stated "Res (resident #500) is a full code at this time". Review of the closed clinical record revealed no other documentation regarding the residents code status. Review of the hospital history and physical dated [DATE] and discharge summary dated [DATE], stated "a [AGE] year old African American male admitted last night because of GI bleed, [DIAGNOSES REDACTED], [MEDICAL CONDITION], hematuria (blood in urine). The patient received 1 unit of blood in the emergency roiagnom on now he is receiving 2 units of blood. His most recent hemoglobin today is 7.1. The patient received 2 units of packed RBC's (red blood cells). Abdomen: soft but distended, bowel sounds are very sluggish, blood pressure ,[DATE], his heart rate 55, temperature is 97.4, respiratory rate 20, O2 saturation (oxygen level) 100% on room air. Discharge Diagnoses: [REDACTED]. Hospital course: no colonoscopy (due to risk of bleeding), Hb (Hgb) 9.4, blood transfusion when Hb less than 7.0". Review of hospital labs are as follows: [DATE] HGB="9.4" and "9.5" (after resident received blood), [DATE]="9.5", [DATE]="9.5" and "9.4". Review of Physician #1's patient history and physical dated [DATE], stated "readmitted following hospitalization for fast dropping Hg., he received blood and was found to have GI bleeding, Foley clear urine, urine bleeding stopped". Review of physician order [REDACTED]. Review of lab dated [DATE], revealed the residents Hgb. was ",[DATE], no n/o (new order), [DATE]". Review of the nurses notes dated [DATE] through [DATE], are as follows: On [DATE] at 9:11 a.m.:"6:30 a.m. resident alert and awake, emptied 450 cc of urine from catheter, no blood at this time, [MEDICAL CONDITION] noted in b/l (both) thighs". On [DATE] at 4:03 p.m.:"Urinary incontinence and indwelling catheter evaluation has been completed for (the resident)". On [DATE] at 11:33 a.m.:"Abdomen distended, round, firm (sign/symptom of GI bleed). Resident refuses to be turned for [MEDICATION NAME] bag PRN (as needed) intervention at this time. Resident stiff posture when provided care, no facial grimace but stiffens body when approached for turning. Will attempt [MEDICATION NAME] bag intervention again this shift". No documentation of any nurses notes dated [DATE] was found. On [DATE] at 5:46 p.m.: "Resident alert at this time and continues on antibiotic therapy. Temp. 97.6 275 ml emptied per catheter at this time. No signs orf (of) facial grimacing noted at this time, resident is calm in bed". No documentation of any nurse's notes or assessments dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] was found. On [DATE] at 2:38 p.m., "Skin assessment reveals area of shearing to coccyx, linear line of 1 cm x 2.5 cm, 0 depth, no drainage, no odor normal appearance surrounding. Dr. notified, new orders written. Family notified of area, (family member) has no questions. Treatment applied. No s/sx (signs/symptoms) of pain noted. Skin alteration record completed". Review of the physician order [REDACTED]. On [DATE] at 11:53 a.m. (the day the resident deceased ): A long nursing note regarding wound care, Foley catheter, non-ambulatory status, peg tube (feeding tube) related to positioning of the resident in bed and type of mattress was documented only. On [DATE] at 8:06 a.m. (the nurse assigned was 7:00 p.m. to 7:00 a.m., charted at the end of shift): "7 p.m. resident sitting up in w/c (wheelchair) beside bed looking at TV. 8:30p (pm) while checking on his tube feed, I asked him if he was ok, barely opening his mouth to amswer (answer) pale color noted, resident tend to have low Hgbs. 9:01pm results for labs, Hgb 4.4 MD paged x 2 called (name of lab) to fax a copy of the lab. 9:20 p.m. RM door partially closed, knock and went in to do vs (vital signs), resident was sitting in w/c with his head nodded, thought he was sleeping called his name no response, shook him and noticed he was unresponsive, paged stat for all nurses, crash cart, O2 at 2 L (liters), resident in bed, CPR started with 2 nurses until MMR (ambulance) arrives, south unit nurse notified family and DON (Director of Nursing). 9:30 p.m. MMR arrived, no CPR performed, resident is asystole (absence of heart beat). Informed MD of code and that resident is deceased . 10:55 p.m. released remains to (funeral home)". No documentation of a complete nursing assessment after the physician assessed the resident on [DATE] to the day he deceased ([DATE]) was found for the dates of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the clinical record revealed blood pressures were taken on the dates of [DATE] (,[DATE] and ,[DATE]), [DATE] (,[DATE] and ,[DATE]), [DATE] (,[DATE]) and on [DATE] (,[DATE]). Review of the 24 hour nursing reports dated [DATE] through [DATE], revealed one set of vital signs (on [DATE]), a temp. (on [DATE]) and stated "no hematuria" (on [DATE]). [DIAGNOSES REDACTED] nursing assessment, nursing dx and interventions: monitor vital signs and level of consciousness for evidence of acute hemorrhage, assess nose, gums, lips, joints, skin (color, bruising), stool and urine for bleeding. Measure abdominal girth to detect occurrence of deep bleeding. Monitor neurologic signs, such as level of consciousness, orientation, pupillary response and reflex's to detect changes, report any pupillary response or decrease in level of consciousness to physician. (Mosby's Manual of Clinical Nursing second edition chapter 15, Thompson, McFarlan, Hirsch, Bowers, The C.V.Mosby Company, 1989) Review of the residents facility hematological condition care plan initiated on [DATE], stated "observe for and report bleeding". Review of the GI distress care plan dated initiated on [DATE], stated "record bowel sounds as needed and report any abnormalities to physician". Review of the pain care plan initiated on [DATE], stated "notify physician and patient's significant other of any significant changes, evaluate for and report pain signs/symptoms, exact location, character, severity, contributing factors/history, breath sounds, guarding, skin color/temperature, non-verbal signs of discomfort". Review of the nutrition care plan initiated on [DATE], stated "report signs and symptoms of hyperosmolar reaction such as nausea, vomiting, [MEDICAL CONDITION] (high sugar level)". Review of the feeding tube care plan initiated on [DATE], stated observe for and report "abdominal distention" and "poor skin turgor, dry mouth, increased lethargy". During an interview and review of the residents clinical record done on [DATE] at 2:10 p.m., with the DON (Director of Nursing) and DCD #1 (Director of Care Delivery), the surveyor asked why there was a lack of documentation of complete nursing assessments and the DON and DCD #1 had no answers. Both the DON and DCD #1 agreed there was a lack of complete nursing assessments and nursing charting form [DATE] to [DATE] regarding resident #500. An interview was done on [DATE] at 2:45 p.m., with Charge Nurse LPN #1 (assigned to the residents hall on [DATE] 7:00 a.m. to 7:00 p.m.) and the DON. When the surveyor asked Charge Nurse LPN #1 why she did not do a complete assessment on the resident the day he deceased she stated "the next shift does the assessment, I should of put more but I was focused on the urine, I think I should of put something about the abdomen. I called the lab to come, they came earlier, I don't know when. I called the lab (for the second time) they told me they had already been there and the girl (the lab tech) forgot the resident, it was a mess". Charge Nurse LPN #1 said the lab tech had to return to the facility to draw resident #500's STAT lab. Charge Nurse LPN #1 denied she informed the DON, DCD or the physician of the delay in the residents STAT lab and when asked why she had no answer. An interview was done on [DATE] at 9:20 a.m., with Charge Nurse LPN #2 (assigned on [DATE], to the hall the resident was on 7:00 p.m. to 7:00 a.m.). Charge Nurse LPN #2 stated "When I came on she (prior nurse) told me there was a STAT lab that was already done, so I should just wait for it. The report she gave me was he did look a little drowsy during the day, she said she would shake him and he was up. There should have been assessments on him, he should have been sent out during the day (transferred to the hospital). The Doctor said the next time if his labs are like that we should start a saline IV on him. I called (family member), she asked me what happened, he should have been on alert charting (a list of residents to alert nurses to do daily charting)". An interview was done on [DATE] at 7:50 a.m., with Charge Nurse RN #3 (assigned on [DATE] and [DATE] to the hall the resident was on). Charge Nurse RN #3 stated "If he was not on the list to be charted on we don't chart on them, the DCD (Director of Care Delivery) makes it out. When I got him his 72 hours was over (chart daily for 72 hours after return from the hospital). We don't have time to chart; the alert charting log is what we go by". An interview was done on [DATE] at 10:55 a.m., with DCD #1. DCD #1 revealed charge nurses and herself are the ones who make out the alert charting log and stated "staff did not notify me of any changes in the resident, he should have been assessed and documented on, he should have been placed on alert charting, it's probably my fault". An interview was done on [DATE] at 8:15 a.m., with Charge Nurse LPN #4 (assigned on [DATE], to the residents hall on). Charge Nurse LPN #4 stated "I was in charge of the whole unit; I did not make any notes on him. The DCD makes out the alert charting log. Because he was having low hemoglobin's and he was just out to the hospital, I would of charted, I got called away to check on something, I must not of come back". An interview was done on [DATE] at 10:00 a.m., with Charge Nurse RN #7 (assigned on [DATE], to the hall the resident was on). Charge Nurse RN #7 stated "I feel the assessments and charting are lacking, we needed to keep a closer watch on him. I feel we should have had him on the alert log. I would appreciate a greater communication between nurses; I did not even know he was a hemophilic until today, when you told me". Review of the facility Alert Charting Logs dated [DATE] through [DATE], revealed one entry of resident #500 dated [DATE], stated "skin on coccyx-forehead" and was to be monitored "daily". Review of the facility Alert Charting policy dated [DATE], stated "situations for alert charting typically include new admission monitoring needs, acute change of patient condition, new admissions or re-admissions, the patient's problem or need, goal and interventions planned to manage the patient's condition". An interview was done on [DATE] at 8:55 a.m., with Charge Nurse LPN #5 (assigned on [DATE] and [DATE], to the hall the resident was on). Charge Nurse LPN #5 stated "Ever since he came back from the hospital (on [DATE]) he acted different, like he could have been in pain. I likely did not chart on him because I passed it on in report. I agree he should have been charted on, it looks like I did not do anything, we help the CNA's (nursing assistants) all day because we don't have any staff". An interview was done on [DATE] at 9:35 a.m., with Charge Nurse RN #6 (assigned on [DATE], [DATE], [DATE], and [DATE], to the hall the resident was on). When the surveyor asked Charge Nurse RN #6 if she felt the resident should have been assessed and charted on for [DATE] and [DATE], she stated "I did the skin check (on [DATE]) "and said "ya". An interview was done on [DATE] at 11:25 a.m., with CNA #1. CNA #1 stated "he had a extra-large BM that was dark black, tar-like (sign of a GI bleed); it smelled like blood around the day he died . I informed (Charge Nurse LPN #1), she came in the room and observed it, she said keep an eye on him. I did not document it". CNA #1 was unable to recall the exact date the resident had the BM. A phone interview was done on [DATE] at 11:35 a.m., with physician #1. Physician #1 denied staff had informed him of the resident having a extra-large black tar-like stool that had the smell of blood around the time he deceased . An interview was done with Charge Nurse LPN #1 on [DATE] at 4:00 p.m., when the surveyor asked why she did not chart on the resident on [DATE] and charted on him on [DATE] (after he had deceased ) she stated "I came in the next day and saw I didn't chart so I charted". Charge Nurse LPN #1 admitted she did not put "late entry" prior to charting on the resident the day after the nurse cared for him. Review of the nurse's notes dated [DATE], revealed no documentation of an order for [REDACTED]. Review of nurses notes dated [DATE] (the day after the resident had deceased ), stated at 7:51 a.m., "Resident noted lethargic for 2 to 3 seconds and is resolved with touch. Notified Dr. of episode. N.O. (new order): Labs CBC, Bmp, vitals:,[DATE], 97.3, 60, 18. Will contact family pending labs " . No "Late Charting" indication for [DATE]" was found documented by the nurse. The nursing process shall be documented for each patient from admission to discharge; standards for documentation ensure the nurse's professional accountability in delivering care. If charting on the day after the data or information was obtained, put "late entry" at the beginning of the nurse's note. (Fundamentals of Nursing Concepts, Process, and Practice, Potter, Perry, The C.V. Mosby Company, 1985) STAT Lab: Review of physician order [REDACTED]. Review of the laboratory results dated [DATE], stated the residents Hgb. was "4.4" and was faxed to the facility at "8:57 p.m.". The STAT lab results were faxed to the facility on [DATE] approximately 10 hours after the order was received by the lab. Review of the nurse's notes dated [DATE], revealed at "9:01 p.m." the facility nurse was notified of the STAT lab. A phone interview was done on [DATE] at 4:05 p.m., with Lab employee #2. Lab employee #2 said the lab was called and informed to come to the facility to get the STAT lab ordered on [DATE] at "12:00 p.m." and stated "there is no documentation that a lab person was out at the facility prior (to 12:00 p.m.)". Lab employee #2 stated the lab had a "3 hour turn around for STAT labs". A phone interview was done on [DATE] at 12:00 p.m., with Lab employee #1. Lab employee #1 revealed her lab only processed the labs; they did not collect the labs from the facilities. Lab employee #1 said she had documentation that the order for the STAT lab was received at "10:44 a.m.", collected from the facility at "5:35 p.m." and delivered to her lab at "8:16 p.m." on [DATE]. Review of the laboratory test request sheet dated [DATE]; revealed documentation the lab had received the request for the stat lab at "10:44 a.m." on "[DATE]". Review of the facility nurses notes dated [DATE], revealed the nurse was informed of the 4.4 Hgb on [DATE] at 9:01 p.m., approximately 10 hours total time. Review of the facility laboratory tracking guidelines policy dated [DATE], stated "contract for laboratory services includes: provision of selected services to include stat services 7 days a week, 24 hours a day. STAT lab tests: If the laboratory technician has not arrived to obtain the STAT test within one hour of the initial contact, the laboratory is contacted again. If after two hours the tech has not arrived, the nurse notifies the ADNS (Assistant Director of Nursing Services). If a delay of three hours occurs the ADNS and physician are contacted for additional direction. Actions taken are documented in the progress notes. STAT laboratory values are received according to timeframe's established in the lab contract, but no longer than 4 hours after the lab sample is obtained. Appropriate notifications and any ordered interventions are documented". Review of resident #500's certificate of death dated [DATE], stated cause of death listed as "Multisystem Failure-Hours, [MEDICAL CONDITION]-Days, [DIAGNOSES REDACTED] A". ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF A LEFT HEEL PRESSURE ULCER FOR ONE RESIDENT NUMBER (#8) FROM 5 RESIDENTS REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF 16 RESIDENTS RESULTING IN COMPLICATIONS RELATED [MEDICAL CONDITION] AND OSTEO[DIAGNOSES REDACTED]. FINDINGS INCLUDE: ACCORDING TO THE FACILITIES ADMITTING RECORD DATED 7/19/12, RESIDENT #8 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. ON 3/6/13 AT APPROXIMATELY 9:20 AM, AN OBSERVATION OF RESIDENT #8 WAS MADE. RESIDENT #8 WAS LYING IN HER BED WITH BOTH FEELS IN [MEDICATION NAME] BOOTS, HEAD OF THE BED WAS ELEVATED AND RESIDENT STATED THAT SHE WAS COMFORTABLE. THE TUBE FEEDING PER [DEVICE] WAS INFUSING AT THE RATE OF 80 MILLILITERS PER HOUR. ON 3/6/13, AT APPROXIMATELY 2:00 PM, DURING THE DRESSING CHANGE OF RESIDENT #8'S LEFT HEEL WITH THE UNIT MANAGER FOR 1 NORTH AND SOUTH STAFF "L", STAFF "L" STATED THAT SHE DOCUMENTED THE WOUND ON THE LEFT HEEL AS A PRESSURE ULCER BECAUSE OF THE LOCATION OF THE WOUND. REVIEW OF THE FACILITIES "PRESSURE ULCER HEALING CHART/THE PRESSURE ULCER HEALING RECORD PUSH TOOL", DATED 11/9/12 AND 11/16/12, DOCUMENTED RESIDENT #8'S LEFT HEEL WAS IDENTIFIED TO HAVE A NECROTIC TISSUE (ESCHAR) CODED AS 4 (DESCRIPTION OF BLACK , BROWN OR TAN TISSUE THAT ADHERES FIRMLY TO THE WOUND BED) AREA MEASURING 9 CENTIMETERS. ON 3/23/13 THE PRESSURE ULCER HEALING RECORD DOCUMENTED THE LEFT HEEL ULCER HAD REMAINED THE SAME SIZE HOWEVER THE TISSUE TYPE WAS CODED AS A 3 SLOUGH ( WHITISH OR YELLOW TISSUE THAT ADHERES TO THE ULCER BED IN STRINGS OR THICK CLUMPS, OR MUCOUS). A REVIEW OF THE NURSING ADMISSION assessment dated [DATE] DOCUMENTED RESIDENT #8 HAD A [DIAGNOSES REDACTED]. THE BRADEN RISK ASSESSMENT FOR SKIN BREAKDOWN DOCUMENTED RESIDENT #8 IS VERY LIMITED IN HER ABILITY TO COMMUNICATE, SKIN IS VERY MOIST AND RESIDENT IS COMPLETELY IMMOBILE, "DOES NOT MAKE EVEN SLIGHT CHANGES IN BODY OR EXTREMITY POSITION WITHOUT ASSISTANCE'. REVIEW OF RESIDENT #8'S ADMISSION SKIN CARE PLAN, 7/30/2012 DOCUMENTED THE RESIDENT WAS AT RISK FOR SKIN BREAK DOWN RELATED TO,"IMMOBILITY, LT SIDE IS FLACCID, INCONTINENCE OF BOWEL AND BLADDER, AND DESIRES TO REMAIN IN BED". INTERVENTIONS IN PLACE WERE PRESSURE REDISTRIBUTION DEVICE ON BED AND CHAIR PRO MAT ON BED. THERE WAS NO DOCUMENTATION FOR KEEPING THE RESIDENT'S HEELS OFF THE BED FOR PRESSURE REDUCTION. THE RADIOLOGY REPORT DATED 1/16/13, PRESCRIBED AN ANTIBIOTIC [MEDICATION NAME] 1 GM X 5 WEEKS. ACCORDING TO THE NURSES NOTED DATED 11/7/12 RESIDENT #8 " PRESSURE ULCER ON LEFT HEEL WITH MODERATE DRAINAGE. NEW ORDER FOR [MEDICATION NAME] AG (A MEDICATED OINTMENT) COVER WITH [MEDICATION NAME] CHANGE DAILY AND AS NEEDED PREVALON BOOT TO LT FOOT ON". IT WAS DOCUMENTED ON 11/7/12 AS A PRESSURE ULCER ; THIS WAS EARLIER ASSESSED ON 7/12 AS [MEDICAL CONDITION]. THE NURSES NOTES FURTHER DOCUMENT ON 11/13/12 "RESIDENT DEVELOPED DEEP TISSUE INJURY TO LT HEEL. SHE HAS LEFT SIDED HEMI PARESES FOLLOWING A [MEDICAL CONDITION]. SHE WAS ON A FOAM PRESSURE RELIEF MATTRESS. THIS HAS BEEN UPGRADED TO PRO MATT, AND BILATERAL PREVALON BOOTS AND RESIDENT IS NOW ON DOCUMENTED TURN SCHEDULE". FURTHER REVIEW OF THE NURSES NOTES DATE 11/15/12 DOCUMENTED "WOUND CARE PROVIDED TO RESIDENT'S HEEL. MODERATE AMOUNT OF DRAINAGE THAT DOES HAVE AN ODOR TO AREA". THE PRESENCE OF AN ODOR MAY BE INDICATIVE OF AN INFECTION. REVIEW OF THE SKIN CARE PLAN DATED 11/26/12 DOCUMENTED OPEN AREA TO LEFT HEEL RELATED TO: IMPAIRED CIRCULATION, IMMOBILITY, OSTEO[DIAGNOSES REDACTED]. AN INTERVENTION WAS IMPLEMENTED TO "FLOAT HEELS AS ABLE INITIATED ON 11/12/12. ON 12/16/12 NURSES NOTED DOCUMENTED DURING THE DRESSING CHANGE TO THE LEFT HEEL, "SCANT AMT OF SEROSANGUINOUS (PINK COLORED) DRAINAGE PRESENT, TISSUE WAS RED RESIDENT STATED THAT SITE WAS TENDER WHEN TOUCHED, DRESSING WAS APPLIED AND PREVALON BOOTS WERE PUT ON". ACCORDING TO THE NURSES ON 12/29/12 A WOUND CULTURE WAS TAKEN AND SENT TO THE LAB, FOUL ODOR WAS NOTED. NURSES NOTED DOCUMENTED ON 12/31/12 DOCUMENT CULTURE TO LEFT HEEL "FEW GRAM NEGATIVE RODS WITH MODERATE TO MANY [MEDICATION NAME] SPECIES ( BACTERIA) . THIS IDENTIFIED AN INFECTION. THE NURSES NOTES DATED 1/15/13, AT 20:01 HOURS, DOCUMENTED RESIDENT #8'S CHANGE OF CONDITION, "NEW ORDER FOR STAT LABS. MIDLINE TO BE PLACED TOMORROW MORNING START IV ABT(INTRAVENOUS ANTIBIOTIC) RESIDENT HAD A CRITICAL LAB VALUE OF WBC 30.34 (WHITE BLOOD CELLS ( CELLS IN THE BODY THAT INDICATE /FIGHT INFECTION) TEMP 100.2 BP (BLOOD PRESSURE) 146/76 PULSE 84 RESIDENT APPEARS FLUSHED AND SWEATING INCREASED CONFUSION MD AWARE OF CONDITION". ACCORDING TO THE NURSES NOTES DATED, 1/16/13 AT 20:06 INDICATED RESIDENT WAS TRANSPORTED TO THE HOSPITAL FOR EVALUATION. ACCORDING TO THE NURSING READMISSION ASSESSMENT RESIDENT #8 RETURNED TO THE FACILITY FROM THE hospital on [DATE], WITH A [DIAGNOSES REDACTED]. ACCORDING TO THE RADIOLOGIST REPORT DATED 1/16/12 THE EXAM OF THE LEFT HEEL/OS (LEFT) CONCLUDED, "LEFT HEEL OSTEO[DIAGNOSES REDACTED] (A BONE INFECTION) AS DESCRIBED. ACCORDING TO THE NURSING NOTES DATED 1/26/13 RESIDENT #8'S HEEL WOUND MEASURED, " 2 X 3 X 1 (CENTIMETERS) PAIL PINK RED TISSUE NO DRAINAGE". THIS WAS A PREVENTABLE LEFT HEEL PRESSURE ULCER THAT DEVELOPED COMPLICATIONS RELATED [MEDICAL CONDITION] AND OSTEO[DIAGNOSES REDACTED]. IT WAS UNCLEAR AS TO RESIDENT #8'S ASSESSMENT OF THE WOUND SINCE THE IT WAS DESCRIBED AS A [MEDICAL CONDITION], DEEP TISSUE INJURY AND PRESSURE ULCER. THE INTERVIEW WITH THE NURSE MANAGER STAFF "L" DESCRIBED IT AS A PRESSURE ULCER ON THE LEFT HEEL ON 3/6/13. THE NURSING PROGRESS NOTES ON 11/12 DOCUMENTED THE PRESSURE ULCER DURING A WOUND TREATMENT. THE PRESSURE ULCER HEALING CHART (PUSH TOOL) WAS UTILIZED ( 11/9/12 AND 11/16/12) TO DESCRIBE THE WOUND. IN ADDITION, A REVIEW OF THE CARE PLAN INITIATED ON 11/12/2012 WITH A FOCUS OF " OPEN AREA AT LEFT HEEL RELATED TO IMPAIRED CIRCULATION..." ' DID NOT APPEAR TO BE MODIFIED AND UPDATED WITH THE DECLINE OF THE WOUND NOR WAS IT CLEAR HOW THE INTERVENTIONS WITH DATES 11/12/12 AND 1/30/13 WERE MONITORED FOR THEIR EFFECTIVENESS OR NOT. THERE WAS NO WAY TO VERIFY THAT THE NURSING STAFF WAS CONTINUOUSLY MONITORING THE SKIN FROM 7/19/12 WHEN IT WAS NOTED AS INTACT BUT AT RISK FOR INJURY AND WAS SENT TO THE HOSPITAL WITH A [DIAGNOSES REDACTED]. IN ADDITION, THERE WAS LACK OF COORDINATED INTERVENTIONS BETWEEN THE CARE PLAN AND THE NURSING ASSISTANT CARE GUIDE. THE INTERVENTIONS FOR FLOATING THE HEELS WAS NOT INCLUDED IN THE ASSISTANT CARE GUIDE. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO TIMELY AND CONSISTENTLY IMPLEMENT THE PHYSICIAN ORDERED INTERVENTIONS TO PROMOTE OPTIMAL HEALING OF A STAGE IV PRESSURE ULCER FOR 1 OF 2 RESIDENTS (#22) REVIEWED FOR PRESSURE ULCERS, FROM A TOTAL SAMPLE OF 10 RESIDENTS, RESULTING IN AN INCREASED POTENTIAL FOR DELAYED OR COMPROMISED HEALING. FINDINGS INCLUDE: ACCORDING TO THE FACILITY ADMITTING RECORD, WITH A PRINT DATE OF 1/25/13, RESIDENT #22 WAS AN [AGE] year OLD FEMALE ORIGINALLY admitted to the facility on [DATE] AND MOST RECENTLY REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE RESIDENT'S CARE PLAN FOR COGNITION, DATED 2/9/11, RESIDENT #22 WAS COGNITIVELY IMPAIRED RELATED TO [MEDICAL CONDITION]/DEMENTIA. REVIEW OF RESIDENT #22'S CARE PLAN (DATE CREATED: 10/2/2012) REFLECTED THE RESIDENT HAD A STAGE IV PRESSURE ULCER ON THE "SACROCOCCYGEAL AREA" (LOWER BACK, TAILBONE AREA). ACCORDING TO THE "RESIDENT ASSESSMENT INSTRUMENT (RAI) MDS (MINIMUM DATA SET) 3.0 MANUAL", A STAGE IV ULCER IS A WOUND CHARACTERIZED BY: "FULL THICKNESS TISSUE LOSS WITH EXPOSED BONE, TENDON OR MUSCLE. SLOUGH OR ESCHAR (DEAD TISSUE) MAY BE PRESENT ON SOME PARTS OF THE WOUND BED. OFTEN INCLUDES UNDERMINING AND TUNNELING." RESIDENT #22'S WOUND HAD STARTED OFF AS SHEARING IN AUGUST 2012, ACCORDING TO THE FACILITY "PROGRESS NOTES" DATED 9/26/12, AND HAD WORSENED OVER TIME. A HOSPITAL "WOUND CARE REPORT" DATED 1/9/13 DESCRIBED RESIDENT #22'S WOUND AS: "CHRONIC STAGE IV DECUBITUS ULCER OVER COCCYGEAL AREA. THE PATIENT'S WOUND IS HUGE...SPREADING TO BOTH BUTTOCKS." ACCORDING TO DOCUMENTATION ENTERED ON THE "ORDERS/WOUND HEALING CENTER" RECORDS SHEETS, RESIDENT #22 WAS BEING SEEN AT THE WOUND CLINIC WITH HER MOST RECENT VISIT BEING ON 5/1/13. BASED ON REVIEW OF THE "ORDERS/WOUND HEALING CENTER" RECORDS SHEETS, ORDERS WERE RECEIVED FROM THE WOUND CLINIC VISITS ON DATES 3/27/13, 4/3/13, 4/17/13 AND 5/1/13. ALL OF THE ORDERS EITHER "HIGHLY RECOMMENDED" OR INDICATED TO CONTINUE THE USE OF A "CLINITRON" MATTRESS (SPECIALTY ALTERNATING AIR FLOW MATTRESS FOR PRESSURE RELIEF). HOWEVER, ON 4/30/13 AT APPROXIMATELY 2:30 P.M., AN OBSERVATION WAS MADE OF RESIDENT #22 IN BED IN HER ROOM WITHOUT A CLINITRON MATTRESS IN USE. THE UNIT MANAGER STAFF "C" CONFIRMED AT THE TIME OF OBSERVATION THAT THE MATTRESS IN USE WAS A "FLAPCAIR" SPECIALTY MATTRESS, WHICH DID NOT HAVE THE ALTERNATING AIR FLOW FEATURE. ON 5/1/13 AT APPROXIMATELY 10:00 A.M., AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) WAS CONDUCTED, AND THE DON WAS ASKED TO EXPLAIN WHY THE CLINITRON MATTRESS, ORDERED BY THE RESIDENT #22'S WOUND CLINIC PHYSICIAN, WAS NOT IN USE. THE DON STATED, "THEY (REFERRING TO DOCTORS) HAVE AGREED SHE (RESIDENT #22) DIDN'T NEED ONE". ON 5/1/13 AT 11:55 A.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH THE CLINICAL COORDINATOR AT THE WOUND CLINIC WHERE RESIDENT #22 HAD BEEN RECEIVING HER TREATMENTS. THE CLINICAL COORDINATOR WAS ASKED ABOUT RESIDENT #22 AND THE ORDER FOR THE CLINITRON MATTRESS. THE CLINICAL COORDINATOR STATED, "SHE IS TO HAVE A CLINITRON MATTRESS", BUT THEN QUERIED, "SHE DOESN'T HAVE A CLINITRON MATTRESS"? THE CLINICAL COORDINATOR AT THE WOUND CLINIC DENIED ANY KNOWLEDGE OF ANY AGREEMENT OR DECISION TO NOT UTILIZE A CLINITRON MATTRESS FOR RESIDENT #22. DURING AN INTERVIEW ON 5/2/13 AT APPROXIMATELY 9:45A.M., UNIT MANAGER STAFF "C" SAID, "I TALKED WITH OUR MEDICAL DIRECTOR AND HE STATED HE DID NOT WANT THE CLINITRON MATTRESS DUE TO THE HUMIDITY AND ESPECIALLY IN THE SUMMER MONTHS. THIS IS AN OLD BUILDING AND IS GETS REAL STUFFY AND THAT MAKES THE SAND IN THE CLINITRON MATTRESS HOT AND STICKY AND IT MALFUNCTIONS." STAFF "C" WAS ASKED IF THE INFORMATION WAS VERIFIED THROUGH THE MANUFACTURER AND STAFF "C" DID NOT CONFIRM THAT THE INFORMATION HAD BEEN VERIFIED. STAFF "C" FURTHER INDICATED THAT THE DISCUSSION WITH THE MEDICAL DIRECTOR HAD JUST TAKEN PLACE, AND THERE WERE NO PHYSICIAN NOTES OR ORDERS IN RESIDENT #22'S MEDICAL RECORD THAT EXPLAINED THE RATIONALE FOR NOT FOLLOWING THE WOUND CLINIC'S ORDER FOR A SPECIFIC TYPE (CLINITRON) MATTRESS. REVIEW OF RESIDENT #22'S MEDICAL RECORD REFLECTED AN ORDER DATED 5/1/13 FROM THE WOUND CLINIC PHYSICIAN THAT READ: "MATTRESS: CLINITRON". ADDITIONALLY, REGARDING THE CURRENT TREATMENT ORDERS FOR THE RESIDENT'S WOUND, THE ORDERS DIRECTED: "COCCYX - HOLD VAC ([DEVICE]) X 1 WEEK - START SANTYL MOIST COVER WITH [MEDICATION NAME] (OCCLUSIVE DRESSING) CHANGE EVERY DAY." HOWEVER, ON 5/2/13 AT APPROXIMATELY 10:40 A.M. (THE DAY AFTER THE ORDERS WERE WRITTEN), AN OBSERVATION WAS MADE OF RESIDENT #22 IN HER ROOM AND THE [DEVICE] WAS STILL APPLIED TO THE RESIDENT'S WOUND. IMMEDIATELY FOLLOWING, AN INTERVIEW WITH THE UNIT MANAGER WAS CONDUCTED. THE UNIT MANAGER STAFF "C" STATED, "WELL, WHEN SHE (RESIDENT #22) RETURNED FROM THE CLINIC YESTERDAY, HER HUSBAND MUST HAVE HANDED THESE ORDERS TO A CNA (CERTIFIED NURSING ASSISTANT), AND SHE DIDN'T REALIZE THESE WERE ORDERS, BUT YOU'RE RIGHT, THE NURSE SHOULD HAVE INITIATED THESE. I DON'T KNOW WHAT HAPPENED. SOMEONE PUT THESE IN THE CHART (REFERRING TO THE MEDICAL RECORD)". ( )

This citation pertains to MI 610, MI 955 & MI 979. Based on interview and record review, the facility failed to prevent the development of pressure sores in 2 of 5 sampled residents (#104 and #101) of 3 reviewed for pressure ulcers, from a total sample of 5 residents, resulting in Resident #104 developing a Stage IV Pressure Ulcer that required hospitalization and treatment, and the development of a Stage II Pressure Ulcer for Resident #101. Findings include: Resident #104 According to the Quarterly Minimum Data Set assessment dated [DATE], Resident #104 had [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] Disorder (abnormal electrical discharge). The MDS Assessment indicated Resident #104 was assessed to require total assistance for bed mobility, transfers, showers/bathing and was incontinent of bowel and bladder. Review of Resident #104's Care Plan, "At risk for alternation in skin integrity related to: normal disease progression with unavoidable decline dementia, incontinence impaired mobility, decline in mental awareness, Diabetes and fragile skin", dated 3/16/09, reflected interventions that included provide for preventive skin care, reassess skin risks, use pillows/positioning and monitor skin, pressure redistributing device on bed (an overlay on the bed consisting of a foam or gel), and report abnormalities. There had been no documented updated changes to the care plan since 3/16/09. Review of Resident #104's Skin Worksheet dated 11/3/12 reflected "Normal" was checked and no other area was marked as abnormal on the form. Review of Resident #104's Skin Worksheet dated 11/7/12 reflected a body figure with "skin opening" written by hand on Resident #104's form. Directions on the form included: "if abnormal circle affected areas: "the left gluteal area had 1 small area circled and the right gluteal had 2 small areas circled on the form. There were no forms available for 11/10/12 or 11/14/12 (scheduled shower days). Review of Resident #104's Physician order [REDACTED]. Review of Resident #104's Progress note (registered dietician) dated 11/9/12 reflected, " Per nursing pt (patient) with new pressure ulcer to sacrum .... " Review of Resident #104's Care Plan, "Pressure ulcer at left side of sacrum related to: impaired mobility, incontinence, friction dated 11/12/12 reflected a goal that resident was to develop "no new areas of skin break down and heal with out complication." A new intervention of "Pro Matt on Bed" (a Pro Matt is a overlay on the bed to redistribute pressure and consisting of a foam or gel) was initiated. Review of Resident #104's Skin Worksheet dated 11/17/12 at 1:00 AM, reflected a body figure with one circle surrounding the coccyx area and enclosed the previous 3 small circles on the right and left gluteal areas. Review of Resident #104's Progress note 11/12/12 reflected, "late entry: resident has developed open ulcer on sacral area (no date). Area measures 7 cm (centimeter) x 9 cm x > .2 cm. Has beefy red granulation tissue and skin is wrinkled up as if pushed around peri wound. Wound presents as shearing type injury but secondary to size of wound and location of wound over sacrum, wound will be staged at Stage II pressure ulcer Resident is on Pro-Matt...Resident is non-compliant with attempts to offload secondary to back pain from lumbar stenosis that is severe and long standing. Resident is a diabetic and is non-compliant with carb-controlled diet..." Review of Resident #104's Treatment Record dated November 2012, reflected Weekly skin audits were done on 11/7/12 and 11/13/12. Audits were documented as changed to a Daily Skin Check on 11/16/12. Resident #104's Weekly audits were recorded in the treatment record as check marks. The check marks were the only "documentation" in the clinical record related to the "audits/assessments" completed on those days. The clinical record did not reflect any measurements of the 3 open areas on 11/7/12 or 11/13/12 according to the documentation reflected on on the Skin Worksheets at the time of Resident #104's shower. The clinical record did not reflect any measurements of the open areas / Pressure Ulcer when the Weekly skin Audits were changed to daily skin checks/audits on 11/16/12. Review of Resident #104's nurse progress notes dated 9/14/12 - 11/12/12 reflected two documented entries of Resident #104's refusal of care. One entry was on 9/15/12, and the second documented entry was on 11/12/12 (see above). The entry on 11/12/12 included documentation of the development of the pressure ulcer on 11/7/12. During an interview on 1/14/13 at 3:10 PM, Wound Nurse, Registered Nurse (RN) #2 reported she felt "shearing and friction had contributed to the development of the pressure ulcer" of Resident # 104. Resident # 104's care plan was reviewed with RN #2. RN #2 reported Resident #104 was reported to have often refused care, and RN #2 agreed there were no interventions related to Resident #104 refusal of care, or repositioning or no changes had been made to the interventions on the care plan to reflect Resident #104's "change in condition." RN #2 reported there had been no education provided to Resident #104 or the family related to Resident's refusal of care, repositioning to prevent skin breakdown, the prevention of pressure ulcers or the inappropriate dietary intake . RN #2 reported it was part of her job responsibility to update Resident #104's care plan. During an interview on 1/23/13 at 11:10 AM, Director of Nursing (DON) #1 reported CNAs are expected to report all resident observed abnormal skin issues that are identified immediately to the charge nurse. DON #1 reported skin issues were often identified during a Resident's shower and were documented on the Skin Worksheets, the nurse was then informed of the abnormal concerns. The Skin Worksheets were reported by DON #1 to have been reviewed by the charge nurses each shift and "ideally" skin issues were to have been documented in the clinical record during that shift on that day. DON #1 reported the charge nurses were to document any abnormal concerns on the 24 hour report for discussion in morning report so all management staff were aware of concerns, and on the alert charting form for Resident follow up, monitoring and documentation in the clinical record. DON #1 reported there was no entry on the 24 hour report for Resident #104 related to the abnormal skin concern on 11/7/12, and there was a page missing for Resident # 104's alert charting for 11/7/12 through 11/9/12. During an interview on 1/30/12 at 12:49 PM, RN # 6 reported she was notified of Resident #104's open area on the coccyx area by Certified Nurse aide (CNA) #4 at the time of Resident's shower on 11/7/12. RN #6 could not recall an observation of the pressure ulcer. RN #6 reported "didn't always have time to document on everybody," and that she instructed CNA to apply white cream (like [MEDICATION NAME]) and instructed CNA #4 to keep Resident #104 off his buttocks and on to his side. RN # 6 reported, RN # 1 and RN # 2 were notified of Resident # 104's pressure ulcer areas and Resident #104's pressure ulcer information was documented on the 24 hour report. RN # 6 reported Resident #104 was often non- compliant with taking medication and occasionally with repositioning. When questioned, RN # 6 agreed information regarding refusal of care and repositioning by Resident #104 was not documented in the nurses notes and the care plan had not reflected interventions for Resident #104's refusals or noncompliance. RN #6 reported the staff nurses were not responsible for updating Resident care plans, and reported the unit managers and DON #1 were responsible for updating Resident care plans. During an interview on 2/1/13 at 9:45 AM, CNA #4 reported on the midnight shift of 11/7/12 following Resident #104's shower, during the process of dressing resident, 3 open areas were observed on residents buttocks. CNA #4 reported the areas "looked like the first layer of skin was coming off and you had to be careful wiping or it looked like you could wipe the skin off and it was pink around it." CNA #4 reported that there was one area open on the left buttock and 2 open areas on the right buttock. CNA #4 reported upon discovery charge nurse #6 was notified of the Resident #104's open areas. RN #6 reported to Resident #104's room, observed the areas, applied a treatment (white cream), and instructed CNA #4 to start to prop up on Resident's sides every 2 hours on all shifts. CNA #4 reported returned to the facility and provided Resident #104 care 2 nights later and both areas on Resident's buttocks looked "more open and bigger." CNA #4 reported Resident #104 was a big guy, bashful and often did not want to be touched, would yell out and required 2 staff to reposition. CNA #4 reported Resident #104 was provided care but the facility was often short staffed and care was provided with 1 staff versus 2, and made care more difficult to provide. Review of Resident #104's Nurse aide "Task List Report," dated 6/18/12, included an intervention of "turn and reposition Q (every) 2 hours and PRN (as needed)." ADL (activity of daily living) Assist Usually 1 person assist with ADL's." Resident #104's CNA Care Plan was not updated since 6/18/12 and had not reflected Resident's change of condition. According to the emergency room [DATE], (admitted [DATE]), Resident #104 was admitted with a 104 degree temperature, unresponsive, with a decreased Hemoglobin of 9.5 g/dl (Gram/Deciliter)( normal 14-18), and with a [DIAGNOSES REDACTED]. During Resident #104's hospital course treatment included [MEDICATION NAME] (antibiotic) for 6 weeks, wound care that included debridement (surgical removal of contaminated/dead tissue) and on 11/20/12 a wound vac (promotes healing with negative pressure) was initiated . "The decub was deep up to the bone, and big (you can put Fist inside)." Resident #101 According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #101's [DIAGNOSES REDACTED]. Review of Resident #101's physician order [REDACTED]. Review of Resident #101's care plan, reflected, "Pressure ulcer /DTI (Deep Tissue Injury) at left heel related to: impaired mobility, friction, hx of left [MEDICAL CONDITION], was dated 11/12/13 with a goal that included to heal without complication and an intervention that included to float heels as able. Review of Resident #101's Nurse Progress note dated 11/8/12, reflected initial documentation related to the pressure ulcer in the Nurse Progress notes was on 11/8/12 at 18:58 (6:58 PM), "bandage changed to left heel. pt (patient) tolerate well. 0 drainage to bandage." Review of Nurse Progress note dated 11/12/12 reflected, late entry from 11/7/12 Resident developed DTI (Deep Tissue Injury) to left heel. Area measures 1.5 x 1 unknown. Area covered with eschar. Review of Pressure Ulcer assessment dated [DATE] (5 days after ) reflected left heel "1.5 x 1.0 x unknown secondary to eschar. During an interview on 1/23/13 at 11:10 AM, Director of Nursing (DON) #1 reported CNA's are expected to report all abnormal skin issues identified to the charge nurse. DON #1 reported the charge nurses were to document any abnormal concerns on the 24 hour report for discussion in morning report so all management staff were aware of concerns, and on the alert charting form for Resident follow up, monitoring and documentation in the clinical record. DON #1 provided a copy of the 24 hour report for 11/6/12 through 11/9/12. Resident #101's left heel was not recorded on any of the 24 Hour Reports reviewed during that time frame. DON #1 Reported charge nurses were expected to document according to the facility policy on abnormal skin conditions. Review of the Nurses' Progress notes for Resident #101 dated 11/8/12, 11/9/12, 11/10/12, 11/14/12, and 11/18/12 reflected documentation that was specific to the "left heel ." There was no information related to an assessment or the facility's policy on charting of the heel. According to the Facility's Policy "Charting: Alert," dated 8/11/06, stated "Situations for alert charting typically include new admission monitoring needs, acute change of patient condition or situations that are expected to resolve or stabilize within 14 days. Some examples may include, but are not limited to: change of condition...skin alterations...The alert charting process includes, but is not limited to: documentation of patient evaluation findings, physician notification and response, family notification and any new orders or instructions received in the interdisciplinary process notes or nurses notes, initiation of an Acute Care Plan ...addition of patient name and information to Alert Charting Log, update to the Change in Status Report, 24 hour report...Documentation for alert charting occurs each shift for a minimum of 72 hours..."

This citation pertains to intake #MI 570 Based on interview and record review the facility failed to ensure residents were free from physical abuse in 1 of 7 sampled residents (Resident #104), from a total of 7 sampled residents, resulting in Resident #104 experiencing unnecessary pain and suffering . Findings include: Review of Resident #104's admitting record revealed he was an [AGE] year old male admitted to the facility on [DATE] and had the following diagnoses, Dementia, and Debility. According to nursing notes, dated [DATE], Resident #104 was on hospice care and expired [DATE]. According to a typed statement dated [DATE] signed by Physician #1, Physician #1 documented she observed a certified nurses aide (CNA) treat a male Resident (Resident #104) rough (position legs) and gave the Resident leg a final push once the legs were positioned. Physician #1 documented that she heard the Resident making noises as if he were in a great deal of pain. Physician #1 was asked if she felt the actions of the CNA were intentional and she responded, "yes." The Physician was asked if she thought the CNA was abusive and she stated, "yes I do". Physician #1 explained she went to treat another Resident after witnessing this event and the Resident had a worried look on her face when explaining she would have her aide come and help clean her and get her out of bed. The physician said that the resident (Resident #104) reluctantly told her the CNA's name and it was the same CNA she had just witnessed treating Resident #104 roughly. During an interview with Physician #1, on [DATE], at 2:17 PM, the Surveyor asked Physician #1 if she still believed that CNA #1's actions on [DATE], when working with Resident #104 was abuse and why? Physician #1 responded, "yes, the Resident was screaming and the CNA did not stop or assess what was causing the pain". Physician #1 said, "there was no reason to push down on Resident #104's knee after she moved his legs." Physician #1 said that CNA #1 lacked [MEDICATION NAME] and and her actions were blatant because "she treated Resident #104 rough, in full eye sight of of others". Physician #1 explained that CNA #1 never made eye contact with Resident #104 while he was screaming in pain. During a second interview with Physician #1, on [DATE] at 1:10 PM, the Surveyor asked Physician #1 if she did anything when she observed CNA #1 treating Resident #104 rough on [DATE]. Physician #1 responded she was approximately 4 feet away from CNA #1 and Resident #104 when the incident occurred and the Physician said she look directly at CNA #1 and said, "What are you doing". Physician #1 said CNA #1 did not respond or make eye contact with her and pushed Resident #104 in his chair to the dinning room. Physician #1 explained she was talking with Registered Nurse (RN) #1 at the time of the incident and Physician #1 explained to RN #1 what she had just observed and RN #1 said she was going to report the event. According to a typed statement dated [DATE] and signed by RN #1, RN #1 was in the hallway with Physician #1 and CNA #1 and Resident #104 were approximately 4 feet away from them. RN #1 observed that a towel she had placed under Resident #104's leg for comfort earlier was still in place and she recalled she had given Resident #104 Tylenol for pain earlier. RN #1 observed CNA #1 attempt to move Resident #104 feet on the foot pedals and her heard Resident #104 groan. RN #1 said CNA #1 continued to move Resident #104 legs and then she took him to the dining room. RN #1 said Physician #1 pulled her aside and said, "she was very rough with him, did you see that.?" RN #1 said she was going to get and a CNA to help another Resident and the Resident scowled when Resident #104 was asked who her aide was, she said CNA #1. RN #1 said Physician #1 asked what the facial expression meant and Resident #104 told her that she did not like CNA #1 and she wanted another CNA to help her. During an interview with RN #1 on [DATE] at 3:30 PM, RN #1 explained during the incident on [DATE] with CNA #1 and Resident #104, RN #1 had her back toward them. RN #1 said when she saw a look of surprise on Physician #1's face she turned to see what was going on behind her. RN #1 said CNA #1 was putting one of Resident #104's feet on the pedal. Later in the interview RN #1 said it bothered her that CNA #1 moved Resident #104's feet because she had change Resident #104 leg position earlier and placed a towel under them for comfort. RN #1 said she had placed a call to Resident #104's physician for additional pain medication. RN #1 denied seeing any rough treatment. Review of a typed statement dated [DATE] and signed by CNA #1 explained that Resident #104 's feet were hanging over his foot bolsters and she moved Resident #104 feet so they were on the pedals. CNA #1 said that RN #1 had said that Resident #104 had been in a lot of pain that day. CNA #1 went on to explain she did not do anything to intentionally hurt Resident #104. CNA #1 denied pushing on Resident #104's knees. During an interview with CNA #1, on [DATE] at 3:20 PM, CNA #1 recalled reposition Resident #104's legs in his wheelchair on [DATE]. CNA #1 denied intentionally trying to hurt Resident #104 and did not think she pushed on Resident #104's knee's after she positioned his legs. CNA #1 explained she returned to work after the Director of Nursing trained her to be more aware of Residents in pain. According to the facility investigation report CNA #1 was suspended pending the outcome of the investigation on [DATE] at 2:40 PM. On [DATE] CNA #1 was give discipline and in-servicing was given. On [DATE] CNA #1 returned to work. According to the time card for CNA #1 she worked [DATE], [DATE], [DATE], [DATE] and[DATE]. According to the time care for CNA #1 was placed on suspension on [DATE]. During an interview with the Nursing Home Administrator (NH) #1 on [DATE] at 1:20 PM the Surveyor asked the NH #1 why he did not determine the incident with CNA #1 and Resident #104 was abuse like Physician #1 had made clear in her statement on [DATE]. NH #1 said he had Physician #1 demonstrate how CNA #1 pushed on the Residents knee on him and he did not feel it was rough. The Surveyor asked NH #1 if he asked Physician #1 why she felt it was abuse and he responded he did not interview her. The Surveyor informed NH #1 on [DATE], at 4:30 PM she would be citing the facility for the Abuse of Resident #104 by CNA #1. On [DATE] at 9:45 AM the Surveyor asked NH #1 about the status of CNA #1 and the NH #1 said CNA #1 was on suspension. ( )

Applies to intakes MI 157, MI 140 and MI 401 Based on observation and records review the facility failed to ensure Resident #105's bed alarm remained functional throughout the shift, failed to ensure Resident #103 was left safely unattended in a wheelchair and ensure Resident #103 was transferred with a mechanical lift as indicated in mechanical lift procedure that had potential to alert staff to intervene and prevent fracture for Resident #105 and potential for injury for Resident #103 out of a total sample of 6. Findings include: Applies to MI 157, Resident # 105 only- Closed medical record file MDS (Minimum Data Set) dated 6/17/10 revealed Resident #105 had [DIAGNOSES REDACTED]. Review of "Additional Admission Physician Orders" dated 4/20/10 revealed the following order: "Bed alarm and check placement and functionality (every)sic shift. (7:00 AM-7:00 PM & 7:00 PM- 7:00 AM)sic" Review of fall care plan revealed the following intervention initiated 3/11/10: "Check on patient frequently." I/A (Incident/Accident) report dated 5/26/10 at 6:45 AM revealed the following incident description:"( Resident # 105 found lying on the right side on the floor in another residents room .)"sic I/A report revealed Resident # 105's bed alarm "had been working all night but did not sound at 6:00 am when fall occurred...alarm was blinking but pad (pressure pad sensor)sic was not working..." Observation on 11/17/10 revealed 36 feet between Resident #105's room and room where fall occurred. Observation revealed 18 feet between Resident # 105's room and nurse's station. Review of nurse's notes dated 5/26/10 signed by RN (Registered Nurse) Staff #5 revealed the following: "...Bed alarm never sounded...it was audible and functional earlier in the night...it was found to be that the pad itself was no longer functioning correctly..." Attempts were made to interview Staff #5; there was no response as of this writing. Review of "Additional Admission Physician Orders" "Administration Record" dated 5/25/10 (7:00 PM- 7:00 AM shift) revealed bed alarmed placement and functionality checked by nurse as ordered by physician. Review of "Patient Diagnostic Report" dated 5/27/10 revealed Resident # 105 sustained left hip fracture as a result of fall. Applies to MI 140, Resident #103 only- Review of nurse's notes dated 10/7/10 revealed Resident #103 was "found on floor with no apparent injury". LPN (Licensed Practical Nurse) Staff #3 was interviewed on 10/21/10 in Resident #103's room and another area. Said heard moan, went to room and found Resident # 103 on floor in front of wheelchair (Staff #3 pointed position of wheelchair and spot Resident #103 was on floor). Said, "Said couldn't recall if sling (maximove mechanical lift sling) was in place but said "foot rest was not on the wheelchair". Said "(Resident #103 slid out of the wheelchair.)"sic Staff #3 failed to indicate if other nursing staff were present when she entered room but indicated roommate was exiting room. She said assessment revealed no apparent injuries but Resident #103 said "it hurt". Review of I/A report dated 10/7/10 at 1:45 PM revealed the following cause of incident: "(Resident #103 in wheelchair with sling under Resident. CNA (Certified Nursing Assistant) went to get lift and Resident #103 slipped out of wheelchair onto floor)."sic "Physician Statement" revealed no injuries or treatments. Applies to MI 401, Resident #103 only- Review of I/A report dated 10/20/10 at 8:45 PM revealed the following incident description: "(Resident #103 being transferred using a maxi lift with 2 person assist and residents legs guided by staff while turning to clear body of lift.)"sic CNA (Certified Nursing Assistant) Staff # 4 was interviewed on 11/17/10 and written statement reviewed. She indicated, she had to "push" Resident # 103's legs about 4 inches to clear around lift while pulling on the sling. Said Resident # 103 "yelled out" during the procedure. LPN (Licensed Practical Nurse) Staff #3 was interviewed on 11/18/10 and written statement reviewed. Said she assisted Staff #4 transfer Resident # 103. Said had to to turn sling to place Resident # 103 in bed. Said, "We have to bend resident feet back approximately 1-2 inches. Resident yelled, that hurt..." Said, "When we turned the sling (Resident # 103's)sic toe barely hit the bar (mast)sic...It was basically (Resident # 103's)sic toe touched the pole (mast)sic" Staff #3 said she assessed the area and found no redness or bruising at that time; x-rays were ordered. Review of "Lift Program Skills Check-off Sheet Mechanical Lifts-Maximove/Marisa/Tempo" (not dated) procedures for operating the Maxilift and other lifts revealed the following procedure (#10): "Move lift away making sure resident's feet and body are clear of lift." Review of x-ray report left/right "Tibia Fibula" dated 10/21/10 revealed no indication of acute abnormality. ( )