Every finding on record at Bay Shores Senior Care and Rehab Center

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 03/10/2026 at 8:44 AM, during the initial kitchen tour, observed residue on the blade of a carving fork, stored inside the knife holder. On 03/10/2026 at approximately 9:08 AM, observed built up residue on juice nozzles. During this observation, Dietary Manager F was asked how often the juice nozzles are cleaned, and he stated the nozzles are soaked after each meal.According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of l\Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens being allowed to exist and spread in the facility's plumbing system with an increased risk of respiratory infection among all residents in the facility. Findings include: On 03/10/2026 at 1:07 PM, during the environmental tour with Maintenance Director H, free chlorine residual was tested at a bathroom hand sink, and the result was zero parts per million (ppm) in room [ROOM NUMBER]. During this observation, Maintenance Director H stated that free chlorine is usually at 0.5 ppm. On 03/10/2026 at 1:11 PM free chlorine residual was tested at the spa tub in Superior 1 hallway and the result was zero. On 03/11/2026 at 9:44 AM record review of the facility's Drinking Water Testing logs, shows the facility has designated a normal range of free chlorine at 0-3ppm and each monthly test result from October 2025 to March 2026 resulted at 0ppm.According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems, dated January 3rd, 2025, Ensure disinfectant residual is detectable throughout the potable water system.

Based on observation, interview, and record review the facility failed to ensure residents were treated in a dignified and respectful manner by respond to call lights timely and complaints of Staff cell phone use in resident care areas for anonymous resident council residents and residents ( #1, #12, #13, #90, #46, #117, #138) resulting in a lack of timely response of care needs, extended wait times for assistance, and residents verbalizations of discourteous staff, feelings of being a burden, frustration and sadness. Findings include: Resident #12: An interview was completed with Resident #12 in their room on 3/10/26 at 10:55 AM. When queried if facility staff treat them with dignity and respect, Resident #12 indicated there is a second shift aide (Certified Nursing Assistant [CNA]) who does not. When asked how the CNA does not treat them with dignity and respect, Resident #12 stated, I will ask to go to bed, and (the CNA) says they will have to come back because another (call) light is on. Resident #12 stated, (The CNA) goes and doesn't come back for 25 to 30 minutes. With further inquiry, Resident #12 verbalized it makes them feel unimportant when the staff leave them knowing they are tired and just want to go to bed. When asked the name of the CNA, Resident #12 responded they did not want to provide their name because they did not want to create additional problems. On 3/11/26 at 11:30 AM, a follow up interview was completed with Resident #12. Resident #12 was asked about staffing in the facility and stated, They are short (staffed). When queried how they know the facility is short staffed, Resident #12 revealed the CNA staff tell them. When queried if their care if negatively impacted because of staffing, Resident #12 stated, On 3/7/26, I didn't get my shower because there were only three girls (staff) here. When asked why they did not get their shower if there were three CNAs working, Resident #12 replied, I don't push it because I know they're short. I feel bad and don't want to bother them. When asked, Resident #12 revealed facility staff tell them they are short staffed which makes them feel guilty for taking up the staff member's time. Resident #12 verbalized they had not received their shower a couple weeks prior to that for the same reason. When queried regarding call light response time, Resident #12 replied that it can take a long time when the facility does not have enough staff. When asked for more specific information, Resident #12 replied, This Tuesday, I shit my pants because they didn't get to me in time. When queried how that made them feel, Resident #12 revealed they felt horrible and embarrassed. Review of Resident #12's Electronic Medical Record (EMR) revealed the Resident was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart failure, anxiety, ovarian cancer, and chronic respiratory failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required maximum to total assistance for toileting and bathing. Resident #90: On 3/11/26 at 10:20 AM, Resident #90 was observed sitting in a recliner in their room. Leg braces were observed sitting on the floor in the room. When queried regarding the braces, Resident #90 stated, I don't walk. Resident #90 then stated, I lost my core in Vietnam and became tearful. An interview was completed with Resident #90's family member Witness U on 3/11/26 at 1:23 PM. When queried regarding nursing care in the facility, Witness U replied, A couple nurses have an attitude problem. When asked to explain what they meant, Witness U revealed there was another resident who resided on the same hall as Resident #90 who had dementia and kept yelling I just need a water one day when they were visiting. When asked who the other resident was, Witness U revealed the resident went to the hospital and did not return to the facility. Witness U continued, I went and told the nurse, and she asked me if (the resident) put their call light on and I said I don't know, I'm just a wife. With further inquiry, Witness U revealed it was not just what the nurse said but also how they said it. When asked who the nurse was, Witness U stated, (Registered Nurse [RN] V). With further inquiry regarding nursing care, Witness U stated, They have problems with their CNA's. Witness U was asked what the problems were and revealed they were told the facility does not have money in the budget for extra CNAs so they take one from one unit and move to another unit. When asked how they knew that CNAs were being moved from unit to unit to cover staffing shortages and not for another reason, Witness U responded that the staff tell them. Witness U then stated, One CNA is crude. I had to request they didn't go into (Resident #90's room). When queried how the CNA was crude, Witness U replied, It's her attitude. When asked, Witness U was unable to recall the CNAs name. With further inquiry regarding nursing care in the facility, Witness U stated, Call lights take up to 45 minutes to answer and indicated they come to the facility daily and ensure their spouse's needs are met. Record review revealed Resident #90 was originally admitted to the facility on [DATE] with diagnoses which included liver cancer, pancreas cancer, Parkinson's disease, and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required maximum to total assistance to complete ADLs with the exception of moderate assistance with eating. Resident #138: On 3/11/26 at 11:53 AM, Resident #138's family member Witness S was observed exiting the Resident's room and walking toward the nurses' station. When greeted, Witness S stated, The call light has been on for 18 minutes and (Resident #138) needs to use the restroom. Witness S revealed they were about to take the Resident to the bathroom with the assistance of another family member but decided to look for staff assistance first. An observation of the call light monitoring screen at the nurses' station was completed at this time. The call light monitor revealed Resident #138's call light was put on at 11:34 AM. Unit Manager RN R was sitting at the nurses' station next to the call light station working on a laptop and no other staff were observed in the vicinity. At 12:00 PM, CNA W approached the nurses' station and began speaking to Unit Manager RN R. When queried who Resident #138's assigned CNA was, CNA W replied, (CNA X). When queried where CNA X was, RN R and CNA W both verbalized CNA X was on their lunch break. When queried who covers their assigned area/residents when they are at lunch, CNA W responded the other CNAs working on the unit cover for staff lunches and breaks. When asked who the other CNAs working on the unit were, CNA W replied, (CNA Y) and (CNA Z). At 12:03 PM, Resident #138's call light had still not been answered (total of 29 minutes). When queried why Resident #138's call light had not been on since 11:34 AM and was still not answered, a response was not provided. CNA W went to answer the call light. A review of the current call lights on at this time was completed with Unit Manager RN R. Per the call light monitoring screen, in addition to Resident #138's call light, room [ROOM NUMBER]'s call light had been on and unanswered since 11:35 AM. When asked if that was okay, Unit Manager RN R replied, No. room [ROOM NUMBER]'s call light had been on since 11:47 AM. When asked if that was acceptable, Unit Manager RN R responded, That is longer than we like. Record review revealed Resident #138 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (dysfunction of the brain caused by system illness, organ failure, or chemical imbalances), fall, dementia, and diabetes mellitus. Review of documentation in Resident #138's Electronic Medical Record (EMR) revealed the Resident was alert to self only and required assistance of a mechanical lift and two staff for transfers. An interview was completed with the Director of Nursing on 3/11/26 at 3:16 PM. The DON was informed of Resident #12's statements regarding staff answering their call light then leaving them to assist others, staff informing them they are short staffed, and the Resident's feelings related to incontinence due to lack of timely staff assistance as well as concerns verbalized by Witness U, and observations of call light response times. When asked if that was acceptable, the DON stated, That is not okay. On 3/10/2026, at 11:04 AM, during resident council multiple residents complained of call light responses by staff and care concerns. The following concerns were voiced: If I'm on her assignment for care it will take her an hour to get to me and she says she's got so many people why didn't you tell me that the first time sometimes they raise their voice they say they are always short they say they are short all the time for instance some say stand up so I can wipe you. Sit down. Get in your chair. often times many people come in and shut my door and use their phone they come in and shut the light off they will cancel my light and say it's not time to get up yet it takes them a long time to answer if my aide is in someone else's room, they will make we wait for my aide there can be several sitting at the nursing station and they won't answer the other girls' lights they don't answer the other girls lights and that goes on a lot I'm glad I have a phone. If I was having a heart attack and when they don't answer I'd have to call 911 They think I'm asleep and go in my bathroom to talk on their phone Confidential group of residents voiced concerns regarding CNA L: She's very loud and she tells you what you need not the other way around she is a bit brusk loud bossy she talks on her phone a lot she tells me what i need: she will do the opposite of what you ask she''ll say calm down calm down Confidential group of residents voiced concerns regarding CNA K: very voicetress she will be on her phone trying to take care of me I had to use a bed pan. She shut my life off and didn't come back I needed to be changed (I was having diarrhea) she told me I will come change you after my break On 3/12/2026, at 1:00 PM, a record review of the facility provided Resident Council Minutes revealed the following: Resident Council Minutes 9/9/2025 revealed resident agree call lights are slowly improving Resident Council Minutes 10/7/2025 revealed Residents agree that call light times continue to improve Resident Council Minutes 11/4/2025 revealed Residents state call light times are starting to be an issue again The corresponding RESIDENT ASSISTANCE FORM revealed . long call light times . is this an ongoing problem . Yes was check marked. FACILITY RESPONSE Continuing to monitor call light times and run reports. Resident Council Minutes 1/9/2026 revealed Res. State call lights have become an issue again Nursing – Residents state they have long waits for call lights at times concern form completed A review of the corresponding RESIDENT ASSISTANCE FORM revealed continue staff education on answering call lights more promptly . will continue to monitor call lights times. Monitor to ensure aids are wearing pagers . Resident Council Minutes 2/3/26 revealed Residents agree that the nourishment rooms/snacks have been stocked more frequently and that call lights are slowly improving On 3/12/2026, at 1:40 PM, The Director of Nursing was interviewed regarding concerns voiced during resident council meetings. The DON was asked if she follows up on resident council concerns and the DON offered, I don't go into council to discuss concerns. The DON was asked how the facility follows up on concerns voiced during resident council and the DON stated, concern forms are given to the unit managers and then they give back the Administrator. Resident #1 R1 is [AGE] years old and recently re-admitted to the facility on [DATE] with diagnoses that include periprosthetic fracture around internal prosthetic right knee joint, fall on same level, dementia and wedge compression fractures of the second and third lumbar vertebrae. On 03/11/2026 at 3:08PM, R1 was observed sitting in her wheelchair in the hallway. This surveyor approached R1 and asked about her day. R1 stated she is having a good day but that she would like to go to bed. This surveyor informed Registered Nurse (RN) G of the request made by R1. RN G asked if R1's call light was on and RN G was informed that the call light was not on and that R1 was sitting out in the hallway in her wheelchair. RN G was observed heading towards R1. At 3:20PM R1 was observed sitting in the door of her room in her wheelchair and still requesting to go to bed. The call light was observed to be turned on. RN C approached R1 and asked if she needed anything. R1 again stated that she would like to go to bed. RN C stated she would find another staff member to help her assist R1 back into bed. At 3:23pm, RN C and another staff member placed R1 in bed. Resident #13 R13 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include falls, surgical aftercare of the circulatory system, heart failure and hypertension. On 03/10/2026 at 9:15AM, R13 was asked about the call light response times of the facility. R13 stated the call light takes a long time to get answered. R13 stated he believes the average time to get a call light answered is 30 minutes and that he has had a few times go over an hour. R13 stated, If I were having a real emergency, I would be dead by the time they got here. Resident #46: Record review of Resident #46' Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental status (BIMs) of 15 out of 15, cognitively intact. Section GG functional abilities- noted resident #46 as dependent or substantial/maximal assistance for toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking of footwear, personal hygiene. In an interview on 03/10/2026 at 12:27 PM with Resident #46 revealed the staff/ aides do use their phones when they're in her room, and that it's very annoying, they just keep talking while they care for her. The staff do shut the lights off and don't come back also. The resident stated that it happens when they are short staffed and its income tax time and they get extra money and call-in. Resident #117: Record review of Resident #117's Minimum data Set (MDS) dated [DATE] revealed a Brief Interview of Mental status (BIMs) of 13 out of 15, cognitively intact. Section GG functional abilities- noted resident #46 as dependent or substantial/maximal assistance for toileting hygiene, shower/bathe, lower body dressing, putting on/taking of footwear, personal hygiene. In an interview on 03/10/2026 at 12:51 PM with Resident #117 stated that the aides do shut off the call light and don't come back, so the resident has to put the call light back on, also stated that the night shift is inconsistent some are good depending on the shift and who is working. The resident stated that the facility staff need more training and have attendance problems. The resident stated that staff use their cell phones while they are in the residents' room and make calls while the resident has to sit and wait. The resident stated that staff talk about residents and other staff while they are working with the resident. The resident stated that the staff are not to use their phones, but they do. They have their cell phones in their pockets and take calls in resident rooms so that the management doesn't see them. Record review of the 'Employee Handbook' dated 11/2018 revealed on page 26, section 4.10 Cell Phones: Personal electronic devices, including but not limited to cell phones, smart phones, camera-equipped phones, MP3 players, and IPad's are not allowed in resident care areas because of resident privacy issues (HIPPA) and quality of care issues. Employees must keep their personal electronic devices in their personal vehicle or a company-provided locker and use it only during break times or other non-working times. In an emergency, there are facility phones available, and family can contact the facility directly to have an employee paged. Record review of 'Health Care Association of Michigan: Rights of Residents in Michigan Nursing Facilities' copyright 2024, Respect and Dignity (C.) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents.

Based on interview and record review, the facility failed to ensure appropriate indication of a psychotropic/antidepressant drug dosage for 4 residents (#2, #9, #94, and #138), resulting in the facility's failure to fully inform the resident or responsible party by obtained signed consents with no medication dosage noted, doses per day or the route of the medication. Findings include: Resident #138: On 3/10/26 at 11:05 AM, Family Member Witness S was observed in Resident #138's room but the Resident was not present. When asked, Witness S revealed Resident #138 was out of their room with staff and they were waiting for them to return. Witness S was asked how long Resident #138 had been at the facility and replied, Since Thursday (3/5/26). When queried regarding the Resident's admission to the facility, Witness S revealed multiple family members including themselves and Resident #138's spouse (Witness T) were present when the Resident was admitted to the facility. Witness S was asked about the admission process and stated, They (facility staff) were just like sign this, sign this and continued, I feel like more guidance would have been better. With further discussion regarding the care Resident #138 was receiving at the facility, Witness S verbalized the family did not understand why the Resident was taking psychotropic medications and stated they did not want (Resident #138) to receive them. When asked if Resident #138 had a legal decision maker, Witness S they were as Witness T did not want to make medical decisions and stated, We are just getting the DNR (Do Not Resuscitate) and the DPOA (Durable Power of Attorney) figured out now. Witness S revealed the family had legal documentation of representative for healthcare decisions but the facility was unable to accept the documentation completed by Resident #138's attorney and were working to straighten it out. With further inquiry regarding the psychotropic medications, Witness S responded that Resident #138 did not have a diagnosis of depression and had never taken an antidepressant medication. Witness S verbalized the Resident was started on an antidepressant and another medication in the hospital but that the medications were only supposed to be short term due to confusion related to their infection. When asked, Witness S disclosed they found out Resident #138 had been receiving the medications at the facility and wanted the medications discontinued. On 3/11/26 at 11:00 AM, Resident #138 was observed in their room sitting in a wheelchair. Witness S and Witness T were present in the room. Resident #138's eyes were closed and they did not respond to verbal stimuli. An interview was conducted with Witness S and Witness T. When queried, Witness T revealed the were concerned about the psychotropic medications Resident #138 was taking and verbalized they did think the Resident needed them and did not want them to take them. With further inquiry, Witness S revealed Resident #138 was receiving Seroquel (atypical antipsychotic medication commonly used to treat schizophrenia, bipolar disorder, and major depressive disorder) and Zoloft (antidepressant medication). When asked, both Witness T and Witness S verbalized they had informed nursing staff of their concerns and desire to discontinue the medications. At 11:05 AM on 3/11/26, Registered Nurse (RN) E entered Resident #138's room to administer medication. Witness T and Witness S discussed their concerns regarding Resident #138 receiving Seroquel and Zoloft with RN E. At 11:10 AM, while RN E was still in the room, Unit Manager RN R entered Resident #138's room and stated they spoke to (Physician Q) and would discontinue the psychotropic medications. Record review revealed Resident #138 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (dysfunction of the brain caused by system illness, organ failure, or chemical imbalances), fall, dementia, and diabetes mellitus. Review of documentation in Resident #138's Electronic Medical Record (EMR) revealed the Resident was alert to self only and required assistance of a mechanical lift and two staff for transfers. Review of Resident #138's face sheet revealed diagnoses of Major Depressive Disorder, Recurrent, Unspecified and Mood disorder due to known psychological condition (mood disruptions resulting from brain dysfunction other than primary psychiatric diseases). A corresponding review of Resident #138's hospital referral documentation in the EMR was completed. The documentation in the hospital referral including History and Physical Reports dated 3/2/26 did not include any history of psychiatric disorders. Review of Resident #138's Health Care Provider (HCP) orders and Medication Administration Record (MAR) revealed the Resident was receiving the following psychotropic medications: - Zoloft 50 milligram (mg) once daily for major depressive disorder (Start Date: 3/6/26) - Seroquel 25 mg once daily for insomnia/restlessness (Start Date: 3/5/26) A review of signed and scanned documents as well as progress notes in Resident #138's EMR revealed no documentation of informed consent for Seroquel and/or Zoloft. An interview was completed with Social Worker (SW) I on 3/12/26 at 10:31 AM. When queried regarding consent for Resident #138's psychotropic medications, SW I stated, they were unsure if got consent and that they would check. On 3/12/26 at 11:25 AM, SW I returned and revealed nursing staff utilize an evaluation form when obtaining psychotropic medication consents. Review revealed the following: - 3/5/26 at 8:11 PM: Psychotherapeutic Medication Information Sheet. Seroquel 25 mg- Insomnia and restlessness. C. Potential benefits of psychotherapeutic medications: Reduced symptoms of depression. Reduced symptoms of psychosis. Reduced symptoms of anxiety. Information Provided to: (Resident #138) and (Witness T) . - 3/5/26 at 8:09 PM: Psychotherapeutic Medication Information Sheet. Sertraline (Zoloft) 50mg-Major depressive disorder C. Potential benefits of psychotherapeutic medications: Reduced symptoms of depression. Reduced symptoms of psychosis. Reduced symptoms of anxiety. Information Provided to: (Resident #138) and (Witness T) . Both forms were completed by RN P and neither form was physically signed by Resident #138 and/or their Resident Representative. On 3/12/26 at 11:40 AM, an interview was completed with Resident #138's family members Witness T. When queried if facility staff discussed Resident #138 taking Seroquel and Zoloft with them upon admission to the facility on 3/5/26, Witness T stated, They just told me that (Resident #138) was on that in the hospital and indicated they were continuing all their same medications. An interview was completed with the Director of Nursing (DON) on 3/12/26 at 12:22 PM. When queried regarding facility procedure and what staff are supposed to discuss and address with residents/resident representatives when obtaining informed consent for psychotropic medications, the DON responded that staff should review the medication including its use and potential side effects. The DON was informed of interview completed with Witness T where they verbalized, they were only informed that the facility was continuing medications Resident #138 was taking at the hospital and that they did not want the Resident receiving psychotropic medications. The DON responded they were unable to speak for the RN who completed the Psychotherapeutic Medication Information Sheet. When asked, the DON revealed RN P was out of the building and verbalized they would attempt to contact them. An interview was completed with the DON and RN P (via phone) on 3/12/26 at 12:38 PM. When queried who was present when they completed the Psychotherapeutic Medication Information Sheets for Resident #138, RN P stated, Definitely (Resident #138) and (Witness T). When queried what they discussed with Resident #138 and Witness T when consent was obtained for Seroquel and Zoloft, RN P responded by saying what they normally review. RN P was asked what they reviewed with Resident #138 and stated, Did not go over the side effects (of the medications). When asked why they did not review the medication side effects, RN P revealed it was late and Witness T was ready to go home. RN P revealed they planned to follow up with Witness T but did not get back to it. After disconnecting the phone call, the DON verbalized understanding of the concern. Resident #2: Record review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed medical diagnosis of anemia, coronary artery disease, hypertension, diabetes, cerebrovascular accident, non-Alzheimer's dementia, malnutrition, anxiety, depression, bipolar disease, and chronic obstructive pulmonary disease. Record review of Resident #2's medical records forms revealed a 'mental Illness/Intellectual Disability/related condition exemption criteria certification Level II Screening was dated 1/14/2025. Record review of Resident #2's March 2026 Medication Administration Record (MAR) revealed antidepressant Lexapro 10 mg by mouth in the morning related to major depressive disorder. Medication order started on 7/18/2025. Record review of Resident #2's 'Psychotherapeutic Medication Information Sheet' dated 1/8/2026 revealed 'Lexapro major depressive disorder' information provided to the POA (Power of Attorney) on 1/8/2026. An interview was conducted on 03/12/2026 at 8:19 AM with the Social Service staff I about Resident #2's antipsychotic consents. Social Services staff I agreed with the surveyor that there should have been a dose, frequency of administration, side effects, and black box warnings noted on the consent. Social services staff I stated that the facility has two forms, a PSYCHOTHERAPEUTIC MEDICATION INFORMATION SHEET is used as the consent, where the PSYCHOACTIVE MEDICATION MONITORING triggers the care plan and for staff to monitor for changes. The contracted behavioral services personnel do follow the residents for behaviors/mood. There is a Nurse Practitioner that comes every 2 weeks to see the residents for psych follow-up. Resident #9: Record review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed medical diagnoses of anemia, coronary artery disease, hypertension, Multidrug-resistant organism diabetes, Parkinson's disease, anxiety, depression, bipolar disease, and schizophrenia. Record review of Resident #9's closed medical record for unnecessary medications revealed the resident was admitted [DATE] and discharged on 2/27/2026. Record review of Resident #9's February 2026 Medication Administration Record (MAR) revealed psychotherapeutic medications of: Buspirone 30mg one tablet by mouth two times a day related to unspecified mood disorder. Clonazepam 1 mg by mouth two times a day related to schizoaffective disorder. Oxcarbazepine/Trileptal 600mg by mouth two times a day related to schizoaffective disorder Bipolar type disorder and Effexor 150mg by mouth two times a day related to depression In an interview on 03/11/2026 at 10:45 AM Social services staff I revealed that Resident #9 had a Brief Interview of Mental status (BIMs) score of 14, was his own responsible party, signed all forms. Record review of Resident #9's Psychotherapeutic Medication Information Sheet' s for Buspirone, Clonazepam, Oxcarbazepine/Trileptal and Effexor all listed the medication, but there were no dosage, frequency or black box warnings noted. Resident #94: Record review of Resident #94's Minimum Data Set (MDS), dated 12/192025, revealed medical diagnoses of anemia, coronary artery disease, hypertension, peripheral vascular disease, renal insufficiency, obstructive uropathy, hyponatremia, non-Alzheimer's dementia, and anxiety. Record review of Resident #94's March 2026 Medication Administration Record revealed antipsychotic Rexulti/brexpiprazole 2 mg by mouth one time a day for hallucinations related to dementia with agitation. Medication order started on 2/4/2026. Record review of Resident #94's 'Psychotherapeutic Medication Information Sheet', dated 12/9/2025, Medication change revealed 'Rexulti dementia unspecified severity with agitation' information provided to the POA (Power of Attorney) on 1/8/2026. There were no dosage, frequency, route or black box warnings noted. Record review of the facility 'Use of Psychotherapeutic Medications' policy, dated 2/1/2025, revealed that facilities must ensure that residents are fully informed and have the right to accept or decline psychotropic medications. Full resident participation: Implement protocols to ensure residents (or their legal representatives) are fully informed of the risk, benefits, and alternatives . Psychotherapeutic medications include antianxiety, antidepressant, antipsychotic and hypnotics. The following information in all physician orders psychotherapeutic medications include Name of Medication and strength, route of administration, frequency of administration, supporting diagnosis, and targeting behaviors/symptoms. Record review of the 'Health Care Association of Michigan, Rights of Residents in Michigan Nursing Facilities; copyright 2024, Respect and Dignity the resident has the right to be fully informed in a language that they can understand or your total health status, including but not limited to the residents' medical condition.

Based on interview and record review, the facility failed to ensure that annual Preadmission Screening and Resident Review (PASARR) assessments were completed for 4 residents (#2, #46, #113, #116) of 8 residents reviewed. Findings include: Medicaid.gov. 'Preadmission Screening and Resident Review'Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires Medicaid-certified nursing facilities:Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID)Offered all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings)Provide all applicants with the services they need in those settingsPASRR is an important tool for states to use in rebalancing services away from institutions and towards supporting people in their homes, and to comply with the Supreme Court decision, [NAME] vs L.C. (1999), under the Americans with Disabilities Act, individuals with disabilities cannot be required to be institutionalized to receive public benefits that could be furnished in community-based settings. PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long-term care.In brief, the PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have SMI or ID. This is called a Level I screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care. Resident #2:Record review of Resident #2's Minimum Data Set (MDS) indicated the resident was initially admitted to the facility on [DATE] with diagnoses: non-Alzheimer's dementia, malnutrition, anxiety, depression, bipolar disease, and chronic obstructive pulmonary disease, anemia, coronary artery disease, hypertension, diabetes, and cerebrovascular accident. Record review of Resident #2's medical records forms revealed a 'mental Illness/Intellectual Disability/related condition exemption criteria certification Level II Screening was dated 1/14/2025. In an interview and records review on 03/11/2026 at 1:16 PM with social service staff I did a record review of Resident #2's PASARR and acknowledged that the annual PASARR was due back in January 2026. Resident #46:Record review of Resident #46 Minimum Data Set (MDS) indicated the resident was initially admitted to the facility on [DATE] with diagnoses: depression, coronary artery disease, heart failure, hypertension, peripheral vascular disease, renal insufficiency, diabetes, cerebrovascular accident, and chronic obstructive pulmonary disease. Record review of Resident #46's medical records forms revealed a 'mental Illness/Intellectual Disability/related condition exemption criteria certification Level II Screening was dated 1/14/2025. In an interview and record review on 3/11/2026 at 1:16 PM with the social service staff I acknowledged that Resident #46 needed a PASSAR, that was due in January 2026. Social service Staff I stated that she was auditing charts to get caught back up the previous Social Worker did not get it done. Resident #113: Record review of Resident #113 Minimum Data Set (MDS) indicated the resident was initially admitted to the facility on [DATE] with diagnoses: non-traumatic brain dysfunction, coronary artery disease, heart failure, hypertension, peripheral vascular disease, Alzheimer's disease, and aphasia. Record review of Resident #113's medical records forms revealed a 'mental Illness/Intellectual Disability/related condition exemption criteria certification Level II Screening was dated 1/3/2025. Resident #116: Record review of Resident #116's care plans indicated the resident was initially admitted to the facility on [DATE] with diagnoses: Alzheimer's disease, hypertension, anxiety disorder, major depressive disorder. Record review of Resident #116's medical records forms revealed a 'mental Illness/Intellectual Disability/related condition exemption criteria certification Level II Screening was dated 1/14/2025. In an interview on 03/11/2026 at 1:04 PM with the social services staff I revealed that the facility did not have a PASARR policy, but that there was a PowerPoint presentation that they used from the Michigan Department of Health and Human Services from last year 2025. Record review of the facility provided PowerPoint 'PASARR for Nursing Homes' 3/13/2025 revealed Preadmission Screen/Annual Resident Reviews Slide 21- Annually, when an individual resides in a nursing home, per the Medicaid Provider Manual, Annually means within every fourth quarter after the previous Level I screening or Level II evaluation, whether it was completed for admission, condition change, or annual review.

Based on observation, interview and record review, the facility failed to operationalize policies and procedures for safe medication storage for two residents (# 29 and #90) of two residents and one ([NAME] One) of four medication carts reviewed. Findings include:Resident #29: On 3/11/26 at 9:45 AM, an observation of Resident #29's room and interview were completed with the Resident and Family Member B on 3/11/26 at 9:45 AM. A bottle of iVIZIA eye drops (long lasting solution for dry eyes) was observed sitting on the dresser next to the Resident's bed. When asked about the eye drops, Family Member B responded they administered them to the Resident four times a day. When asked why the facility nursing staff did not administer the medication, Family Member B revealed they brought the eye drops to the facility because the Resident needs them, so they do it. When asked if the drops were always sitting on the bedside dresser, Family Member B verbalized they were. Record review revealed Resident #29 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included metabolic encephalopathy (brain dysfunction caused by toxins, organ failure, and/or systemic illness), kidney cancer, stage 4 (severe) chronic kidney disease with surgical kidney removal, heart disease, and osteomyelitis (infection in the bone). Review of the Minimum Data Set (MDS) assessment, dated 2/1/26, revealed the Resident was cognitively intact and required moderate-to-total assistance with the exception of oral hygiene. A review of Resident #29's Electronic Medical Record (EMR) revealed the Resident did not have a Self-Medication Administration Assessment and/or assessment for bedside medication storage. Further review revealed the Resident did not have a Health Care Provider (HCP) order for iVIZIA eye drops. Resident #90: On 3/11/26 at 10:20 AM, Resident #90 was observed sitting in a recliner in their room. A clear plastic cup with a spoon and visible sediment like a dissolvable medication was observed sitting on the overbed table in front of the Resident. When asked what was in the cup, Resident #90 stated, I don't know. Resident #90 was asked if there was a medication in the cup and stated, I already got my meds. On 3/11/26 at 10:30 AM, Registered Nurse (RN) E was asked if they administered Resident #90's morning medications and responded that they did. When queried what was in the clear plastic cup with the spoon in it on the Resident's overbed table, RN E stated, Those are (Resident #90's) cancer pills. With further inquiry, RN E verbalized they medication is dissolved in water, and they left it at the Resident's bedside for them to take. RN E was informed Resident #90 did not know what was in the cup. RN E was then asked to come to Resident #90's room to confirm the cup on the bedside table contained the Resident's cancer medications. RN E went to Resident #90's room and confirmed the clear plastic cup on the overbed table were the Resident's dissolved medications. RN E told Resident #90 the cup contained their medications and then exited the room. Record review revealed Resident #90 was originally admitted to the facility on [DATE] with diagnoses which included liver cancer, pancreas cancer, Parkinson's disease, and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required maximum to total assistance to complete ADLs with the exception of moderate assistance with eating. Review of Resident #90's electronic Medication Administration Record (MAR) revealed the Resident received, Everolimus (targeted therapy medication used to treat certain cancers and tumors) Oral Tablet 10 mg (milligram). 1 tablet by mouth in the morning. Dissolve tab in 25ml of water. upon rising daily. A review of Resident #90's EMR revealed the Resident did not have a Medication Self-Administration Assessment. An interview was completed with the Director of Nursing (DON) on 3/11/26 at 3:16 PM. The DON was informed of observations of both Resident #29 and Resident #90's medications at bedside as well as interview with RN E. When asked, the DON verbalized a self-medication assessment should be completed prior to Resident's and/or their families administering medications. When queried regarding RN E leaving Resident #90's medication on their bedside table, the DON stated, Not okay. Should not have been left. The DON indicated they would address both medications. Review of facility policy/procedure entitled, Medication Storage in the Facility (Dated June 2019) revealed, Bedside Medication Storage . Bedside medication storage is permitted for residents . upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate . Medication Cart: On 03/12/2026 at 9:11AM, observation revealed the [NAME] 1 Med Cart unlocked and the screen to the computer is open and displaying resident information. The nurse is observed talking to another staff member at the desk, with her back turned and not watching the medication cart. There are medications on top of the medication cart and accessible to residents. The nurse on duty reapproached the medication cart and began to administer medication again. An interview was conducted with Registered Nurse (RN) D. RN D was asked if they should leave the medication cart unlocked and computer screen open with resident information on it if you are not present at the med cart. RN D stated, no, I should not, the cart should be locked and screen closed. RN D stated, I got distracted with a resident need and I went to help him and when I left the room and went back to my cart, I noticed the Nurse Practitioner (NP) was present I went and talked to her. Review of the policy titled, Medication Storage in the Facility, revealed, B. Administration 16. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. In addition, privacy is maintained always for all resident information (e.g., MAR) by closing the MAR book/covering the MAR sheet or computer screen, when not in use.

Based on observation, interview and record review, the facility failed to ensure a pummel cushion (wheelchair cushion with a raised wedge in the center) was used for the treatment of documented medical symptoms for one resident (Resident #88) of one resident reviewed for restraints, resulting in a lack of a clear indication for use and ongoing assessment/reassessment for use. Findings include:Resident #88: On 3/10/26 at 1:50 PM, Resident #88 was observed sitting in a high back wheelchair in their room with Family Member J. Both footrests were in place on Resident #88's wheelchair with their feet positioned on the footrests. A pummel cushion was in place on the wheelchair. The front of the pummel cushion was slid down with the wedge of the pummel cushion partially off the edge of the wheelchair seat. Upon observation of the back of the wheelchair seat, the pummel cushion was noted to be positioned all the way to the back of the seat. An interview was completed at this time. When queried regarding the reason for the pummel cushion, Family Member J replied, I think it is because (Resident #88) slid down and fell. When queried if Resident #88 had other falls at the facility, Family Member J responded they had but indicated it had been a while. When asked about staff assistance needed for transferring, Family Member J stated, Supposed to be two (staff) but don't always have two. With further inquiry, Family Member J stated, They don't have enough staff. Family Member J revealed they are at the facility from approximately 10:00 AM until 7:00 PM daily and stated, They (staff) do not check on (Resident #88). Family Member J stated hey Have to go get them (staff) when the Resident needs something. Family Member J was asked if they use the call light in the Resident's room when the Resident needs something and responded that they have tried to use the call light, but it takes the staff up to 25 minutes to come and is quicker to just go get them. Throughout the interview, Resident #88 appeared uncomfortable and kept trying to move and reposition themselves in their wheelchair unsuccessfully with the pummel cushion in place. When asked if they were uncomfortable or if they needed something, Resident #88 responded verbally but about an unrelated topic to the question asked. Record review revealed Resident #88 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease, dementia, heart failure, cervical disc disorder with myelopathy (spinal cord compression in the neck), difficulty walking and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required moderate to maximum assistance to complete all Activities of Daily Living (ADLs) with the exception of eating. The MDS further specified the Resident did not have any restraints in place. Review of Resident #88's Health Care Provider (HCP) orders in the Electronic Medical Record (EMR) revealed the Resident did not have a current and/or discontinued order for a pummel cushion. Further review of the Resident's EMR no assessment/reassessment for the pummel cushion and no documentation for indication of use. A review of Resident #88's care plans revealed a fall care plan with an intervention for the pummel cushion initiated 8/21/25 but did not include a reason/indication for implementation. A review of Resident #88's EMR Progress Note documentation from 3/12/25 to present revealed no documentation related to pummel cushion implementation/use. Additionally, no documentation of wheelchair positioning concerns, such as medical necessity for hip abduction (away from midline/prevent crossing) and/or sliding forward due to physical conditions affecting wheelchair positioning were present to insinuate the necessity of pummel cushion use as a positioning device. The EMR did include documentation that Resident #88 displayed impulsive behaviors and would ambulate without assistance and/or assistive devices. Further review of Resident #88's EMR revealed the Resident had several falls from March 2025 until July 2025 but none of the falls occurred due to the Resident's wheelchair positioning and no falls occurred in August 2025. The most recent Fall Assessment in Resident #88's EMR was dated 7/30/25. The assessment specified the Resident reached down to pick up a Kleenex off the floor and fell over. The facility implemented a Dycem (non-slip pad) to wheelchair cushion at this time. Corresponding incident note documentation was dated 7/31/25 at 2:37 AM and specified Resident #88 was observed at the end of the hall on the floor, leaning against the wall with the handrail broken behind them. A consent for use of the pommel cushion was not present in Resident #88's EMR. On 3/11/26 at 2:00 PM, an interview was completed with the Director of Nursing (DON) and the Infection Control (IC) Registered Nurse (RN) A. When queried regarding the reason Resident #88 had a pommel cushion on their wheelchair, the DON replied, Think for falls because they were sliding down. When asked if there was a consent for use of the Pummel cushion, the DON stated, No. When queried why there was not a HCP order for the pummel cushion, the DON replied, No order, just in care plan. The DON was then asked if an assessment for the pummel cushion had been completed and responded that pummel cushions come from therapy. When asked if a pommel cushion could be considered a restraint, the DON confirmed it could. When queried why a consent and/or assessment for the pummel cushion was not present in Resident #88's EMR, the DON indicated they would need to review the Resident's medical record further. An interview was conducted with Occupational Therapist (OT) Therapy Director N on 3/11/26 at 2:10 PM. When queried regarding the pummel cushion on Resident #88's wheelchair and the reason for the pummel cushion, Director N revealed they were aware of the pummel cushion on the Resident's wheelchair. When queried regarding observation of the Resident appearing uncomfortable and attempting to reposition themselves in their wheelchair unsuccessfully, Director N responded that they were unaware of the Resident having difficulty. Director N revealed Resident #88 has good and bad days due to their Parkinson's disease. When asked if the pummel cushion was recommended by therapy services, Director N revealed they would need to review the Resident's medical record. After reviewing Resident #88's therapy documentation, Director N verbalized they located the following documentation: - 8/21/25: Physical Therapy Treatment Encounter Note. Summary of Daily Skilled Services. Fall Risk. resident is able to stand with pummel cushion in wc safely. Transfers: Sit to stand = Partial/moderate (staff) assistance.- 8/21/25: Occupational Therapy Treatment Encounter Note. Precautions. transfer 2 PA (Person Assist) with FWW (Front Wheeled Walker) . Sit to stand to FWW mod assist (moderate staff assistance) with extra time to complete task. Mod A (Moderate Assist from staff) to sit to stand with and without pummel to FWW.The documentation provided by Director N did not address the ability of the Resident to transfer independently with and without the pummel cushion in place nor did it specify the reason the pummel cushion was implemented.When queried regarding the reason the pummel cushion was applied to the wheelchair, Director N replied, I think the purpose is to stop them from sliding. When asked why the pummel cushion would be placed on the wheelchair to prevent the Resident from sliding when there was no documentation of the Resident sliding and when they did not have a recent fall, Director N was unable to provide an explanation. When asked who monitors the pummel cushion to ensure ongoing appropriateness and placement, Director N revealed the Resident was not currently receiving therapy services and nursing staff would need to notify Therapy if there was a concern. Observations of the position of Resident #88's pummel cushion was explained to Director N at this time. Director N responded, Yeah, that isn't where it is supposed to be. Director N then stated, I need to look and see if there is supposed to be a dysem under it. An observation of Resident #88 in their wheelchair was completed with Director N at this time in the main Activity room. Director N confirmed the pummel cushion was not positioned correctly in the wheelchair. Director N further verified the cushion was positioned all the way to the back of the seat but was hanging off the front of the wheelchair. As Resident #88 was participating in an activity, Director N verbalized they would eval when the Resident returned to their room. On 3/12/26 at 8:42 AM, an interview was completed with the DON. When queried regarding Resident #88 and the interview completed with Director N including lack of documentation of reason for the pummel cushion use, the DON confirmed lack of clear documentation for the reason the pummel cushion was implemented. When queried regarding ongoing evaluation to ensure appropriateness and functionality of the pummel cushion, including observation of the Resident's unsuccessful self-repositioning attempts and interview with Director N, the DON indicated the Resident was able to reposition themselves in the wheelchair even when they were having a bad day related to their Parkinsons. The DON provided additional documentation for Resident #88 at this time. Review of the provided documentation included the following:- Physical Therapy Treatment Encounter Notes dated 9/21/25 and 1/11/26. Neither note addressed and/or evaluated use of the pummel cushion.- Nurses Note dated 9/25/25 which contained, Resident will frequently attempt to self-transfer or stand by self.- BH - Psychiatry Follow up note dated 3/6/26 which included, Patient's wife reported that patient had appeared more impulsive and frequently getting up and walking without using wheelchair, with staff implementing safety measures. An interview was completed with Licensed Practical Nurse (LPN) O on 3/12/26 at 9:40 AM. When queried, LPN O stated, (Resident #88) does try to self-transfer when they need to use bathroom, but it takes them awhile. LPN O elaborated, (Resident #88) can't quite push themselves up real well. LPN O was then asked the reason for the pummel cushion on Resident #88's wheelchair and indicated it was to prevent falls. LPN O stated, I don't think it helps because (Resident #88) hasn't slid down or fell out the wheelchair. When asked why the pummel cushion was implemented and in place if Resident #88 did not have wheelchair positioning concerns and/or as an intervention related to a fall, LPN O did not provide a response. When queried if the pummel cushion prevented Resident #88 from getting out of their wheelchair by themselves quickly and without staff assistance, LPN O stated, I think so. LPN O was then asked how the pummel cushion was not a restraint if it was being used to subdue the Resident's ability to move independently but did not provide further explanation. Review of facility provided policy/procedure entitled, Restraints (Dated: 7/1/2008) revealed, Restraints to be used for the safety and well-being of residents and only after other alternatives have been unsuccessful. Procedure: 1. Restraints must be used only as a last resort and the medical record must indicate the events which led up to the necessity for restraint usage. 2. Restraints only to be used with a Physician order. 3. Restraints not to be used as a punishment, convenience of staff or as a substitute for supervision. 12. Restraints will be identified on care plan and resident care guide. 13. Resident/ RP to be notified of the necessity for use and notification documented in medical record.

Based on interview and record review, the facility failed to transmit a Minimum Data Set assessment (MDS) for one resident (Resident #108) of one resident reviewed for resident assessments. Findings include. Resident #108: On 3/11/2026, at 10:00 AM, a record review of Resident #108's electronic medical record revealed a 10/20/2025 Discharge Return Anticipated MDS assessment that was completed and not submitted to CMS. A review of the progress notes revealed Resident #108 did not return to the facility. On 3/11/2026, at 11:03 AM, a record review along with MDS Nurse M of Resident #108's MDS assessments revealed the 5-day was submitted, but the discharge assessment was not. MDS Nurse M offered they must have submitted the 5-day assessment instead of submitting the discharge assessment. MDS Nurse M denied having an error report or any way of reconciling assessments that were export ready but not transmitted timely. MDS Nurse M during the interview completed and submitted the discharge assessment for Resident #108.

Based on observation, interview and record review, the facility failed to store nebulizer equipment in a sanitary manner for one resident (R11) of one resident reviewed for respiratory care. Findings include:Resident #11 (R11): R11 is [AGE] years old and admitted to the facility most recently on 02/25/2026 with diagnoses that include acute and chronic respiratory failure, congestive heart failure and chronic obstructive pulmonary disease.On 03/10/2026 at 9:35AM, during an interview with R11, an observation was made of a nebulizer mask fully assembled in a basket on the nightstand, liquid was still present in the medication cup. R11 was asked when the last breathing treatment was administered. R11 stated that she believed it was 2:00am on 03/10/2026, just prior to putting her Continuous Positive Airway Pressure (CPAP) mask on. On 03/10/2026 at 9:51AM, an interview was conducted with Registered Nurse (RN) C. RN C was asked what the process for cleaning nebulizer equipment after the treatment is. RN C stated when the treatments are done, we rinse the medication cup out, wipe them down and then set it on a paper towel to dry in a basin on the nightstand. RN C was asked when R11 last received a breathing treatment. RN C stated that the last administered nebulizer was documented on 3/6/26 at 19:54PM. RN C was made aware of the nebulizer still being in one piece in the room and RN C stated it would be corrected. On 03/10/2026 at 10:00AM, record review revealed a physician's order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 1 vial inhale orally every two hours as needed for shortness of breath (SOB). Review of the policy titled, Nebulizer, revealed: Equipment Cleaning: 10. Following medication administration, disconnect nebulizer cup/mask/mouthpiece from tubing, rinse equipment with hot water and place on paper towel to completely air dry.

Based on observation, interview and record review, the facility failed to 1) Provide antiviral medication timely for one resident (Resident #61), 2) Ensure barrier use, and 3) Ensure reusable medical equipment was sanitized prior to clean storage, resulting in influenza symptoms going untreated, contamination of medication cart with the likelihood of continued contamination. Findings include: Resident #7: 02/06/25 8:10 AM, observation of Nurse I prepare AM medications for Resident #7. Nurse I prepared blood glucose machine which was housed inside the alcohol swab cardboard box along with the following supplies: glucose strips, alcohol swabs and lancets. Nurse I entered Resident #7's room placed the cardboard box on the over bed table with no barrier. Once Nurse I competed the task, she placed the items inside the cardboard box and left out to the medication cart. Nurse I took the blood glucose machine and wiped down the front and the back with an alcohol swab, placed the machine back inside the alcohol swab box and placed inside the medication cart. On 2/06/25, at 9:55 AM, a record review of the facility policy provided pertaining to blood glucose meter instructions along with the DON was conducted. The policy did not mention as to what the expectations are of the facility staff on cleaning/disinfection between residents. The DON was asked what the facility used to disinfect the meters between residents and the DON stated, bleach wipes. The DON offered that Nurse I did use a bleach wipe once the surveyor walked away. The DON was alerted that Nurse I did not use the bleach wipe prior to placing the meter inside the box with the other supplies and then inside the top drawer of the medication cart. The DON was also alerted that Nurse I carried the entire box of supplies inside the residents room and placed it directly on their over bed table and the DON offered, ok without a barrier. 38471 Resident #61: During initial tour on 2/5/2025, it was found Resident #61 was positive for Influenza A, with the appropriate transmission-based precautions adorned on his door and PPE (personal protective equipment) caddy. Upon entering his room, he appeared to be comfortable, but a conversation did not ensue. On 2/6/2025 at 9:30 AM, Nurse O reported there is one resident positive for influenza A and the unit has been offered Tamiflu (antiviral medicine that treats or prevents flu symptoms causes by influenza virus). On 2/6/2025 at approximately, 11: 55 AM, a review was completed of Resident #61's medical records and it revealed the resident admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease, Vascular Dementia, Diabetes, Hypertension and Atrial Fibrillation. Further review yielded the following: Physician Orders: Resident #61 was not being administered Tamiflu nor was there a declination located. Molecular Diagnostic Report: Collected 2/2/2025 at 16:50 and reported 2/3/2025 at 15:46. Influenza A Virus- Detected Care Plan: .Actual Infection r/t (related to) Influenza A .date initiated 2/2/2025. Progress Notes: 2/2/2025 at 17:20: Resident has fever of 103.4, cough and stated he feels terrible. Rapid was collected and was negative, PCR sent out resident placed on precautions Tylenol administered. On call PCP notified will continue to monitor. 2/3/2025 at 18:26: Resident was positive for Influenza A. is on transmission-based precautions. Still is having fevers was 101.9 administered Tylenol is now 101.1. Resident has to be fever free for 24 hours before he can be off of contact precautions resident was notified along with PCP. 2/4/2025 at 14:27: Attempted to call son . to get consent or declination for Tamiflu. Left VM, awaiting return call. 2/4/2025 at 17:42: Resident continues on droplet precautions r/t influenza A, current temp 100.0. Occasional non-productive cough noted, denies SOB or CP. Fluids encouraged. Currently resting in bed with call light in reach. 2/4/2025 at 20:30: Continues with transmission based precautions related to positive for influenza A. Oxygen at 2L per nasal cannula. Occasional non productive cough. No complaints of pain. 2/5/2025 at 10:3: Resident continues on TBP precautions r/t influenza A, current temp 99.0. Occasional non-productive cough noted, denies SOB or CP. Fluids encouraged. Currently resting in bed with call light in reach. It can be noted there was only one attempt documented to contact the Resident's responsible party. On 2/6/2025 at 1:05 PM, an interview was conducted with Infection Preventionist U regarding Resident #61. Preventionist U explained upon him testing positive they contacted his son/DPOA (durable power of attorney) about prescribing Tamiflu on 2/3/2024. His son said he would like to discuss it with family and contact the facility back. They attempted to contact him again on 2/4/2025 but received no response. There was no contact attempted with him on 2/5/2025 and given that Tamiflu is most effective within 48 hours, the resident would be outside of the efficacy parameters. Review was completed of Resident #61's notes and there was only one progress not related to communication with the resident's son. Preventionist U stated she sat next to the nurse as she contacted his son on 2/3/2025 and requested a progress note was put in to detail the conversation but that was not completed. 39059

Based on observation, interview and record review, the facility failed to update care plan interventions for 3 residents (R23, R24, R164) of 4 residents reviewed, resulting in the likelihood for missed interventions in treatment and unmet needs. Findings include: Record review of 'Facility Assessment Tool', dated ,d+[DATE], page 8 under staff education: Person-Centered Care- This should include but not be limited to person-centered care planning, education of resident and family/resident representative about treatments and medications, documentation of resident treatment preferences, end-of-life care, and advanced care planning. Record review of the facility 'Call Light' policy, dated [DATE], revealed call lights will receive consistent and adequate response in order to best meet the individuals' needs of each resident. Procedure: Call lights will be placed within reach of the resident. Resident #23 Hydration: Observation was made on [DATE] at 09:56 AM of Resident #23 laying in his bed, thin in appearance with no fluids/water within reach. Observed on table across room next to the entrance room wall away from the bed was a clear plastic mug with handle with a black lid with a straw. A clear thin liquid noted in the cup. Observation on [DATE] at 09:06 AM of Resident #23 lying in bed with fluid/water on bedside table across the room again next to the wall out of reach of the resident. Observation and interview conducted on [DATE] at 08:09 AM of Resident #23. Resident #23 was Observed with water in clear mug with handle with black top with a straw, across the room from resident's bed, out of reach. In an interview and observation, Certified Nurse Assistant (CNA) B stated that Resident #23 drinks too fast and she did not want him to choke. CNA B observed the call light on the floor under the bed. CNA B stated that Resident #23 had a pad style/soft touch call light, and they took it away last week before the state came. I don't know why they changed his call light. Record review of Resident #23's Care plan at risk for falls related to frequent falls at home,-knees buckle, cardiac diagnosis, dementia, difficulty walking, osteoarthritis with revision date of [DATE] intervention: Call light accessible dated [DATE] and soft touch call light in place dated [DATE]. Record review of Resident #23's Care plans pages ,d+[DATE] revealed: Alteration in bowel elimination/constipation related to weakness and debility created [DATE] with interventions: Encourage fluids dated [DATE]. Alteration in my Mood state related to Major Depressive Disorder revision date [DATE] interventions: Offer me a snack/drink dated [DATE]. Record review of Resident #23's Nutritional preferences/hydration care plan related to COVID-19: depression, acute kidney failure, hypothyroidism, chronic heart failure (CHF), dysphagia, dementia, hypertension, high cholesterol, Coronary Artery Bypass Graft (GABG) revision date [DATE] interventions: Regular diet, puree texture, thin liquids, supplements as ordered, total assist revision dated [DATE]. There were no interventions found in the care plans as to why the liquids were kept out of reach of the resident. Resident #164: Record review of Resident #164's electronic medical record revealed an admission to the facility date of [DATE] from the acute care setting. An interview on [DATE] at 10:12 AM with Resident #164's family member G revealed that the resident had been at the facility since the afternoon of [DATE]st, 2024, and had not had a shower yet. Family member G stated that they have asked every day for a shower, and they said today's the day. Family member G stated that they went to the social worker designee to inquire about showers and were told that Resident #164 would get a shower that day. Family member G stated why did she have to beg for a shower for the resident? We don't know what days his shower days are, he also goes to hemodialysis 3 days a week, so we need to know. It's been 6 days, and he's starting to smell. Record review on [DATE] at 11:29 AM of Resident #164's shower/bath task in the electronic medical record revealed an admission on [DATE] and no bath till [DATE] when family members complained. It was 6 days as documented with no shower. Record review of Resident #164's care plans, pages 1- 26, revealed an Activity of Daily Living deficit related to ESRD (End Stage Renal Disease), dependence on dialysis, hypertension, history of cardiovascular accident (CVA), Urinary Tract Infection (UTI), and aspiration pneumonia. created on [DATE]. Interventions included: Bed bathe/shower 2 x per week, no preference to days/times. In an interview on [DATE] at 12:11 PM with Social Work designee F about Resident #164's Showers, Social work designee F stated 'so that was brought to my attention by the (Family member) yesterday, I notified unit manager Register Nurse A, and she said that he would be getting a shower. It was discussed again during the care conference later that day. There should be showers 2 times a week, or more if requested. An interview and record review was conducted on [DATE] at 12:16 PM with Registered Nurse (RN) A CCC (Clinical Care Coordinator) regarding Resident #164 not having showers. Resident #164 had no shower until [DATE]. He was offered one on [DATE] and refused. The (Family member) brought it to our attention and I assigned it to second shift to give a shower on [DATE] and he refused. The CNA is to try 3 times and then notify the nurse of refusals so the nurse can go in and offer. A refusal should be charted by the nurse in progress notes. Record review of Resident #164's progress notes revealed there were no refusals documented in the progress notes by the nurse. Record review of the facility shower schedule noted the Resident according to the resident room number would receive showers on Wednesday and Saturday. Resident #164 missed receiving a shower on Wednesday [DATE], causing the family to complain to the state surveyor. 38471 Resident #24: On [DATE] at 11:30 AM, Resident #24 was observed resting in bed as we conversed about her time at the facility and past traumas related to her marriage and upbringing. On [DATE] at approximately 1:00 PM, a review was conducted of the Level II OBRA (Omnibus Budget Reconciliation Act) evaluation completed by the local CMH ( Community Mental Health) on [DATE] and it stated the following, .(Resident #24's parents had issues with substance abuse and both parents died at the age of 58 .She reported she was kicked out of her parents home .her husband was abusive and controlling but she stayed with him for nine years .Resident #24 married her second husband in 2002 but he died of a heart attack after one to two months of marriage . On [DATE] at approximately 1:30 PM, a review was completed of Resident #24's clinical record and it revealed the resident was readmitted to the facility on [DATE] with diagnoses that included, Chronic Obstructive Pulmonary Disease, Hypertension, Agoraphobia, Borderline Personality Disorder, Bipolar Disorder and Anxiety Disorder. Further review of the records yielded the following: Care Plan: Behavior .At times, I will choose to stay in my room or in bed. Trauma assessment positive . MOOD/BEHAVIOR: (1 of 2) . Trauma Assessment - negative . Resident #24's care plan was contradictory regarding her trauma history. On [DATE] at 5:15 PM, an interview was conducted with Social Worker D regarding Resident #24's trauma. The social worker explained when completing their quarterly trauma assessments, they ask about new trauma and if there has been none they answer accordingly. Review was completed of the Level II evaluation, and it was asked why that was not added into her trauma care plan. It was explained because the resident did not share those specifics with her is why it was not included in the care plan. It was expressed that the information from the Level II per regulations are to be incorporated into care planning. We then reviewed where the care plan was contradictory regarding trauma. Social Worker D reported it should be one or the other, as they do cancel one another out. On [DATE] at 1:18 PM, the Administrator shared that the facility does not have a comprehensive, revision and/or updating care planning policy.

Based on observation, interview and record review the facility to accurately code the MDS (Minimum Data Set) for one resident (#24) and properly reflect one resident's (#61) pertinent care categories on the CMS (Centers for Medicare and Medicaid) 802 form of 22 residents reviewed for assessment accuracy, resulting in Resident #24 being miscoded as utilizing restraints on the MDS and Resident #61's infection not being designated on the CMS 802. Findings include: Resident #24: On 2/5/2025 at 11:30 AM, Resident #24 was observed resting in bed as we conversed about her time at the facility. The resident was asked if she required any usage of a restraint when in/out of bed and she stated she did not. The resident and motorized wheelchair was free was restraints. It can be noted in the survey system Resident #24 triggered for restraints. On 2/5/2025 at 12:44 PM, Nurse O was asked if Resident #24 utilized any type of restraint. The nurse stated, no, but said she did have enabler bars in the past. On 2/6/2025 at 11:10 AM, MDS (Minimum Data Set) Nurse Q was asked regarding Resident #24 MDS restraint coding. Nurse Q stated Resident #24 does not have any form of restraint and she was informed while that may be the case she is triggering for restraint usage. The nurse reviewed the MDS and found the resident was coded for Limb restraint-used less than daily, in the December 2024 quarterly MDS completed by Nurse P. On 2/5/2025 at approximately 1:30 PM, a review was completed of Resident #24's clinical record and it revealed the resident was readmitted to the facility on [DATE] with diagnoses that included, Chronic Obstructive Pulmonary Disease, Hypertension, Agoraphobia, Borderline Personality Disorder, Bipolar Disorder and Anxiety Disorder. Further review of the records yielded the following: 12/19/2024 Quarterly MDS: Indicated she utilized a limb restraint less than daily. On 2/6/2025 at 11:23 AM, an interview was conducted with MDS Nurse P regarding Resident #24's inaccurate MDS coding. Nurse P completes the assessments offsite with a collection of the necessary data from the resident clinical record. If there is something he cannot confirm via the medical record, he will contact the facility for assistance. Nurse P reported after reviewing his notes Resident #24 does not utilize restraints and is miscoded. Resident #61: During the initial tour on 2/5/2025, it was found that Resident #61 was positive for Influenza A, with the appropriate transmission-based precautions adorned on his door and PPE (personal protective equipment) caddy. Upon entering his room, he appeared to be comfortable, but a conversation did not ensue. On 2/6/2025 at 11:49 AM, review was completed of the MDS (Minimum Date Set) Resident Matrix (provided upon entrance), and it indicated Resident #61 did not have any current infections. On 2/6/2025 at approximately, 11: 55 AM, a review was completed of Resident #61's medical records and it revealed the resident admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease, Vascular Dementia, Diabetes, Hypertension and Atrial Fibrillation. Further review yielded the following: Care Plan: .Actual Infection r/t (related to) Influenza A .date initiated 2/2/2025. Progress Notes: 2/2/2025 at 17:20: Resident has fever of 103.4, cough and stated he feels terrible. Rapid was collected and was negative, PCR sent out resident placed on precautions Tylenol administered. On call PCP notified will continue to monitor. 2/3/2025 at 18:26: Resident was positive for Influenza A. is on transmission-based precautions. Still is having fevers was 101.9 administered Tylenol is now 101.1. Resident has to be fever free for 24 hours before he can be off of contact precautions resident was notified along with PCP. On 2/6/2025 at 1:20 PM, the DON (Director of Nursing) reported the resident's symptoms started on 2/2/2025 and he tested positive on 2/3/2025. Review was completed of MDS Resident Matrix, and the DON agreed his positive influenza status should have been indicated on the matrix.

Based on observation, interview and record review, the facility failed to ensure timely assessment of transfer/mobility status for one resident (Resident #315) of four residents reviewed for care planning, resulting in unsupervised self-ambulation and transfer and an incomplete baseline care plan. Findings include: Resident #315: On 2/05/25, at 11:11 AM, Resident #315 was in their room in their bathroom with the door slightly ajar. While meeting with their roommate, Resident #315 hollered out, I got a problem in here. Resident #315 was observed standing on their pulled down pants with their socks half off all in a pile of bowel movement. There was a staff member walking by who was alerted who came quickly to assist the resident. On 2/06/25, at 12:12 PM, a record review of Resident #315's electronic medical record revealed an admission on 2/03/2025 at 2:00 PM with diagnoses that included Alzheimer's disease, Hypertension and Glaucoma. A review of the Care Plan I have a potential/actual ADL deficit R?T (related to) Chronic A-fib HTN UTI BPH Glaucoma OA late onset Alzheimer's dementia . Date Initiated: 02/03/2025 . Interventions I have been provided a copy of my baseline care plan within 48 hours of admission. Date Initiated: 02/03/2025 . Ambulation with specify (1, or 2 PA) specify device Date Initiated: 02/03/2025 . transfer (specify 1, 2 PA, full lift, sit to stand) Date Initiated: 02/03/2025 . A review of the Task Description list revealed no documentation as to how much assistance Resident #315 needed to transfer. On 2/06/25, at 12:17 PM, Resident #315 was sitting in their wheelchair leaning forward moving the foot pedals up and down. Resident #315 was able to move about their room in their wheelchair using their feet. On 2/06/25, at 12:38 PM, Rehab Director L was interviewed regarding Resident #315 admission therapy screen and Rehab Director L offered, to their understanding Resident #315 was signing on to hospice and that they wouldn't recommend a transfer status as the nurse on admission should have. On 2/06/25, at 1:04 PM, The Director of Nursing (DON) was asked how the staff assisted Resident #315 with their transfers and the DON offered, I believe he is a lift. The DON was alerted Resident #315 did not have a personalized transfer status on their care plan nor their Kardex. The DON offered, they would go check. On 2/06/25, at 2:04 PM, the DON followed up on Resident #315's transfer and ambulation status. The DON further offered that the care plan and Kardex are fixed and that the resident was planning to sign onto hospice soon. On 2/06/25, at 3:30 PM, CENA M was asked how Resident #315 was assisted to the bathroom and what their transfer needs were. CENA M stated, we get report and share each shift change how their doing. CENA M further explained, that Resident #315 was making it to the bathroom with just the one assist and that therapy usually assessed them. On 2/07/25, at 9:00 AM, a further record review of Resident #315's care plan revealed . Interventions . Ambulation with 1PA with FWW (front wheeled walker) Revision on: 02/06/2025 . transfer 1PA with FWW . Revision on: 02/06/2025 .

Based on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL) for one resident (R164) of 18 residents reviewed for ADL care, resulting in residents feeling frustrated, anger, embarrassment from poor hygiene, unmet needs and complaints to the state surveyor. Findings include: Record review of the facility 'Activity of Daily Living (ADL) (Daily Life Functions) policy, dated 7/1/2008, revealed the purpose was to assist residents in achieving maximum functional ability with dignity and self-esteem. To provide assistance to residents as necessary. To supervise and assess resident function in order to plan care to maintain optimum ADL function as long as possible. To re-educate resident in techniques of daily life functions. To teach resident use of assistive devices to maintain optimum ADL function as long as possible. To improve the quality of life. Record review of facility shower M1 and M2 shower room schedules undated revealed that there were set days for residents to get two showers every 7 days. Bed baths only if care planned, see your nurse if the resident is requesting. If no shower aid on duty it is the Certified Nurse Assistant assigned by the nurse is responsible for that shower. The schedule is to be split between the two shifts . If a resident refuses a shower report to nurse on duty. Must attempt more than once and chart. Do not chart NA Resident #164: Record review of Resident #164's electronic medical record revealed an admission to the facility date of 1/31/2025 from the acute care setting. An interview on 02/05/25 at 10:12 AM with Resident #164's family member G revealed that the resident had been at the facility since the afternoon of December 31st, 2024, and had not had a shower yet. Family member G stated that they have asked every day for a shower, and they said today's the day. Family member G stated that they went to the social worker designee to inquire about showers and were told that Resident #164 would get a shower that day. Family member G stated why did she have to beg for a shower for the resident? We don't know what days his shower days are, he also goes to hemodialysis 3 days a week, so we need to know. It's been 6 days, and he's starting to smell. Record review on 02/06/25 at 11:29 AM of Resident #164's shower/bath task in the electronic medical record revealed an admission on 1/31/2025 and no bath till 2/5/25 when family members complained. It was 6 days as documented with no shower. In an interview on 02/06/25 at 12:11 PM with Social Work designee F about Resident #164's Showers, Social work designee F stated 'so that was brought to my attention by the (Family member) yesterday, I notified unit manager Register Nurse A, and she said that he would be getting a shower. It was discussed again during the care conference later that day. There should be showers 2 times a week, or more if requested. An interview was conducted on 02/06/25 at 12:16 PM with Registered Nurse (RN) A CCC (Clinical Care Coordinator) regarding Resident #164 not having showers. Resident #164 had no shower until 2/5/2025, he was offered one on 2/4/25 and refused. The (Family member) brought it to our attention and I assigned it to second shift to give a shower on 2/4/25 and he refused. the CNA is to try 3 times and then notify the nurse of refusals so the nurse can go in and offer. A refusal should be charted by the nurse in progress notes. Record review of Resident #164's progress notes revealed there were no refusals documented in the progress notes by the nurse. Record review of the facility shower schedule noted that the resident according to the resident room number would receive showers on Wednesday and Saturday. Resident #164 missed receiving a shower on Wednesday 2/1/2025, causing the family to complain to the state surveyor on 2/5/2025.

This Citation pertains to Intake Number MI00150074. Based on observation, interview and record review, the facility failed to ensure timely completion of wound care for one resident (Resident #93) of one resident reviewed for dressing changes, resulting in missed wound care treatments, not following physician's orders and voiced frustration. Findings include: Resident #93: On 2/05/25, at 11:00 AM, Resident #93 complained there was two missed wound care treatments the week prior because they were short staffed. On 2/07/25, at 11:50 AM, a record review of Resident #93's electronic medical record revealed a readmission on 1/10/2025 with diagnoses that included Lymphedema, Left lower leg fracture and Obesity. Resident #93 required assistance with all Activities of Daily Living and had intact cognition. A review of the TREATMENT ADMINISTRATION RECORD 1/1/2025-1/31/2025 revealed Cleanse left leg with wound cleanser, use wet to dry dressing, cover with super absorber and ABD pad and wrap with kerlex and ace wrap twice a day. Two times a day for wound to left leg -Start Date-01/16/2025 . For the days Tue 21 and Fri 31 the box was left blank which indicated missed treatments. A review of the TREATMENT ADMINISTRATION RECORD 2/1/2025-2/28/2025revealed Cleanse left leg with wound cleanser, use wet to dry dressing, cover with super absorber pad and wrap with kerlex and ace wrap twice a day. Two times a day for wound to left leg -Start Date-02/04/2025 . For the day Wed 5 the box was left blank. A review of the progress notes revealed no mention as to the reason for the missed wound care treatments. On 2/07/25, at 12:53 PM, Resident #93 was resting in their bed and had complaints that the night nurse doesn't have time to care for their wound. Resident #93 further explained, my biggest complaint is the missed treatments, and my sister had to call the nurse on the phone to come change my dressing and when the nurse came in, they offered they didn't have time to change the dressing.

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to prevent pressure ulcer (wounds caused by pressure) development and worsening for two residents (#4 and #217) of two residents reviewed resulting in Resident #4's Stage II (partial thickness loss of first and second layer of skin) pressure ulcer progressing to a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle), and Resident #217 developing an unstageable Deep Tissue Injury (DTI- pressure ulcer with unknown depth), unnecessary pain and the potential for decline in overall health. Findings include: Resident #4: On 2/6/25 at 9:55 AM, an interview was completed with Registered Nurse (RN) N on 2/6/25 at 9:55 AM. When queried regarding the etiology of Resident #4's pressure ulcers, RN N revealed they believed the pressure ulcer worsened at the facility. Review of the facility-provided CMS-802 Resident Matrix form detailed Resident #4 did not have a facility- acquired pressure ulcer. On 2/6/25 at 1:38 PM, Resident #4 was observed in their room. The Resident was sitting in a motorized wheelchair next to the bed. The Resident was wearing socks, and their feet were positioned directly on the built-in footrest of the motorized chair. When asked if they had any wounds and/or open areas, Resident #4 stated they have a sore on their bottom. Resident #4 was asked when the sore had developed but was unable to recall specific information. When queried if they are able to move and reposition themselves to alleviate and redistribute pressure on their bottom, Resident #4 replied, Not really. The Resident indicated they were able to move their upper body but were unable to shift and maintain themselves in a different position to redistribute pressure. When asked if staff reposition them when they are sitting in their chair, Resident #4 replied, No. When queried, Resident #4 verbalized they required staff assistance to transfer from their bed to the electric wheelchair. Resident #4 was asked what time they got up in their chair and replied, About noon. When asked if they get up in the chair every day, Resident #4 confirmed they do. Resident #4 was then asked how long they usually sit up and stated they go back to bed after supper. The Resident revealed they get into the chair at different times every day. When queried if facility staff turn and reposition them in bed, Resident #4 responded that they are only repositioned when they receive incontinence care for a bowel movement. When asked about continence, Resident #4 indicated they know when they have a bowel movement and wear incontinence briefs. The Resident revealed they inform staff when they need to be changed. When queried how long it typically takes for staff to respond to their call light on average, Resident #4 replied, 45 minutes on average. Record review revealed Resident #4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Congestive Heart Failure (CHF), kidney disease, pain, and chronic respiratory failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required maximum to substantial assistance for transferring, mobility, and hygiene care. The MDS further detailed Resident #4 had one Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) and one unstageable suspected Deep Tissue Injury (sDTI- pressure ulcer with unknown depth) pressure ulcers. Review of Resident #4's Admission MDS assessment, dated 8/13/24, revealed that the Resident had one Stage II (partial thickness loss of first and second layer of skin often presenting as a shallow open area with a pink/red wound bed) pressure ulcer. Review of Resident #4's Discharge- Return Anticipated MDS assessment, dated 10/24/24, detailed the Resident had an unstageable pressure ulcer. Review of Resident #4's Electronic Medical Record (EMR) revealed a care plan entitled, Skin Management: Resident with DX (diagnosis) of . CHF, Chronic Pain . resident will refuse showers, declines dressing changes at times, prefers to lay on back . prefers to sit at the side of the bed for ease of breathing. Resident will sit up for multiple hours declining to lay down to offload pressure. Sacrum Stage 4 pressure injury . Unable to apply a Roho cushion in powerchair r/t (related to) safety (Initiated: 8/7/24; Revised: 1/29/25). The care plan included the interventions: - Air mattress, alternating pressure, set per resident preference (Initiated: 08/22/24; Revised: 1/6/25) - Assist me with floating my heels (Initiated: 11/26/24) - Educated resident on importance of turning and repositioning to off load pressure and promote wound healing . (Initiated: 9/19/24) - Encourage me to make small, frequent shifts in my position (Initiated: 8/7/24) - Please help me get turned and repositioned while in bed or in my wheelchair (individualize as needed) (Initiated: 8/7/24) A review Resident #4's Skin Management care plan history revealed the Stage 4 sacral pressure ulcer was added to the care plan on 11/5/24. Review of wound documentation in Resident #4's EMR revealed the pressure ulcer worsened while at the facility. The documentation detailed: - 8/7/24 at 11:46 AM: Wound Evaluation . #1 - Pressure - Stage 2 . Location: Sacrum - Middle . New - 4 hours old . Present on Admission . Length 5.18 cm (centimeters) . Width 10.49 cm . Wound Bed . Granulation (type of tissue that forms in wound bed during healing process) . 100 % . Exudate: Light . Sanguineous/Bloody . Notes: Resident admitted to facility with Stage 2 pressure injury to sacrum . The attached wound image showed a large wound on the Resident's sacrum/coccyx area which spread across both buttocks with skin bridges. The wound beds appeared pink/red in color and a white colored cream was present. - 8/22/24 at 12:48 AM: Wound Evaluation . #1 - Pressure - Stage 2 . Sacrum . Improving . Length: 0.95 cm . Width 1.1 cm . Wound Bed . Epithelial (new tissue during the final stage of wound healing) . 100 % . Exudate: None . Notes Treatment in place. Area has improved . The attached wound image showed the wound bed to be decreased in size overall with six open areas. The largest open area was near the coccyx. - 9/6/24 at 9:45 AM: Wound Evaluation . #1 - Pressure - Stage 2 . Sacrum . Length: 7.95 cm . Width 2.78 cm . Wound bed . Slough (buildup of dead cells and tissue which can delay healing): Yes . Periwound . Surrounding Tissue: Denuded (exposed, raw tissue with the outermost layer of skin gone) . Erythema (red, discolored, inflamed) . Fragile . Deteriorating . The attached wound image showed an open area over the Resident's coccyx with an off-white/yellow colored wound bed. The Resident's left buttock was deep red in color with an irregularly shaped open wound and a second area covered with black colored tissue. The right buttock was also discolored with three visible open areas. - 9/18/24 at 4:49 PM: Wound Evaluation . #1 - Pressure- Unstageable (Slough and/or eschar) . Sacrum . Length 6.95 cm . Width 1.83 cm . Wound bed . Slough . 80 % . Exudate: Light . Serosanguineous . Deteriorating . Notes Treatment adjusted to autolytically debride wound . - 10/4/24 at 4:35 PM: Wound Evaluation . #1 - Pressure- Unstageable . Sacrum . Length: 5.44 cm . Width 1.87 cm . Wound bed . Slough . 100 % . Exudate: Light . Serosanguineous . In the attached image, visible wound depth was present. The edges of the open wound appeared rolled with slough present. The wound measurements on the assessment did not include depth. - 10/10/24 at 1:10 PM: Wound Evaluation . #1 - Pressure- Unstageable . Sacrum . Length: 2.71 cm . Width: 2.6 cm . Notes Treatment adjusted at wound clinic appointment today. Wound appears to have been debrided at wound clinic. Wound clinic has wound staged as a stage 3; however, slough is approximately 90% of wound bed. Base of wound bed unable to be visualized. Denuded tissue to periwound. - 10/31/24 at 3:55 PM: Wound Evaluation . #1 - Pressure- Stage 4 . Sacrum . Length 12.33 cm . Width 14.87 cm . Deepest Point 4.5 cm . Max Undermining 5.5 cm . Undermining 3.0 cm from 12 to 2 o'clock, 5.5 cm from 2 to 4 o'clock . Exudate: Moderate . Serosanguineous . Notes Treatment in place. Resident went to the hospital and wound was surgically debrided. Bone is now exposed . has a Foley catheter . - 11/6/24 at 3:55 PM: Wound Evaluation . #1 - Pressure- Stage 4 . Sacrum . Length: 13.25 cm . Width: 16.57 cm . Max Undermining 6 cm . Undermining 6.0 cm from 1 to 3 o'clock . Longest Tunnel 6 cm . Tunneling 6.0 cm at 4 o'clock . Exudate: Moderate . Serosanguineous . Deteriorating . Notes Treatment in place. Bone exposed. Periwound is red . - 12/11/24 at 12:04 PM: Wound Evaluation . #1 - Pressure- Stage 4 . Sacrum . Length: 8.16 cm . Width: 9.24 cm . Deepest Point 3 cm . Max Undermining 4 cm . Undermining 4.0 cm from 2 to 4 o'clock . Exudate: Moderate . Serosanguineous . - 1/7/24 at 1:41 PM: Wound Evaluation . #1 - Pressure- Stage 4 . Sacrum . Length: 6.7 cm . Width: 6.53 cm . Deepest Point 2 cm . Max Undermining 3.5 cm . Undermining 3.5 cm from 2 to 5 o'clock . Exudate: Moderate . Serosanguineous . - 2/4/25 at 11:07 AM: Wound Evaluation . #1 - Pressure- Stage 4 . Length: 6.45 cm . Width 5.65 cm . Deepest Point 205 cm . Max Undermining 2.5 cm . Undermining 2.5 cm from 2 to 4 o'clock . Review of Resident #4's Health Care Provider Orders and Treatment Administration Record (TAR) revealed the Resident had a treatment order in place for their sacral wound as well as: - Skin prep to bilateral heels Q (every) shift . for boggy, pink, blanchable heels (Start Date: 8/7/24) - Left heel: cleanse with wound cleanse, apply skin prep to periwound, cover with an aquacel foam as needed (Start Date: 12/11/24) - Offer offloading interventions and repositioning every 2 hours. Document refusals every shift (Start Date: 12/2/24). - Resident to be side to side turning and repositioning only; document refusals every shift (Start Date: 10/31/24) No documentation of refusals were noted in recent documentation. On 2/6/25 at 4:21 PM, an interview was completed with Certified Nursing Assistant (CNA) T. When queried how frequently residents with or at risk for pressure ulcers are supposed to be turned and repositioned in bed and when sitting up in a chair, CNA T replied, We try to do every two hours. When asked what they meant when they said they try to turn and reposition residents every two hours, CNA T revealed that it can variable based upon staffing and other resident needs. CNA T then stated that if a resident is sleeping/resting and looks comfortable, they will not turn and/or reposition them. On 2/6/25 at 4:34 PM, an interview was completed with RN N. When queried if Resident #4's heels were intact and the reason the treatment orders, RN N revealed they were not aware of the Resident having a skin alteration on their heels. An observation of Resident #4's feet and heels was completed with RN N at this time. A black colored, circular shaped area was observed on the back of Resident #4's left heel directly over the bony prominence. The tissue surrounding the black colored area was discolored and purplish in color. When queried regarding the area and surrounding tissue, RN N applied pressure and stated, non-blanchable. A dark colored area was observed on Resident #4's lateral right heel. The area was in the shape of a line. On 2/7/25 at 7:47 AM, Resident #4 was observed sitting on the edge of their bed. The Resident did not have socks or shoes on, and their feet were directly on the floor. There were no pillows on the bed and/or devices to elevate their lower extremities while in bed. When asked if elevate their heels when in bed, Resident #4 stated, No. When queried if staff offered to assist them to elevate their legs/heels when in bed, Resident #4 responded they did not. At 8:00 AM on 2/7/25, a request to observe Resident #4's wounds was made to the Director of Nursing (DON). On 2/7/25 at 8:57 AM, an interview was completed with Licensed Practical Nurse (LPN) R. LPN R responded, (RN S) is in there changing the dressing now. Upon knocking and entering the room, the dressing change was completed, and Resident #4 was sitting in the motorized chair. An interview was completed with the DON on 2/7/25 at 12:38 PM. When queried if Resident #4's pressure ulcer worsened from a Stage II to a Stage IV while at the facility, the DON confirmed. The DON was asked if the Resident was at risk for pressure ulcer worsening when they were admitted to the facility and confirmed they were. When asked what interventions were implemented and in place to prevent pressure ulcer development and/or worsening, the DON reviewed Resident #4's care plan and stated, On 8/7- help me get repositioned when in bed or wheelchair, an alternating air mattress was added on 8/22/24, education regarding turning and repositioning and importance of incontinence care on 9/19/24 and sent to the wound clinic on 10/7/24. The DON stated, (Resident #4) still sees them (wound clinic). When asked how often Resident #4 should be turned and repositioned, the DON revealed every two hours. When queried if Resident #4's heels are supposed to be elevated when in bed, the DON replied, Yes. The DON was informed of observation of Resident #4's room/bed, Resident #4 stating they are not assisted to turn/reposition, and/or elevate their heels, and CNA T stating they do not reposition Residents who are sleeping and/or appear comfortable. The DON stated, That is not what they (staff) are trained to do. When queried regarding pressure ulcer worsening and lack of planned interventions, the DON verbalized understanding of concern. Resident #217: On 2/6/25 at 8:52 AM, an interview was conducted with RN N. When asked if Resident #217 had any wounds, RN N responded they had a new heel pressure ulcer. Review of the facility-provided CMS-802 Resident Matrix form detailed Resident #217 did not have a facility acquired pressure ulcer. On 2/6/25 at 9:03 AM, Resident #217 was observed in their room in bed. A walking boot (removable brace designed to protect and stabilize the foot and ankle while allowing walking) was in place on the Resident's Right Lower Extremity (RLE- leg). Their Left Lower Extremity (LLE) and heel were positioned directly against the mattress. Resident #217 was pleasantly confused and unable to provide meaningful responses to questions. At 9:10 AM on 2/6/25, RN N was observed in the hallway of the facility near Resident #217's room. RN N was asked if the Resident's heel was supposed to be elevated and indicated it was. RN N was then asked to come into Resident #217's room. When queried, RN N confirmed Resident #217's LLE and heel were positioned directly against the mattress. Review of the facility-provided CMS-802 Resident Matrix form detailed Resident #217 did not have a facility- acquired pressure ulcer. Record review revealed Resident #217 was admitted to the facility on [DATE] with diagnoses which included right femur fracture, falls, anxiety, Alzheimer's disease and dementia. Review of the MDS assessment, dated 1/20/25, revealed the Resident was severely cognitively impaired and was dependent upon staff for transferring. The MDS further detailed the Resident was at risk for pressure ulcer development but had no pressure ulcers. Review of Resident #217's EMR revealed a care plan entitled, Skin Management: Right femur fracture, Incontinence, right ankle fx (fracture), DTI left heel (Initiated: 1/14/25; Revised: 2/6/25). The care plan included the interventions: - Air mattress, set per resident preference (Initiated: 2/5/25) - Attempt to keep heels off bed as resident allows (Initiated: 1/28/25; Revised: 2/6/25) - Cam boot on at all times RLE (Initiated: 1/30/25) - CNA's will check my skin daily with care and report anything unusual they notice to the nurse (Initiated: 1/14/25) - Float heels while abed (Initiated: 2/5/25) - Please help me get turned and repositioned while in bed or in my wheelchair (individualize as needed) (Initiated: 1/14/25) - Treatments/medication as ordered (Initiated: 1/14/25; Revised: 2/6/25) On 2/6/25 at 1:37 PM, Resident #217 was observed sitting alone at a table in the central dining area. The Resident had an uneaten food tray in front of them. Their feet were positioned directly against the footrests on the wheelchair. On 2/6/25 at 4:01 PM, Resident #217 was observed sitting in their wheelchair in their room. The Resident's right foot was bare and positioned directly against the floor. At 4:05 PM on 2/6/25, an observation of Resident #217 was completed with RN N. RN N confirmed the Resident did not have a sock and/or foot covering in place on their right foot and their foot was positioned directly against the floor. RN N stated, I have found (Resident #5) with no socks on before. When queried regarding interventions to prevent and offload pressure, RN N revealed the Resident's RLE was supposed to be elevated when in bed. When asked if the Resident had heel boots in place as an intervention, RN N stated, That would be good. An observation of Resident #217's right heel was completed with completed with RN N at this time. A dark colored wound with unattached edges, slightly larger than a dime and circular in shape was observed on the Resident's heel. On the lateral side of the right heel a dark purple colored area, approximately a half dollar in size was present. When asked, RN N stated the areas were non-blanchable. On 2/6/25 at 4:14 PM, an interview was completed with the DON. When queried regarding Resident #217, the DON confirmed the Resident had a facility-acquired pressure ulcer. When asked about interventions to prevent pressure when in bed and sitting in their chair such as heel boots, the DON verbalized heel boots were not implemented due to concerns that the Resident might self-transfer. The DON indicated the Resident's heels are supposed to be elevated when in bed. When asked about other options and products for pressure reduction, the DON verbalized they would research products. When informed of observation of the Resident's heel being positioned directly against the mattress, the DON did not provide an explanation. On 2/6/25 at 4:21 PM, an interview was completed with Certified Nursing Assistant (CNA) T. When queried Resident #217 transfers, CNA T replied, Hoyer (mechanical lift). CNA T continued, (Resident #217) is non-weight bearing on the right side. When asked if the Resident is able to turn and/or reposition themselves, CNA T stated, We turn them. When queried regarding interventions for Resident #217's heel pressure ulcer, CNA T indicated they were unaware the Resident had a pressure ulcer on their heel but stated the Resident's heel has been very tender for several days. Review of documentation in Resident #217's EMR revealed the following: - 2/2/25 at 3:06 PM: eINTERACT Change in Condition Evaluation . Skin wound or ulcer . new wound on left heel 1 cm (by) 0.6 cm . - 2/2/25 at 3:22 PM: Nurses Note . While performing care a wound was noted to resident's left heel. The open area measures 1 cm X 0.6 cm and is dark in color, peri wound is pink and blanchable . Area cleansed with wound cleaner, skin prep applied to periwound and Aquacel foam was placed. Care plan has been updated for resident's heel to be floated while laying in bed . - 2/3/25 at 2:20 PM: Wound Evaluation . Pressure - Deep Tissue Injury . New - Minutes old . In-House Acquired . Length 1.06 cm . Width 1.01 cm . 2/3/25 at 8:22 PM: Incident Note . IDT review: Resident has open area on left heel, open area measures 1 cm X 0.6 cm, wound bed is dark, no drainage noted . Resident has right ankle fracture and uses left foot to propel self in wheelchair and bumps the back of heel on the wheelchair pedal. Treatment applied. Review of Resident #217's Health Care Provider Orders and TAR revealed the following: - Skin prep to left heel BID (twice daily) . for skin integrity (Start: 2/3/25; Discontinued: 2/6/25) - Left heel wound: cleanse with wound cleanse, apply skin prep and cover with an Aquacel foam one time only for 1 Day (Start Date: 2/6/25). The treatment was documented as completed on 2/7/25 at 5:17 AM. - Left heel wound: cleanse with wound cleanse, apply skin prep and cover with an Aquacel foam as needed (Start Date: 2/6/25). There was no documentation of treatment completion. On 2/7/25 at 7:46 AM, Resident #217 was observed in their room. The Resident was in bed, positioned on their back with their eyes closes. The Resident's LLE was positioned directly against the mattress and walking boot was in place on their RLE and also positioned directly against the mattress. A follow up interview was completed with the DON on 2/7/25 at 8:18 AM. When asked if Resident #217 was at risk to develop pressure ulcers upon admission to the facility, the DON confirmed they were. When queried regarding the lack of meaningful interventions in place upon admission to prevent pressure ulcer development, with known risk, the DON reviewed the Resident's care plan and stated, I agree. Review of facility provided policy/procedure entitled, Wound Management Program (Revised: 8/17/17) revealed, To eliminate, modify or minimize factors that place residents at risk for skin breakdown . To assure that residents who are admitted with, or acquire, wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing . Process . 3. Place initial interventions for residents at risk for development of skin breakdown in Care Plan/Kardex .

Based on observation, interview and record review, the facility failed to provide feeding assistance for Resident #43 and to prevent weight loss for Resident #23, resulting in Resident #43 to be observed with no dining assist at bedside and Resident #23 experiencing a 10 pound weight loss. Findings include: Record review of the facility 'Weight Policy' dated 11/21/2024 revealed each individual's weight will be determined and documented upon admission to the facility . Subsequent weights will be obtained monthly, unless physician's orders or an individual's condition warrants more frequent determinations. Re-Weights will be done for a weight change of +/- 3# (pounds) for anyone under 100 pounds and for +/- 5 pounds for anyone 100 pounds or over. Record review of the facility 'Diet Types' dated 9/26/2019 revealed each resident and guest admitted to the facility will be assessed by a Registered Dietitian and/or Clinical Certified Dietary Manager. Assessment will take place to evaluate the need for medical nutrition therapy according to each person's individual medical condition, needs, desires, and rights. Record review of the facility 'Nutrition at Risk' dated 5/20/2019 stated that residents with altered nutrition status or with potential for nutritional risk will receive appropriate interventions to make sure nutritional needs are met to maintain/improve their quality of life. Criteria- risk criteria will be identified through admission assessment, quarterly review, weight monitoring, and/or food intake record/observation. Risk criteria may include the following: significant weight loss/gain, insidious weight loss, dysphagia, significant decline in activities of daily living, pressure ulcers, dehydration risk, significant change in food intake as well as any other diagnoses/clinical condition placing the resident at nutrition risk. Resident #23 Hydration: Observation on 02/05/25 at 09:56 AM of Resident #23 showed the resident to be thin in appearance, laying in his bed with no water within reach. Observed on a table across room next to the entrance room wall away from the bed was a clear plastic mug with handle with a black lid with a straw. A clear thin liquid noted in the cup. Observation on 02/06/25 at 09:06 AM of Resident #23 lying in bed with water on bedside table across the room again next to the wall out of reach of the resident. Observation and interview on 02/07/25 at 08:09 AM, Resident #23 was observed with water in clear mug with handle with black top with a straw, across the room from residents' bed, out of reach. In an interview and observation with Certified Nurse Assistant (CNA) B stated that Resident #23 drinks too fast and she did not want him to choke. Record review of Resident #23's Care plans pages 1-51 revealed: Alteration in bowel elimination/constipation related to weakness and debility created 12/15/2022 with interventions: Encourage fluids dated 12/15/2022. Alteration in my Mood state related to Major Depressive Disorder revision date 8/20/2024 interventions: Offer me a snack/drink dated 12/8/2022. Nutritional preferences/hydration related to COVID-19, depression, acute kidney failure, hypothyroidism, chronic heart failure (CHF), dysphagia, dementia, hypertension, high cholesterol, Coronary Artery Bypass Graft (GABG) revision date 1/28/2025 interventions: Regular diet, puree texture, thin liquids, supplements as ordered, total assist revision dated 1/28/2025. Resident #23 Nutrition: Record review of Resident's #23's electronic weight log revealed: 12/11/2024 at 22:03 PM a weight of 129.6 pounds. 12/20/2024 at 5:21 PM a weight of 119.6 pounds. 12/20/2024 at 5:22 PM a weight of 119.6 pounds. A 10-pound weight change noted with no re-weight for 14 days. 1/3/2025 at 2:59 PM a weight of 111.4 pounds. An 8.2-pound weight change with no re-weight for 18 days. 1/21/2025 at 2:26 PM a weight of 110.0 pounds. Record review on 02/06/25 at 03:31 PM of Resident #23's weights: Six months look back: On 8/7/2024 weight of 132.2 pounds and on 1/21/2025 110.0 pounds = 16.79% weight loss. One month look back: On 12/11/2024 weight of 129.6 pounds and on 1/21/2025 110.0 pounds = 15.12% weight loss. Record review of Resident #23's electronic medical record weight change notes dated 1/4/2025 (almost a month after weight loss) at 2:26 PM weight warning: 119.6 pounds 5.0% change over 30 days, 9.1% of 12.0 (pounds). Note regular diet, mechanical soft texture, thin liquid. Appetite 0-50% oral intake per food acceptance record (FAR) (0-1000 kcals, 0-40g protein). Mighty shake three times daily. Weight 119.6 pounds re-entry admission (-10% in 1 month, -14% in 6 months) Goal: gradual weight gain as medically feasible). Record review of Resident #23's Nutritional preferences/Hydration care plan revision date 1/28/2025 noted interventions: Honor food preferences date 1/5/2025. Will remove dentures at times and place in shirt pocket date 4/4/2023. No weight or labs due to hospice services/comfort care date 1/11/2025. Not appropriate for diet education related to low Brief Interview of Mental status (BIMS) dated 8/2/2023. Offer HS (bedtime) snack dated 1/15/2024. RD to coordinate with hospice as needed date 1/28/2025. Regular diet, puree texture, thin liquids, supplements as ordered, total assist dated 1/28/2025. Supplement as ordered date 1/5/2025. There were no interventions implemented in December 2024 at the time of the 10-pound weight loss. An interview and record review on 02/07/25 at 09:32 AM with Registered Dietitian (RD) C of Resident #23's weight log revealed that the resident would be weighed by standing, wheelchair, mechanical lift or seated scale, not in a consistent format. Nutritional notes revealed weight loss from 12/11/24 of 129.6 pounds and on 12/20/24 119.6 pounds, of a 10 pound loss with no re-weight for 14 days. Why? no answer was given. RD C stated that the facility did have a seated scale, flat wheelchair/standing scale, and a mechanical lift scale. The aides seem to be using any of those. I can see where it is not consistent. 38471 Resident #43: On 2/6/025 at approximately 9:00 AM, a review was conducted of Resident #43's medical record and it revealed she admitted to the facility on [DATE] with diagnoses that included, Chronic Obstructive Pulmonary Disease, Dementia, Protein-Calorie Malnutrition and Major Depression. Further review yielded the following: Care Plan: .Regular Diet, Mechanical soft textures, thin liquids, Total assist . On 2/7/2025 at 12:50 PM, Resident #43 was observed with lunch tray alone in her room while watching television. She stated this is the first time she had been up in weeks. Resident #43's lunch was as follows: hamburger , milk-no opened, cola can- not opened, [NAME] Dunes, fries and [NAME] slaw. Review was completed of her meal ticket which stated, Feeding Assistance, Soda-Cola (Large Glass). On 2/7/2025 at 1:05 PM, the Administrator and Culinary Specialist V were in Resident #43's room. Resident #43 was still alone with her lunch tray. They were both shown her meal ticket and asked what feeding assistance and Cola (Large Glass) meant. They stated that someone should be with the resident assisting them with their meal and the Cola should be in a glass.

This Citation pertains to Intake Numbers MI00149163 and MI00149254. Based on interview and record review the facility failed to ensure appropriate indication of a psychotropic drug dosage increase for one resident (Resident #47) and failed to ensure informed consent was obtained prior to administration of psychotropic medications for one resident (Resident #46) of four residents reviewed for unnecessary medications, resulting in Residents #46 and #47 bring administered antipsychotic medications without appropriate consent and risk versus benefit analysis of the medications explained to the resident/responsible party and the increased potential for serious side effects and adverse reactions . Assessment and Documentation: (c.) (ii.) Informed consent forms the resident and/or responsible party along with education regarding potential side-effects . Findings include: Record review of the facility 'Use of Psychotherapeutic Medications' policy, dated 6/23/2019, revealed a resident will not receive psychotherapeutic medications unless such a medication is needed to treat a specific condition as diagnosed and documented in the clinical record with clearly defined target behaviors and non-pharmacological interventions are not effective. Psychotherapeutic medication includes Antianxiety, Antidepressant, Antipsychotics and Hypnotics . Assessment and Documentation: (c.) (ii.) Informed consent from the resident and/or responsible party along with education regarding potential side-effects . Resident #46: Record review on 02/06/25 at 11:07 AM of Resident #46's physician orders noted the resident was prescribed: Alprazolam (Xanax) 0.5mg take 3xs daily anxiety Lamictal 100mg 1 tablet daily Bipolar Quetiapine Fumarate (Seroquel) 100mg tablet daily Bipolar Record review of Resident #46's December 2024 Medication Administration Record (MAR) noted: Lamictal (Lamotrigine) oral 100mg tablet, give 1 tablet by mouth in the morning related to unspecified mood (affective) disorder start date of 10/24/2024. Seroquel (Quetiapine Fumarate) oral tablet 50mg, give 1 tablet by mouth at bedtime related to unspecified mood (affective) disorder start date of 10/22/2024. Xanax (alprazolam) oral tablet 0.5mg, give 1 tablet by mouth three times a day related to anxiety disorder start date 11/22/2024. Record review of Resident #46's t January 2025 Medication Administration Record (MAR) noted: Lamictal (Lamotrigine) oral 100mg tablet, give 1 tablet by mouth in the morning related to bipolar disorder, current episode manic without psychotic features unspecified start date of 1/9/2025. Seroquel (Quetiapine Fumarate) oral tablet 100mg, give 1 tablet by mouth one time a day for bipolar start date of 1/10/2025 (dose increase). Xanax (alprazolam) oral tablet 0.5mg, give 1 tablet by mouth three times a day related for anxiety start date 1/8/2025. Record review and interview on 02/06/25 at 12:26 PM with Registered Nurse (RN) Clinical Care Coordinator (CCC) A of Resident #46's physician orders revealed medications to treat psychological disorders. Record review of Resident #46's anti-psychotropic medication only revealed a consent for Xanax. RN A stated that psychotropic medication consents are on the anti-psychotic information sheets or anti-psychotic monitoring form. Record review of medications Lamictal and Quetiapine Fumarate (Seroquel) both to treat Bipolar with delusions had no psychotropic medication information sheet or anti-psychotic monitoring form and no signed consents found. An interview and record review on 02/06/25 at 12:29 PM with Social Worker D revealed that the process was that the unit managers get the consents for psychotropic medication usage prior administration. Record review of Resident #46's psych forms found only Xanax medication information and monitoring forms were found. Social worker D stated that the medication Lamictal was being used for bipolar with moods/behaviors with psychotic features. No consent, no medication information sheet, no medication monitoring sheet were found. Record review of Resident #46's Seroquel (quetiapine Fumarate) for bipolar with delusions. No consent, no medication information sheet, no medication monitoring sheet were found. An interview on 02/06/25 at 12:36 PM with the Director of Nursing (DON) regarding psychotropic medications, revealed that a behavior care services come in to see residents and make recommendations, may try different medications and make recommendations. Record review of Resident #46's electronic forms file revealed only Xanax medication information and monitoring sheet. There was no Seroquel or Lamictal to information or monitoring forms to treat Bipolar. 39059 Resident #47: On 2/06/25, at 3:49 PM, a record review of Resident #47's electronic medical record revealed an admission on 6/20/2022 with diagnoses that included Anxiety Disorder, Alzheimer's Disease and Dementia. Resident #47 required assistance with Activities of Daily Living and had severely impaired cognition. A review of the psychological treatment (BCS) notes revealed the last visit was on 12/26/2024 and revealed . Based on the data obtained and discussions with patient and staff, this provider concludes: a change in medication was considered, but will not be implemented at this time as the current plan of care is most effective at this time . Recommend to monitor serum sodium level every 6 months due to SSRI therapy. Recommend to monitor Depakote levels, liver function tests, and CBC with diff every 3-6 months . Follow-Up per the request of: patient, family, PCP or facility staff . A review of the PSYCHOACTIVE MEDICATION MONITORING Date: 1/8/2025 . Medication Dosage Depakote increased from 125 mg BID to 250 mg BID Order Date: 1/8/2025 . Increase recommended by PCP due to Valproic acid level A review of the physician progress notes revealed 1/8/2025 . Summary: Patent seen and evaluated today for acute visit. Discussed patients seizure med's with her, lab levels were low so her Depakote is being increased. Patient is agreeable to plan . PLAN: . Depakote increased . On 2/06/25, at 4:01 PM, a further record review revealed Resident #47 did not have a diagnosis of Seizures. On 2/07/25, at 9:05 AM, an interview with the Director of Nursing (DON) was conducted regarding Resident #47's increase in their Depakote dosage on 1/8/25. The DON offered, BCS did recommend lab levels for valproic acid. The Nurse Practitioner did do a clarified progress note and that BCS is ok with the increase to the 250 MG BID. The DON was questioned why BCS would be OK with the dosage increase when they documented on their last visit on 12/6/244 to keep medication the same at that time. Again, the DON offered that the NP did put in a new progress note for the increased dose. A further record review of Physician progress notes revealed PHYSICIAN PROGRESS NOTE Date: 2/6/2026 17:12 . Patient has no history of seizures, no further Valproic acid labs required. Patient is on Depakote for adjustment disorder There was no Physician order to decrease the 250 mg BID Depakote back down to the BCS recommended 125 mg BID dose.

Based on observation, interview and record review, the facility failed to ensure proper insulin administration and provide the proper medication dosage for two residents (Resident #57, Resident #164) of five residents reviewed for medication administration, resulting in unsafe injection practices, the uncertainty of an accurate insulin dose administered and improper medication reconciliation after hospitalization . Findings include: Resident #57: On 2/06/25, at 7:30 AM observation of Nurse H prepare am medications for Resident #57. Nurse H had the insulin pen resting on top of the medication cart. Nurse H picked up the insulin pen, screwed a needle onto the pen and dialed the pen to 5 units. Nurse H did not prime the needle with the required 2 units prior to administration into Resident #57's abdomen. On 2/06/25, at 9:44 AM, the Director of Nursing (DON) was alerted that Nurse H failed to prime the insulin pen needle with the required 2 units of insulin prior to administration. The DON was asked to provide the policy for medication administration and how to clean the blood glucose meter machines. On 2/06/25, at 9:55 AM, a record review along with the DON of the Medication Administration Subcutaneous Insulin 05/16 policy revealed . always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by ensuring that pen and needle work properly. Removing air bubbles. A. Select the dose of units by turning the dosage selector . The diagram shows the dial turned to 2 units for the safety test and to prime the needle. Resident #164: In an interview on 02/05/25 at 10:15 AM, Resident #164 family member G stated that Resident #164 was suppose to get 2 tablets of Renvela (sevelamer carbonate) 800 mg oral three times a day, but the facility only ordered 1 tablet Renvela 800 mg oral three times a day. Family member G stated that the dose was on the hospital discharge paperwork and that the family member became upset at the wrong dose and went to speak with the nurse. Record review of Resident #164's hospital history & physical dated 1/24/2025 medication list noted sevelamar carbonate (Renvela) 800 mg tablet, take 1600 mg by mouth three times daily with meal. Record review of Resident #164's January 2025 Medication Administration Record (MAR) noted Renvela oral 800 mg, give 1 tablet by mouth with meals related to end stage renal disease. Record review noted that Resident #164 received the dose 800 mg 1 tablet oral on 1/31/2024 at 12:00 PM and again at 5:00 PM. Record review of Resident #164's February 2025 Medication Administration Record (MAR) noted Renvela oral 800 mg, give 1 tablet by mouth with meals related to end stage renal disease. Record review noted that Resident #164 received the dose 800 mg 1 tablet oral on 2/1/2024 at 8:00 AM and at 12:00 PM and again at 5:00 PM. On 2/2/2025 at 5:00 AM Resident #164's Renvela oral 800 mg order was changed to: Renvela oral 800 mg, give 2 tablets by mouth three times a day related to end stage renal disease. Record review of the 'Nursing 2017 Drug Handbook' page 1311 revealed medication Renvela was used control phosphorous level in chronic kidney disease patients on dialysis. Record review on 02/06/25 at 11:47 AM of Resident #164's Progress notes: On 1/31/2024 at 5:54 PM noted order entered: Renvela oral tablet 800 mg, give 1 tablet by mouth with meals related to end stage renal disease. On 2/1/2025 at 12:06 PM Resident #164 was on a leave of absence for dialysis. On 2/1/2025 at 2:49 PM nurse noted that resident and family member stated that resident doesn't take medications when he returns from dialysis but at 5 AM with hot oatmeal, milk and brown sugar. Kitchen manager aware of dietary request and resident refused medications at this time. Resident and family request all medications be given at 5 AM on dialysis mornings. In an interview on 02/06/25 at 12:16 PM, Registered Nurse (RN) A CCC (Clinical Care Coordinator) (in regard to Resident #164 medications Reval 800 mg 1 tablet was ordered for 3 times daily) stated that it should have been 2 tablets 3 times daily. Again the family member brought it to my attention today, but stated it was corrected. Staff do double check admission- orders one nurse enters the order into the computer and a second nurse double checks the orders. 39059

Based on observation, interview and record review, the facility failed to ensure safe medication storage for one medication cart of four medication carts reviewed during the medication storage task, resulting in medications stored unlabeled in a clear plastic medication cup. Findings include: On 2/07/25, at 1:00 PM, During medication storage task, an observation of Center hall medication cart along with Clinical Care Coordinator (CCC) J was conducted. CCC J opened up the second medication drawer. There was a clear plastic unlabeled medication cup filled with numerous medications sitting in the container labeled 227-1. CCC J removed the medication cup that housed Resident #710's am oral medications and began to look for the Nurse assigned to the medication cart. On 2/07/25, at 1:05 PM, Nurse I approached the medication cart and CCC J offered, you can't store med's in a cup in your drawer. Nurse I offered, they put them in there because the resident was unavailable. A record review of Medication Administration Record for Resident #710 along with Nurse I and CCC J revealed the am medications ordered were not signed out as given by Nurse I. On 2/07/25, at 2:15 PM, a record review along with the Director of Nursing (DON) was conducted regarding Nurse I's competency for medication administration. The DON was asked what the initials SS meant, and the DON offered, that is the Nurse on the hall that did that. The DON further offered that they usually do not do a medication pass with new nurses. A review of the facility provided PREPARATION AND GENERAL GUIDELINES September 1,2023 revealed . When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared .

Based on observation, interview and record review, the facility 1) Failed to provide wound care as ordered and prevent an infection for one resident (Resident #48) and 2) Failed to follow hospital discharge instructions for one resident (Resident #285) of two residents reviewed for quality of care, resulting in a missed dressing change, pain, infection, distended bladder and abdomen, and hospitalization with the likelihood of a further complication of ruptured bladder and/or death. Findings include: Resident #48: On 12/07/22, at 9:53 AM, Resident #48 was lying in their bed. There was a white dressing to their right lower leg that was dated 12/3. Resident #48 was asked how often they get their leg dressing changed and if it hurt at all and Resident #48 stated, they change it every other day but had missed a couple days. Resident #48 stated that it hurts when they take the dressing off and spray it with the solution they use On 12/07/22, at 9:55 AM, CCC X was asked to enter Resident #48's room. CCC X was asked what date they saw on their right lower leg dressing and CCC X stated, 12/3. On 12/07/22, at 10:06 AM, observation of Resident #48's wound care along with Nurse Y and Unit Manager J was conducted. Nurse Y cut the outside Kerlix dressing off with red crafting scissors they pulled out of their right pocket. Unit Manager J left the room to get more supplies. Nurse Y was asked where they found the red scissors at and Nurse Y stated, that they were in the wound cart and had cleaned them prior to putting them in her pocket. Nurse Y began to spray the dried intact Vaseline gauze with wound spray as it was adhered to the wound. Nurse Y continued to spray the gauze and pull off the wound simultaneously while Resident #48 scowled and stated, Oh that feels like acid when she sprays and it sets in. Unit Manager J entered Resident #48's room and instructed Nurse Y to place the 4 inch gauze square pads on the wound over the top of the adhered Vaseline gauze and pour normal saline on top to loosen the dressing. Resident #48 was asked if the dressing change is normally that painful and Resident #48 stated, It hasn't' been changed in a while so the longer it sits on there and gets stuck, it burns. Nurse Y allowed the normal saline soaked gauze to moisten the adhered Vaseline gauze and began to pull the dressing off the leg wound and Resident #48 hollered out slightly, Ahh, it feels just like your poured acid on it. Resident #48 was asked if the doctor had been in recently to see the wound and Resident #48 stated, No, not in a while. The entire dressing was removed to reveal numerous yellow slough areas throughout the wound bed. The old dressing had a moderate amount of yellow, white, gray raised drainage to the old dressing. The Vaseline gauze that was removed was all intact. On 12/07/22, at 3:00 PM, a record review of Resident #48's Electronic Medical Record revealed an admission on 2/15/22 with diagnoses that included Peripheral Vascular Disease, Hypertension and Left Lower Leg Deep Vein Thrombosis. Resident #48 required extensive assistance with Activities of Daily Living (ADL) and had intact cognition. On 12/07/22, at 3:55 PM, Unit Manager J was interviewed regarding Resident #48's wound and the appearance. Unit Manager J was asked what the yellow drainage was and Unit Manager J stated, that it was from the xeroform (Xeroform Petrolatum (Vaseline) dressing works to cover and protect low to non-exudating wounds. Uses for Xeroform include covering wounds like donor sites, lacerations, burns, abrasions, and skin graft sites. The non-adherent product is excellent for maintaining a moist wound environment while promoting healing.) A record review of Resident #48's wound pictures from 11/9/22 and 12/7/22 was conducted with Unit Manager J who denied any sign of infection to the wound. Unit Manager J was asked if they entered the note regarding the wound appearance and Unit Manager J stated, yes and that there was no need for a culture because the wound isn't infected. On 12/07/22, at 4:03 PM, the Director of Nursing (DON) was asked to review the wound notes for Resident #48 and the DON stated, the wound looked happy red and did not appear infected. On 12/12/22, at 9:03 AM, Resident #48 was lying in their bed. Resident #48 stated, the doctor had come in and started antibiotics. Resident #48 stated that the last time the dressing was changed, it did not hurt and was nothing like last week when it felt like acid burning. On 12/12/22, at 11:15 AM, a record review of a physician visit note 12/9/2022 18:31 (6:31 PM) . I examined the wound on R lower leg, discoloration of legs, pt (patient) has h/o (history of) PVD and he has seen (physician name) before, pt has stasis ulcers and venous ulcers on R lower leg, will take long time to heal, Doxycycline (antibiotic) was started, cont (continue) wound care and increase activity . A review of the physician orders revealed 12/9/2022 . Doxycycline Hyclate Table 100 MG (milligrams) . Give 1 table by mouth two times a day for infection for 10 days . Resident #285: On 12/06/22, at 1:00 PM, Resident #285 was sitting in their wheelchair in their room along with family. Resident #285 had their head leaned forward and appeared to be uncomfortable. On 12/07/22, at 1:01 PM, a record review of Resident #285's Electronic Medical Record (EMR)revealed an admission on 11/23/22 with diagnoses that included Stroke, urinary retention and aphasia. Resident #285 required extensive assistance with all Activities of Daily Living and was severely cognitively impaired. A review of the AFTER VISIT SUMMARY from the hospital revealed: Foley was placed 11/16/22 and will need to be exchanged every 30 days/Trial of void in urology office . A review of the progress notes from admission to discharge revealed no nurses' note documentation of the Foley catheter discontinuation or any follow up on how the resident urinated with the catheter discontinued. A review of the Treatment Administration Record 11/1/2022 - 11/30/2022 revealed Foley cath to dependent drain. Ensure cath strap intact every shift. Foley cath care every shift . Start Date- 11/24/2022 0700 -D/C Date- 11/26/2022 14:03 . The days were check marked for 11/23 and 11/24 and only the day shift for 11/26 which appeared the catheter was discontinued at the end of day shift or sometime in the afternoon shift. On 12/12/22, at 3:05 PM, an interview was conducted with Unit Manager J who was asked to review Resident #285's electronic medical record and offer what nurse documented the removal of the Foley Urinary catheter. Unit Manager J stated, well it looks like it was discontinued on 11/26. Unit Manager J was asked if they knew who removed the catheter and Unit Manager J stated, 'No, I don't. Unit Manager J was asked to provide the physician's order to discontinue the Foley catheter and Unit Manager J stated, that there wasn't an order. Unit Manager J stated that the physician note on 12/7/2022 and stated that the Nurse Practitioner called and wanted the resident sent to the ER. The note revealed: . wants resident sent to ER due to his lab results of BUN 119 and Create 2.4, and also due to resident's Foley catheter being discontinued when it was to remain in until resident seen by (urologist) . On 12/15/22, at 12:30 PM, a record review of the hospital documents revealed the following: Admission H & P (history and physical) Chief Complaint abnormal BUN/Create . Notably abdominal distention, with urinary retention, Foley catheter inserted in the ER with 2 L (liters) (2000 milliliters) of urinary output . Assessment/Plan . 3. Acute urinary retention . The Director of Nursing (DON) was asked if they knew what nurse discontinued the Foley catheter on Resident #285 and the DON stated, that they were still trying to figure it out. According to WebMD, . The bladder is lined by layers of muscle tissue that stretch to hold urine. The normal capacity of the bladder is 400-600 mL. (milliliter)

Based on interview and record review, the facility failed to correctly reconcile [MEDICATION NAME] (blood pressure medication) and [MEDICATION NAME] (a diuretic medication) per the discharge medication list from the hospital and failed to assess and monitor weight per standards of practice for [MEDICAL CONDITIONS], for one resident (Resident #301) of three residents reviewed for medication reconciliation, resulting in Resident #301 not receiving the correct dose of [MEDICATION NAME] and [MEDICATION NAME], having ongoing bilateral leg [MEDICAL CONDITION], and a four day hospitalization for uncontrolled hypertension and [MEDICAL CONDITION] exacerbation on the day Resident #301 left the facility. Findings include: On 9/10/20, at 8:30 AM, a review of Resident #301's electronic medical record revealed an admission on 6/25/20 with [DIAGNOSES REDACTED]. Resident required assistance with Activities of Daily Living (ADL's) and had intact cognition. A review of the discharge orders from Resident #301's hospital stay revealed After Visit Summary 6/18/2020 - 6/25/2020 . Continuing Care . Medication List START taking these medications . [MEDICATION NAME] 20 MG tablet Commonly known as: [MEDICATION NAME] Take 20 mg by mouth daily. Last time this was given: 20 mg on June 25, 2020 8:28 AM . [MEDICATION NAME] 2.5 MG tablet Commonly known as: [MEDICATION NAME] Take 7.5 mg by mouth twice daily. Last time this was given: 7.5 mg on June 25, 2020 8:28 AM . Discharge Instructions . For Heart Failure/Cardiac Patients: . Weighing myself daily and reporting a gain of 2-3 pounds a day and/or 5-6 pounds a week to my physician is important. If any of my Heart Failure symptoms worsen, I am to contact my doctor or go to the nearest emergency department . A review of physician orders [REDACTED]. Signed By: (Physician B) A review of history and physical examination [REDACTED]. s/p (status [REDACTED]. LE: (lower extremity) mild [MEDICAL CONDITION] noted bilaterally Medical Treatment Plan continue current treatment . current medications reviewed discussed with nursing staff D/C (discontinue) [MEDICATION NAME] Start on [MEDICATION NAME] . A review of progress notes revealed 6/25/2020 16:49 [AGE] year old female admitted for skilled therapy . (Physician B) notified of admission and orders will continue as received at this time. There was no Nurses or Physician note regarding why [MEDICATION NAME] was left off the medication regimen and why the [MEDICATION NAME]'s dose was lessened. A review of Nurses Notes revealed: Nurses Note 7/2/2020 0905 . + 2 [MEDICAL CONDITION] to bilateral lower extremities . Nurses Note 7/9/2020 13:46 . res has increase in BLLE (bilateral lower leg [MEDICAL CONDITION]) 1 + pitting spoke with NP (nurse practitioner) orders to give one time dose of [MEDICATION NAME] 20 mg today and check her labs in the morning prior to D/C (discharge) A review of Orders Note 7/9/2020 13:45 . The order you have entered [MEDICATION NAME] Tablet 20 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time only for increase [MEDICAL CONDITION] for 1 Day . A review of Resident #301's vitals revealed only two weights during their 15 day stay. On 9/10/20, at 8:50 AM, the Director of Nursing (DON) was asked if the facility treats [MEDICAL CONDITION] and if they could provide the [MEDICAL CONDITION] policy. The Don stated, Yes., they do daily weights but it would be up to the doctors discretion during Covid. The DON further offered that they felt it would put the resident at risk to come out of their room to get a daily weight and stated No when asked if they had a scale that could be placed in the resident room for daily weights. The DON stated that usually two nurses do the reconciliation when the resident comes from the hospital and that I will have to look when asked why Resident #301's [MEDICATION NAME] was missed and the [MEDICATION NAME] dose was incorrect. On 9/14/20, at 10:30 AM, a review of the facility provided . Admission Checklist . Medications entered into PCC (electronic medical record) queued. Verified with initials on transfer summary by 2 nurses. Admitting Dr. (Tele Med if after hours) notified of admission, meds verified and recorded in progress note -And meds activated and sent . On 9/14/20, at 1:00 PM, a record review of hospital admission records admitted : 07/10/2020 discharge date : 07/13/2020 . Reason for Admission: Bilateral lower extremity swelling . This patient presented to emergency department with a concern of bilateral lower extremity [MEDICAL CONDITION] . The patient's daughter contacted . cardiologist who recommended evaluation in the emergency department. The patient was admitted started on IV (intravenous) [MEDICATION NAME] for diastolic heart failure exacerbation . Admitting Diagnoses: [REDACTED]. Hypertensive urgency . Weight Continuous Daily . Chest X-Ray Exam Date: 7/10/2020 1:39 PM . Impression: Mild [MEDICAL CONDITION] vascular congestion. Small bilateral effusions . A further review of progress notes revealed 7/10/2020 09:59 Nurses Note . Resident discharge reviewed with resident . stated her daughter would be handling her medications . No distress observed . Resident discharged in stable condition with daughter . There was no mention of Resident #301's lower extremity [MEDICAL CONDITION] or what their recent weight was. On 9/14/20, at 2:00 PM, a record review of facility provided policies revealed: CARE PATH Symptoms of Heart Failure (HF) Symptoms of Signs of HF in a resident with know HF risk factors for HF . Weight gain of 3 lbs (pounds) in three days or 5 lbs in seven days worsening [MEDICAL CONDITION] . Admission Criteria Revised December 2012 . Admit residents who can be cared for adequately by the facility . Physician Services Revised August 2006 . The medical care of each resident is under the supervision of a licensed Physician . The resident's Attending Physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, and providing consultation of treatment when called by the facility . Cardiovascular Conditions Monitoring and Follow-Up 1. The physician will help monitor the progress of individuals with HF (heart failure), including ongoing evaluation and documentation of signs, symptoms, and condition changes . Heart Failure-Clinical Protocol Revised October 2010 . As part of the initial assessment, the physician will help identify individuals with a history of heart failure and will clarify, as much as possible, its severity and underlying causes . In addition, the nurse will assess and document report the following: a. Vital signs; b. general physical assessment . d. All current medications, especially antihypertensive therapy . The physician will review and make recommendations for relevant aspects of the nursing care plan . The physician will prescribe treatments for residents with heart failure that are consistent with relevant guidelines and protocols; for example, those of the American Heart Association and American Medical Directors Association (AMDA) .

Based on observation, interview and record review, the facility failed to prevent a fall, update the safety care plan with appropriate interventions to prevent a fall causing a femur fracture for 1 (Resident #62) who had a history of [REDACTED]. On 9/18/18, at 9:18 AM, Resident #62 complained, Oh I fell and reinjured my hip. The first time I fell at home in my garage. I quit exercise, they cut that off and nobody has helped me since. I was able to walk 30 feet and after the second surgery I wasn't able to. Resident #62 was asked if there was pain in the hip and Resident #62 stated, It's just when I move around and I have no strength. I need 2 (staff) to help me sit down now to the bathroom. I'm not sure why I don't exercise anymore. On 9/18/18, at 2:00 PM, a record review of Resident #62's face sheet indicated an original admission on 6/26/18 with a readmission on 7/7/18 after an emergency discharge on 7/4/2018 from a fall with the following [DIAGNOSES REDACTED]. Resident #62 required extensive assistance with transfers including bed mobility and had intact cognition. On 9/18/2018, at 11:00 AM, a record review of Resident #62's electronic medical record revealed the following: The Safety: Risk for falls r/t (related to) . hx (history) of Falls . impaired balance . pain, left hip fx. (fracture) care plan dated initiated 06/26/2018 . Goal . Resident wishes to have no falls or injuries through 9/24/18 date initiated 06/26/2018. Interventions . anti-tippers on wheelchair date initiated 09/06/2018 . assess and treat pain date initiated 06/26/2018 . offer to lay down after lunch date initiated 08/10/2018 . try to support resident when leaning to the left as this is resident's weak side date initiated 07/10/2018. Hospital medical records for Resident #62 date of service 07/04/2018 . the patient apparently had fallen last night and has been unable to ambulate since the fall . the patient complains of pain in his left hip . x-ray was read by the radiologist as a minimally displaced acute fracture in the region of the lesser trochanter in hip. The discharge instructions revealed procedure performed 7/6/18 ORIF (open reduction internal fixation) left hip revision. Administrative statement investigative analysis . on (MONTH) 3, (YEAR) at approximately 1906 (7:06 PM) the resident was assisted to the toilet; the resident was provided the call light in the bathroom to call for assistance when done . The resident in room called to alert me that he was finished using the restroom . I saw the resident remove his glasses while standing with the walker and lean forward to place them on his bedside table which was in the corner of the room near the head of the bed. As I finished turning down the bed, I turned back to the resident and observed him actively falling backwards. I reached to attempt to stall the fall but was only able to slow his descent. Once the resident had come to rest on his backside . The Fall report dated 7/3/2018 19:06 listed predisposing situation factors the box Gait belt not used was checked. Visual/bedside Kardex report . print date 7/4/2018 . Locomotion ambulation with 1 person assist and 2ww (wheeled walker) to/from bathroom/meals/therapy . Transfer 1 assist with 2ww On 9/18/18, at 11:59 AM an interview with the DON B reviewing Resident #62's falls and his lack of ambulation at the facility which revealed (the resident) was made 1 on 1 until he went to the hospital even with a bims (brief mini-mental assessment used for cognition) of 15 with a potential for an injury, we stay with the resident. Resident #62 had a fall on 8/2/18 (the residents) knees buckled and was lowered to the floor with 2 staff. The DON B stated the intervention was that the resident was changed to a 2 person assist and offer a rest after lunch. The DON was further questioned why Resident #62 was walking 40 ft upon therapy discharge and now isn't walking at all and the DON B stated He is getting range of motion and he is telling us that he is not wanting to. The DON B was asked to provide documentation that Resident #62 was refusing. The DON B did not provide any documentation prior to exit. On 9/18/18, at 9:39 AM, an interview with Interim Therapy Manager PP, revealed that Resident #62 was walking 40 ft with minimal assist on discharge. (The resident) was discharged [DATE]. On 9/19/18, at 2:24 PM, Resident #62 stated, Oh yeah I have pain. I started taking exercises then it kept getting worse. No pain now but when I move it does hurt. I can't stand on it. Resident #62 also stated that he is not sure if (the resident) will be able to go back home now that (the resident) broke his hip again. On 9/19/2018, at 3:00 PM, a review of the facility policy Falls reduction program . origination date: (MONTH) 2008 . revision date: 9/25/2016 . Purpose: To provide a safe environment for residents, modify risk factors and reduce risk of fall-related injury.

Based on observation, interview and record review, the facility failed to add appropriate care plan interventions to prevent the worsening of a suspected deep tissue injury pressure ulcer in a timely manner, prevent an infection to the right heel pressure ulcer for 1 resident (Resident #62) reviewed for pressure ulcers resulting in pain and the potential for further complications. Findings include: On 9/18/18, at 2:00 PM, a record review of Resident #62's face sheet indicated an original admission on 6/26/18 with a readmission on 7/17/18 with the following [DIAGNOSES REDACTED]. Resident #62 required extensive assistance with transfers including bed mobility and had intact cognition. On 9/18/18, at 4:42 PM, an observation of Resident #62's wound care with Nurse CC, revealed a dressing to Resident #62's right heel dated 9/18 which had a moderate amount of green drainage. Nurse CC, removed the old dressing revealing open wound measuring approximately 1.5 inches by 1.5 inches and about a centimeter deep. The wound bed had yellow slough tissue covering approximately 75 % of the wound bed. Resident #62 stated, when (the nurse) changes the dressing it hurts. Nurse CC cleansed and covered the wound following the physician order. On 9/19/19, at 8:00 AM, a record review of Resident #62's electronic medical record revealed the following: Nurses Note dated 7/17/18 by Nurse NN stated purplish blister (A blister is a stage 2 pressure ulcer which is superficial and presents clinically as a blister or shallow crater, partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough) noted to right heel. Wound assessment dated [DATE]) wound is to the right heel. Wound is now unstageable (unstageable: full thickness tissue loss in which the base of the ulcer is covered by slough) r/t (related to) slough tissue. Wound assessment dated [DATE] . treatment is in place. There is odor present and redness noted to periwound. Slough tissue continues to loosen . antibiotic until 9/23/18. Skin Management care plan date initiated 06/26/2018 . Interventions . air mattress date initiated: 08/01/2018 . off load heels as tolerated date initiated: 08/06/2018. On 9/19/18, at 12:07 PM, an interview with the DON B was conducted to discuss the deterioration of Resident #62's right heel wound and the DON B had their lap top opened up, the DON B opened up the wound tab revealing wound progress notes that were not available to the surveyor. The DON B stated, I'm in PCC (point click care) Point click care was the online electronic medical records program the facility used. The DON B was asked why the facility was not giving the wound documents when they were asked to provide them and the DON B stated, ok I will have to ask (Nurse OO) because corporate sometimes don't let us give things. On 9/19/18, at 12:59 PM, Nurse K , was interviewed regarding the worsening of Resident #62's right heel wound and Nurse K stated on 9/13 it became infected. Nurse K also stated it was a stage 2 on 7/25 then it became unstageable and it opened on 8/2. Nurse K was asked if the wound became worse in the facility and nurse K stated Yes, it did.

The following deficient practice refers to intakes MI 800 and MI 801. This citation has two deficient practice statements. Based on observation, interviews, and record review, the facility failed to provide supervision to prevent accidents for 1 resident (Resident #101) of 10 sampled residents, from a total sample of 10 residents, resulting in Immediate Jeopardy for Resident #101 who was assessed to be at risk for falls, required assistance with all Activities of Daily Living (ADL's) and ambulation and who was found on her bathroom floor bleeding and unresponsive, resulting in Resident #101 being transferred to the hospital and placed on a ventilator. Resident #101 subsequently died . This deficient practice places 30 residents, identified as being at risk for falls, at high risk for serious injury, harm and/or death. Findings Include: Resident #101: Review of the face sheet, minimum data set (MDS, resident assessment tool), dated [DATE]; Physician and Nurses' notes, dated [DATE] through [DATE]; [DIAGNOSES REDACTED].#101 had been admitted to the facility on [DATE], was able to make her needs known, required assistance with all ADL's and the assistance of 2 staff for ambulation and had decreased hearing and poor vision. Resident #101's [DIAGNOSES REDACTED]. The resident was transferred to the facility for short term rehabilitation. Resident #101 was admitted on [DATE] at 4:55 p.m., and was found un-responsive in her bathroom on [DATE] at 1:15 a.m. (8 hours and 20 minutes after admission), given Cardio-Pulmonary Resuscitation (CPR), transferred to the hospital and subsequently died . Review of the facility unusual occurrence report and investigation, dated [DATE], revealed that on [DATE] at 1:15 a.m., Resident #101 was found by Certified Nursing Assistant (CNA) #1. The report stated that the resident was "laying on the bathroom floor face down, laceration noted above right eye with bleeding, bleeding from nose also observed". CPR was initiated by staff, 911 was called and the resident was transferred to the hospital. The resident's bed was in the low position with her call light within reach, at the time of her fall. Review of the facility Nurses' Notes, dated [DATE] at 2:35 a.m. and signed by Charge Nurse LPN #1 stated "at approx. (approximately) 0115 (1:15 a.m.) cena (CNA) called this nurse to Res. (resident) RM (room), Res. Found face down on bathroom floor, Br. (bright) red blood noted bleeding heavily from nose, Res. Non-responsive. Rolled Res. Over to back via 2 assist, lg. (large) open wound noted above R (right) eye brow noted bleeding heavily. Pulse noted upon initial assessment, pupils non-reactive, O 2 (oxygen) via non-re-breather mask on 10 L/min (liters per minute), skin dusky, checked for pulse, no pulse palpable, no heart beat heard upon auscultation. 911 called, CPR started, paramedics arrived approx. 0120 (1:20 a.m.). Res. Sent to E.R. (emergency room ) for eval and tx (evaluation and treatment), family called and notified". Review of the Pre-hospital Care Report (ambulance report), dated [DATE], revealed "elderly female fell and is unresponsive, pt. (patient) has a laceration on her forehead, eyes were open and pupils were fixed, nurse said she was found a few minutes ago like this and was apparently trying to walk to the bathroom". Review of the Emergency Services report, dated [DATE], revealed "The patient is in severe distress, she has a large head contusion and scalp laceration over her right forehead. She does not follow commands at all. There was mild posterior displacement of the dens (part of the spine, neck region), there is also discontinuity in the left posterior aspect of the C 1 (upper part of the spine) ring; it could be an acute deformity since there was a dens fracture also. Fractured left nasal bone, right frontal soft tissue swelling". Further review of hospital records revealed a C 2 (upper part of the spine, neck region) fracture. Review of the Hospital Emergency Services record, dated [DATE], identified a possible hip fracture and revealed "alignment of the hips appear normal, it may or may not possibly be a fracture of the right hip, wrote down a fracture cannot be excluded". Further review of hospital records, dated [DATE], revealed no documentation of a hip fracture. Review of the Hospital consultation, dated [DATE], revealed "a [AGE] year-old, who up to recently was living independently. She has been recently in the hospital and actually discharged on [DATE]. She went to the nursing home and they found her non-responsive in the bathroom. She was admitted to the intensive care unit. She was intubated (a breathing tube) she had sustained a C 2 fracture (a fracture of the neck). She had significant hematoma (bruising) involving the periorbital (eye area) regions and the side of head, there was bruising on the right side of the body, prognosis for any type of meaningful survival in my opinion is essentially 0 at an age 95 with the findings I am seeing. Unfortunately I feel this is a probable terminal event". Review of the hospital emergency department CT preliminary report, dated [DATE], stated "fracture of the left nasal bone, right frontal soft tissue swelling ". Review of the hospital CT maxillofacial area, dated [DATE], stated " Minimal left-sided nasal bone fracture". Review of the hospital CT of head and C spine radiology report, dated [DATE], stated "fracture of C 2". In an interview on [DATE] at 12:30 p.m., CNA #2 stated "I assisted her to bed. She (the resident) shuffled her feet, she was a 1 transfer. Therapy was not here to assess her. She shuffled her feet and was slow when I put her on the toilet. She said to me that if she could take herself to the bathroom, she'd be able to go home tomorrow, I know I told (the ADON) and I did tell her (Charge Nurse LPN #1) and she (Charge Nurse LPN #1) said they would keep an eye on her and if they needed to alarm her they would. I think an alarm might have prevented it, I think she tripped on the bathroom floor, I guess I did the best I could". Review of the facility investigation interview with CNA #2, dated [DATE] ([DATE]) at 3:00 p.m., stated "10:45 p.m., she (the resident) wanted to prove to her family that she could go home tomorrow (by taking herself to the bathroom), CENA stated not a good idea, tucked back in, left room 10:55 p.m. when she left room reported to nurse (Charge Nurse LPN #1) that resident transferred herself". In a telephone interview on [DATE] at 10:50 a.m., Family Member #2 stated "I had told everybody there (at the facility), even the rehab girl in the hallway that she (Resident #101) said she could not walk. (The rehab employee) introduced herself to her (the resident) and said she was going to work with her tomorrow and I said how much rehab are you going to do with a [AGE] year old". Family Member #2 was unable to recall the name of the rehab staff member who she talked with in the hall on [DATE]. In an interview on [DATE] at 11:05 a.m., CNA #1 stated "I got report and I was told she (the Resident #101) was x 1 assist. The nurse told me one assist to the bathroom. I heard a crash, I went running and found her laying on the bathroom floor, she was laying on her belly with her head to the side facing the left with blood from her nose, it looked like quite a bit, it was running down the drain, she was between the toilet and the shower, I ran back to the door to yell for help. She had oxygen in her room, not on her. (Charge Nurse LPN #1) had me help turn her over, I was very nervous about turning her; she did not look like she was breathing. (Charge Nurse LPN #1) started CPR and told them to call 911. She did not have an alarm, the only thing that could of prevented it was to have an alarm". Review of the facility investigation interview with CNA #1, dated [DATE] at 2:30 p.m., stated "Do not remember seeing wheelchair by bed. Typically, WC (wheelchair) are in BR (bathroom) on that unit for residents who don't ambulate, never spoke to her (the resident) directly, she did not use the call light". In a telephone interview on [DATE] at 12:18 p.m., Charge Nurse LPN #1 confirmed the facility ADL sheets revealed Resident #101 required assist of 2 staff members for ambulation, and stated "she (Resident #101) was a fall risk, the CNA told me at 11:00 p.m., she said (residents room number) had transferred herself, keep an eye on her. After I got done with report I went down and talked with the resident, she agreed to use the call light, CNA called me down to the room; the resident (#101) was laying chest/face down in the bathroom and heavily bleeding from her nose. The resident was un-responsive, once we got her rolled over I noticed a large laceration above her eyebrow on the right side of her forehead, a stat call was called". When the surveyor asked Charge Nurse LPN #1 if the fall could have been prevented she stated "yes, ya I guess maybe if there was an alarm on her". Review of the facility investigation interview with Charge Nurse LPN #1, dated [DATE] at 8:30 a.m., stated "No alarms in use, was not deemed a fall risk upon admission, alert oriented with forgetfulness, during 2nd shift tried to transfer herself once, (Charge Nurse LPN #1) spoke with resident (#101) informed her of the possibility of alarm intervention". In an interview on [DATE] at 12:05 p.m., Charge Nurse RN #3 stated "She was on the floor, there was a lot of blood, I helped with CPR. I heard she was self-transferring during the day, (Charge Nurse LPN #1) told me she was upset and said she (Resident #101) should have had an alarm". An interview was conducted on [DATE] at 11:55 a.m., with Charge Nurse LPN #4. When Charge Nurse LPN #4 was asked by the surveyor why the resident did not have an alarm, she stated "she gave no signs of trying to get up, I based it on she (Resident #101) made no attempts to get up on her own, the family did not tell me she was a fall risk, it's not our protocol to put alarms on residents who do not try to get out of bed". Charge Nurse LPN #4 said she worked the hall where the resident (Resident #101) on [DATE], 7:00 a.m. to 7:00 p.m. and said she had done the resident's (#101's) admission and completed her fall risk assessment, dated [DATE]. Charge Nurse LPN #4 stated "it's a possibility it could have been prevented". Review of the facility Fall Risk Assessment, dated [DATE], revealed Resident #101 was scored at a "26", which put her at risk for falls and stated "When resident's total score is 10 or more, interventions should promptly be put in place". In an interview on [DATE] at 3:15 p.m., Charge Nurse LPN #8 confirmed the facility admission data was correct and the resident (#101) required the assist of 1 staff with toileting and the assist of 2 staff for ambulation. When asked if the resident was at risk for falls, Charge Nurse LPN #8 stated "yes, I think it could have been prevented, there could have been an alarm". In an interview on [DATE] at 1:50 p.m., the Assistant Director of Nursing (ADON) #1 stated "all she (the resident #101) had was a bed in low position, had it been me and I was the charge nurse and a CNA had reported that the resident said she was going to get up or attempt to get up, I would have put a sensor pad on the bed". An interview was done on [DATE] at 2:30 p.m., with the Director of Nursing (DON). The DON stated "I don't think any other interventions (other than her bed being in low position) should have been put in place. I would not of had a low bed (high/low bed), I would not have put alarms on, I would not have put her on a parameter mattress, I would not have put floor mats, because I think those things would of contributed to falls". The DON said if a resident was a new admit in a new environment and at risk for falls she would "check frequently and document on her at least every hour while awake". The DON said Charge Nurse LPN #4 got her information regarding the resident's functional status from the "transfer record from the hospital" and from interviews with the "resident" and "family", and stated "so it's relevant". A second interview was done on [DATE] at 10:15 a.m., with the DON. The DON stated "no, we didn't add an alarm to the care plan yet, we would of added it after the IDT (interdisciplinary team) meeting the next day (on [DATE]). The nurses can add it to the care plan; we were in the process of training them at the time". In interviews on [DATE] at 11:40 a.m., Physical Therapist #1 (PT #1) and Occupational Therapist #1 (OT #1) agreed the Charge Nurse had assessed the resident's functional status correctly from the hospital discharge data and the resident required assistance of 1 for toileting and 2 for ambulation. PT #1 and OT #1 said they had not gotten a chance to assess Resident #101 prior to her fall because she was admitted on 2nd shift and they had gone home. Review of the Hospital Inter Agency Referral form, dated [DATE] (hospital transfer sheet at time of admission to the facility), stated "patient requires continuous oxygen 2 L O2 (2 liters, oxygen), HOH (heard of hearing), glasses, needs assistance (for) dressing, bathing" and required assistance "of 2" for "transfers". Review of the facility Admission Data Collection, dated [DATE], stated Resident #101 was "alert" "oriented to person" and "mental function varies", vision was "poor, with glasses" and based on interview and review of the hospital transfer record, required assistance of 1 with bed mobility, dressing, toileting, personal hygiene, bathing and assistance of 2 with ambulation. Review of the facility Admission Nurses Notes, dated [DATE] at 1600 (4:00 p.m.), revealed "Received A (alert) and O (oriented) x ,[DATE]". Review of Resident #101's facility fall admission care plan, dated [DATE], revealed the safety/fall interventions put in place were "orient to surroundings, PT (Physical Therapy evaluation), OT (Occupational Therapy evaluation), maintain bed in lowest possible position for safe transfers". Review of the cardiac admission care plan, dated [DATE], stated "monitor for endurance". Review of the Resident Care Guide (CNA guide to the residents care), un-dated, revealed no documentation of any safety interventions in place (including no seizures precautions- resident had history of seizures) and revealed the resident was a "2 assist" for mobility. Review of the PM ADL Documentation, dated [DATE] and the AM ADL Documentation dated [DATE], revealed Resident #101 was assisted by 1 with transfers and toileting. Review of facility conclusion of investigation, time line of events prior to the residents fall on [DATE] (un-dated), revealed "(Charge Nurse LPN #1) in phone interview stated that she spoke to (Resident #101) about self-transfer, and discussed the possibility of alarm intervention if she continued to self-transfer". The Administrator was notified on [DATE] at 3:55 p.m. of the Immediate Jeopardy which was identified on [DATE] and began on [DATE], due to a lack of supervision of Resident #101 who was assessed by the facility to be at risk for falls, required assistance with all Activities of Daily Living, required the assistance of two persons for ambulation and was found on her bathroom floor bleeding and unresponsive. The resident was transferred to the hospital and put on a ventilator. Resident #101 subsequently died . On [DATE] at 4:15 p.m., the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy. 1. On [DATE] at 4:40 p.m., the facility held a quality assurance meeting to review the notification to the facility of Immediate Jeopardy report and developed the abatement plan. 2. On [DATE] at 4:40 p.m., the facility's Fall Reduction Program (NRS-248A) was reviewed by the interdisciplinary team and found to be acceptable. 3. On [DATE] at 4:40 p.m., the facility's Alarm Devices Policy (NRS-105) was reviewed by the interdisciplinary team and found to be acceptable. 4. On [DATE], the interdisciplinary team reviewed the Resident Fall CAA, Care Plan, Resident Care Guide, Individual Resident Tracking of Occurrences, Modifiable/non-modifiable risk factors, current transfer/ambulation orders, assessed individuals at risk of falls (29 and 1 discharged identified in the Immediate Jeopardy report) orders, risk factors and interventions. 5. On [DATE] at 11:00 a.m., the Director of Nursing or Designee inspected all fall alarms in the facility for functionality and replaced as indicated. 6. On [DATE], the Nursing Assistants checked all tab/sensor alarms for placement/functionality at the start of each shift. Documentation of alarm placement/functionality was put on the Resident Care Guide. 7. On [DATE], the Licensed Nurses started auditing, once per shift, the Nursing Assistants documentation of alarm placement and functionality. 8. On [DATE], the Licensed Nurses started auditing, once per shift, all residents with fall alarms for proper placement and function, and documented it on the Medication Administration Record. 9. On [DATE] at 6:30 a.m., the RN Staff Educator or Designee initiated all staff inservices regarding the facility's Fall Reduction Program (NRS-248A), Use of Alarm Devices (NRS-105), and providing care as directed by the care plan and care guide. 30 facility staff members out of 152 had been educated by [DATE] at 2:00 p.m. and no staff will be allowed to work until education is completed and documented. 10. On [DATE] at 1:00 p.m., the RN Staff Educator or Designee initiated all Licensed Nurses inservices prior to the facility admitting a resident to the facility on the Admission Data Collection process for appropriate safety risk analysis and individualized safety interventions. 6 facility Licensed Nurses out of 35 had been educated as of [DATE] as of 2:00 p.m. No Licensed Nurse will be allowed to do an admission until the education is completed and documented. 11. On [DATE], newly admitted residents will have their Admission Data Collection completed utilizing data obtained from observation, interview, assessment and transfer record by a Licensed Nurse. Any safety concerns will be immediately documented on the Admission Care Plan and Resident Care Guide and appropriate individualized interventions put in place. 12. On [DATE], each new admit to the facility will be reviewed by the interdisciplinary team (IDT) for appropriate safety risk analysis and individualized safety interventions at the IDT meeting following the admission. Although the Immediate Jeopardy was removed on [DATE] at 4:15 p.m., the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff not having been in serviced and sustained compliance had not been verified by the State Agency. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONDUCT RELIABLE DETAILED SKIN ASSESSMENTS, FAILED TO ADEQUATELY REASSESS RISK FACTORS, FAILED TO TIMELY DEVELOP AND IMPLEMENT INTERVENTIONS TO PREVENT PRESSURE ULCERS FROM DEVELOPING, AND FAILED TO ENSURE A RELIABLE PROCESS FOR REDISTRIBUTING PRESSURE RELIEF, AND FAILED TO ENSURE THAT STAFF WERE CONSISTENT WITH DOCUMENTATION STANDARDS IN TWO RESIDENTS (#2 & #11) KNOWN TO REQUIRE ASSISTANCE WITH PRESSURE RELIEF IN FIVE RESIDENTS REVIEWED FOR PRESSURE ULCERS IN A TOTAL SAMPLE OF 24 RESIDENTS. RESIDENT'S #2 & #11 DEVELOPED MULTIPLE AVOIDABLE PRESSURE ULCERS THAT WERE SUSCEPTIBLE TO INFECTION AND FURTHER DETERIORATION. DUE TO THESE RESIDENTS' HEALTH PROBLEMS, THE ANATOMICAL LOCATION OF THEIR ULCERS, AND THEIR DEPENDENCE ON STAFF TO PROVIDE SAFE AND EFFECTIVE TREATMENT, THE HEALTH AND SAFETY OF RESIDENTS #2 & #11 IS IN IMMEDIATE JEOPARDY. A THIRD RESIDENT (#8) WAS IDENTIFIED AS HAVING DEVELOPED AN AVOIDABLE, FACILITY ACQUIRED STAGE III ULCER, AFTER THE FACILITY FAILED TO ASSESS THE REASONS FOR THE RESIDENT'S NON-COMPLIANCE WITH PREVENTATIVE SKIN INTERVENTIONS THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED AT 12:30 P.M. ON 10/16/12. THE IMMEDIATE JEOPARDY BEGAN AT 11:00 A.M. ON 10/4/12 WHEN (ACCORDING TO FACILITY "TREATMENT NOTES" DATED 10/4/12) RESIDENT #2, A [AGE] year OLD RESIDENT WHO HAD BEEN ASSESSED BY THE FACILITY UPON ADMISSION TO BE AT "MODERATE" RISK FOR PRESSURE ULCER DEVELOPMENT, WAS FOUND TO HAVE A "SUSPECTED DEEP TISSUE INJURY" WOUND TO HER LEFT HEEL AND A "STAGE II" PRESSURE ULCER ON HER LEFT BUTTOCK THAT WERE ACQUIRED AT THE FACILITY AND THAT WERE AVOIDABLE. ACCORDING TO THE FACILITY'S "WOUND ASSESSMENT DETAILS REPORT" DATED 10/9/12, THE CONDITION OF THE LEFT HEEL ULCER DETERIORATED, AND WAS DESCRIBED AS AN "UNSTAGEABLE" WOUND THAT HAD "100%" NECROTIC (DEAD) TISSUE. WITHIN TWO DAYS, A SECOND RESIDENT (#11), WHO WAS ALSO ASSESSED BY THE FACILITY TO BE AT "MODERATE RISK" FOR PRESSURE ULCER DEVELOPMENT, WAS FOUND TO HAVE A "SUSPECTED DEEP TISSUE INJURY" TO HER LEFT HEEL. RESIDENT #11'S HEEL ULCER WAS FURTHER DESCRIBED (ON THE "WOUND ASSESSMENT DETAILS REPORT" DATED 10/6/12) TO HAVE "100% NECROTIC TISSUE TYPE." JUST ONE DAY LATER, RESIDENT #11 WAS FOUND TO HAVE ANOTHER NEW ULCER. ACCORDING TO THE "WOUND ASSESSMENT DETAILS REPORT" DATED 10/9/12, THIS SECOND ULCER WAS DISCOVERED ON 10/7/12. THE ULCER WAS DESCRIBED AS A NEWLY ACQUIRED "SUSPECTED DEEP TISSUE WOUND" TO THE LEFT BUTTOCK AND WAS FURTHER DESCRIBED AS "NECROTIC". DURING AN INTERVIEW CONDUCTED AT 12:10 P.M. ON 10/16/12, THE DIRECTOR OF NURSING (DON) WAS ASKED WHY THREE OF THE FOUR WOUNDS, INVOLVING RESIDENTS #2 & #11 WERE NOT DISCOVERED UNTIL THERE WAS ALREADY EVIDENCE OF DEEP TISSUE INJURY OR NECROSIS IN THE TISSUES. THE DON INDICATED THE FACILITY STAFF FAILED TO PERFORM SKIN ASSESSMENTS FOR THESE TWO "AT RISK" RESIDENTS. THE DON RESPONDED BY SAYING THE FACILITY DOES NOT HAVE ANY DOCUMENTATION DEMONSTRATING THE NURSES WERE ASSESSING RESIDENT #2'S & #11'S HEELS UNTIL THE NIGHT(S) THEIR PRESSURE ULCERS WERE DISCOVERED. AT THE WEBSITE http://tc.nphhi.org , THE 2012 NATIONAL ASSOCIATION OF PUBLIC HOSPITALS HEALTH SYSTEMS REGARDING PRESSURE ULCERS READS, "A PRESSURE ULCER IS A LOCALIZED INJURY TO THE SKIN AND/OR UNDERLYING TISSUE CAUSED BY PRESSURE OR THE COMBINATION OF PRESSURE AND FRICTION. THE PRESSURE IS GENERALLY DUE TO THE WEIGHT OF A PATIENT'S BODY PART APPLIED TO A SMALL AREA OF A MATTRESS, SUCH AS THE WEIGHT OF A HEEL, HIP OR ELBOW...THE HARM THEY CAUSE VARIES WIDELY....PRESSURE ULCERS THAT PROGRESS ARE A MUCH MORE SERIOUS PROBLEM, CAUSING SIGNIFICANT PAIN AND COMPROMISING DAILY ACTIVITIES. SEVERE PRESSURE ULCERS PUT PATIENTS AT SIGNIFICANT RISK FOR INFECTION AND CAN POTENTIALLY RESULT IN DEATH..." ON 10/16/12 AT 12:30 P.M., THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY (IJ) AND A WRITTEN PLAN FOR REMOVAL OF THE IJ WAS REQUESTED. DURING THE COMPLETION OF THE EXTENDED SURVEY ON 10/16/12, THE IJ WAS REMOVED WHEN THE FACILITY IMPLEMENTED THE FOLLOWING ACTIONS: - AT 4:55 P.M., RESIDENTS #2 & #11 WERE BEING MONITORED ON AN HOURLY BASIS BY FACILITY STAFF, TO ENSURE THE APPROPRIATE PRESSURE RELIEVING INTERVENTIONS WERE BEING PROVIDED. - AT 4:55 P.M., DIRECTOR OF NURSING (DON) REVIEWED THE ASSESSMENT, TREATMENTS, CARE PLANS AND CARE GUIDES OF RESIDENT #2 & #11 AND REVISE AS NECESSARY. - AT 4:20 P.M., THE DON AFFIRMED SHE WOULD BE ASSUMING THE RESPONSIBILITY OF WOUND CARE PROGRAM OVERSIGHT. THIS INCLUDED THE ADMISSION SKIN ASSESSMENT INCLUDING RISK DETERMINATION, DEVELOPMENT AND IMPLEMENTATION OF CARE PLANS AND CARE GUIDES, MONITORING OF THE CARE PLANS AND ALL SKIN/WOUND INTERVENTIONS. - AT 2:30 P.M., THE DON AFFIRMED DETERMINATION OF PARAMETERS AND CATEGORIES FOR ASSESSING RESIDENTS AT RISK TO DEVELOP PRESSURE ULCERS BASED ON THE RESIDENT'S BRADEN SCORE AND MODIFIABLE/NON-MODIFIABLE RISK FACTORS. - REGISTERED NURSES TO REVIEW ALL RESIDENTS WITHOUT CURRENT SKIN/WOUND ISSUES TO DETERMINE LEVEL/CATEGORY OF RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS AND REPORT FINDINGS TO THE DON. - ANY RESIDENT DETERMINED TO BE AT RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS WILL BE ASSESSED BY THE DON. - ALL LICENSED NURSES AND CERTIFIED NURSE AIDES (CNAS) TO BE EDUCATED ON THE WOUND MANAGEMENT PROGRAM POLICY AND USE OF ACCOMPANYING FORMS. ALL LICENSED NURSES WILL HAVE TO BE TRAINED PRIOR TO THE START OF THEIR NEXT SCHEDULED SHIFT. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE REMAINED AT SEVERITY LEVEL OF ACTUAL HARM WITH SCOPE ISOLATED DUE TO: - RESIDENT #2 ACQUIRED AN AVOIDABLE "SUSPECTED DEEP TISSUE INJURY" WOUND WITH A STRONG ODOR TO HER LEFT HEEL AND A "STAGE II" PRESSURE ULCER WITH YELLOW SLOUGH (DEAD TISSUE) ON HER LEFT BUTTOCK. THE CONDITION OF THE LEFT HEEL ULCER DETERIORATED, AND WAS DESCRIBED AS AN "UNSTAGEABLE" WOUND THAT HAD "100%" NECROTIC (DEAD) TISSUE. - RESIDENT #11 ACQUIRED AN AVOIDABLE, PAINFUL "SUSPECTED DEEP TISSUE INJURY" TO HER LEFT HEEL WITH 100% NECROTIC TISSUE AND AN AVOIDABLE "STAGE II" PRESSURE ULCER TO HER LEFT BUTTOCK. - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH ENSURING THAT A RESIDENT WHO ENTERS THE FACILITY WITHOUT A PRESSURE SORE, DOES NOT DEVELOP A PRESSURE SORE UNLESS IT HAS BEEN DETERMINED UNAVOIDABLE AND WHEN A RESIDENT HAS A PRESSURE SORE, THE FACILITY PROVIDES THE NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING, PREVENT INFECTION AND PREVENT NEW SORES FROM DEVELOPING. FINDINGS INCLUDE: DURING THE INITIAL TOUR OF THE FACILITY, ON 10/9/2012 AT APPROXIMATELY 11:00 A.M., RESIDENT #2 WAS IDENTIFIED BY MINIMUM DATA SET (MDS) REGISTERED NURSE (RN) "F" AS HAVING DEVELOPED PRESSURE ULCERS ON HER HEEL AND COCCYX WHILE BEING CARED FOR BY FACILITY STAFF. A REVIEW OF RESIDENT #2'S ADMISSION "SKIN ASSESSMENT" DATED 8/31/2012 REFLECTED RESIDENT #2 HAD ENTERED THE FACILITY WITH INTACT SKIN ON HER HEELS. NONE OF THE BOXES ON THE 8/31/2012 FORM (UNDER PRE-EXISTING CONDITIONS) WERE CHECKED TO INDICATE THAT ANY OF THE PRECURSORS TO UNSTAGEABLE HEEL ULCER DEVELOPMENT HAD BEEN PRESENT (SUCH AS: PURPLE, DISCOLORED, HARD OR MUSHY HEELS) AT THE TIME OF RESIDENT #2'S ADMISSION TO THE FACILITY. ACCORDING TO THE UNDATED ADMISSION FACE SHEET FOR RESIDENT #2, SHE WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] FROM AN ACUTE CARE HOSPITAL FOLLOWING A STROKE. RESIDENT #2'S "ADMISSION RECORD" FOR 8/31/12 REFLECTED MULTIPLE CO-MORBIDITIES WITH [DIAGNOSES REDACTED]. ACCORDING TO THE FACILITY'S MINIMUM DATA SET (MDS) ASSESSMENT, DATED 9/7/2012, RESIDENT #2 ENTERED THE FACILITY WITHOUT ANY PRESSURE ULCERS. RESIDENT #2'S BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) RECORDED A SCORE OF 15 OUT OF 15, REFLECTING THAT RESIDENT #2 WAS COGNITIVELY INTACT. THE SAME MDS ASSESSMENT RECORDED RESIDENT #2 AS BEING TOTALLY DEPENDENT UPON STAFF FOR BED MOBILITY AND PERSONAL HYGIENE, HAD "FUNCTIONAL IMPAIRMENT" IN BOTH HER UPPER AND LOWER EXTREMITIES BILATERALLY, AND WAS "ALWAYS INCONTINENT" OF STOOL. A REVIEW OF THE FACILITY'S "BRADEN SCALE" SKIN ASSESSMENTS (DATED 8/31/12, 9/7/2012, 9/14/12, 9/21/12 AND 9/28/12), RESIDENT #2 RECEIVED A "RISK" SCORE OF "16", INDICATING MODERATE RISK FOR PRESSURE ULCER DEVELOPMENT WITH EACH ASSESSMENT. ON ALL DATES NOTED, THE FACILITY RECORDED RESIDENT #2 HAD "NO IMPAIRMENT" IN "SENSORY FUNCTION", WAS "RARELY MOIST" (RELATIVE TO HER SKIN'S EXPOSURE TO BODILY FLUIDS PRESENT IN SWEAT, URINE OR STOOL), AND WAS "CHAIR FAST" BUT NOT BED FAST. THESE RISK ASSESSMENTS WERE INADEQUATE AND INCONSISTENT WITH THE MINIMUM DATA SET assessment dated [DATE] AND THE RESIDENT'S MEDICAL [DIAGNOSES REDACTED]. DURING AN INTERVIEW CONDUCTED WITH RESIDENT #2 ON 10/11/12 AT 10:10 A.M., RESIDENT #2 STATED SHE WAS NOT ABLE TO FEEL MOST OF HER BODY FROM THE CHEST DOWN. THIS STATEMENT CONFLICTED WITH THE ASSESSMENT FINDINGS DOCUMENTED ON THE BRADEN SCALE INDICATING THE RESIDENT HAD NO SENSORY IMPAIRMENTS. ADDITIONALLY, DURING AN INTERVIEW AT 11:15 A.M. ON 10/16/12, CNA "S" SAID RESIDENT #2 WAS TOTALLY INCONTINENT OF HER BOWELS, IN THE AMOUNT OF TWO TO THREE INCONTINENT EPISODES A DAY, AND ON SOME DAYS, REFUSED TO GET OUT OF BED INTO A CHAIR. THESE STATEMENTS ALSO CONFLICTED WITH THE RISK ASSESSMENT FINDINGS DOCUMENTED ON THE BRADEN SCALE. CNA "S" SAID SHE HAD ASSISTED IN CARING FOR RESIDENT #2 EVER SINCE THE RESIDENT'S ADMISSION TO THE FACILITY, AND FELT SHE KNEW RESIDENT #2'S CARE ROUTINES PRETTY WELL. SIX DAYS AFTER THE LAST BRADEN ASSESSMENT DOCUMENTED ON 9/28/12, RESIDENT #2 WAS DISCOVERED WITH TWO AVOIDABLE, FACILITY ACQUIRED PRESSURE ULCERS. A REVIEW OF THE FACILITY'S "WOUND ASSESSMENT DETAILS REPORT" DATED 10/4/2012 (WITH A PICTURE OF RESIDENT #2'S LEFT HEEL) REFLECTED RESIDENT #2 DEVELOPED A PRESSURE BLISTER OF THE LEFT HEEL. THE WOUND MEASURED 4.80 X 4.80 CM (CENTIMETERS) WITH AN UNKNOWN DEPTH. THE WOUND WAS IDENTIFIED AS "SUSPECTED DEEP TISSUE INJURY." A REVIEW OF THE "WOUND ASSESSMENT DETAILS REPORT" DATED 10/4/2012 (WITH A PICTURE OF A BUTTOCK WOUND) REFLECTED RESIDENT #2 HAD ALSO DEVELOPED A STAGE II PRESSURE ULCER OF THE LEFT BUTTOCK ON THAT SAME DAY. THE BUTTOCK WOUND WAS DESCRIBED AS HAVING "LIGHT SEROSANGUINEOUS DRAINAGE" AND MEASURED 3.0 X .5 X 0.01 (CENTIMETERS). BECAUSE OF RESIDENT #2'S MULTIPLE DIAGNOSES, INCLUDING DIABETES, SHE WAS AT SIGNIFICANT DISADVANTAGE RELATED TO HER BODY'S ABILITY TO FIGHT POTENTIAL INFECTION AND HEAL EXISTING WOUNDS. (IT WAS NOTED THAT THE FACILITY USED THE TERMS "COCCYX" AND "BUTTOCK" INTERCHANGEABLY TO DESCRIBE THE ANATOMICAL LOCATION OF THIS WOUND.) DURING AN INTERVIEW BEGINNING AT 10:35 A.M. ON 10/16/12, THE DON EXPLAINED SHE HAD ASSUMED HER POSITION AS THE FACILITY'S DON JUST TWELVE DAYS EARLIER. WHEN ASKED TO EXPLAIN THE POSSIBLE REASONS WHY RESIDENT #2 DEVELOPED TWO AVOIDABLE PRESSURE ULCERS ON THE SAME DAY, THE DON SAID RESIDENT #2 HAD DEFINITELY BEEN AT RISK, BUT THE INTERVENTIONS WERE NOT PUT IN PLACE AT THE TIME OF ADMISSION IN ORDER TO MINIMIZE THE RISK. THE DON SAID THE FACILITY HAD BEGUN ASKING QUESTIONS, AND VERIFIED THERE HAD BEEN NOTHING UNUSUAL WITH STAFFING THE WEEK OCTOBER 1 THROUGH 7, 2012. SHE SAID A WOUND CARE NURSE HAD BEEN ASSIGNED EVERY DAY. (THERE WERE TWO NURSES DESIGNATED BY THE FACILITY AS WOUND CARE NURSES, STAFF "M" AND STAFF "N".) DURING A FOLLOW-UP INTERVIEW AT 12:20 P.M. THAT DAY, THE DON ELABORATED ON HER EARLIER STATEMENT BY STATING, "IF THERE WAS POOR ASSESSMENTS CONDUCTED ON ADMISSION, THAT FAILURE WOULD JUST CARRY THROUGH." BASED ON REVIEW OF THE "SKIN RISK" CARE PLAN FOR RESIDENT #2 (INITIATION DATE OF 9/13/12), RESIDENT #2'S LACK OF SENSORY PERCEPTION WAS NOT IDENTIFIED AS A RISK FACTOR FOR SKIN BREAKDOWN; AND THE LEVEL OF SENSORY IMPAIRMENT HAD NOT BEEN CLARIFIED OR INVESTIGATED. ADDITIONALLY, RESIDENT #2'S NON-COMPLIANCE WITH GETTING OUT OF BED (AS REPORTED BY CNA "S") WAS SIMILARLY NOT IDENTIFIED AS A RISK FACTOR ON THE CARE PLAN. FURTHERMORE, DESPITE RESIDENT #2'S COMPLETE DEPENDENCE UPON STAFF FOR ALL OF HER POSITIONING NEEDS IN BED, THERE WERE NO INTERVENTIONS ON THE CARE PLAN TO EXPLAIN HOW STAFF WERE SUPPOSED TO POSITION RESIDENT #2'S FEET AND HEELS TO ALLEVIATE PRESSURE ON THE DELICATE SKIN OF HER HEELS. THERE WERE NO INTERVENTIONS TO SHOW THAT STAFF HAD ASSESSED THE REASONS FOR RESIDENT #2'S NON-COMPLIANCE WITH GETTING OUT OF BED. WHEN CNA "S" WAS INTERVIEWED AT 11:15 A.M. ON 10/16/12, SHE SAID RESIDENT #2 HAD TOLD HER SHE DID NOT WANT TO REPOSITION AND GET OUT OF BED, "BECAUSE IT HURT TOO MUCH." CNA "S" WAS ASKED IF SHE HAD REPORTED THAT INFORMATION TO ANYONE, AND CNA "S" REPLIED SHE REPORTED THE INFORMATION TO WOUND CARE REGISTERED NURSE "N", STAFF NURSE "T" AND OTHERS. CNA "S" SAID THAT NURSE "N" HAD TOLD HER SHE WOULD LET THE THERAPY STAFF KNOW ABOUT IT. DURING AN INTERVIEW AT 11:30 A.M. ON 10/16/12, WOUND CARE REGISTERED NURSE "N" AND OCCUPATIONAL THERAPIST (OT) "K" CONFIRMED THEY HAD BOTH ASSISTED IN CARING FOR RESIDENT #2. BOTH STAFF DENIED THEY HAD EVER ASSESSED RESIDENT #2 IN ORDER TO DETERMINE HER SENSORY LIMITATIONS OR HER SUBJECTIVE EXPERIENCE OF PAIN. DURING THE INTERVIEW, OT "K" STATED SHE THOUGHT PHYSICAL THERAPY STAFF HAD ASSESSED RESIDENT #2 AS HAVING DECREASED SENSATION IN HER LOWER BODY, BUT OT "K" SAID SHE WAS NOT CERTAIN IF THAT WAS TRUE. THE DON (PRESENT DURING THE SAME INTERVIEW) SAID SHE REMEMBERED HEARING, OR READING IN RESIDENT #2'S MEDICAL RECORDS, THAT RESIDENT #2 HAD LIMITED ABILITY TO FEEL SENSATION IN HER LOWER BODY. ALTHOUGH ALL THREE STAFF PRESENT AGREED THE CONCERNS SHOULD HAVE BEEN EVALUATED, THE FACILITY PROVIDED NO EVIDENCE THEY HAD, AND RESIDENT #2 DID NOT RECEIVE THE APPROPRIATE SKIN CARE AND SERVICES TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS BASED UPON HER NEEDS. DURING INTERVIEWS CONDUCTED AT 11:45 A.M. ON 10/16/12, WOUND CARE REGISTERED NURSE "N" SAID, "(THE) AIDES WOULD TELL ME (NAME OF RESIDENT #2) REFUSED TO TURN, BUT I DIDN'T ASK WHY, AND THEY DIDN'T TELL ME." DURING THE SAME INTERVIEW, OT "K" DENIED BEING INFORMED RESIDENT #2 WAS REFUSING TO BE TURNED BECAUSE SHE WAS IN PAIN. BASED ON REVIEW OF RESIDENT #2'S SKIN RISK CARE PLAN (INITIATED 9/13/12), PAIN WAS NOT IDENTIFIED AS A RISK FACTOR THAT INTERFERED WITH THE RESIDENT'S WILLINGNESS TO REPOSITION. (REPOSITIONING IS NECESSARY TO ALLEVIATE PRESSURE TO THE DELICATE SKIN COVERING THE BONEY PROMINENCES, SUCH AS THE SKIN COVERING THE HEELS, HIPS AND PELVIC BONES.) THERE WAS NO DOCUMENTATION IN THE CLINICAL RECORD REFLECTING RESIDENT #2'S ALLEGED NON-COMPLIANCE WITH SKIN CARE INTERVENTIONS HAD BEEN ASSESSED. THERE WERE NO INTERVENTIONS DOCUMENTED ON RESIDENT #2'S CARE PLAN THAT EXPLAINED HOW STAFF WERE SUPPOSED TO TURN RESIDENT #2 IN ORDER TO MINIMIZE HER PAIN AND PROMOTE HER COMPLIANCE WITH REPOSITIONING. DURING AN INTERVIEW WITH RESIDENT #2 AT 10:10 A.M. ON 10/11/12, RESIDENT #2 PRESENTED AS ALERT AND ORIENTED. SHE ANSWERED QUESTIONS APPROPRIATELY. WHEN ASKED IF FACILITY STAFF WERE TURNING HER, RESIDENT #2 RESPONDED, "...THE DAY SHIFT DOES NOT. I TRY TO TURN MYSELF." DURING AN INTERVIEW ON 11:30 A.M. ON 10/16/12, WITH THE DON AND WOUND CARE REGISTERED NURSE "N" BOTH PRESENT, THE WOUND CARE NURSE WAS ASKED WHO IN THE FACILITY WAS RESPONSIBLE FOR MONITORING TO ENSURE THE SKIN CARE PLAN INTERVENTIONS (INCLUDING PRESSURE ULCER PREVENTATIVE MEASURES) WERE CARRIED OUT. WOUND CARE NURSE "N" FIRST RESPONDED BY SAYING THE MDS NURSES DID THE MONITORING, THEN ADDED, "THAT WOULD BE THE FLOOR NURSES AND US...ME." DURING THE INTERVIEW, WOUND CARE REGISTERED NURSE "N" WAS NOT ABLE TO CONFIDENTLY STATE WHAT HER RESPONSIBILITIES WERE AS WOUND CARE NURSE. DURING A FOLLOW-UP INTERVIEW AT 12:20 P.M. ON 10/16/12, THE DON SAID THE FACILITY'S WOUND CARE NURSES WERE DEFINITELY RESPONSIBLE FOR MONITORING THE IMPLEMENTATION OF RESIDENTS' SKIN RISK CARE PLANS. WHEN ASKED IF IT HAD SOUNDED LIKE WOUND CARE REGISTERED NURSE "N" WAS AWARE THAT SHE WAS RESPONSIBLE, THE DON RESPONDED, "NO. WELL, SHE WAS PARTLY AWARE. I DON'T KNOW WHAT HER ORIENTATION (TO HER POSITION AS WOUND NURSE) WAS." DURING AN INTERVIEW AT 12:15 P.M. ON 10/11/2012, OT "K" EXPLAINED SHE HAD BEEN CHECKING ON RESIDENT #2 FREQUENTLY BECAUSE STAFF HAD NOT BEEN TURNING HER, "FOR AT LEAST THE PAST WEEK WHILE I HAVE BEEN WATCHING." DURING A FOLLOW-UP INTERVIEW AT 11:45 A.M. ON 10/16/12, OT "K" WAS ASKED WHAT SHE HAD DONE WITH THAT INFORMATION (I.E., INFORMATION INDICATING THAT RESIDENT #2 WAS NOT BEING TURNED) AND OT "K" RESPONDED SHE HAD REPORTED THE INFORMATION TO THE ASSISTANT DIRECTOR OF NURSING (ADON) "R". HOWEVER, THERE WAS NO DOCUMENTATION IN THE CLINICAL RECORD TO INDICATE ADON "R" OR OTHER NURSING STAFF IN THE FACILITY HAD ACTED ON, OR INVESTIGATED, THOSE CONCERNS. DURING AN INTERVIEW AT 11:55 A.M. ON 10/16/12, LICENSED PRACTICAL NURSE (LPN) "T" SAID SHE WAS THE NURSE WHO HAD DOCUMENTED DISCOVERY OF RESIDENT #2'S TWO NEW WOUNDS IN THE TREATMENT NOTES ON 10/4/12. WHEN ASKED WHY SHE THOUGHT RESIDENT #2 DEVELOPED TWO NEW ULCERS ON THE SAME DAY, LPN "T" SAID, "I THINK PEOPLE NEED TO ASSESS MORE. I'M NOT SURE THAT THE INTERVENTIONS WERE IN PLACE. I DIDN'T ASK HER (RESIDENT #2) WHY SHE REFUSED (THE INTERVENTIONS). I NEVER RECALL THE AIDES TELLING ME (RESIDENT) DIDN'T TURN BECAUSE IT HURT HER." RESIDENT #2'S HEEL AND BUTTOCK WOUNDS WERE OBSERVED IN THE RESIDENT'S ROOM DURING A DRESSING CHANGE AT 2:10 P.M. ON 10/11/12. RESIDENT #2'S LEFT HEEL WOUND WAS OBSERVED TO HAVE AN ESTIMATED 4 CM BY 4 CM AREA OF BLACK, NECROTIC (DEAD) TISSUE. THE ESCHAR PREVENTED VISUALIZATION OF THE EXTENT OF THE WOUND AND THE EXTENT OF THE DEPTH OF THE TISSUE DAMAGE. THE HEEL WOUND HAD A STRONG UNPLEASANT FOUL ODOR. RESIDENT #2'S COCCYX (TAILBONE) WOUND WAS APPROXIMATELY 2 CM BY 1 CM WITH YELLOW SLOUGH (DEAD TISSUE) AND RED EDGES, CONSISTENT IN APPEARANCE WITH TISSUE THAT IS IRRITATED, OR BECOMING INFLAMED OR POTENTIALLY INFECTED. DURING AN INTERVIEW ON 10/11/2012 AT 11:45 A.M., WOUND CARE NURSE "M" SAID RESIDENT #2 HAD A "FLOAT HEELS" INTERVENTION AT THE TIME OF HER ADMISSION. DURING THE INTERVIEW, WOUND CARE NURSE "M" COULD NOT EXPLAIN WHY THE INTERVENTION TO "FLOAT HEELS" HAD NOT BEEN ADDED TO RESIDENT #2'S CARE PLAN. FURTHERMORE, THERE WAS NO DOCUMENTATION IN THE CLINICAL RECORD REFLECTING RESIDENT #2'S HEELS HAD BEEN FLOATED OR ELEVATED. DURING THE SAME INTERVIEW, WOUND CARE NURSE "M" STATED THAT PRESSURE RELIEVING BOOTS WERE NOT PLACED ON RESIDENT #2 HEELS UNTIL AFTER A "SUSPECTED DEEP TISSUE INJURY" PRESSURE ULCER WAS DISCOVERED ON 10/4/2012. DURING AN OBSERVATION IN RESIDENT #2'S ROOM, ON 10/11/2012 AT 10:10 A.M., FOAM HEEL BOOTS WERE OBSERVED ON BOTH FEET AS RESIDENT #2 LAY IN HER BED, BUT HER HEELS WERE NOT ELEVATED OFF THE BED AND, FOR THIS REASON, SOME PRESSURE WOULD STILL HAVE BEEN PRESENT AGAINST HER HEELS. DURING AN INTERVIEW CONDUCTED AT THAT TIME, RESIDENT #2 SAID STAFF HAD NEVER ELEVATED (FLOATED) HER HEELS OFF THE BED WITH A PILLOW OR FOAM CUSHION. AT 12:10 P.M. ON 10/11/2012, RESIDENT #2 WAS OBSERVED LAYING ON HER BACK IN BED. RESIDENT #2 STATED SHE HAD BEEN LYING ON HER BACK ALL MORNING AND HAD NOT BEEN TURNED (REPOSITIONED FOR PRESSURE RELIEF) SINCE THE MIDDLE OF THE NIGHT. A REVIEW OF THE (UNDATED) "RESIDENT CARE GUIDE" (A DOCUMENT INTENDED FOR USE BY NURSE AIDES WHO WERE PROVIDING CARE) INDICATED THE STAFF WERE TO "FLOAT HEELS AND PLACE A SPECIALTY BOOT ON THE LEFT (HEEL)." THE CARE GUIDE DIRECTED STAFF TO TURN AND REPOSITION RESIDENT #2 "EVERY TWO HOURS AND PRN (AS NECESSARY)." THE GUIDE REQUIRED: "PRESSURE RELIEF BOOT TO LEFT FOOT. REMOVE FOR CARE". HOWEVER, THERE WERE NO SPECIFIC PRECAUTIONS OR INTERVENTIONS DOCUMENTED ON THE CARE GUIDE FOR THE PREVENTATIVE PROTECTION OF RESIDENT #2'S RIGHT HEEL. DURING A FOLLOW-UP INTERVIEW AT 11:30 A.M. ON 10/16/12, WOUND CARE NURSE "N" WAS ASKED IF SHE KNEW THE REASON WHY PROTECTIVE BOOTS WERE NOT PROVIDED TO RESIDENT #2 PRIOR TO HER HEEL BREAKING DOWN. NURSE "N" SAID THERE HAD NOT BEEN ENOUGH BOOTS FOR EVERYBODY TO HAVE THEM. A COMPARISON OF A WRITTEN SKIN CARE PLAN FOR RESIDENT #2 PROVIDED BY THE FACILITY ON 10/9/12 WAS DONE WITH A WRITTEN SKIN CARE PLAN FOR RESIDENT #2 PRESENTED BY THE DON ON 10/11/12. THE REVISED 10/11/12 CARE PLAN REFLECTED HEEL BOOTS WERE TO BE APPLIED TO RESIDENT #2'S FEET AT ALL TIME. THIS INTERVENTION HAD NO DATE OF INITIATION OR INITIALS OF THE NURSE WHO WROTE IT ON THE CARE PLAN. THE DON STATED SHE HAD REVIEWED AND UPDATED ALL THE SKIN CARE PLANS FOR RESIDENTS WITH PRESSURE ULCER THE NIGHT BEFORE. ON 10/12/12, RESIDENT #2 WAS OBSERVED IN HER ROOM AT 7:50 A.M. BEING TRANSFERRED INTO HER WHEELCHAIR WITH STAFF ASSISTANCE AND A MECHANICAL LIFT. RESIDENT #2 DID NOT HAVE HER HEEL BOOTS ON AT THAT TIME. RESIDENT #2 WAS OBSERVED AGAIN AT 9:55 A.M. (ON 10/12/12) SITTING IN HER WHEELCHAIR IN HER ROOM. RESIDENT #2 DID NOT HAVE HER HEEL BOOTS ON, AND HER SOCK-COVERED HEELS WERE OBSERVED TO BE RESTING DIRECTLY ON THE HARD FOOT PEDALS OF HER WHEELCHAIR. (RESIDENT #2 HAD LIGHT, SOFT HOSPITAL SLIPPER SOCKS ON, BUT NO SHOES OR SLIPPERS.) AT THE TIME OF OBSERVATION, RESIDENT #2 SAID SHE HAD BEEN SITTING IN THAT POSITION SINCE STAFF GOT HER OUT OF BED, AND SHE DID NOT HAVE HER HEEL BOOTS ON AT ALL DURING THAT TIME. AN INTERVIEW TOOK PLACE WITH RESIDENT #2'S CERTIFIED NURSING ASSISTANT (CNA) "L" ON 10/12/2012, IMMEDIATELY FOLLOWING THE ABOVE OBSERVATION. CNA "L" STATED SHE DID NOT KNOW RESIDENT #2 WAS SUPPOSED TO HAVE HER HEEL BOOTS ON AT ALL TIMES. AT THAT TIME, THE DIRECTOR OF NURSING WAS OBSERVED TO PLACE THE PROTECTIVE HEEL BOOTS ON RESIDENT #2. DURING AN INTERVIEW AT 12:20 P.M. ON 10/16/12, THE DON WAS ASKED IF THERE WAS ANY FACILITY-SPECIFIC PROTOCOL THAT EXPLAINED WHAT STEPS WERE TO BE TAKEN WHEN SPECIFIC SKIN RISK CONDITIONS WERE ASSESSED. SPECIFICALLY, THE DON WAS ASKED, FOR EXAMPLE, WHAT STEPS SHOULD BE TAKEN WHEN A RESIDENT IS ASSESSED AT MODERATE RISK FOR SKIN BREAKDOWN? WHAT STEPS SHOULD BE TAKEN WHEN A RESIDENT IS ASSESSED AT HIGH RISK FOR SKIN BREAKDOWN? THE DON SAID SHE HAD BEEN LOOKING FOR A POLICY OR PROCEDURE THAT WAS FACILITY SPECIFIC AND HAD NOT FOUND ONE. THE CLINICAL PRACTICE GUIDELINE (CPG) FOR PRESSURE ULCER DEVELOPED BY THE AMERICAN MEDICAL DIRECTORS ASSOCIATION (AMDA) FOUND AT WEBSITE WWW.AMDA.COM LISTS THE FOLLOWING RISK FACTORS FOR DEVELOPING PRESSURE ULCERS; - IMPAIRED OR DECREASED MOBILITY AND FUNCTIONAL ABILITY - INCREASE IN FRICTION OR SHEAR - MODERATE TO SEVERE COGNITIVE IMPAIRMENT - RESIDENT REFUSAL OF SOME ASPECTS OF CARE AND TREATMENT THE CLINICAL PRACTICE GUIDELINE (CPG) FOR PRESSURE ULCER DEVELOPED BY THE AMERICAN MEDICAL DIRECTORS ASSOCIATION (AMDA) FOUND AT WEBSITE WWW.AMDA.COM DEFINES THE STAGING OF PRESSURE ULCERS: - A "SUSPECTED DEEP TISSUE INJURY...PURPLED OR MAROON LOCALIZED AREA OF DISCOLORED INTACT SKIN OR BLOOD-FILLED BLISTER DUE TO DAMAGE OF UNDERLYING SOFT TISSUE FROM PRESSURE AND/OR SHEAR. THE AREAS MAY BE PRECEDED BY TISSUE THAT IS PAINFUL, FIRM, MUSH, BOGGY, WARMER OR COOLER AS COMPARED TO ADJACENT TISSUE"... - A "STAGE II...PARTIAL THICKNESS LOSS OF DERMIS PRESENTING AS A SHALLOW OPEN ULCER WITH A RED PINK ULCER BED, WITHOUT SLOUGH. MAY ALSO PRESENT AS AN INTACT OR OPEN/RUPTURED SERUM-FILLED BLISTER"... - A "STAGE III ...FULL THICKNESS TISSUE LOSS. SUBCUTANEOUS FAT MAY BE VISIBLE BUT BONE, TENDON OR MUSCLES ARE NOT EXPOSED. SLOUGH MAY BE PRESENT BUT DOES NOT OBSCURE THE DEPTH OF TISSUE LOSS. MAY INCLUDE UNDERMINING AND TUNNELING " ... - AN "UNSTAGEABLE"...FULL THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE ULCER IS COVERED BY SLOUGH...AND/OR ESCHAR...IN THE ULCER BED"... ( / ) DURING THE INITIAL TOUR OF THE FACILITY ON 10/9/12 AT ABOUT 10:30 A.M., RESIDENT #11 WAS IDENTIFIED BY MDS NURSE "O" AS HAVING DEVELOPED FACILITY ACQUIRED PRESSURE ULCERS ON HER HEEL AND BUTTOCKS. ACCORDING TO THE ADMISSION RECORD, DATED 9/28/12, RESIDENT #11 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE], THEN REadmitted on [DATE]. DURING AN INTERVIEW ON 10/9/12 AT 3:30 P.M., RESIDENT #11 STATED SHE HAD BEEN ANTICIPATING GOING HOME, WHEN SHE STOOD UP FROM HER BED (AT THE FACILITY) AND fell IN HER ROOM, FRACTURING HER PELVIS. AFTER hospitalization , RESIDENT #11 WAS readmitted TO THE FACILITY WITH [DIAGNOSES REDACTED]. RESIDENT #11'S "WOUND ASSESSMENT DETAILS REPORT" DATED 10/6/12 WAS REVIEWED. THE REPORT INCLUDED A PICTURE OF RESIDENT #11'S LEFT HEEL ULCER WITH BLACK ESCHAR (DEAD TISSUE) DETECTABLE IN THE PHOTOGRAPH. THE WOUND WAS DESCRIBED ON THE REPORT AS A "SUSPECTED DEEP-TISSUE INJURY". IN RESIDENT #11'S ROOM ON 10/10/12 AT 12:10 P.M., RESIDENT #11'S LEFT HEEL WAS OBSERVED TO BE RED WITH A BLACK CENTER MEASURING 1.6 CENTIMETERS (CM) BY 1.0 CM. RESIDENT #11 SAID HER HEEL WAS PAINFUL WITH PRESSURE. A REVIEW OF RESIDENT #11'S "TREATMENT NOTES" DATED 10/7/12 READS, "...ALERTED...TO AREA ON L (LEFT) BUTTOCKS." A REVIEW OF RESIDENT #11'S "WOUND ASSESSMENT DETAILS REPORT" DATED 10/9/12 DESCRIBED THE AREA ON RESIDENT #11'S LEFT BUTTOCKS AS "...SUSPECTED DEEP-TISSUE INJURY." ON 10/10/12 AT 12:10 P.M., WOUND CARE FOR RESIDENT #11 WAS AGAIN OBSERVED WITH WOUND CARE NURSE "M". RESIDENT #11'S LEFT BUTTOCK WOUND WAS AN OPEN WOUND THAT WAS REDDISH/PINK IN COLOR AND CONSISTENT IN APPEARANCE WITH A STAGE II PRESSURE ULCER. THE WOUND WAS 2 CM BY 1.8 CM BY 0.1 DEEP. A REVIEW OF RESIDENT #11'S NURSES NOTES (9/27/12 THROUGH 10/6/12) FAILED TO REFLECT ANY SKIN ASSESSMENT CONDUCTED BY THE FACILITY NURSING STAFF DURING THE DAYS PRIOR TO THE DISCOVERY OF THE HEEL AND BUTTOCK WOUNDS. A REVIEW OF THE SKIN ASSESSMENT, COMPLETED ON THE RESIDENT'S DATE OF ADMISSION (9/27/12) INDICATED RESIDENT #11 DID NOT HAVE PRESSURE ULCERS PRESENT AT THE TIME OF HER ADMISSION TO THE FACILITY. A REVIEW OF THE FACILITY'S BRADEN SCALE-FOR PREDICTING PRESSURE SORE RISK" DATED 9/27/12 REFLECTED THE FACILITY HAD DETERMINED RESIDENT #11'S RISK OF DEVELOPING PRESSURE ULCERS AS "14", INDICATING ONLY "MODERATE RISK". (A SCORE OF 12 OR HIGHER REFLECTED HIGH RISK.) A REVIEW OF RESIDENT #11'S PLAN OF CARE FOR SKIN IMPAIRMENT (INITIATED AND CREATED ON 7/30/12), REFLECTED THE FACILITY HAD NOT DATED ANY NEW PREVENTIVE MEASURES AS HAVING BEEN IMPLEMENTED PRIOR TO THE DISCOVERY OF RESIDENT #11 LEFT HEEL PRESSURE SORE, EVEN THOUGH HER RISK FACTORS AND CARE NEEDS HAD CHANGED SIGNIFICANTLY FOLLOWING HER hospitalization AND READMISSION TO THE FACILITY. FOR EXAMPLE: ACCORDING TO RESIDENTS #11'S MDS dated [DATE], SHE HAD BEEN TOTALLY INDEPENDENT IN HER ABILITY TO POSITION HERSELF IN BED, AND SHE HAD TRANSFERRED AND WALKED WITHOUT ANY PHYSICAL ASSISTANCE PROVIDED BY STAFF. BUT AFTER READMISSION POST PELVIC FRACTURE, ACCORDING TO SECTION "I" OF HER PARTIALLY COMPLETED MDS dated [DATE], SHE HAD AN "ADDITIONAL ACTIVE DIAGNOSIS" OF "DIFFICULTY WALKING." A REVIEW OF RESIDENT #11'S PLAN OF CARE FOR "CHRONIC PAIN" REVEALED "TX (TREATMENT) TO L (LEFT) BUTTOCK DATED 10/7/12. THE "CHRONIC PAIN" PLAN OF CARE REFLECTED INTERVENTIONS FOR A "SPECIALTY MATTRESS" AND "T (TURN) & (AND) R (REPOSITION) R (RIGHT) SIDE & BACK ONLY", HOWEVER, THERE WERE NO DATES TO INDICATE WHEN THOSE INTERVENTIONS WERE IMPLEMENTED. RESIDENT #11'S CURRENT PLAN OF CARE FOR SKIN IMPAIRMENT (INITIATED AND CREATED ON 7/30/12), DID NOT REFLECT THAT RESIDENT #11 HAD PRESSURE ULCER ON HER BUTTOCK, SO THERE WAS NO MEASURABLE CARE PLAN GOAL FOR RESOLUTION OF THE ULCER. RESIDENT #11'S "CNA (CERTIFIED NURSING ASSISTANT) ADL (ACTIVITIES OF DAILY LIVING) CARE GUIDE" DOCUMENTATION DATED 9/28/12 TO 10/4/12 REFLECTED RESIDENT #11 NEEDED EXTENSIVE ASSISTANCE FROM TWO AIDES FOR BED MOBILITY, ROLLING SIDE TO SIDE, BEING PULLED UP IN BED AND SITTING UP. FOR ALL DATES (9/28/12 TO 10/4/12), THE DOCUMENT REFLECTED THE NUMBER "8" (DID NOT OCCUR) ENTERED INTO THE SPACES ON THE FORM WHERE STAFF WOULD DOCUMENT TRANSFERS FROM THE RESIDENT'S BED TO A CHAIR. ACCORDING TO THIS DOCUMENTATION, RESIDENT #11 HAD NOT BEEN TRANSFERRED OUT OF BED FOR SEVEN DAYS IN A ROW PRIOR TO THE DISCOVERY OF THE NEW PRESSURE ULCERS ON HER HEEL AND BUTTOCK. THERE WAS NO DOCUMENTATION IN RESIDENT #11'S CARE PLAN, OR ELSEWHERE IN HER CLINICAL RECORD, TO SHOW THAT STAFF HAD ANTICIPATED THE INCREASED RISKS ASSOCIATED WITH IMMOBILITY AFTER HER FALL AND FRACTURE, OR THAT STAFF HAD DEVELOPED PREVENTATIVE INTERVENTIONS TO MINIMIZE THE INCREASED RISKS (SUCH AS INCREASED SUPPORTIVE POSITIONING ASSISTANCE OR FLOTATION INTERVENTIONS TO KEEP HER HEELS OFF OF THE MATTRESS). ON 10/11/12 AT 11:30 A.M., AN INTERVIEW WAS HELD WITH THE DON, WOUND CARE NURSE "M" AND MDS NURSE "F". WOUND CARE NURSE "M" STATED RESIDENT #11'S LEFT HEEL PRESSURE ULCER HAD INITIALLY BEEN REPORTED TO THE FACILITY'S OTHER WOUND CARE NURSE "N" ON 10/6/12. WOUND CARE NURSE "M" SAID RESIDENT #11'S LEFT HEEL ULCER WAS UNSTAGEABLE AND THE STAGE II PRESSURE ULCER ON RESIDENT #11'S LEFT BUTTOCK WAS REPORTED ON 10/7/12. DURING THE MEETING, WOUND CARE NURSE "M" WAS ASKED WHEN THE SPECIALTY PRESSURE-RELIEF MATTRESS WAS IMPLEMENTED TO PREVENT PRESSURE SORES. WOUND CARE NURSE "M" SAID IT WAS NOT IMPLEMENTED UNTIL 10/7/12, AFTER RESIDENT #11'S "SUSPECTED DEEP-TISSUE INJURY" TO HER LEFT BUTTOCK WAS REPORTED. ( ) ACCORDING TO THE OCTOBER 2012 physician's orders [REDACTED]."I HAVE A HEALING STAGE III PRESSURE ULCER ON MY LEFT HEEL THAT I WAS admitted WITH. THE WORDS "THAT I WAS admitted WITH" HAD A LINE DRAWN THROUGH THEM, INDICATING THAT THE ULCER WAS ACQUIRED BY THE RESIDENT AFTER HIS ADMISSION TO THE FACILITY . A FURTHER REVIEW OF THE SAME CARE PLAN REFLECTED RESIDENT #8 WAS "NONCOMPLIANT WITH LAYING DOWN AND ELEVATING MY BLE (BILATERAL LOWER EXTREMITIES) TO REDUCE [MEDICAL CONDITION] (SWELLING DUE TO FLUID ACCUMULATION) AND PROMOTE WOUND HEALING." THE INTERVENTIONS ON RESIDENT #8'S CARE PLAN DIRECTED FACILITY STAFF TO: "ENCOURAGE RESIDENT TO KEEP LEGS ELEVATED AT ALL TIMES. WHILE IN BED POSITION LEGS UP ON PILLOWS FOR ELEVATION AND USE FOOT STOOL TO ELEVATE LEGS WHILE RESIDENT IN W/C (WHEEL CHAIR), AND TO ELEVATE BLE IN HIS RECLINER...PREVENTATIVE SKIN MEASURES INCLUDE...SPECIAL WEDGE SHOE TO PREVENT PRESSURE ON LEFT HEEL DURING TRANSFERS AND AMBULATION." RESIDENT #8 WAS OBSERVED ON THE 300 HALL AT 10:10 A.M. ON 10/16/12, UP AND DRESSED AND SITTING IN A WHEELCHAIR IN THE DOORWAY OF HIS ROOM. HE WAS OBSERVED TO BE A HEAVY SET MAN. HE WORE SOCKS AND STRAPPED SANDALS ON BOTH OF HIS FEET, WHICH WERE PLACED DIRECTLY ON THE FLOOR (NOT ELEVATED) AS HE SAT IN HIS WHEELCHAIR. THE FOOTWEAR RESIDENT #8 HAD ON DID NOT APPEAR TO AFFORD ANY PARTICULAR PRESSURE RELIEF TO HIS HEELS. DURING AN INTERVIEW, BEGINNING AT 10:35 A.M. ON 10/16/12, THE DIRECTOR OF NURSING (DON) SAID RESIDENT #8'S LEFT HEEL ULCER WAS DISCOVERED AFTER HE COMPLAINED OF PAIN IN HIS FOOT. THE DON SAID THE ULCER WAS A FACILITY ACQUIRED ULCER DISCOVERED ON 8/2/12 AND REMAINED UNRESOLVED. THE DON DESCRIBED THE ULCER AS A "HEALING STAGE III" PRESSURE ULCER DURING FOLLOW-UP INTERVIEW WITH THE DON AT 12:20 P.M. ON 10/16/12, SHE ELABORATED ON HOW RESIDENT #8 MAY HAVE DEVELOPED THE ULCER. THE DON SAID, "WE HAVE A VERY SIMILAR SITUATION AS WITH (NAME OF SAMPLE RESIDENT #2). HE (RESIDENT #8) DOESN'T WANT TO TURN. HE DOESN'T WANT TO DO THE INTERVENTIONS WE'VE GOT LINED UP FOR HIM TO DO." WHEN ASKED IF RESIDENT #8 HAD A CARE PLAN THAT ADDRESSED THE REASONS, AND POSSIBLE INTERVENTIONS FOR, HIS NON-COMPLIANCE, THE DON SAID, "HE DOES NOT HAVE A SPECIFIC NON-COMPLIANCE CARE PLAN." THEN THE DON SAID SHE HAD NO EVIDENCE TO SHOW THAT NURSING STAFF HAD ASSESSED THE REASONS FOR RESIDENT #8'S NON-COMPLIANCE WITH HIS SKIN CARE PLAN INTERVENTIONS, OR THAT THEY HAD TRIED DIFFERENT INTERVENTIONS OR UNDERTAKEN TEACHING IN ORDER TO EDUCATE RESIDENT #8 ABOUT THE CONSEQUENCES OF THE INTERVENTIONS NOT BEING FOLLOWED. ACCORDING TO RESIDENT #8'S SKIN-RISK CARE PLAN INITIATED 12/20/11, HE WAS A "VERY INDEPENDENT" INDIVIDUAL. AN "INITIAL SOCIAL SERVICES ASSESSMENT" DATED 9/16/11 DESCRIBE

THIS CITATION PERTAINS TO MI 206. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO 1). PROVIDE SUPERVISION TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY IN 1 OF 9 SAMPLED RESIDENTS (RESIDENT #500), RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #500 WHEN ON [DATE] AT 2:00 P.M., RESIDENT #500 ELOPED FROM THE FACILITY UNBEKNOWNST TO FACILITY STAFF, AND WAS OBSERVED BY CERTIFIED NURSING ASSISTANT (CNA) #1 IN A DRIVEWAY UNDER THE CARPORT, AND 2.) ENSURE THE MAIN FRONT DOOR ALARM SYTEM WAS FUNCTIONAL FOR 9 OF 15 SAMPLED RESIDENTS WITH WANDERGUARD'S (RESIDENTS #500, #501, #504, #506, #507 AND 4 NON-SAMPLED RESIDENTS), RESULTING IN HIGH RISK FOR FURTHER ELOPEMENTS TO OCCUR. THIS DEFICIENT PRACTICE PLACED RESIDENT #500 AND 14 ADDITIONAL RESIDENTS WITH WANDERGUARD'S, AT HIGH RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET, MINIMUM DATA SET (RESIDENT ASSESSMENT TOOL) DATED [DATE], NURSES AND SOCIAL WORKER NOTES DATED [DATE] THROUGH [DATE] , physician progress notes [REDACTED].#500 WAS admitted to the facility on [DATE] WITH SHORT AND LONG TERM MEMORY LOSS, IMPAIRED COGNITION, A HISTORY OF FALLS, HAD BEEN ASSESSED BY THE FACILITY TO BE AT RISK FOR ELOPEMENT, AND A WANDERGUARD WAS PLACED ON HIM. RESIDENT #500 WAS ALERT WITH PERIODS OF CONFUSION, DECREASED SAFETY AWARENESS, WAS NON-COMPLAINANT WITH SAFETY PREVENTIVE MEASURES, AND had a history of [REDACTED]. OBSERVATION OF RESIDENT #500 WAS DONE ON [DATE] AT 7:30 A.M. RESIDENT #500 WAS OBSERVED IN HIS WHEELCHAIR AND HAD A WANDERGUARD ON. DUE TO DECREASED COGNITION AND POOR MEMORY, RESIDENT #500 WAS UNABLE TO RECALL THE ELOPEMENT FROM THE FACILITY ON [DATE] AT 2:00 P.M. AN OBSERVATION WAS MADE OF THE FACILITY MAIN FRONT DOOR (A WANDERGUARD ALARMED DOOR) ON [DATE] AT 7:10 A.M., WITH THE DIRECTOR OF MAINTENANCE #4. DIRECTOR OF MAINTENANCE #4 USED A TESTER WANDERGUARD (#90G139, EXPIRATION DATED ,[DATE]) AND WALKED THROUGH THE FRONT DOORS 5 TIMES. THE FRONT DOOR ALARM SYSTEM WAS ACTIVATED ONLY 2 OUT OF 5 TIMES THAT IT WAS tested . OBSERVATIONS WERE DONE ON [DATE] BETWEEN 7:40 - 8:05 A.M., OF THE MAIN FRONT WANDERGUARD EXIT DOOR WITH THE DIRECTOR OF MAINTENANCE #4 AND DIRECTOR OF NURSING (DON) #1. A TOTAL OF 15 RESIDENTS WITH WANDERGUARD'S IN PLACE WERE TAKEN TO THE MAIN FRONT WANDERGUARD DOOR TO ENSURE THE ACTIVATION OF THE DOORS. THE MAIN FRONT DOOR ALARM SYSTEM WAS NOT ACTIVATED BY 9 (SAMPLED RESIDENTS #500, #501, #504, #506, #507 AND 4 NON-SAMPLED) OUT OF 15 RESIDENTS. REVIEW OF THE FACILITY INCIDENT REPORT DATED [DATE], REVEALED AT 2:00 P.M., CNA #1 OBSERVED RESIDENT #500 OUTSIDE UNSUPERVISED UNDER THE CARPORT IN THE DRIVEWAY IN FRONT OF THE BUILDING. FACILITY STAFF WERE UNAWARE RESIDENT #500 HAD ELOPED FROM THE BUILDING. RESIDENT #500 TOLD STAFF HE WAS LOOKING FOR HIS DOG. THE REPORT INDICATED THAT THE FRONT DOOR ALARM DID NOT SOUND, NOR DID THE DOOR LOCK TO PREVENT HIM FROM LEAVING THE BUILDING. THE FRONT DOOR ALARM DID HOWEVER SOUND WHEN HE WAS BROUGHT BACK INTO THE FACILITY BY CNA #1. REVIEW OF THE BRIEF INTERVIEW FOR MENTAL STATUS (BIM'S) DATED [DATE], REVEALED RESIDENT #500'S COGNITIVE STATUS HAD BEEN ASSESSED TO BE A ,[DATE] WHICH INDICATED "SEVERE IMPAIRMENT". REVIEW OF THE FACILITY FALLS RISK ASSESSMENTS (DATED [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] AND [DATE]), REVEALED RESIDENT #500 WAS COGNITIVELY IMPAIRED AND WAS AT HIGH RISK FOR FALLS. REVIEW OF THE FACILITY ELOPEMENT RISK ANALYSIS DATED [DATE], DOCUMENTED "THERE ARE SEVERAL AREAS IN WHICH (RESIDENT #500) DEMONSTRATES POOR SAFETY AWARENESS, HE WILL SELF-TRANSFER, HE IS IMPULSIVE, NON-COMPLIANT WITH SAFETY ALARMS, PROPELS IN WHEELCHAIR, WANDERING AROUND EXIT DOORS AND HAS THE ABILITY TO OPEN A DOOR". REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE SAFETY CARE PLAN DATED [DATE], REVEALED ON "[DATE], TODAY, I ATTEMPTED TO ELOPE FROM THE FRONT DOOR, I AM STRONG ENOUGH TO OPEN THE DOOR, I AM IMPULSIVE AND I HAVE FALLEN AT THE FACILITY". FACILITY STAFF WERE TO MONITOR THE RESIDENT FOR SAFETY. REVIEW OF THE NURSES FOR RESIDENT #500 REVEALED: DATE: [DATE] AT 10:30 A.M., "POOR SAFETY AWARENESS". DATE: [DATE] AT 11:30 A.M., "CONTINUES TO BE IMPULSIVE". DATE: [DATE] AT 1:00 A.M.,"NO S/S (SIGNS AND SYMPTOMS) OF INJURY R/T (RELATED TO) FALL ON [DATE]". DATE: [DATE] AT 4:50 A.M., "RESIDENT OBSERVED ON THE FLOOR". DATE: [DATE] AT 11:30 P.M., "RES (RESIDENT) HAS POOR SAFETY AWARENESS". DATE: [DATE] AT 5:25 A.M., "CNA FOUND RESIDENT ON THE FLOOR NEXT TO THE BED". DATE: [DATE] AT 11:00 A.M., "RES ON FLOOR IN BATHROOM". DATE: [DATE] AT 2:30 A.M., "RES OBSERVED SITTING ON FLOOR". DATE: [DATE] AT 3:30 A.M., "RES OBSERVED ON BUTTOCKS ON FLOOR MAT NEXT TO BED". DATE: [DATE] AT 6:25 P.M., "RES WAS STOPPED ATTEMPTING TO GET OUT THE FRONT DOORS". DATE: [DATE] AT 4:15 A.M., "CNA NOTIFIED THIS NURSE THAT RESIDENT WAS LYING ON FLOOR IN ROOM". DATE: [DATE] AT 6:00 P.M., "AT APPROXIMATELY 2:00 P.M., RESIDENT WAS SEEN THROUGH A WINDOW OUTSIDE THE MAIN ENTRANCE. CNA (CNA #1) RETURNED HIM TO BUILDING AND REPORTED INCIDENT. WANDERGUARD WAS ON RESIDENTS ANKLE BUT NO ALARM WAS HEARD". DATE: [DATE] AT 6:00 P.M., "N/O (NEW ORDER) INITIATE EVERY 15 MIN VISUAL CHECKS". REVIEW OF THE PHYSICIAN ORDER [REDACTED].#500) PUT ON 15 MIN CHECKS FOR SAFETY". REVIEW OF THE PHYSICIAN ORDER [REDACTED].#500. IN AN INTERVIEW ON [DATE] AT 10:05 A.M., CNA #1 STATED, "I WAS WALKING IN THE HALLWAY (ON [DATE]) AND I POKED MY HEAD IN (A RESIDENTS ROOM) AND I SAW HIM (RESIDENT #500) SITTING OUTSIDE. HE WAS OUTSIDE, ALONE, IN THE DRIVEWAY IN HIS WHEELCHAIR AND HE WAS HOLLERING AT A LADY ASKING IF SHE HAD SEEN HIS DOG. HE HAD BEEN ASKING EVERYBODY ABOUT HIS DOG THAT DAY. HE HAD BEEN WANDERING AL DAY, LOOKING FOR HIS DOG DOWN EVERY HALLWAY. THERE WERE PEOPLE COMING AND GOING IN THE DRIVEWAY UNDER THE CARPORT, DIAL-A-RIDE, VISITORS AND THE AMBULANCE ALL COME (DRIVE) UP THERE. WHEN I (CNA #1) BROUGHT HIM IN, THE ALARM WENT OFF. NO ONE HEARD THE DOOR ALARM GO OFF WHEN HE LEFT, NO ONE KNEW HE HAD LEFT". CNA #1 SHOWED THE SURVEYOR WHERE SHE FOUND RESIDENT #500. AN OBSERVATION ON [DATE] AT 1:15 P.M., DIRECTOR OF MAINTENANCE #4 AND THIS SURVEYOR MEASURED THAT THE DISTANCE FROM THE FRONT DOOR TO THE LOCATION OF WHERE RESIDENT #500 WAS FOUND BY CNA #1 TO BE "47 FEET". IN AN INTERVIEW ON [DATE] AT 8:20 A.M., LICENSED PRACTICAL NURSE (LPN #2) REPORTED THAT RESIDENT #500 WAS ON THE HALL SHE WAS ASSIGNED TO ON [DATE] WHEN HE ELOPED. LPN #2 STATED, "I DID NOT HEAR ANY ALARMS GO OFF (DOOR ALARMS ON [DATE]), IT DID NOT SHOW-UP ON MY PAGER, AND I LOOKED AT THE BOARD AT THE DESK, IT DID NOT SHOW UP THERE EITHER. I DID NOT KNOW HE WAS OUTSIDE UNTIL (CNA #1) BROUGHT HIM TO ME AND TOLD ME HE WAS OUTSIDE ALONE LOOKING FOR HIS DOG. THE NIGHT NURSE (7:00 P.M. ON [DATE] TO 7:00 A.M. ON [DATE]) TOLD ME HE HAD SOME INCREASED CONFUSION AND HAD BEEN LOOKING FOR HIS DOG." IN AN INTERVIEW ON [DATE] AT 8:10 A.M., REGISTERED NURSE (RN) #1. STATED, "I WAS THE ON-CALL NURSE ON SUNDAY ([DATE]). (LPN #2) CALLED ME ABOUT 2:00 P.M. AND TOLD ME (RESIDENT #500) HAD GOTTEN OUT OF THE BUILDING. SHE SAID NO ONE HAD HEARD THE FRONT DOOR ALARM GO OFF WHEN HE LEFT THE BUILDING, BUT IT WORKED WHEN HE CAME BACK IN. I ASKED HER TO GO THROUGH HER PAGER, IT WILL ALERT US THAT A RESIDENT WITH A WANDERGUARD IS EXITING ONE OF THE WANDERGUARD DOORS. SHE DID AND SHE SAID IT DID NOT HAVE AN ALERT ON IT. I ALSO HAD HER CHECK THE NURSES STATION CALL-LIGHT BOARD AND SHE SAID THERE WAS NO DOOR ALARMS ON IT". IN AN INTERVIEW ON [DATE] AT 7:15 A.M., DON #1 STATED, "SUNDAY ([DATE]) I GOT A PHONE CALL FROM (RN #1) AT APPROXIMATELY 3:00 P.M., SAYING THAT (RESIDENT #500) HAD ELOPED. SHE SAID HE WAS UNDER THE CARPORT TALKING TO A FAMILY MEMBER. NO ONE HEARD HIM LEAVE, NO ALARM WAS HEARD AND NO ONE SAW HIM LEAVE THE BUILDING. THE CNA (CNA #1) SAW HIM OUT THE WINDOW. I CAME IN (ON [DATE]), I FOUND 3 RESIDENTS WITH WANDERGUARD'S THAT DID NOT WORK". DON #1 STATED (SAMPLED RESIDENTS #501'S) ALARM DID NOT WORK ON BACK HALLWAY DOOR, (RESIDENT #502'S) ALARM DID NOT WORK ON COURTYARD DOOR AND (RESIDENT #503'S) ALARM DID NOT WORK ON COURTYARD AND BACK HALLWAY DOORS WHEN SHE CHECKED THEM ON [DATE]. IN AN INTERVIEW ON [DATE] AT 8:00 A.M., SOCIAL WORKER #1 AND THE DIRECTOR OF ACTIVITIES #1 SAID THAT ON [DATE], THEY "TOOK THE RESIDENTS WITH WANDERGUARD'S TO EACH OF THE 3 WANDERGUARD DOORS AND 3 RESIDENTS ALARMS DID NOT WORK AT DIFFERENT DOORS (SAMPLED RESIDENTS #501 ALARM DID NOT WORK ON BACK HALLWAY DOOR, #502 ALARM DID NOT WORK ON COURTYARD DOOR AND #503 ALARM DID NOT WORK ON COURTYARD AND BACK HALLWAY DOORS)". REVIEW OF THE HANDWRITTEN INVESTIGATION DATED [DATE], REVEALED "WANDERGUARD DID NOT SOUND WHEN RESIDENT (RESIDENT #500) WENT OUT THE FRONT DOOR, IT DID SOUND WHEN RESIDENT WAS BROUGHT BACK INTO THE BUILDING. I (DON #1) CAME INTO THE FACILITY TO INVESTIGATE (ON [DATE]) AT APPROXIMATELY 4:30 P.M. I NOTED THAT THE WANDERGUARD WHICH WAS PLACED ON (RESIDENT #500) WAS EXPIRED ,[DATE], I FOUND ONE WITH DATE ,[DATE]. HOLDING THIS WANDERGUARD, I WALKED OUT THE FRONT DOOR WITHOUT THE ALARM SOUNDING. WHEN I CAME BACK INTO THE BUILDING THE ALARM SOUNDED. I CHECKED THE PREVIOUS WANDERGUARD HE (THE RESIDENT) WAS WEARING AND AGAIN, I COULD GET THROUGH THE FRONT DOOR. ALL RESIDENTS USING WANDERGUARD'S WERE WHEELED TO WANDERGUARD DOORS (X 3) TO SEE IF THEY WOULD LOCK PROPERLY. THERE WERE THREE RESIDENTS WHOSE WANDERGUARD'S DID NOT WORK AT EVERY DOOR. THESE PERSONS WERE PLACED ON EVERY 15 MINUTE VISUAL CHECKS (SAMPLED RESIDENTS #501 AND #503 AND NON-SAMPLED RESIDENT #509). INTERVIEWED (CNA #1), SHE REPORTED THAT (RESIDENT #500) WAS AT THE END OF THE CARPORT. HE WAS RESTLESS ALL MORNING, LOOKING FOR HIS DOG COCO. (LPN #1) INTERVIEWED (RESIDENT #500), HE STATED THAT HE PUSHED THE HANDICAP BUTTON AND GOT OUT". IN A TELEPHONE INTERVIEW ON [DATE] AT 9:00 A.M., ADMINISTRATOR #1 REPORTED THAT FACILITY STAFFS DID NOT CALL AND INFORM HIM RESIDENT #500 HAD ELOPED FROM THE BUILDING ON [DATE] AND HE WAS NOT AWARE THAT THE WANDERGUARD DOOR ALARM SENSOR STRIPS NEEDED TO BE CHECKED AND ADJUSTED. IN AN INTERVIEW ON [DATE] AT 2:20 P.M., DOOR ALARM SERVICE TECHNICIAN #1 SAID THE FACILITIES MAIN DOOR ALARM SYSTEM WAS "RECEIVING A SIGNAL OF SOME SORT, IT COULD COME FROM A WASHER, DRYER, LIGHT, TV'S, AIR CONDITIONER, OUTSIDE HALOGEN LIGHT, ANYTHING THAT CAN BE PLUGGED IN", WHICH COULD INTERFERE WITH THE DOORS ALARM SYSTEM. DOOR ALARM SERVICE TECHNICIAN #1 SAID "THE FACILITY NEEDS TO ADJUST THE GAIN (PART OF THE SENSOR STRIP OF THE ALARM SYSTEM) ON THE WALL RECEIVERS IF THERE WAS A LOT OF INTERFERENCE." DOOR ALARM SERVICE TECHNICIAN #1 ADJUSTED THE RIGHT SENSOR STRIP AT THE MAIN FRONT EXIT DOOR AND SAID "IT MIGHT HAVE BEEN TURNED TO HIGH". DOOR ALARM SERVICE TECHNICIAN #1 ALSO HAD TO ADJUST 2 SENSOR STRIPS AT THE COURTYARD EXIT DOOR. REVIEW OF THE SERVICE CALL JOB FORM DATED [DATE], REVEALED "GOT TO SITE, I FOUND THAT THE MAIN ENTRANCE DOOR WAS ACTING-UP, SOME NOISE (RADIO FREQUENCY NOISE INTERFERING WITH THE PROPER FUNCTIONING). FOUND THAT DUE TO THE RECEIVERS GAIN WAS SET TO HIGH. ADJUSTED GAIN AND PROBLEM WAS RESOLVED. WENT THROUGH AND tested THE OTHER 2 DOORS AS WELL (THE COURTYARD AND BACK HALLWAY DOORS). ENDED-UP MAKING ADJUSTMENTS TO THE GAIN ON THE SMOKERS (COURTYARD) DOOR AS WELL. ALL 3 DOORS TEST GOOD NOW". IN AN INTERVIEW ON [DATE] AT 7:35 A.M., DIRECTOR OF MAINTENANCE #4 STATED, "I WAS NOT AWARE THAT THE ALARM SENSOR STRIPS NEEDED TO BE CHECKED WEEKLY AND ADJUSTED IF NEEDED. THERE WAS NO MAINTENANCE LOGS (PREVENTIVE MAINTENANCE LOGS) WITH CHECKING THE SENSOR PADS ON IT. I DID NOT ORIENTATE ON THE ALARMS". IN A TELEPHONE INTERVIEW ON [DATE] AT 10:10 A.M., MAINTENANCE EMPLOYEE #2 SAID HE AND THE FORMER DIRECTOR OF MAINTENANCE HAD BEEN ADJUSTING THE 3 WANDERGUARD DOORS SENSOR STRIPS USING A SCREW DRIVER, BUT HAD NOT TOLD ANYONE HOW TO DO IT BECAUSE "THEY NEEDED TO BE TRAINED". MAINTENANCE EMPLOYEE #2 STATED "THE LIGHT WILL NOT BE GREEN (ON THE DOOR ALARMS) IF THERE IS ANY RADIO FREQUENCY INTERFERENCE". IN A TELEPHONE INTERVIEW ON [DATE] AT 8:50 A.M., FORMER MAINTENANCE EMPLOYEE #1 STATED, "SOMETIMES RADIO INTERFERENCE OR THE WEATHER CAN CAUSE THE FREQUENCY TO NOT WORK, EVEN LOUD NOISES LIKE THUNDER. BEFORE WHEN THIS WOULD HAPPEN WE WOULD CHECK THE WANDERGUARD SYSTEM AT THE THREE DOORS AND ADJUST THE SENSOR BARS USING A TINY SCREW DRIVER COUNTER CLOCKWISE JUST A LITTLE. WE WERE TOLD TO DO THAT BY THE COMPANY (ALARM COMPANY). IT HAPPENED EVERY ONCE IN A WHILE WHEN I WORKER THERE". REVIEW OF THE FACILITY ELOPEMENT AND/OR EXIT-SEEKING MANAGEMENT POLICY [DATE], REVEALED "ELOPEMENT: WHEN A RESIDENT LEAVES A SAFE OR SECURE AREA, FOR AN UNSAFE AREA WITHOUT ASSISTANCE OR SUPERVISION. MAINTAIN PREVENTIVE MAINTENANCE PROCEDURE FOR ALARMS. ASSESS DAILY FOR PLACEMENT AND FUNCTION". REVIEW OF THE ADDENDUM TO POLICY REGARDING WANDERGUARD'S DATED [DATE], DOCUMENTED "WANDERGUARD'S WILL BE ASSESSED DAILY FOR PLACEMENT AND FUNCTION, THAT WILL BE DOCUMENTED ON A DAILY BASIS". REVIEW OF THE MICHIGAN UNIT WANDERGUARD CHECK-OFF SHEET DATED ,[DATE], REVEALED ON [DATE], [DATE] AND [DATE], NO DOCUMENTATION WAS FOUND THAT CONFIRMED STAFF CHECKED 3 RESIDENTS WANDERGUARD'S PLACEMENT AND FUNCTION. REVIEW OF THE SUPERIOR UNIT WANDERGUARD CHECK-OFF SHEET DATED ,[DATE], REVEALED ON [DATE], [DATE] AND [DATE], NO DOCUMENTATION WAS FOUND THAT CONFIRMED STAFF CHECKED 10 RESIDENTS WANDERGUARD'S PLACEMENT AND FUNCTION. ON [DATE], NO DOCUMENTATION WAS FOUND THAT CONFIRMED STAFF CHECKED 8 RESIDENTS WANDERGUARD'S PLACEMENT AND FUNCTION. REVIEW OF THE HURON UNIT WANDERGUARD CHECK-OFF SHEET DATED ,[DATE], REVEALED ON [DATE], NO DOCUMENTATION WAS FOUND THAT CONFIRMED STAFF CHECKED 1 RESIDENTS WANDERGUARD PLACEMENT AND FUNCTION. REVIEW OF THE EXIT ALARM RECEIVER INSTALLATION GUIDE DATED [DATE] (GIVEN TO THE SURVEYOR BY THE ALARM COMPANY TECHNICIAN), DOCUMENTED, "COMMON SOURCES OF INTERFERENCE INCLUDE TV'S, COMPUTER MONITORS, ELECTRIC MOTORS, ELECTRICAL DISTRIBUTION PANELS, CERTAIN TYPES OF FLUORESCENT LIGHTS WITH ELECTRIC BALLAST'S. YOU MUST TEST THE EXIT ALARM RECEIVER LOCATION FOR INTERFERENCE. VERIFY THAT THE EXIT ALARM RECEIVER IS ABLE TO RECEIVE THE TRANSMITTER AT THE SPECIFIED DISTANCE AND THAT THE EXIT ALARM CONTROLLER CAN SUCCESSFULLY DECODE THAT TRANSMITTER. IF THIS DOES NOT OCCUR, THE GAIN CONTROL REQUIRES ADDITIONAL TUNING. TURNING THE GAIN UP CAN GIVE YOU ADEQUATE COVERAGE BUT MAKES IT EASIER TO FLOOD THE RECEIVER WITH NOISE, TURNING THE GAIN DOWN IS LESS LIKELY TO FLOOD THE RECEIVER WITH NOISE BUT MAY NOT PROVIDE ADEQUATE COVERAGE". ON [DATE] AT 4:30 P.M., DON #1 WAS NOTIFIED OF AN IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AS A RESULT OF THE FACILITY'S FAILURE TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF RESIDENT #500, WHO WAS AN ELOPEMENT RISK, AND THE FACILITIES FAILURE TO ENSURE THAT THE MAIN FRONT WANDERGUARD DOOR WAS FUNCTIONING PROPERLY. ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], RESIDENT #500'S WANDERGUARD ALARM WAS tested AT THE MAIN FRONT DOOR OF THE FACILITY AND IT WAS FOUND TO BE IN WORKING CONDITION. 2. ON [DATE], 14 ADDITIONAL RESIDENTS WERE IDENTIFIED THROUGH BEHAVIOR MANAGEMENT AND/OR ELOPEMENT RISK TO HAVE CODE ALERT TRANSMITTERS ON (WANDERGUARD'S). THEY WERE CHECKED AND FOUND TO BE WORKING PROPERLY. 3. ON [DATE] AT APPROXIMATELY 9:00 A.M., 3 FACILITY EMPLOYEES WERE STATIONED AT EACH WANDERGUARD EXIT DOOR FOR THE PURPOSE OF VISUALLY WATCHING SO RESIDENTS WITH WANDERGUARD'S COULD NOT LEAVE THE FACILITY. THE EMPLOYEES WERE DISMISSED AT 3:30 P.M. 4. ON [DATE], A TECHNICIAN CAME IN TO THE FACILITY AND CHECKED ALL WANDERGUARD DOORS. THE TECHNICIAN ADJUSTED THE RIGHT SENSOR STRIP ON THE MAIN FRONT DOOR AND BILATERAL SENSOR STRIPS ON THE COURTYARD DOOR. THE DIRECTOR OF MAINTENANCE WAS SHOWN BY THE TECHNICIAN HOW TO ADJUST THE SENSITIVITY OF THE SENSORS. 5. THE ELOPEMENT RISK ANALYSIS WAS UP-DATED FOR RESIDENT #500 ON [DATE] AT 5:30 P.M. 6. ON [DATE], RESIDENT #500 WAS PLACED ON 15 MINUTE CHECKS. THE INTERDISCIPLINARY TEAM WILL REVIEW WEEKLY AT BEHAVIORAL MANAGEMENT MEETING TO DETERMINE THE NEED TO CONTINUE 15 MINUTE CHECKS. THERE WILL BE NO EXIT SEEKING BEHAVIOR BY RESIDENT #500 FOR A PERIOD OF 2 WEEKS BEFORE THE TEAM WILL CONSIDER DISCONTINUING THE 15 MINUTE CHECKS. 7. RESIDENT #500 HAD HIS PHQ9 (MOOD ASSESSMENT OF MDS) REDONE ON [DATE], HIS SCORE WAS "0". 8. CHARGE NURSES CONTINUE TO CHECK PLACEMENT AND FUNCTION OF THE WANDERGUARD ALERT TRANSMITTERS DAILY ON EACH RESIDENT WHO WEARS ONE. ANY CONCERNS WILL BE REPORTED TO THE ASSISTANT DIRECTOR OF NURSING AND WILL BE ADDRESSED IMMEDIATELY. THE WANDERGUARD FUNCTION IS LOGGED ON A TRACKING SHEET IN THE MEDICATION ADMINISTRATION RECORD (MAR). 9. ON [DATE], 122 RESIDENTS WERE ASSESSED UTILIZING THE ELOPEMENT RISK AUDIT TOOL. NO NEWLY IDENTIFIED RESIDENTS WERE FOUND TO BE AT RISK FOR ELOPEMENT. THREE ELOPEMENT BOOKS WERE REVIEWED AND UP-DATED. 10. BEGINNING ON [DATE], THE DIRECTOR OF MAINTENANCE WILL CHECK THE FUNCTIONING OF THE 3 WANDERGUARD DOORS DAILY FOR 5 DAYS AND THEN WEEKLY. 11. ON [DATE], 82 OF 148 OF EMPLOYEES WERE IN-SERVICED BY THE IN-SERVICE DIRECTOR REGARDING THE ELOPEMENT AND EXIT SEEKING POLICY. ALL ON-COMING STAFF WILL BE IN-SERVICED PRIOR TO THE START OF THEIR SHIFTS. THE WEEKEND MANAGER WILL CONDUCT THE IN-SERVICES FOR THE EMPLOYEES WORKING SATURDAY AND SUNDAY. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AS A SCOPE OF PATTERN AND SEVERITY OF NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO ALL STAFF HAD NOT YET BEEN IN-SERVICED AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

This citation pertains to MI# 829, MI# 616 Based on observation, interview and record review, the facility failed to provide a safe environment and supervision for 2 (#102, #105) of 5 sampled residents, from a total sample of 5 residents, resulting in a fall with fracture for resident #102, and resident #105 (who was on suicidal precautions) being found outside the facility rolling down the road away from the facility toward a busy road with the potential for harm or death. Findings include: Resident #102 Record review of 'Unusual Occurrence' form dated [DATE] at 9:20 PM for resident #102, reflected that on [DATE] resident #102 was observed on the floor and stated that she fell out of her wheelchair. Resident #102 was sent to the emergency room for evaluation and treatment. Record review of resident #102's minimum data set ((MDS) dated [DATE] revealed a [AGE] year old female with moderately impaired vision and hearing, with a brief interview of mental status (BIMs) score of 5, severe impairment. Resident #102 had a history of [REDACTED]. Record review of resident #102's fall risk assessment dated [DATE] revealed a score of 20 (Moderate score ,[DATE]). On the back of the fall risk assessment was written fall committee review summary: 'This fall is isolated and is resident's first fall at facility. Resident typically does not attempt to self-transfer........ ' The fall risk assessment completed on [DATE] reflected a score of 26 (Moderate score ,[DATE]). There were no fall committee review notes written. Record review of resident #102's fall care plan updated [DATE] reflected that the resident was at risk for falls and there were no fall/safety devices or interventions noted to the care plan. Entry dated [DATE] reflected: 'I am confused, I am propelling myself about looking for my car and my purse. I want to go home'. There were no safety devices added to bed or chairs with the noted change of behavior/mental status. Record review of resident#102's cognitive care plan updated [DATE] reflected that the resident had memory impairments related to dementia and required cues with daily decisions. The care plan noted that the resident's mood fluctuates at times and that her hearing and vision were impaired. Record review of resident #102's nursing notes dated [DATE] at 4:30 PM revealed: 'Resident confused. She is propelling about the facility in her wheelchair looking for her car and her purse. Verbalized the desire to go home. Propelled up to front door, but did not attempt to elope. Wander gaurd on lower extremity to alert staff of any attempts to elope from the facility. To re-evaluate need on Monday [DATE]'. The note was signed by the assistant director of nursing. Record review of physician orders [REDACTED]. There were no orders for safety devices to chairs or bed. In an interview on [DATE] at 11:30 AM, assistant director of nursing (ADON) RN#3 revealed that resident #102 was found by a certified nursing assistant (CNA) on the floor. ADON #3 stated that on [DATE] resident #102 was confused and not her normal self. ADON #3 stated that the resident verbalized desire to go home and that a wander guard was applied due to confusion. ADON #3 stated that staff talked about the residents change in increased confusion and that a urine analysis (U/A) was ordered, but that the U/A did not get done because the resident fell before it could be done. ADON #3 stated that resident #102 was sent to the hospital for right hip pain and later deceased . Record review of social worker notes dated [DATE] (untimed) revealed that the resident was looking for her car and could not find her purse. Social worker attempted to re-direct the resident without success. Resident #102 was noted to state that she only came for tests and she needed to go home. The social worker left the resident sitting in her room and when she went back to check on resident #102 she was in her room crying. The social work note revealed that nursing was notified of increased confusion. At approximately 5:00 PM the social worker found the resident near the front door and a wander guard was applied. Record review of resident #102's nurse noted dated [DATE] at 9:35 PM revealed: 'Resident extremely agitated this evening, yelling out states she wants to go home. Explained to resident why she is here and that we are here to care for her. Resident states she doesn't care, she wants to go home anyway. Resident refused any pain medication for complaint of left hip pain. Certified nurse assistant came to this nurse at 9:20 PM stating resident is on floor in her room. Upon investigation resident lying on floor on right hip, complaint of pain to right hip. Vital signs stable. Page out to doctor'. There was no mention of assessment of the resident's right hip or of right leg shortening or leg rotation. There was no mention of right hip stabilization or of ice being applied. In an interview on [DATE] at 2:29 PM, CNA #6 revealed that she was providing care to resident #102 on [DATE] and that the resident was "having an off day". CNA #6 stated that resident #102 refused care and wanted to be left alone and was sitting up in her wheelchair when CNA #6 left the room. CNA #6 stated that resident #102 had no safety alarms and was not on fall alarms. CNA #6 stated "that day was very unusual, resident #102 was very confused, different that day". CNA #6 stated "I told the nurse (LPN #7) that I had a hard time with resident #102 that day, refusing care, became a little combative and I told the nurse (LPN #7). The nurse (LPN #7) was communicating with the ADON #3. Another aide found her on the floor. Her roommate was yelling out in the hall that resident (#102) was on the floor. I was in another room helping another resident. After the fall she was already in bed when I seen her". In an interview on [DATE] at 2:39 PM, LPN #7 reflected that resident #102 was agitated that day and her mood went up and down a lot, she was having a down day. LPN #7 stated that resident #102 was found on the floor and was picked up and put in her wheelchair, but was uncomfortable and then moved to the bed. LPN #7 stated that the resident was more confused than normal, stating she wanted to go home. LPN #7 acknowledged that there were no safety/fall devices applied with the increased confusion being noted. Record review of hospital emergency room record dated [DATE] at 11:23 PM revealed resident #102 sustained a fall from wheelchair with complaint of right hip pain. X-rays results revealed a right femoral neck fracture with impaction. Record review of resident #102's discharge MDS dated [DATE] reflected that the resident had signs and symptoms of delirium with disorganized thinking and incoherent conversation. Behaviors of psychosis with delusions were noted. The [DIAGNOSES REDACTED]. Resident #105: Record review of facility incident report dated [DATE] for resident #105 revealed: [AGE] year old alert and oriented resident discovered propelling himself in his wheelchair down driveway. He was intercepted and brought back into facility with no adverse physical effects. Facility interview with resident #105 dated [DATE] at 9:15 AM revealed the resident was asked what he was trying to do. The resident (#105) was noted to respond 'I (he was trying to kill himself and was on his way to funeral home'. The Resident was asked how he was trying to do this and resident #105 responded by stating "fast cars". Record review of the facility investigation summary dated [DATE] revealed that: On [DATE] if he (resident #105) had a gun he'd shoot himself. On [DATE] verbalized he "wanted to die". 15 minute checks in place. Resident verbalized his intentions to wrap phone cord around his neck. Resident #105 was sent to hospital for evaluation and returned [DATE]. On [DATE] 15 minute visual checks were discontinued. On [DATE] resident #105's wife reported that he was suicidal. Resident #105 was sent to hospital for evaluation and returned on [DATE], 15 minute visual checks continued. On [DATE] resident #105 was found outside the facility approximately 525 feet away. In an interview on [DATE] at 2:40 PM, resident #105 revealed "Last Saturday I went outside onto the road/driveway. I was going home, I live a mile away from here. No, I didn't tell anyone, I just went out. I went to the dining room for breakfast that day and then I left". In an interview on [DATE] at 2:45 PM, CNA #8 stated, "I was his aide that day. I came into his room at 7:55 AM, he was dressed, got up for breakfast, transferred to wheelchair. He really wasn't talking much, stated he didn't want to be here. I wheeled him, usually he self-propels, to the dining room at 8:00 AM. He was on 15 minute checks and alarm to wheelchair. I took him to dining in Huron unit and went back to my hall". In an interview on [DATE] at 11:00 AM, registered nurse (RN) #4 revealed that she was told by a visitor that they saw a bald man moving really fast by the front door. The nurse stated that she secured her medication cart and went to the front door and looked out the door, but did not see anyone. RN #4 notified her staff to do a head count and notified the other units. RN #4 stated that when she looked out the front door she saw a van that was turning into the doctors building down the road, but no resident. RN #4 stated that the resident could have been behind the van or ahead of it on the road. RN #4 sent CNA #5 to go back out and look to double check. In an interview on [DATE] at 3:05 PM with CNA #5 revealed that she was told to go outside and check again to make sure no one was out there. CNA #5 stated that when she opened the door, she saw a wheelchair with a pink pillow case with a blue catheter bag cover hanging and she knew it was one of the facility's residents in front of the ambulance garage. CNA #5 stated that resident #105 was down the road past the doctors building near the stop sign at the end of the road. CNA #5 stated that she had to sprint to get to the resident, and told him he had to come back. Record review of resident #105's 'Elopement and/or Exit Seeking Behavior Risk Analysis' form dated [DATE] revealed resident was discovered outside of the facility in the drive past physician office and directed back into the facility. Wander guard initiated. #

This citation pertains to MI 153 Based on observation, interview, and record review, the facility failed to prevent a fall in 1 of 4 sampled residents (#104) , from a total sample of 4 residents, resulting in Resident #104 falling from her bed during care on 11/11/11 and sustaining a buckle fracture of the distal tibia and fibula of the left lower leg which was not discovered until 11/18/11, after the x-ray report was found. Findings include: Review of the facility Unusual Occurrence Statement Form dated 11/10/11 revealed that at 10:45 PM, Resident #104 slipped off the side of the bed after CNA's turned Resident #104 to her left side while changing her linens. Resident #104 had received a skin tear to left arm, an open area to left knee, and an abrasion to left abdominal fold. Review of the facility incident report dated 11/18/11 revealed that on 11/11/11 at 12:35 AM certified nursing assistants (unidentified) were changing Resident #104, turned her onto her left (side), when the alternating air pressure mattress suddenly deflated and Resident #104 slipped off the bed and onto the floor. Review of the nurse notes dated 11/1/11 at 11:00 AM revealed that the facility was aware that Resident #104's air mattress was not working properly 10 days before she fell out of the bed, but continued to use the mattress. An interview on 1/17/12 at 9:15 AM, Resident #104 reported that she was being cleaned up and had been turned up on her left side. Resident #104 reported that the certified nurse assistant (CNA - unidentified by resident) that was on her right side left the bedside and left her turned up on her left side. Resident #104 stated that her back was to the CNA and that the CNA left to get something and she (Resident #104) fell from the bed and broke her ankle bone. An observation of Resident #104's bed on 1/17/12 at 9:15 AM revealed a Theraflo mattress (inflatable mattress) was in place. Record review of the manufactures product information guide revealed that under the warnings section 3.0, second paragraph on the left hand side of the page listed 'Patient Falls'- failure to use bed in raised position could lead to accidental patient falls. Air mattresses have soft edges that may collapse when patients roll to that edge. Record review of the facility 'Nursing Basic Policy & Procedures Manual' located at each nursing station revealed that there was no inflatable mattress policy & procedure. Observations on 1/17/12 during the investigation of all resident rooms/beds in the facility revealed that there were four different types of inflatable air mattress or inflatable air mattress overlay being used in the facility. In a telephone interview on 1/17/12 at 3:10 PM, CNA #5 stated on 11/10/11 at approximately 10:00 PM, she and CNA #11 were cleaning up Resident #104 and had Resident #104 turned up on her left side close to the edge. CNA #5 stated that Resident #104 did not fit in the bed, and that the bed was to narrow so that Resident #104 was always close to the edge. CNA #5 reported CNA #11 stepped away from the bed to get washcloths across the room and the bed deflated. CNA #5 stated that the bed had deflated a couple of times that she was aware of. CNA #5 reported Resident #104 slid off the bed and that she was holding her top, but Resident #104 was too heavy and she fell . CNA #5 reported all of Resident #104's weight was on her left leg and that the "left leg was bent backwards and twisted like". CNA #5 stated she told CNA #11 to go get the nurse. CNA #5 stated that the nurse (unidentified) assessed Resident #104 and that it took five staff members to pick up Resident #104 with each person grabbing a limb and the head and put her back into bed. CNA #5 stated that she now inflates the mattress all the way up and then the mattress doesn't deflate when she has to turn Resident #104. CNA #5 reported she had not been in-serviced on the Theraflo air pressure mattress prior to Resident #104's fall. In an interview on 1/17/12 at 12:00 PM, Registered Nurse (RN) education/In-servicing nurse #6 revealed that she had been at the facility for over a year. RN #6 stated that she did not have any educational material on the Theraflo mattress and that no education on the mattress was ever done prior to the fall for facility staff. A second interview on 1/17/12 at 1:00 PM, RN #6 revealed that there was no policy for the inflatable mattress used when she had looked for one and that there was no staff in-servicing done. In an interview on 1/17/12 at 2:00 PM, RN #8 (unit manager) reported that an unidentified floor nurse found Resident #104's x-ray on 11/18/11 which revealed a fracture. RN #8 reported she reviewed Resident #104's nursing notes from 11/11/11 through 11/18/11 and there was no mention of x-ray results noted. RN #8 reported there was 7 days between when the x-rays results came and when the staff noticed the fracture results. Record review of Resident #104's x-ray preliminary report dated 11/11/11 at 2:55 PM, with a faxed time and date stamp of 11/11/11 at 2:56 PM revealed Resident #104 had 5 x-rays performed and that the x-ray for Resident #104's left tibia/fibula (lower leg bones) revealed a buckle fracture at the distal tibia and fibula. Record review of a hand written statement by licensed practical nurse (LPN) #12 reflected that LPN #12 had received a phone call from the radiology company on 11/11/11 at approximately 3:00 PM, who gave a verbal report to LPN #12 that Resident #104's x-rays were negative for fracture. LPN #12 documented that she reported the information to the assistant director of nursing (ADON) #3 and passed it on in report to the on-coming nurse. LPN #12 documented that she had to leave early due to a family emergency. Record review of the radiology company x-ray procedure outlined the process of obtaining x-rays and getting results. The procedure reflected: #7) Verbal results will be called to the charge nurse on all abnormal pathology within 12-24 hours. #8) Typed results will be faxed to the facility within 1-2 business days. The faxed report is your hard copy for the chart. In an interview on 1/17/12 at 2:25 PM, ADON #3 reported she had done the investigation regarding Resident #104's fall starting on 11/11/11 at 8:00 AM. ADON #3 stated that she had hospice exchange the air mattress for a different one and that LPN #12 had reported to her that all of the x-rays for Resident #104 were negative. ADON #3 stated that it was not until 11/18/11 when physician #13 asked about Resident #104's x-ray results that her fracture was discovered and treated. ADON #3 stated that the radiology preliminary report was faxed to the facility on [DATE] and that it was misplaced by the facility for 7 days. #

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS CONDITION OF SKIN AS DIRECTED IN THE PLAN OF CARE FOR ONE RESIDENT (#8) AND FAILED TO DEVELOP A SKIN RISK CARE PLAN FOR ONE RESIDENT ASSESSED AS BEING AT RISK FOR PRESSURE ULCERS (#3), FROM A TOTAL SAMPLE OF 21 RESIDENTS REVIEWED THAT INCLUDED 5 REVIEWED FOR PRESSURE ULCERS, RESULTING IN RESIDENT #8 DEVELOPING AN UNSTAGEABLE PRESSURE ULCER AND BEING PLACED AT RISK FOR DEVELOPMENT OF INFECTION AND PAIN AND RESULTING IN RESIDENT #3 BEING PLACED AT INCREASED RISK FOR DEVELOPING AVOIDABLE ULCERS. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION RECORD FACE SHEET, DATED 05/16/11, RESIDENT #8 WAS A [AGE] year OLD FEMALE WITH MULTIPLE MEDICAL [DIAGNOSES REDACTED]. ACCORDING TO NURSE'S NOTES AND THE WEEKLY PRESSURE ULCER WOUND DOCUMENTATION SHEET, BOTH DATED 10/8/11, RESIDENT #8 HAD DEVELOPED A PRESSURE ULCER TO HER RIGHT HEEL ON 10/8/11. THE WEEKLY PRESSURE ULCER WOUND DOCUMENTATION SHEET INDICATED THAT THE WOUND WAS APPROXIMATELY 1.6 X 1 CM (CENTIMETERS) AND WAS "UNSTAGEABLE". ACCORDING TO THE "NATIONAL PRESSURE ULCER ADVISORY PANEL'S NEW PRESSURE ULCER STAGING SYSTEM: UNSTAGEABLE PRESSURE ULCERS" (RETRIEVED FROM HTTP://WWW.MEDSCAPE.COM ON 10/24/2011), AN UNSTAGEABLE PRESSURE ULCER IS DEFINED AS: "FULL THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE ULCER IS COVERED BY SLOUGH (YELLOW, TAN, GRAY, GREEN, OR BROWN) AND/OR ESCHAR (TAN, BROWN, OR BLACK) IN THE WOUND BED." BASED THE WEEKLY PRESSURE ULCER WOUND DOCUMENTATION SHEET FOR RESIDENT #8 FOR 10/8/11, THE FOLLOWING WAS DOCUMENTED IN REGARDS TO THE RESIDENT'S HEEL ULCER: "PREVIOUS WOUND SITE, NOW DRY BLK (BLACK) TO WD (WOUND) BED."ADDITIONALLY, THE TISSUE TYPE WAS DESCRIBED AS "100% ESCHAR (NECROTIC)". ACCORDING TO THE NURSING CARE PLAN DATED 11/20/09, RESIDENT #8 WAS ASSESSED BY THE FACILITY AS BEING AT RISK FOR SKIN BREAKDOWN RELATED TO DECREASED MOBILITY, INCONTINENCE, DEPRESSION, POOR APPETITE AND ARTHRITIS. TWO OF THE CARE PLAN INTERVENTIONS THAT WERE DATED 2/18/10 WERE FOR NURSE AIDE STAFF TO CONDUCT DAILY SKIN INSPECTIONS AND LICENSED NURSING TO CONDUCT WEEKLY SKIN ASSESSMENTS. ON 10/20/11 AT APPROXIMATELY 2:15 PM, WOUND NURSE "E" WAS INTERVIEWED REGARDING RESIDENT #8'S PRESSURE ULCER. WOUND NURSE "E" SAID THE RESIDENT'S RIGHT HEEL WENT FROM INTACT SKIN TO AN UNSTAGEABLE PRESSURE ULCER OVERNIGHT. DURING THE INTERVIEW, WOUND NURSE "E" WAS ASKED FOR DOCUMENTATION TO SUPPORT THAT THE FACILITY WAS PERFORMING THE DAILY SKIN INSPECTIONS AND WEEKLY SKIN ASSESSMENTS IN ACCORDANCE WITH THE RESIDENT'S CARE PLAN, BUT NO SUCH DOCUMENTATION WAS PROVIDED. THERE WAS NO DOCUMENTATION PROVIDED TO EXPLAIN WHY, IF THE SKIN INSPECTIONS AND ASSESSMENTS HAD BEEN PERFORMED, THE PROBLEM WITH THE RESIDENT'S HEEL ULCER HAD NOT BEEN DISCOVERED AT AN EARLIER STAGE OF DEVELOPMENT; FOR EXAMPLE, WHEN THE SKIN ON HER HEEL WAS STILL INTACT BUT "MUSHY" RATHER THAN NECROTIC. ON 10/21/11 AT APPROXIMATELY 9:50 AM, RESIDENT #8 WAS OBSERVED IN HER ROOM AND THE TREATMENT TO HER RIGHT HEEL PRESSURE ULCER WAS OBSERVED. THE WOUND BED WAS DEEP RED IN COLOR AND THE EDGES OF THE WOUND WERE REGULAR. THE WOUND BED WAS CLEAN AND THE SURROUNDING TISSUE WAS RED-PINK. OBSERVATION OF RESIDENT #8 DURING THE WOUND TREATMENT REVEALED A SEVERELY COMPROMISED RESIDENT WHO WAS UNABLE TO TURN OR RE-POSITION HERSELF INDEPENDENTLY. SHE WAS NOTED TO HAVE CONTRACTED (STIFFENED) LOWER EXTREMITIES AND CONTRACTURES OF THE FEET. ACCORDING TO THE RESIDENT'S MDS (MINIMUM DATA SET) ASSESSMENTS, DATED 5/11/11 AND 8/11/11, THE RESIDENT WAS COMPLETELY DEPENDENT UPON STAFF FOR TRANSFERRING FROM ONE SURFACE TO ANOTHER AND FOR MOBILITY IN HER ENVIRONMENT. THE RESIDENT'S HEEL ULCER HAD NOT RESULTED IN A DECLINE IN HER FUNCTION; HOWEVER THE EROSION OF HEALTHY TISSUE BY DEAD TISSUE REPRESENTED A SIGNIFICANT INJURY THAT PLACED THE RESIDENT AT INCREASED RISK FOR CLINICAL COMPROMISE SUCH AS INFECTION AND PAIN. ( ) ON 10/20/11 AT APPROXIMATELY 2:00 PM, RESIDENT #3'S MEDICAL RECORD WAS REVIEWED. ACCORDING TO THE "BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK" (2011), RESIDENT #3 WAS ASSESSED FOR PRESSURE SORE RISK ON 9/28/11, 10/5/11, 10/12/11, AND 10/19/11. ON ALL 4 DATES, RESIDENT #3 SCORED A "17", WHICH INDICATED THAT HE HAD A MILD RISK FOR PRESSURE ULCER DEVELOPMENT. (ACCORDING TO THE SCALE, A SCORE OF "12" OR LESS REPRESENTED "HIGH RISK".) HOWEVER, A RISK FOR PRESSURE ULCER DEVELOPMENT CARE PLAN WAS NOT OBSERVED IN RESIDENT #3'S MEDICAL RECORD. DURING AN INTERVIEW AT 2:00 P.M. ON 10/20/11, MINIMUM DATA SET (MDS) NURSE "F" SAID THAT A PRESSURE ULCER CARE PLAN WAS NOT INITIATED FOR RESIDENTS WHEN THEIR BRADEN SCORE WAS "18" OR MORE. MDS NURSE "F" WAS SHOWN RESIDENT #3'S BRADEN SCALE SHEET, AND WAS ASKED WHY RESIDENT #3 DID NOT HAVE A CARE PLAN INDICATING HIS RISK FOR PRESSURE ULCER DEVELOPMENT. MDS NURSE "F" STATED, "I DON'T KNOW HOW I MISSED IT. I SHOULD DO ONE." ( )