Every finding on record at Briarwood Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure that safe cleaning practices, humidification, dispensation of oxygen and storage of respiratory equipment was maintained. This deficiency affected four residents (R77, R82, R84 and R89) of four residents reviewed for respiratory standards of care. Findings include: Resident 82 (R82): On 6/1/26 at approximately 9:30 AM, an interview was conducted with R82 who answered questions and engaged in conversation. An observation was made of a water bottle for humidification positioned on the concentrator but not connected to the concentrator or tubing that was on the Resident. The bottle was empty and there was not a date on the humidification container. The Resident reported that the oxygen was drying to her nose. A review of R82's medical record revealed an admission into the facility on 4/9/25 with diagnoses that included chronic obstructive pulmonary disease and asthma. A review of the Resident's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) revealed a score of 15/15 that indicated intact cognition. On 6/3/26 at 11:27 AM, an observation was made with Unit Manager, Nurse C of Resident 82 lying in bed with her oxygen on that was connected to the concentrator. The humidification was not attached to the tubing or concentrator. The UM asked the Resident about the oxygen and the Resident reported that it dries out her nose and throat and will make her cough. The Resident reported that bottle had been on the concentrator for a couple months. There was not a date on the container. The UM indicated the container should be dated when applied. The UM told the resident that he was unsure if humidification was ordered but it sounds like you need it so I will make sure that it gets on there. Resident 84 (R84): On 6/1/26 at approximately 9:15 AM, an observation was made of Resident #84 eating breakfast sitting up on the side of the bed. The Resident was interviewed, answered questions and engaged in conversation. The Resident had Oxygen (O2) tubing in her nose (nasal cannula) that was attached to a concentrator at 4 L (liters)/(per) minute. The Resident reported she was not supposed to change the concentration of the oxygen. The concentrator was positioned not within reach of the Resident while in bed. An observation was made of humidification bottle with a short tubing that was positioned on the concentrator but was empty and not connected to the tubing to the Resident. The Resident was asked if the oxygen at 4 Liters/minute was comfortable for the Resident. The Resident reported that sometimes she gets bloody noses and the oxygen dries out her nose. The Resident was not aware the humidification was not attached. A review of Resident 84's medical record revealed an admission into the facility on 9/11/19 and readmission on [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, depression, anxiety disorder, dependence on supplemental oxygen and adult failure to thrive. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 12/15 that indicated moderate cognitive impairment. A review of R84's medical record revealed orders for oxygen at 3 Liters/min and an order for Nasal Four Nasal solution 1%, 1 spray in both nostrils every 1 hours as needed for irritation, may have at bedside. On 6/2/26 at 4:09 PM, an interview was conducted with Unit Manager (UM), Nurse C regarding Resident #84's oxygen and the lack of humidification. The UM indicated there did not need to have an order for the humidification and it would be if the Resident needed it. An observation was made of Resident #84's oxygen. The Resident was in the room and had the oxygen nasal cannula in her nose with the tubing connected to the concentrator and set at 4 L/min. The humidification was on the top of the concentrator, empty and not connected to the concentrator and resident. The Resident was asked if the oxygen caused issues in her nasal passages and the Resident reported it made her nose dry, caused it to bleed and she would put a Q-tip in there to get the hardened crusty blood out. The UN educated the Resident about placing items in her nose and reported they would get humidification connected to the oxygen. A review of facility policy titled, Oxygen Administration, revealed, .Assessment: .3. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered per physician order. 5. O serve the resident upon setup and periodically thereafter to be sure oxygen is being tolerated and continues at the prescribed liter flow. 6. Periodically re-check water level in humidifying container and change as needed. R77: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R77 was admitted to the facility on [DATE] with diagnoses that included: congestive heart failure (CHF/ decreased ability of heart to pump blood), respiratory failure, chronic obstructive pulmonary disease (COPD/ progressive lung disease), morbid obesity with obstructive sleep apnea (OSA), diabetes mellitus (DM), hypertension (high blood pressure) and atrial fibrillation (AFIB/ irregular rapid heart rate). The MDS assessment dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. On 06/01/2026 at 1:23 PM, observed R77's oxygen tubing was dated 5/18 set at 3L and Continuous Positive Airway Pressure (Cpap) mask was sitting on top of the nightstand not in use and uncovered. On 06/02/2026 at 9:33 AM, during an interview with R77 he said they do not clean his Cpap mask, and it was never stored in plastic and was always on his nightstand. Observed R77's oxygen tubing was dated 5/18 set at 3L and Cpap mask was sitting on top of the nightstand not in use and uncovered. According to a record review of R77 orders: Dated 05/05/2026: Oxygen at 2 lpm via nasal cannula, notify MD if SpO2 is less than 90%.Dated 05/07/2026: Home Auto CPAP 8-20cmH2O with home settings and o2 bled in at 2 liters to be worn at NOC (night) and as needed for naps. According to a record review of R77's care plan: Focus: Has/At risk for respiratory impairment related to CHF, COPD, sleep apnea, chronic resp fx (failure) O2 use. With interventions: CPAP (8-20) use per physician orders; Administer oxygen as per physician order: 2 liters via nasal cannula. There were no orders or care plans placed for oxygen or CPAP equipment cleaning care and maintenance. R89:A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R89 was admitted to the facility on [DATE] with diagnoses that included: history of repeated falls, obstructive sleep apnea (OSA), atherosclerotic heart disease (ASHD), congestive heart failure (CHF / decreased ability of heart to pump blood) and depression. The MDS assessment dated [DATE] indicated the resident had moderate impaired cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 10/15. On 06/01/2026 1:13 PM, R89 was not present in room to interview, an observation of R89's Cpap mask hanging high on wall not in use and not covered. On 06/02/2026 at 9:27 AM, observed R89's cpap in the same position hanging high on the wall not in use and uncovered. When asked R89 said that is where they keep it, the hook was here before she moved in. On 06/02/2026 at 3:51 PM, R89 was again asked about her Cpap that was observed in the same position uncovered and high up on the wall on a hook, R89 said she was unable to reach the hook and that one of the CNAs assisted her at night to put it on/off and they put it back on the hook, she said however that she did not wear it last night. When asked she said that she had never seen anyone clean it. According to a record review of R89's care plan:Focus: I have altered respiratory status r/t OSA. With interventions: Home cpap to be worn at HS (bedtime) and NOC (night). According to a record review of R89's orders:Dated 05/11/2026: Home cpap to be worn at HS and NOC.There were no orders or care plans placed for the CPAP equipment cleaning, care and maintenance. On 06/02/2026 at 3:53 PM, during an interview with CNA J she was asked if she cleaned the residents Cpap masks and she said yes. CNA J was asked what she cleaned the mask with and she said wipes, asked what kind of wipe and she said bleach wipes and showed SA a canister of wipes with a purple top and said it was like those but that the canister with the bleach wipes had a white top, she but that couldn't find one at the time. CNA J was asked how the Cpap mask was stored when not in use and she said most residents keep then in their closet or nightstand and in a plastic bag to cover them. CNA J was asked who was responsible for the storage of the masks and she said the Nurses were. On 06/02/2026 at 3:56 PM, during an interview with Nurse K was asked who was responsible for cleaning the Cpap masks she said the respiratory therapy staff, she was asked how often they are clean she said she did not know. Nurse K was asked how the masks are stored when not in use and she said in the nightstand in a plastic bag. Nurse K was asked who was responsible for ensuring storage of the mask she said any staff that was working with the resident. Nurse K was asked how often oxygen tubing was replaced and she said every Sunday by the night shift nurse. On 06/02/2026 at 4:17 PM, during an interview with the ICP B he was asked who was responsible for cleaning of residents Cpap masks and he said it was respiratory therapy. When asked how often cleaning of Cpap masks were done he said it used to be daily, but he is not sure. ICP B was advised his staff said the masks were cleaned with bleach wipes and he was asked to confirm, he said 'I am not sure what is used but I know it is not bleach wipes on respiratory equipment.' ICP B was asked how often oxygen tubing was replaced, he said every Sunday on night shift by the nurse on duty. The infection control preventionist (ICP) B was asked to go on a walkthrough of both R77 and R89's rooms for observation. ICP verbally acknowledged that R77's oxygen tubing was dated 5/18 and the Cpap mask was uncovered and not in use on the nightstand. ICP verbally acknowledged that R89's Cpap mask was hanging high out of reach of resident and was uncovered and not in use.According to a record review of the facilities policy labelled Cleaning and disinfection or resident-care items and equipment: Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. With policy implementations: 1.The . Classification System is used to distinguish the levels of sterilization/disinfection necessary for items used in resident care; 1.b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment).; 5.a. Single resident-use items are cleaned/disinfected between uses by a single resident. According to a record review of the facilities infection prevention rounds tool – nursing department: Focus area: Unused oxygen tubing, nebulizers stored in lactic bags; tubing dated and changed per guidelines. According to a record review of the facilities Policy labelled Oxygen administration: Assessment: 4.date the oxygen tubing per the policy there was no guidelines written for timeframe of tubing placements. According to a review of the facilities ResMed CPAP preventative maintenance guidelines: 1. Daily Maintenance: Mask cushion/pillows: Wash daily with warm drinking quality water (~30 degrees C / 86 degrees F) and mild, non-scented detergent to remove facial oils and maintain seal integrity. Rinse thoroughly and air dry away from sunlight; Humidifier water tub (routine care): Empty remaining water each morning, rinse, and allow to air dry out of direct sunlight. Use distilled water only for therapy. And 6. Important safety notes: Avoid harsh chemicals, bleach, alcohol, scented soaps, antibacterial detergents or UV/ozone cleaners, as these may damage components.

Based on observation, interview and record review, the facility failed to 1) Ensure proper storage of medications for Resident #23 and Resident #112; 2) Ensure that medication carts and treatment carts were secured; 3) Ensure that expired medications were disposed of; 4) Ensure that a medication cart was in sanitary condition; and 5) Ensure that medication cart keys, which included narcotic keys, were not shared between nurses, for three of six medication carts, one of three medication storage areas, one treatment cart and one wound care cart reviewed for storage of medications, supplies and narcotics. Findings include: On 6/1/26 at 8:25 AM, an observation was made in the 100-Hall area of a treatment cart positioned in the hallway against the wall. The Treatment Cart was left unlocked and not secured. Staff were going up and down the hall, and there was not any Resident's in the area at this time. The Nurse had been at a medication cart at the end of the hall. The Medication cart was up against the wall with the drawers facing the hallway. The Nurse was observed assembling medication and went into the room and was not within vision of the medication cart that was left unlocked and positioned in the hallway. On 6/1/26 at 8:38 AM, an interview was conducted with Nurse V who came back out of the Resident's room and returned to the unsecured medication cart. The Nurse was asked if the medication cart should be locked when not in direct vision of the nurse and the Nurse reported that Yes, it should be locked. When asked if they had been in the treatment cart that was positioned partially down the hallway, the Nurse reported she had been in there earlier. When asked if the treatment cart should be locked when in not direct vision of the nurse, the Nurse indicated it should be locked as well. A review of the treatment cart with Nurse V revealed treatment/dressing supplies, and prescription ointments, powders and treatments. On 6/1/26 at 1:10 PM, an observation was made in the 100-Hall area of the medication cart stored at the end of the hallway up against the wall with the drawers facing the hallway. There was a resident in the hallway. The medication cart was unlocked. Nurse T was observed earlier at the cart and had gone up the hall and off the unit. The Medication cart was not directly supervised by the nurse. A couple minutes later Nurse T came back and when asked about the security of the medication cart, the Nurse locked the cart. On 6/2/26 at 4:15 PM, an observation was made in the 200-Hall of a treatment cart unlocked and positioned near a resident's door with the drawers facing up the hallway and would be in reach for Residents. There were three Residents propelling themselves in the hallway. At 4:17 PM, the treatment cart remains unsecured. An observation was made of a Nurse walking by the treatment cart, passed the cart without securing the cart, the nurse goes into the med room, comes back by the treatment cart and down the hall where they go into a Resident's room and not in direct vision of the treatment cart. An observation was made of three other residents propelling themselves past the treatment cart. At 4:20 PM, an interview was conducted with Nurse T who comes out of the Resident's room where the treatment cart was positioned near. When asked the Nurse reports the treatment cart should be locked when they are not there. The Nurse reported the treatment cart was the wound cart and contained dressing and treatment supplies. On 6/3/26 at 9:28 AM, an observation was made on the 600 Hall during medication storage review with Nurse H who was also observed passing medication to Residents. The Nurse was getting a narcotic medication out for a Resident and had asked the other for the keys to the middle cart. The Nurse had passed the keys to the other Nurse, and a narcotic count had not been completed. When asked about why the other Nurse had the keys, Nurse H reported that they had two med carts in use, but she had some residents' medications in the middle cart. The Nurse explained that they sometimes have three nurses but due to census, they only had the two nurses working and the other Nurse had taken the medications out of the cart at the beginning of the shift, but she still had the keys even though she had some of her residents' medication in that cart. When asked who had counted the narcotics on the middle cart, the Nurse reported she had. An observation was made of the narcotic count sheet that the nurses were to sign upon counting the narcotic medication and it was blank where she should have signed after narcotic count. The Nurse reported she had forgot to sign after counting with the nightshift nurse and signed the sheet at this time. The 600-Hall medication cart was reviewed with Nurse H and the following items were identified: -The medication discard bottle to waste medication was in a bag with brown liquid leaking out of the bottle, down the sides and there was brown liquid on the bottom of the drawer where the liquid was kept with bottles of medication. -Container of Acetaminophen 325mg (milligrams) expired 4/2026. -Container of Famotidine 10 mg, expired 1/2026. -Container of Melatonin 3 mg, expired 1/2026. -Container of Aspirin 325mg, expired 1/2026 that had a date of opening on 5/18/26. -Container of Vitamin B1, expired 3/2026. -The glucose monitor control solutions were opened with the date opened on 12/20 (2025). When queried regarding how long the control solution was good for, the Nurse was unsure and indicated the nightshift nurses perform the glucose controls on the monitors. Reviewing the box of control solutions, the box had underneath the manufacturer's expiration date instructions that revealed, good for 45 days after opening. On 6/3/26 at 10:19 AM, an observation was made with Nurse U, of the Central Supply medication storage area where over-the-counter medications and medical supplies were stored, with the following items identified: -Hydrophilic coated Cure Catheter x (times) 6 catheters, expired 2/8/2026. -14 French catheter expired 7/13/2025. -Self Catheters x 13, expired. -Vitamin B6 x 2 bottles, expired 3/2026. -Vitamin B6 bottle, expired 1/2026. -Melatonin 3 mg expired 1/2026. -Melatonin 3 mg expired 2/2026. -Acetaminophen 325 mg, expired 4/2026. -Vitamin B12 expired 5/2026. -Geri Kot, x 2 containers, expired 1/2026. On 6/3/26 at 10:58 AM, a review of the medication cart in the 400-Hall area was reviewed with Nurse C. An observation was made of Sevelamer Carbonate tablets for a Resident that were in a bottle that had an expiration date of June 2025. The Nurse explained that they had gotten the bottle from the Resident's family and will check to see if they had some that were not expired. A review of the treatment cart in the 400 hall with Nurse C was reviewed. There were open bottles of iodoform dressing for packing that were not dated with an open date. When asked if the items were to be dated, the Nurse stated, I can't tell how long it's been open, I don't know how long it is good for, when there was not an expiration date, just a lot number. On 6/3/26 at 1:16 PM, an interview was conducted with Unit Manager, Nurse T regarding facility policy on ensuring secure medication carts and treatment carts. The Unit Manager indicated that the med carts should be locked when the nurse was not within reach or vision of the med cart of treatment cart. Regarding expired medications in the medication carts, the Unit Manager reported that the Nurses should be checking for expired meds on a monthly basis and stated, We need to establish a schedule. On 6/3/26 at 1:28 PM, an interview was conducted with the Director of Nursing regarding the medication cart observations not secure. The DON reported they should be locking the carts when the carts were not in sight of the nurse. Regarding the expired medications, the DON reported she will make sure they were disposed of and that the night nurses should be looking at it and indicated they had a weekly schedule. Regarding the glucose monitoring solutions opened for extended period of time, the DON stated, They should be getting rid of it after the 45 days. It was reviewed with the DON that the two Nurses both had access to the med cart keys that included the narcotic keys but had not ensured an accurate account of the narcotic medications. A review of facility policy titled, Storage of Medications, revealed, .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 8. Compartments.containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended. 14. Access to controlled medications is limited to authorized personnel. Personnel access to controlled medications is recorded. A review of the facility policy titled, Storage of Controlled Substances, revealed, .Procedures: .2. Schedule II through V medications and other medications subject to abuse or diversion are stored in either a permanently affixed, double locked compartment separate from all other medications or in accordance with state regulations. The access system to controlled medications is not the same as the access system for other medications (e.g., the key that opens the compartment is different from the key that opens the medication cart). If a key system is used, the medication nurse on duty maintains possession of the key to controlled substance storage areas. a. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented. Resident #23: On 6/1/2026 at approximately 8:30 AM, Resident #23 was observed lying in bed after finishing breakfast. At the bottom of her bed were two bottles of OTC (over the counter) [NAME] and an unlabeled Albuterol inhaler with 46 administrations remaining. The resident was asked about the medications and stated she takes [NAME] as needed when she is stuffed up. She added she has COPD and uses an inhaler daily- she stated they (the nursing staff) don' t know that she has the inhaler in her room. Resident #23 then asked for medications to be covered prior to leaving the room. Nurse N entered the room to complete vitals on Resident #23 and observed the medications at the end of her bed. She picked up the medications and walked to her cart and reported the resident and her significant other have been educated multiple times on bringing in OTC and home medications. Nurse N checked the cart and saw Resident #23's Albuterol box was empty and determined the inhaler in her room was the one from the medication cart. Nurse N reported she did not administer an inhaler to her, so it was a different shift that provided her with the inhaler. On 6/2/2026 at approximately 10:00 AM, a review was conducted of Resident #23's records and it revealed the resident admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure, Diabetes, Major Depression, Mood Disorder, and Atrial Fibrillation. Further review yielded the following: June 2026 MAR (Medication Administration Record): Albuterol Sulfate HFA Inhalation Aerosol Solution- 2 puff inhale orally every 4 hours as needed for SOB (shortness of breath). It was last administered on 6/1/2026 at 11:12 PM. Progress Notes: 6/1/2026 at 10:20 AM: Pt (patient) educated on not having family bring in medications from home, pt has been educated before and educated again we have a routine med pass time and medication administration of meds, pt stated she understood this. On 6/3/2026 at 2:00 PM, the DON stated they have educated Resident #23 and her significant other on bringing in home medications. She stated they should not have been at bedside with her. Resident #112: On 6/1/2026 at approximately 8:00 AM, Resident #112 was greeted in her room. She recently admitted to the facility after fracturing her leg from a fall at home. Sitting on Resident #112's bedside dresser was a bottle of Omeprazole 40 mg (milligrams) with approximately 40 capsules in the bottle. The resident shared she had her family bring in her medication this weekend to show the nurse what she takes. The nurse from the weekend knew the omeprazole was in her room but not her current nurse. Resident #112 reported she was unaware of the facility rules regarding unsecured medications. Nurse M was outside of the resident room and was asked if she observed the bottle of omeprazole on the bedside dresser. Nurse M stated while she had been in the residents' rooms this morning, she did not see the medication bottle on the dresser now did the resident alert her to the medication. On 6/1/2026 at approximately 8:10 AM, the DON (Director of Nursing) was informed of the medications found at Resident #112's bedside. The DON reviewed her chart and shared on day of admission Omeprazole was ordered so she was uncertain why she would bring them in. On 6/2/2026 at approximately 10:30 AM, a review was conducted of Resident #112's record and it revealed she was admitted to the facility on [DATE] with diagnoses that included, Hypotension, left fibula fracture, Diabetes, Atrial Fibrillation, GERD (Gastro-Esophageal Reflux Disease), COPD and Heart Disease. Further review of the record yielded the following: May 2026 MAR: Omeprazole Oral Capsule Delayed Release 40 MG- Give 1 cap by mouth two times day. Medication was first administered on 5/25/2026 at 5:00 AM.

Based on observation, interview and record review the facility failed to ensure that menus and/or food preferences were followed for three residents (#12, #13, #84) of three residents reviewed for preferences and nine residents observed during the dining task.Findings include:Resident 84 (R84): A review of Resident 84's medical record revealed an admission into the facility on 9/11/19 and readmission on [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, depression, anxiety disorder, dependence on supplemental oxygen and adult failure to thrive. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 12/15 that indicated moderate cognitive impairment. On 6/1/26 at approximately 9:00 AM, an interview was conducted with R84 who answered questions and engaged in conversation. The Resident was observed with her breakfast tray at her bedside, and the Resident was putting jelly into her oatmeal. The Resident was asked about food and the Resident reported that she uses brown sugar and jelly in her oatmeal for breakfast. The Resident reported that they never bring her brown sugar. The Resident had a single packet of white sugar and said, Who puts white sugar in their oatmeal! The Resident reported she only got one jelly today and she uses more than one. The Resident reported going down to the kitchen yesterday to complain and they still have it wrong. The meal tag was on the Resident's tray, and it indicated the Resident was to get oatmeal and also indicated jelly and sugar. When asked if she usually used the white sugar or brown sugar on her oatmeal, the Resident reinstated who puts white sugar on oatmeal, I want the brown sugar, and reported she should not have to go down there to complain and then they still don't get it right. Resident #13: On 6/1/2026 at approximately 7:10 AM, Resident #13 was observed resting in bed and shared he had a fall at home and was admitted to the facility for strengthening and to get back to his prior level of functioning. He added he routinely is not provided with the menu items that are listed on the meal ticket and that can become frustrating. On 6/1/2026 at 8:05 AM, Resident #13 breakfast tray had been delivered, and we reviewed the meal ticket to his tray provided for completeness. The ticket stated, scrambled eggs with ham, on his plate it only appeared to be eggs without ham. The resident reported they typically dice the ham and cook it with the eggs but there was no ham cooked into his eggs this morning. Resident #13's roommate was still enjoying breakfast and asked about his scrambled eggs with ham-. He reported there was no ham in his eggs and moved around the eggs on his plate to ensure the ham was not missed. Observation was made of multiple resident's breakfast trays on 300 Unit and the following was observed: 303-1- Sitting up in bed with breakfast tray in front of her. The meal ticket read scrambled eggs with ham, there was no ham observed on her plate or cooked in with the eggs. 303-2- The resident reported there was no ham on her plate although that was listed on the meal ticket. 304-1- Observation of meal tray and ticket and there was no ham on her plate or cooked within her eggs. 305-1 – CNA (Certified Nursing Assistant) P was observed assisting the resident with her breakfast and was asked if there was ham cooked with the eggs or anywhere on the plate when received. CNA P reported there was no ham provided. 305-2 Observation of meal tray and ticket and there was no ham on her plate or cooked within her eggs. 308-1- Observation of meal tray and ticket and there was no ham on her plate or cooked within her eggs. 309-1- Observation of meal tray and ticket and there was no ham on her plate or cooked within her eggs. 309-2- Observation of meal tray and ticket and there was no ham on her plate or cooked within her eggs. 311-1- Observation of meal tray and ticket and there was no ham on her plate or cooked within her eggs. On 6/1/2026 at approximately 1:50 PM, a review was conducted of Resident #13 medical record and it revealed he admitted to the facility on [DATE] with diagnoses that included Hypertensive Heart Disease, Heart Failure, Diabetes, Generalized Anxiety Disorder and Spinal Stenosis. His diet is listed at general diet, regular texture, think consistency. On 6/2/2026 at 3:24 PM, an interview was conducted with Dietary Manager Q regarding breakfast provided to the residents on 6/1/2026. Manager Q was asked if they currently have ham and she stated yes as they received a shipment today and last week. She was asked why ham was not provided to facility residents during breakfast yesterday morning. She reported she did not receive any complaints yesterday regarding breakfast and was unaware of this. If if there was no diced ham, they could have used the sliced ham and diced it to their needs. Observation was made of the following in the kitchen freezer: 1- unopened box of diced ham delivered on 6/2026. 1- unopened box of diced ham delivered on 5/28/2026 On 6/2/2026 at 3:50 PM, Dietary [NAME] R stated he was the cook for breakfast yesterday (6/1/26).He explained the menu called for scrambled eggs with ham and they typically have pre-diced ham that they cook into the eggs but they did not have any ham yesterday – so he only made the scrambled eggs. Shortly after the phone call ended [NAME] R called back and stated that there indeed was ham in the freezer but he did not realize that and took full accountability. On 6/3/2026 at 9:15 AM, review was completed of the menu for 6/1/26 it showed the following: Choice of juice Choice of hot or cold cereal Scrambled Egg with cheese English Muffin Jelly Margarine 2% milk Coffee/Hot Tea Condiments There were 70 residents that were supposed to be served scrambled eggs with ham on 6/1/2026.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include: On 06/01/2026 at 6:16AM whole milk with a best buy date of 5/28/26 was observed in the walk-in cooler. On 06/01/2026 at 6:17AM lemon flavor thickener with a best buy date of 4/24/26 was observed in the walk-in cooler. According to the 2022 Food Code, 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.On 06/01/2026 at 6:18AM large chunk of built-up ice accumulation on food storage shelf, was observed in the walk-in freezer.According to the FDA 2022 Food Code, 6-501.12 Cleaning, Frequency and Restrictions, Physical facilities shall be cleaned as often as necessary to keep them clean. Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of food is exposed such as after closing.On 06/01/2026 at 6:20AM a knife was observed visibly soiled, stored in the knife rack. According to the facility's policy on Sanitation, All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair.According to the FDA 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.On 06/01/2026 at 6:23AM the ice machine drain was observed sitting inside the drain, located in the dining room adjacent to the kitchen. According to the 2022 FDA Food Code, 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. On 06/01/2026 at 7:04AM interviewed Dietary Manager A on how long milk is kept for, and she stated the facility doesn't keep it past the expiration date. On 06/01/2026 at 7:09AM two gnats were observed on the floor in the dishwashing area. On 06/01/2026 at 7:10AM several gnats were observed flying around the drain to the dishwasher. On 06/01/2026 at 7:20AM interviewed Dietary Manager A on how often pest control comes out to the facility, she stated they will come once a month.According to the FDA 2022 Food Code, 6-501.111 Controlling Pests, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by .Routinely inspecting incoming shipments of food and supplies .Routinely inspecting the premises for evidence of pests .Using methods, if pests are found, such as trapping devices or other means of pest control . Eliminating harborage conditions.Record review of the facility's pest control logs under service comments found that .3 drain flies were found in the kitchen. Changed glue boards, replaced bait, and cleaned equipment as necessary.

Based on observation, interview, and record review, the facility failed to ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination to the water supply, affecting all residents. Findings include: On 06/03/2026 at 9:10AM the cap to an atmospheric vacuum breaker to the utility sink was observed missing in the supply closet in Station C Hall. On 06/03/2026 at 10:26AM an attached hose with a spray nozzle downstream of a hose bib vacuum breaker on an outside spigot was observed around the corner from the front entrance. During this observation, Maintenance Director S stated there's another hose at the front entrance that is probably set up the same way. On 06/03/2026 at 10:27AM an attached hose with a spray nozzle downstream of a vacuum breaker on outside spigot was observed at the front entrance.According to the State of Michigan's 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).

Based on observation, interview, and record review, the facility failed to ensure that the prescribed nutritional formula was consistently available and that the quality was maintained. This failure affected one resident (Resident #106) of one resident reviewed for enteral nutrition standards of care. Findings include: Resident #106 (R106): A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R106 was admitted to the facility on [DATE] with diagnoses: hemiplegia (mild to moderate weakness on one side) and hemiparesis (severe to complete paralysis on one side) following cerebral infarction (interrupted blood flow to brain) affecting right dominant side, aphasia (cognitive communication deficient with speech and understanding), dysarthria (motor speech disorder), percutaneous endoscopic gastrostomy tubes (PEG / delivers nutrition and medications directly into the stomach) placed 05/22/2026, adult failure to thrive, neuromuscular dysfunction of bladder. The MDS assessment dated [DATE] indicated the resident had moderate impaired cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 10/15 and was bed bound (confined to bed) and dependent on assistance for care. 06/01/2026 6:02 AM, observed R106 resting in bed with eyes closed. Tube feeding Jevity 1.5 calorie label had a black handwritten date of 05/30/2026 at 0200 (2AM) on label side, the back side of same tube feeding formula bottle had a black handwritten date of 05/31/2026 at 2000 (8PM), the rate was running at 45 ml (milliliter)/ hour.According to record review of R106: R106 had a PEG tube placed at (hospital name) on 05/22/2026 related to decreased oral intake.According to a record review of R106's Nutritional evaluation dated 05/26/2026 revealed: 3. 05/26/2026 most recent body weight 103.6#'s; 4. UBW (usual body weight) 150#'s and 6d. Jevity 1.5 at 30 ml/hr. Discrepancy noted in goal rate noted. Current TF order is at 30 ml/ hr. and MD note reference's goal of 45 ml/ hr. TF currently observed to be infusing at 45 ml/hr.06/01/2026 08:15 AM, CNA D was asked to observe to two dates on the tube feeding bottle and then was asked what the two dates were about, she said she was unsure and that was a question for the nurse.06/01/2026 8:20 AM, the Unit Manager (UM) C was asked what the date on the tube feeding was and he said it was the date it was opened and hung. UM C was asked how long a tube feeding was appropriate for use after opening, and he replied, for 24 hours. UM C was asked to observe R106's tube feeding formula bottle and verified the two different dates, after it was observed he was asked which date the Tube feeding was opened and hung and he said he was unsure. UM C proceeded to unhook the tube feeding formula and said he would take of it and get a new one hung and dated.06/01/2026 8:40 AM, Nurse E was observed at the medication cart and was requested for SA to observe when the new tube feeding replaced. Nurse E said she would do it after she passed pain medications to her other residents and that she would inform SA prior.06/01/2026 at 10:21AM, Registered Dietician (RD) G approached SA and requested an interview. RD G said there is currently no tube feeding in the facility available for the R106 and that the physician put it on hold until they were able to get it. RD G said it is on its way and should be there soon. RD G said they planned to increase the rate to 68 ml/ hour to make up the nutritional loss. RD G was asked how she calculated the loss and the new rate since they did not know how long R106 would be without formula since none was available yet and she said it could be adjusted. RD G said that R106 had some oral intake and when asked she was unable to verify how much oral intake R106 had. RD G said R106 was a 1:1 assist with oral feeding and that it was not charted for the morning yet. RD G was asked how long tube feeding formula was good for and she was unable to answer. According to a review of progress notes for R106:Dated: 6/1/2026 at 09:16 Nutrition-Note Text: Tube feeding formula updated d/t (due to) product availability, Jevity 1.5 currently out of stock. Order changed to Osmolite 1.5 as substitute. Physician notified and in agreement. Will continue to monitor and make recommendations as indicated.A record review of R106's history of medical orders for tube feeding formula revealed: Dated 05/28/2026: Enteral Feed- .Jevity Formula, infuse at 45mLs/hour. Infuse until 1080mls infused.Dated 06/01/2026: Enteral Feed- .Osmolite 1.5 Formula, infuse at 45mLs/hour. Infuse until 1080mls infused. 06/1/2026 at 11:29AM, observation of resident resting in bed with eyes closed there was no tube feeding hanging. CNA D assigned to R106 was asked what resident consumed at breakfast and she said, maybe one bit and that R106 does not eat much but that she will usually drink her juice.06/1/2026 at 1:19PM, additional observation of resident resting in bed eyes closed, with no tube feeding formula hanging. 06/02/2026 at 9:39 AM, observation of R106 resting in bed eyes closed. There was a tube feeding formula Jevity 1.5 running at 60 ml/hour with a black handwritten date of 06/01/2026 at 1700 on the label.According to an additional review of progress notes for R106:Dated: 6/1/2026 at15:29 Nutrition- Note Text: Notified substitute formula was not immediately available. TF was interrupted ~8 hrs. related to tube feeding shortage. According to an additional record review of R106's history of medical orders for tube feeding formula revealed: Dated 06/02/2026: Enteral Feed- .Jevity 1.5 Formula, infuse at 60 mLs/hour . Infuse until 1440 mls has infused.Dated 06/02/2026: Enteral Feed- .Jevity Formula, infuse at 45mLs/hour. Infuse until 1080mls infused.According to a review of the facilities policy titled Enteral Nutrition: Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered.

Based on observation, interview and record review the facility failed to assess and monitor for potential changes in condition of a hydrocele (fluid-filled sac in the scrotum that causes swelling) for one resident (Resident #97) of one resident reviewed for assessment and monitoring. Findings Include:Resident #97:On 6/1/2026 at 10:30 AM, as Nurse N entered the room to complete vitals and assess Resident #97's roommate, prior to her assessment she observed Resident #97 sitting up on the side of the bed and it appeared he was attempting to get up unassisted. Resident #97 only had on white shirt sleeve T-shirt and a large hydrocele about the size of a melon was observed.On 6/1/2026 at approximately 11:30 AM, a review was conducted of Resident #97's record and it revealed he admitted to the facility on [DATE] with diagnoses the included Dementia, Anxiety, Overactive Bladder, Spinal Stenosis, and Hydrocele. Review was conducted of his care plan and Kardex and there was nothing noted regarding monitoring of Resident #97's hydrocele. Further review yielded the following:Progress Notes:8/13/2025 at 8:41 AM: 78yo male admitted from (hospital) on 8/12/25 . Imaging showed a small left hydrocele and a massive complex right hydrocele measuring 10.7 X 13.7 X 10.3 cm. Hydrocele was noted to be a chronic problem. The patient was evaluated by Urology in the ER (Emergency Room) they recommended outpatient workup with his primary urologist. Skin Assessment: Scrotal swelling noted, Treatment Plan; Monitor scrotum for increased swelling or s/s of infection Q shift.The measurements listed in the chart were completed at the hospital on 8/5/2025 and there were no other measurements, assessment or monitoring found regarding Resident 97's hydrocele.On 6/3/2026 at 10:20 AM, Nurse N stated Resident #97 admitted with the hydrocele and she typically observed the area while completing care or in moments such as Monday. Nurse N reviewed the chart and stated she was unable to locate measurements or monitoring of the hydrocele- she continued since there is no open area it would not be under the wound tab. On 6/3/2026 at 10:30 AM, CNA (Certified Nurse Assistant) O reported Resident #97 admitted to the facility with the hydrocele and it appears it has enlarged since his admission. She explained when she assists him to the bathroom he has to maneuver around to fit the hydrocele within the toilet bowl and this has not always been the case.On 6/3/2026 at 10:55 AM, an interview was conducted with Wound Nurse C regarding Resident #97's hydrocele. He reported they are not following Resident #97 for wounds as he does not have any current open areas. He was asked if there was any ongoing monitoring, assessment or measurements of the hydrocele and he stated there would not be. Nurse C was asked how the facility would recognize if the hydrocele had increased in size since and nurse stated they would not be able to.

Based on the interview and record review, the facility failed to ensure the adequate competency and verification of skills for one (1) certified nursing assistant of five (5) certified nursing assistants reviewed for completion of annual 12 contact hours, and the competency/training checklist required by the facility was completed before being taken off the training schedule for resident care.Findings include:On 6/3/26 at 9:22 AM, the employee records of Certified Nursing Assistant TB (CNA TB) were reviewed. CNA TBs employee record revealed that her original hire date was 8/25/25. Her termination date was 11/11/2025. CNA TB was rehired on 1/26/2026 and was verified as currently employed during the state recertification survey from June 1, 2026, to June 3, 2026. The Human Resources (HR) Director stated that she was new in her position as HR, and the Regional HR asked to be present during the interview with the HR staff and the review of 5 CNAs (Certified Nurse Aide) Records. The 2 HR staff agreed that CNA TB did not have a record of the facility completing 12.0 Continuing Education because she was considered a new hire and restarted in January 2026. The facility's Staffing Scheduler CB was interviewed on 6/3/26 at 12:40 PM and confirmed that CNA TB was on the facility CNA schedule and was off the training/orientation schedule assigned to patient care independently for quite some time now after she was rehired in January 2026. The Staff Scheduler indicated that she did not know when they would complete their training. And stated, They will not be on the floor if they have not signed off on their competencies. CNA TB had been released from the orientation schedule, so she assumed the competency checklist had been completed. Staffing Scheduler CB stated, Besides, she was a rehire, so she should have received all the training needed in her prior employment with us. The facility scheduler, CB, denied reviewing the completed checklist before scheduling CNA TB because it was the training/in-service nurse's and HR (Human Resources) 's job.Staff Inservice/Training Manager was interviewed on 6/3/26 at 3:50 PM. He denied knowledge of CNA TB's missing training checklist in the past hired date and the current employment date. The training/in-service nurse indicated that he will help search for it.CNA TB was not present at the facility and was unavailable for interview on June 3,2026 during survey.The Director of Nursing on June 3,2026 at 3:30 PM, was aware and revealed that they looked for CNA TB's orientation checklist in the past employment (HR) file and the current rehire HR file, and they could not find any record or proof that the orientation/competency checklist was completed by CNA TB.The Administrator confirmed on 6/3/26 at 3:45 PM that the competency checklist was not in CNA TBs HR File. The proof of the competency checklist record was not found for both 2025 and 2026 employment.The facility policy entitled New Staff Member Orientation, with a facility review date of 05/2025, indicated that the Certified Nursing Assistant (CNA) Timeline for Completion of Training is 3 to 5 Training Days.The Facility Policy Interpretation and Procedure specified the following: .2. The new staff member will complete the appropriate new-hire document during orientation.3. The orientation program is separate from the required state-approved Nurse Aide Training Program and the role-specific training and/or in-service training of new and existing staff.4. The administrators and Managers will ensure completion of the new hire general orientation as well as all new hire documents.5. A general Orientation Checklist will be completed and maintained as part of the staff members' personal files.6. In addition to our general orientation, each department orients the newly hired employee/transfer/volunteer/contractor to his or her other data that will aid and procedures, as well as the department's policies and procedures, as well as other data that will aid him/her in understanding the team concept , attitudes, and approaches to resident care7. The Department Orientation Checklist will be completed and maintained as part of the member's personnel file. This must be completed to verify the staff member's competency and understanding of the department in which they will work. Completion and verification are REQUIRED to be taken off the training schedule.

Based on observation, interview, and record review, the facility failed to identify, implement and follow enhanced barrier precautions (EBP) for a resident identified with qualifying medical needs for one resident (Resident #106) (R106) of three residents reviewed for infection prevention. Findings include: Resident #106 (R106):A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R106 was admitted to the facility on [DATE] with diagnoses: hemiplegia (mild to moderate weakness on one side) and hemiparesis (severe to complete paralysis on one side) following cerebral infarction (interrupted blood flow to brain) affecting right dominant side, aphasia (cognitive communication deficient with speech and understanding), dysarthria (motor speech disorder), percutaneous endoscopic gastrostomy tubes (PEG / delivers nutrition and medications directly into the stomach), adult failure to thrive, neuromuscular dysfunction of bladder with the presence of indwelling urinary catheter. The MDS assessment dated [DATE] indicated the resident had moderate impaired cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 10/15 and was dependent on assistance for care.On 06/01/2026 6:02 AM, observed R106 resting in bed with eyes closed. Tube feeding Jevity 1.5 calorie label had a black handwritten date of 05/30/2026 at 0200 (2AM) on label side, the back side of same tube feeding formula bottle had a black handwritten date of 05/31/2026 at 2000 (8PM), the rate was running at 45 ml (milliliter)/ hour. There was no sign posted for enhanced barrier precautions (EBP) posted for R106's room and there was no personal protective equipment (PPE) cart present at door.On 06/01/2026 08:15 AM, observed R 106's foley catheter had 600+ milliters of yellow urine in it. Observed CNA D don gloves, no gown and emptied R106's foley catheter and performed catheter care. CNA D was asked what if any precautions the resident had with care and she said standard, gloves and hand washing.On 06/01/2026 8:20 AM, Unit manager C was asked to observe R106 tube feeding and catheter. UM C was asked if a resident with catheter and PEG tube and indwelling catheter had any precautions with care and he paused then stated EBP, I believe and then He was asked to identify where the PPE cart and EBP sign was for R106. UM C looked around and walked over to the door of the room and stated, it should be right here, and it is not. Observed UM C verbally confirm with the ICP B that R106 should have EBP and advised him there was nothing posted to identify that and there was no PPE present at R106's room.A record review of R106 medical record revealed: R106 was originally admitted to the facility on [DATE] and was sent out to the hospital on [DATE] for decreased oral intake, R106 had a PEG tube placed 05/22/2026 and was readmitted to the facility on [DATE]. There was no EBP in place for resident until after observation and interview with UM C on 06/01/2026. On 06/03/2026 at 10:00 AM, Observed EBP sign on R106's door and PPE cart inside room door. Observed CNA D don gloves no gown and perform a bed bath for R106's. A record review of R106's medical orders revealed: Dated 05/29/2026: 14 fr (French) urinary catheter with 10 ml (milliliters) balloon, change PRN (as needed) for pain, occlusion, infection.Dated 06/01/2026: Enhanced Barrier Precautions - Gloves and gown prior to the high-contact care activity. Eye protection when performing activity with risk of splash or spray.Dated 06/02/2026: Enteral Feed- .Jevity Formula, infuse at 45mLs/hour. Infuse until 1080mls infused. A record review of R106's care plan revealed: Focus: I am at risk for MDRO infection r/t (related to) presence of TF (tube feeding) / Foley catheter (urinary catheter) Date Initiated: 06/01/2026. With Intervention: Enhanced Barrier Precautions: Staff will wear PPE (gown and gloves) while engaged in high contact activities Educate on Hand hygiene. On 06/03/2026 at 10:12AM, During an interview with the ICP B for infection control task he was asked about high contact activities with infection control practices, and he said that the staff have education on it, and he does weekly walk throughs and monthly rounds to observe compliance. ICP reviewed high contact activities which included bathing and catheter care. ICP B advised on observed continued noncompliance with R106 after the EBP was posted on 06/01/2026 and he said he planned to reeducate staff and increase surveillance of staff compliance with the posted CDC signs. According to a record review of infection prevention rounds tool - nursing department performed monthly per ICP B: Focus area: Proper PPE worn based on patient precautions and tasks. Focus area: signage posted for specific precautions, if applicable. According to a record review of the facilities policy labelled Enhanced barrier precautions revealed: Policy Statement Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. With Implementations: 1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities; 2. Enhanced barrier precautions apply when: b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices.; 5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies.; 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. 7a. Gloves and gown are applied prior to performing the high contact resident care activity; 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care); i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and.; 12.Enhanced barrier precautions are in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that place that at higher risk; 16. Staff are trained prior to caring for residents on EBPs; 17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required.According to a record review of the facilities policy labelled Infection prevention and control program (IPCP) revealed: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. With Implementation: 4. The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers.; 2.c.(2) assessment of staff compliance with existing policies and regulations.; 7.a. (7) implementing appropriate enhanced barrier and transmission-based precautions when necessary.

This Citation pertains to Intake Number 2988534. Based on interview and record review, the facility failed to ensure coordination of care with external care providers for one resident (Resident #701) of three residents reviewed. Findings include:Resident #701:Review of intake documentation revealed a concern that facility staff were provided a medication prescription by Resident #701's orthopedic surgeon for Valium (controlled, antianxiety medication commonly used before surgery to reduce anxiety) on 4/7/26 to take before their scheduled surgery on 4/13/26 but the facility did not administer the medication. Record review revealed Resident #701 was admitted to the facility on [DATE] with diagnoses which included displaced transcondylar fracture of the right humerus (serious fracture where bones are not aligned near the elbow), periprosthetic fracture around internal prosthetic left shoulder joint (break in bone around artificial joint), left knee laceration, right shoulder replacement, heart disease, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required maximum to total assistance to complete Activities of Daily Living (ADLs).Review revealed Resident #701 was transferred back to the hospital on 4/13/26 and did not return to the facility. An interview was completed with Resident #701 on 5/5/26 at 10:37 AM. When queried, Resident #701 revealed they went to the hospital after leaving the facility and stated, I had to have another two surgeries. When queried if they received their medications while at the facility, Resident #701 revealed the staff did not always tell them what they were giving them. Review of documentation in Resident #701's Electronic Medical Record (EMR) revealed the following: - 4/7/26 at 4:20 PM: Nursing/Clinical. returned from Ortho appointment with new orders for. Valium 5 mg (milligrams) 24 hrs (hours) prior to surgery and 12 hours prior to surgery. No time given yet. Patient needs revision of ORIF (Open Reduction and Internal Fixation - surgical procedure) to Rt (right) Humerus. Do not remove splint- may remove ace wrap and rewrap it as needed. - 4/7/26 at 4:30 PM: Nursing/Clinical. returned from ortho appt, no new orders given, no concerns noted or reported. - 4/9/26 at 5:57 PM: Nursing/Clinical. noted blood to Rt elbow with cast placed. unable to remove cast ABD pads (wound dressing) placed and ace bandage applied. ortho aware d/t (due to) patient calling them. No new orders given, patient to have surgery on the rt elbow on Monday the 13th. - 4/10/26 at 11:18 AM: PMR (Physical Medicine and Rehabilitation) follow up (Health Care Provider- HCP Note) . consulted by the primary medical team to optimize therapy, pain control, and discharge planning. Follow up with PCP (Primary Care Provider) and specialists as disclosed. Set to have RUE (Right Upper Extremity) surgery on 4/13/26. - 4/13/26 at 1:30 PM: Nursing/Clinical. transported by daughter to (Hospital) for scheduled surgical procedure. NPO (nothing by mouth) except for medications and sips of clear liquids up until 12pm on the 4/13/26. Review of Resident #701's HCP orders revealed one order for Valium. The order was dated 4/13/26 and specified, Valium 5 mg. 1 tablet by mouth every 24 hours as needed for Anxiety. (Start Date: 4/13/26; Hold from 4/13/26 to 4/14/16 for surgical procedure). A review of Resident #701's Medication Administration Record (MAR) revealed Resident #701 did not receive any Valium while at the facility.Further review of Resident #701's HCP orders revealed the order, NPO (Nothing by Mouth) at midnight every shift for 1 Day may have clear liquids up until 2 hours before procedure (Ordered: 4/9/26; Start Date: 4/12/26). Review of scanned documentation in Resident #701's EMR revealed no consultation documentation from the external orthopedic provider appointment on 4/7/26. There was a scanned prescription from the external orthopedics provider dated 4/7/26 for Valium 5 mg, 1 tablet 12 hours prior to surgery and 24 hours prior to surgery. An interview was completed with Infection Control (IC) Licensed Practical Nurse (LPN) E on 5/5/26 at 12:00 PM. LPN E was asked where the consultant report for Resident #701's orthopedic appointment was in Resident #701's EMR. LPN E reviewed the Resident's EMR and verbalized there was no consultation note. When queried regarding the scanned script for Valium in Resident #701's EMR and facility policy/procedure related to scripts from external HCPs, LPN E revealed the medication recommendations are typically put in the orders. An interview was completed with the Director of Nursing (DON) on 5/5/26 at 1:52 PM. When asked if Resident #701 was admitted to the facility for skilled services, the DON responded they were. When queried regarding the prescription scanned into Resident #701's EMR from the external orthopedic provider, the DON stated, (Resident #701) didn't get the Valium. When asked if Resident #701 should have received the Valium as directed on the prescription from the orthopedic provider, the DON verbalized the order should have been entered but was missed. When queried regarding consultation notes/documentation from the orthopedic provider appointment on 4/7/26, the DON confirmed there was no documentation from the orthopedic provider in Resident #701's EMR and indicated they would attempt to locate it. An interview was completed with Unit Manager Registered Nurse (RN) D on 5/5/26 at 3:22 PM. When queried regarding consultation documentation from the provider for Resident #701's external orthopedic appointment on 4/7/26, RN D stated, I don't know where it is at but I remember seeing it. RN D confirmed they wrote the Nursing/Clinical note dated 4/7/26 at 4:20 PM in Resident #701's EMR and verbalized they obtained the information they put in the note from the consultation report. When queried regarding the prescription for Valium, RN D stated, The script was for pre-op. I didn't put in the order because I didn't have the surgical date. RN D explained the consultation documentation did not specify the planned date of the surgery and they were unable to put the order for Valium in the EMR without a date. When queried regarding the NPO order for surgery being entered into the EMR on 4/9/26 by LPN N and HCP documentation dated 4/10/26 specifying the Resident was having surgery on 4/13/26, RN D stated, In hindsight it got missed. With further inquiry, RN D revealed other facility staff are responsible for making external appointments and they were not notified of the surgical date and did not enter the order in Resident #701's EMR. When asked about the facility procedure for entering orders from external HCPs, RN D revealed they (Unit Managers) review the recommendation and enter orders into the EMR. Resident #701's written orthopedic provider consultation notes for their appointment on 4/7/26 was located and provided by the DON on 5/6/26. Review of the Physician's Consultation Notes did not provide any additional information pertaining to the Valium and/or surgical date. Review of facility provided policy/procedure entitled, Outside Appointments/Consults (Reviewed 12/25) revealed, Our facility will assist residents in arranging outside appointments/consults when necessary. 4. Consult form will be used for communication. 5. Outside recommendations from appointments/consults will be reviewed by the facility provider.

This Citation pertains to Intake Number 2986995. Based on interview and record review, the facility failed to correctly assess the wound status of one resident (Resident #702) upon admission of three residents reviewed, resulting in a lack of timely and comprehensive identification, and the assessment and care of an alteration in skin integrity. Findings include:Resident #702: Review of intake documentation revealed a concern that Resident #702 was admitted to the facility on [DATE] with no alterations in skin integrity. The Resident was transferred back to the hospital on 4/15/26 due to a change in condition with skin tears and a black eye. An interview was completed with Family Member Witness A on 5/4/26 at 12:10 PM. When queried regarding Resident #702, Witness A responded that the Resident passed away. When asked, Witness A disclosed Resident #702 went to the facility on 4/11/26 for therapy after having a CVA (stroke) which resulted in their right side being flaccid and aphagia (difficulty speaking). Witness A revealed the Resident was transferred back to the hospital on 4/15/26 due to a change in condition and did not return to the facility. Witness A verbalized concerns related to the care Resident #702 received at the facility. Witness A stated that when Resident #702 was transferred back to the hospital on 4/15/26 their Bottom was excoriated and they had two briefs on. Witness A stated the Resident's brief was full of bm and urine. Witness A stated, (Resident #702) had a black eye and a large skin tear on their right upper extremity and lower extremity. Witness A explained Resident #702 did not have the any skin tears when they went to the facility. Witness A was asked if the Resident had a fall or injury at the facility and responded that no family member had been notified of any falls/injuries. Witness A continued, I called the DON (Director of Nursing) to let them know and they were very passive-aggressive. Witness A was asked what they meant and responded (The DON) told me it was charted on the 13th or 14th. I told (the DON) that (Resident #702) was admitted on the 11th and (the Resident) did not have any skin tears when they were admitted . Witness A verbalized the DON asked them if it was their friends at the hospital who told them that and said, I was very concerned being a nurse. Witness A proceeded to provide time and location stamped images of Resident #702's right arm dated 4/15/26 at 9:30 PM at the hospital. The picture showed a saturated, kerlix (gauze wrap) dressing in place on the Resident's right arm just under the arm of their hospital gown. A second picture with a location stamp at the hospital, dated 4/16/26 at 2:55 AM, showed bruising around Resident #702's right eye. Record review revealed Resident #702 was admitted to the facility on [DATE] and discharged on 4/15/26 with diagnoses which included depression, chronic kidney disease, myocardial infarction (heart attack), and cerebrovascular accident (CVA-stroke) with resulting right sided weakness, dysphagia (difficulty swallowing) and anarthria (difficulty with expressive speech). Review of the Minimum Data Set (MDS) assessment, dated 4/15/26, revealed that the Resident was rarely/never understood and required maximum-to-total assistance to complete Activities of Daily Living (ADL). Review of Resident #702's Nursing Assessment Admission/Readmission dated 4/11/26 at 7:00 PM detailed, Skin: Is there a skin issue present? Yes. 16) Left antecubital: Bruising 15) Right antecubital: Bruising 29) Right hand (back): Bruising 30) Left hand (back): Bruising. Review of documentation in Resident #702's Electronic Medical Record (EMR) revealed no documentation pertaining to the Resident's skin until 4/13/26. The documentation specified, - 4/13/26 at 9:22 AM: Nursing/Clinical. Skin Assessment: Extensive Bruising to BUE (Bilateral Upper Extremities) and hands in various stages of healing from hospital IVs (Intravenous access) and blood draws. Skin over entire body is thin and fragile which may contribute to skin tears and other skin integrity issues. Skin tear with full flap loss to RUE (Right Upper Extremity) superior to AC (antecubital- inner elbow), surrounding tissue is intact with bruising, no drainage noted. Skin tear with full flap loss to posterior RUE at triceps, surrounding tissue is intact with bruising, no drainage noted. Treatment Plan: Cleanse skin tear to RUE superior to AC with NS (Normal Saline), pat dry, apply xeroform to wound bed and cover with dry dressing QD (every day) and PRN (as needed). Cleanse skin tear to posterior RUE at triceps area with NS, pat dry, apply xeroform to wound bed and cover with dry dressing QD and PRN.- 4/13/26 10:24 AM: SW - Skin Issues. Skin Issue: #001: New skin Issue. Location: Above right elbow. Issue type: Skin tear. Progress: New: new wound. Type 3: Total flap loss. Wound was present on admission. It is unknown how long the wound has been present. Length: 2.57 centimeters (cm), Width: 4.54 (cm). Surrounding tissue: Dark reddish brown. Fragile. Skin Issue: #002: New skin Issue. Upper right outer arm. Skin tear . new wound. Total flap loss. Wound was present on admission. It is unknown how long the wound has been present. Length: 4.15 (cm) Width: 1.43 (cm). Surrounding tissue: Dark reddish brown . Discoloration. Intact. Fragile. Review of Resident #702's SBAR/Change in Condition assessment dated [DATE] at 6:10 PM detailed, Skin Evaluation.Right antecubital right upper fa (facility acquired) skin tear. Review of Resident #702 Health Care Provider (HCP) orders revealed there were no orders in place for wound care until 4/13/26. The treatment orders included:- Cleanse skin tear to RUE superior to AC with NS, pat dry, apply xeroform to wound bed and cover with dry dressing QD and PRN. every day shift every 3 day(s) (Start: 4/13/26) - Cleanse skin tear to RUE triceps area with NS, pat dry, apply xeroform to wound bed and cover with dry dressing QD and PRN. as needed (Start: 4/13/26) - Cleanse skin tear to RUE triceps area with NS, pat dry, apply xeroform to wound bed and cover with dry dressing QD and PRN. every day shift every 3 day(s) (Start: 4/13/26) A review of Resident #702's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2026 revealed the start dates of the treatments did not match the HCP order. The following were included on the MAR and TAR:- An as needed (PRN) order to Cleanse skin tear to RUE triceps area with NS, pat dry, apply xeroform to wound bed and cover with dry dressing QD and PRN every day shift every 3 day(s) (Start Date: 4/13/26).There was no documentation indicating the treatment had been completed. - A scheduled order to Cleanse skin tear to RUE triceps area with NS, pat dry, apply xeroform to wound bed and cover with dry dressing QD and PRN every day shift every 3 day(s) (Start Date: 4/14/26).The treatment was documented as completed on 4/14/26. - A scheduled order to Cleanse skin tear to RUE superior to AC with NS, pat dry, apply xeroform to wound bed and cover with dry dressing QD and PRN every day shift every 3 day(s) (Start Date: 4/16/26)There was no documentation indicating the treatment had been completed. Review of Resident #702's EMR revealed a care plan entitled, I am at risk for altered skin integrity related to decreased mobility, weakness, debility, recent pacemaker placement, high risk for falls that could result in skin alteration, advanced age, impulsivity with poor safety awareness (Initiated: 4/11/26; Revised: 4/13/26). The care plan did not include any specific interventions pertaining to the Resident's altered skin integrity. Admit 4/11 Skin tear with full flap loss to posterior RUE at triceps, surrounding tissue is intact with bruising, no drainage. related to: friction (Initiated and Revised: 4/13/26). The care plan included the intervention, Administer treatment per physician orders (Initiated: 4/13/26).A second care plan entitled, Admit 4/11 Skin tear with full flap loss to RUE superior to AC, surrounding tissue is intact with bruising, no drainage noted related to: friction (Initiated and Revised: 4/13/26) and included the intervention, Administer treatment per physician orders (Initiated: 4/13/26). An interview was conducted with Wound Care Licensed Practical Nurse (LPN) E on 5/5/26 at 12:36 PM. LPN E was asked when they first assessed Resident #702's skin tears and replied 4/13/26. When queried regarding the etiology of the skin tears on Resident #702's RUE, LPN E responded that the skin tears were present upon Resident #702's admission to the facility. LPN E was asked how they knew the skin tears were present when the Resident was admitted and responded, I took off a dressing with one of our nurses' initials on it, so it was present on admission. When queried whose initials were on the dressing, LPN E revealed they did not know. LPN E was then asked to review Resident #702's wound care orders. After review, LPN E was queried when treatment order for the skin tears were first entered into the Resident's EMR and responded 4/13/26. When queried why a nurse at the facility would complete a wound dressing without a HCP order, LPN E replied, I can't speak to what other people do. LPN E was then asked to review Resident #702's EMR for documentation of the skin tears prior to 4/13/26. After reviewing the EMR, LPN E stated, I don't see anything (documentation) before mine (on 4/13/26). LPN E was then asked if it could be possible that the skin tears were not present when the Resident was admitted to the facility and stated, Could be. When queried if there should be documentation when a resident is admitted if there are open areas/skin tears, LPN E replied, Yes. LPN E explained they utilize the wound camera and complete wound staging, but floor nursing staff document the present of any abnormalities. LPN E was asked what admission nurses should document and responded they should document any skin alterations, the location, and approximate size. On 5/5/26 at 2:11 PM, an interview was completed with Registered Nurse (RN) F. When queried if they provided care to Resident #702, RN F revealed they were the Resident's assigned nurse on 4/15/26 when they were transferred to the hospital. When queried, RN F responded that was the first time they had provided care to Resident #702. When queried regarding Resident #702's skin integrity, RN F replied, They (other nurse) said (Resident #702) had a skin tear on their arm when they got report. When asked, RN F revealed they did not look at and/or assess the skin tear due to sending the Resident to the hospital. An interview was completed with LPN G on 5/5/26 at 2:19 PM. When queried, LPN G confirmed they admitted Resident #702 to the facility. LPN G was asked if they completed a skin assessment on the Resident and responded they did. When queried what they do when they complete a skin assessment, LPN G revealed they observe all areas of the skin for any abnormalities. When asked if the Resident had any skin tears on their skin when they were admitted , LPN G stated, (Resident #702) had multiple bruising on their upper extremities but they did not have a skin tear. LPN G verbalized they documented the Resident's skin assessment in the admission assessment. LPN G stated, I also told the DON that (Resident #702) didn't have a skin tear when they asked me too. LPN G was asked when the DON asked them about Resident #702's skin and were unable to recall the specific date. LPN G stated, The DON called me and kept asking like they wanted me to say it (skin tear) was there when it wasn't. I wasn't comfortable with that. On 5/5/26 at 3:00 PM, an interview was conducted with Certified Nursing Assistant (CNA) H and CNA L. When queried if they provided care to Resident #702, both staff verbalized they had. When asked if the Resident had a skin tear and/or wound dressing in place on their RUE, both CNA H and CNA L replied, No. An interview was completed with Unit Manager RN D on 5/5/26 at 3:38 PM. When queried regarding the skin tears on Resident #702's RUE, RN D stated, My impression was that they were present on admission. When queried where it was documented that the skin tears were present when the Resident was admitted , RN D reviewed the Resident's EMR and verbalized there was no documentation of Resident #702's skin tears until 4/13/26. RN D was asked where the skin tears came from as there was no documentation of them being present upon admission and stated, I see where you're coming from. Upon request for any Incident and Accident and/or concern forms with corresponding investigation documentation for Resident #702, the following was provided:- 4/17/26: Complaint/Grievance Report. Describe Concern in Detail: Arrived at hospital double briefed, black eye, and skin tears. not aware of skin concerns. Findings of Investigation: Interviewed staff, Patient did not have black eye at d/c (discharge) to hospital. Skin tears were present upon admission. CNA did double brief Resident. Plan. Education to CNAs in regarding to double briefing. Education to nurses in regards to accurate skin assessments at admission. - Unsigned Statement form for LPN G: Date of Interview: 4/21/26. over phone. Were you (Resident #702's) nurse when admitted to facility on April 11th? Yes. Did you complete a skin check? Yes. Did (Resident) had any skin tears upon admission? . Didn't notice at time of admission. Did you do a thorough skin check without looking at every part of skin? . don't think I removed gown.Review of the schedule/assignment sheets revealed LPN G worked the afternoon shift on 4/11/26. - Signed Statement by CNA J dated 4/20/26. The statement included, Do you know the condition of (Resident #702's) skin on their arms? I didn't notice any skin tears but (the Resident) was in the chair out by the nurses' station. I didn't really do anything with their arms, I just changed (the Resident's) brief. On Sunday, I do remember (Resident #702) kept pulling their hospital gown off and they had a blanket on them that we had to keep pulling up and readjusting their gown. Maybe (Resident #702) scratched their arm or something.Review of facility schedule/assignment sheets revealed CNA H worked on 4/11/26 and 4/15/26. - Signed Statement by RN M dated 4/30/26. The statement detailed, Do you know the condition of (Resident #702's) skin on their arms? You received report from 2nd shit that (Resident) had skin tear on arm, don't remember what arm. Did (Resident #702) have a dressing on their arm? Yes.Review of facility schedule/assignment sheets revealed RN M worked midnight shift on 4/11/16, 4/12/26, and 4/13/26. - Signed Statement by RN F dated 4/17/26. The statement specified RN F was Resident #702's nurse when they were transferred to the hospital and that the Resident had a skin tear on their right arm that was bandaged up.Review of facility schedule/assignment sheets revealed RN F worked on 4/15/26. - Signed Statement by Wound Care LPN E dated 4/24/26 which detailed Resident #702 had a bandage covering a skin tear on their arm that I removed, took picture and then replaced with a new dressing.Wound Care LPN E worked on 4/13/26. - Signed Statement by CNA J dated 4/20/26. The statement included, Did you notice any skin tears on (Resident #702's) skin? Yes, did have bandages but I can't remember which arm it was.Review of the schedule/assignment sheets revealed CNA J worked day shift on 4/15/26, after Resident #702's wound care treatments were implemented. - Signed Statement by RN O dated 4/17/26 which detailed Resident #702 had two skin tears.Review of the schedule/assignment sheets revealed RN O worked the afternoon shift on 4/13/26 after Resident #702's wound care treatments were implemented. On 5/5/26 at 6:00 PM, an interview was completed with RN M. When queried if they provided care to Resident #702, RN M verbalized they were assigned to the Resident on midnight shift the day they were admitted . When queried if the Resident had any skin tears, RN M replied they believe they were informed that the Resident had a skin tear in report. RN M stated, There was a bandage on it as well. It was not huge. RN M was asked what type of bandage was covering the wound and replied, A Band-Aid. When asked to clarify if the skin tear was covered with a normal size Band-Aid, RN M replied, Like a bigger Band-Aid. When queried if they assessed the skin tear, RN M replied, No and revealed they only saw the band-aid. When asked if the Resident's RUE was wrapped with Kerlix gauze, RN M replied, No, not that I remember. RN M then stated, I remember I documented it somewhere. A review of Resident #702's no documentation of the Resident's skin tears by RN M.Review of facility schedule/assignment sheets revealed RN M worked midnight shift on 4/11/16, 4/12/26, and 4/13/26. On 5/6/26 at 9:00 AM, an interview was completed with CNA J. When queried if they had provided care to Resident #702, CNA J verbalized they had on the day the Resident was transferred to the hospital (4/15/26). When queried, CNA J stated, I remember (Resident #702) having bandages on their left arm. Review of staffing/schedule sheets revealed LPN N was assigned to Resident #702 on 4/15/26 during the day shift.An interview was conducted with LPN N on 5/6/26 at 9:25 AM. When queried if they recalled Resident #702, LNP N verbalized they did. LPN N was asked about the skin tears and dressings on Resident #702's right arm and revealed they did not remember the Resident having a wound dressing in place on their arm. LPN N stated, I do remember bruising though. When asked if the Resident's arms were covered with clothing, LPN N stated, Always wore a (hospital style) gown and indicated the Resident's arms were visible. Review of staffing/schedule sheets revealed CNA K was assigned to Resident #702 on 4/11/26 and 4/12/26 on the midnight shift.On 5/6/26 at 10:07 AM, an interview was conducted with CNA K. When queried if Resident #702 had wound dressings in place on their arm, CNA K stated, I do not remember seeing bandages on their arms. When queried regarding care provided and if they observed the Resident's arms, CNA K stated, (Resident #702) did have an accident and we changed their gown. When asked what they meant when they said we, CNA K replied, I did have another aide assist me every time with (Resident #702) because they didn't move their legs well. Review of staffing/schedule sheets revealed CNA I was assigned to Resident #702 during the afternoon shift on 4/12/26.An interview was completed with CNA I on 5/6/26 at 10:25 AM. When queried, CNA I verbalized they remembered Resident #702. CNA I was asked if they changed the Resident's brief during their shift and verbalized, they had. When queried if they had changed Resident #702's gown, CNA I stated, Yeah. CNA I was asked if Resident #702 had any wound dressings in place on their arms and stated, I don't remember seeing him with any really. CNA I then stated, (Resident #702) would unrobe a lot at the nurses station. When asked if the Resident always wore a gown, CNA I replied, Yeah but they would always take it off. A review of requested documentation from the hospital for Resident #702's hospital stay from 3/30/26 to 4/11/26 was completed. There was no documentation in the hospital medical records, including the discharge medical records to the facility of Resident #702 having a skin tear and/or of a wound care treatment for a skin tear. An interview was completed with the DON on 5/6/26 at 1:20 PM. When queried regarding the etiology of Resident #702's skin tear, the DON stated, Had it before they came here. The DON was asked why there was no documentation of the skin tear being present upon admission in the nursing and/or HCP documentation and replied, The nurse didn't do a complete (skin) assessment. When asked why none of the other nurses assigned to care for the Resident identified, assessed, and documented information pertaining to the skin tear until 4/13/26 if it was present upon admission, the DON revealed the nurses did not receive a task to complete or do anything with the skin tear because there was no order. When queried why the facility nursing staff did not identify that the skin tear was not being addressed, if it was present upon admission, the DON did not provide an explanation. The DON was then asked if they were aware that there was no documentation of the Resident having a skin tear and/or wound treatment/dressing in place at the hospital and upon discharge to the facility and stated, I know. The DON stated, (RN D) and I reviewed the documentation from the hospital today. When queried how they could say the skin tears did not occur at the facility, when there is no documentation of the Resident having a skin tear when they were discharged from the hospital and no documentation of the skin tear being present at the facility until 4/13/26, the DON stated they did not receive an Incident and Accident report about Resident #702's skin while at the facility and RN M said there was a dressing in place on midnight shift. When queried regarding RN M stating Resident #702's skin tears being covered with a large band aid as well as stating they documented on the skin tear when there was no documentation present, the DON verbalized RN M must have meant a border foam dressing. When queried why RN M said band-aid if the wound was not covered with a band-aid and why they would say the skin tear was not huge when it was a large skin flap, the DON did not provide further explanation. When queried regarding the lack of implementation and documentation of treatment for the wound until 4/13/26, the DON verbalized understanding. No further explanation was provided. An interview was completed with the Administrator on 5/6/26 at 2:10 PM. When queried why Resident #703's skin tear was not reported as an injury of unknown origin, the Administrator replied, We determined that (Resident #702) came with it. Review of facility provided policy/procedure entitled, admission Assessment and Follow Up: Role of the Nurse (Revised: 1/26) revealed, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission. 8. Conduct a physical assessment, including the following systems. j. Skin. 12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. The following information should be recorded in the resident's medical record. 3. All relevant assessment data obtained during the procedure. Review of facility provided policy/procedure entitled, Wound Care (Revised: 1/26) revealed, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the wound care was given. 4. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. Review of facility provided policy/procedure entitled, Abuse and Neglect Procedural Guidelines (Reviewed: 9/2025) revealed, Abuse, neglect. of any kind against residents, by any person, is strictly prohibited. Prevention. The resident has the right to be free from any form of abuse. Neglect: failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

This Citation pertains to Intake Number 2986995. Based on interview and record review, the facility failed to identify, comprehensively assess, and document nutritional/hydration needs and intake for one resident (Resident #702) of three residents reviewed for quality of care resulting, in a lack of identification of risk for dehydration, timely initiation of a Health Care Provider (HCP) ordered diet, documentation of fluid intake, and a decline in health status. Findings include:Resident #702: Review of intake documentation revealed a concern that Resident #702 was admitted to the facility on [DATE] and transferred back to the hospital on 4/15/26 due to confusion and a change in condition. An interview was completed with Family Member Witness A on 5/4/26 at 12:10 PM. When queried regarding Resident #702, Witness A responded that the Resident passed away. When asked, Witness A disclosed Resident #702 went to the facility on 4/11/26 for therapy after having a CVA (stroke) which resulted in their right side being flaccid and expressive aphagia (difficulty speaking). Witness A revealed the Resident was transferred back to the hospital on 4/15/26 due to a change in condition and did not return to the facility. With further inquiry regarding the reason Resident #702 was transferred back to the hospital, Witness A stated, (Resident #702) was severely dehydrated and in acute kidney failure. Witness A revealed they were a Registered Nurse (RN) and stated Resident #702's laboratory values related to kidney function were normal when they left (the hospital) on the 11th (4/11/26). Witness A verbalized Resident #702 was completely orientated and alert when they left the hospital on 4/11/26 and was unresponsive and not responsive when they were transferred to the emergency room (ER). When asked, Witness A revealed Resident #702 was able to respond to yes/no questions and understood what people were saying. When queried if they visited the Resident at the facility, Witness A revealed they did not and stated, I talked to the nurse on the phone, and she said (Resident #702) was more confused and not drinking or eating. Witness A was asked when the phone conversation occurred and replied, Monday. Witness A continued, (Family Member Witness B) went there (to facility) and said (Resident #702) was not good. (Witness B) said (Resident #702) was very confused and couldn't even nod their head to answer questions. Record review revealed Resident #702 was admitted to the facility on [DATE] and discharged on 4/15/26 with diagnoses which included depression, chronic kidney disease, myocardial infarction (heart attack), cardiac pacemaker placement on 4/3/26, Benign Prostatic Hyperplasia (BPH- enlarged prostate), and cerebrovascular accident (CVA-stroke) with subsequent right sided weakness, dysphagia (difficulty swallowing) and anarthria (difficulty with expressive speech). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required maximum to total assistance to complete Activities of Daily Living (ADLs) including eating.Review of Resident #702 Health Care Provider (HCP) orders revealed the Resident did not have a diet order in the Electronic Medical Record (EMR) until 4/13/26. On 4/13/26, the diet, General diet Puree texture, Nectar consistency was ordered. Review of Resident #702's Nursing Assessment Admission/Readmission dated 4/11/26 at 7:00 PM revealed the Resident had No natural teeth or tooth fragments, did not have dentures, and their food intake was Adequate: Eats over half of most meals. Resident #702's Nursing Assessment Admission dated 4/11/26 at 7:00 PM included a section titled, Oral and Nutrition. Initial Care Planning which included sections for initial care plans related to oral/dental health problems, swallowing problems, and nutritional or potential nutritional problems. None of the initial care plans pertaining to alterations/potential alterations in nutrition were selected and implemented. Review of Resident #702's care plans in the EMR revealed a care plan entitled, I am at risk for injury related to handling and drinking of hot liquids (Initiated: 4/11/26; Revised: 4/13/26). The care plan included the interventions, Cup with lid or other adaptive cup (Initiated: 4/7/26) and Staff assistance with hot liquids (Initiated: 4/7/26). Resident #702 also had a care plan entitled, I have an ADL self-care performance deficit related to. (Initiated: 4/11/26; Revised: 4/13/26) in their EMR. This care plan included the intervention, Eating: I require set up assistance to eat (Initiated: 4/7/26). A care plan entitled, I have a nutritional problem. (Initiated: 4/11/26; Revised: 4/14/26) was also present in Resident #702's EMR. The care plan did not include a diet and/or any specific dietary interventions until 4/14/26.On 4/14/26 the following interventions were added to the care plan:- Monitor for s/sx (signs/symptoms) dysphagia: difficulty or excessive chewing, difficulty or pain swallowing, holding/pocketing food in mouth, spillage of food from mouth, coughing/choking. (Initiated: 4/14/26)- Diet as ordered: general, puree, nectar thick liquids (Initiated and Revised: 4/14/26) Review of Resident #702's Kardex included the interventions, I require set up assistance to eat and Cup with lid or other adaptive cup. The Kardex did not include the Resident's diet including modified diet/fluids. Review of Resident #702's task documentation and the Documentation Survey Report revealed the Resident did not have documentation of oral fluid intake and/or amount of urine output. There was task documentation for the percentage of meal eaten and bedtime snack. The task documentation detailed Resident #702 detailed the following:- 4/11/26: A Bedtime Snack was accepted at 8:09 PM.- 4/12/26: 11:54 AM: 100% eaten; 12:08 PM: 100% eaten; 5:59 PM: 25% eaten. A Bedtime Snack was accepted at 3:57 PM.- 4/13/26: 12:35 PM: 0% eaten (same data documented twice at the same time); 8:84 PM: 100% eaten. A Bedtime Snack was accepted at 8:40 PM.- 4/14/26: 8:00 AM: 100% eaten; 12:04 PM: 50% eaten; 9:21 PM: 25% eaten. A Bedtime Snack was offered and refused at 9:21 PM.- 4/15/26: 9:25 AM: 100% eatenResident #702 did have a task titled, Bladder Continence and Toilet Use which did not include amount of urine output. Task documentation specified if the Resident was continent or incontinent, self-performance of toileting activities and amount of toileting assistance provided. Review of progress not documentation in Resident #702's EMR revealed a Nursing/Clinical note dated, 4/12/26 at 2:52 PM which specified, Patient is alert x1 and resting in Geri chair at the nurses' station. Patient is nectar thick and a feed.Further review of documentation in Resident #702's EMR revealed the following: - 4/15/26 at 5:50 PM: Nursing/Clinical. Resident appeared to be lethargic/ hypotensive (low blood pressure) / bradycardic (low heart rate) message to (HCP). resident needs transport to (Hospital). - 4/15/26 at 6:10 PM: SBAR/Change in Condition. bradycardia/hypotensive. Most Recent Blood Pressure. 84/48 (low) . Pulse 52 (low) (4/15/26 at 5:39 PM) . Most Recent Blood Glucose: 98 (normal) 5/10/26 at 8:58 AM. Other: Lethargic. Functional status Evaluation 10. Describe functional status changes: 1. Needs more assistance with ADLs 2. General weakness 3. Decreased mobility. 5. Swallowing Difficulty. functional status signs or symptoms: lethargy/weakness. Cardiovascular Evaluation. cardiovascular changes. Inability to stand without severe dizziness or light headedness. bradycardia/hypotension. Genitourinary Evaluation. changes. Decreased urinary output over 1-2 days. - 4/16/26 at 7:26 AM: (Authored after Resident #702 was transferred to the hospital) Physician/Practitioner Progress Note. Patient seen on 04/15/2026 at 11:00 a.m. per staff is not really consistently eating drinking much they tried to feed (Resident #702) oral intake is limited. Labs reviewed sodium is 150 8 due to poor oral intake. overall oral intake is quite poor overall prognosis poor. An interview was completed with the Director of Nursing (DON) on 5/5/26 at 1:52 PM. The DON was asked if Resident #702 was admitted to the facility for skilled services and verbalized they were. When queried regarding the lack of daily skilled nursing assessment documentation, the DON responded that the daily skilled nursing assessment documentation is related to billing and reimbursement and does not need to be completed daily by nursing staff. An interview was completed with Licensed Practical Nurse (LPN) G on 5/5/26 at 2:19 PM. LPN G was asked if they admitted Resident #702 to the facility and confirmed they did. When queried Resident #702's cognition and communication, LPN G stated, (Resident #702) was A & O (alert and orientated) X 3 (person, place, time). LPN G continued, (The Resident) was able to communicate. They could give a yes or no. When queried regarding Resident #702's diet, eating and drinking, LPN G stated, I didn't feel comfortable until they were seen by OT (Occupational Therapy). With further inquiry, LPN G stated, (Resident #702) was on a special diet- like mashed potatoes and gravy and thickened liquids. When queried regarding a diet order not being placed in the EMR, LPN G did not provide an explanation. When queried what the Resident ate as a bedtime snack if they did not have an order placed for a diet, LPN G responded that a paper slip is completed and sent to the kitchen. When asked if Resident #702 was seen by OT on 4/11/26 prior to eating, as they said they were uncomfortable, LPN G replied, No. No further explanation was provided. When queried, LPN G verbalized that was the only time they cared for Resident #702 during their stay at the facility. On 5/5/26 at 3:00 PM, an interview was conducted with Certified Nursing Assistant (CNA) H and CNA L. When asked, both staff verbalized they had provided care to Resident #702. When queried regarding the level assistance Resident #702 needed for ADL care, CNA H responded, (Resident #702) was mostly up in the Geri chair (specialized, reclining wheeled chair with cushioned seats and solid footrest area for individuals with limited mobility) so we could monitor them. CNA H verbalized they were a Total check and change indicating the Resident was incontinent and dependent upon staff for toileting. When queried regarding Resident #702's oral intake and diet, CNA L stated, (Resident #702) would spit it out. When asked if they were talking about food, CNA L responded that Resident #702 did not seem to like the pureed food they were provided. When queried regarding drinking, CNA L replied, It would kind of run out of their mouth. When asked if the Resident drank any fluids, CNA L reiterated that fluids would run out of the Resident's mouth. When asked if they were working when Resident #702 was transferred to the hospital ER on [DATE], CNA H responded they were. When queried what happened, CNA H stated, (Resident #702) was in the Geri chair and probably an hour into the shift, (the Resident) wasn't responding. CNA H was asked what time their shift starts and replied, Two (2:00 PM). When queried how long after staff identified Resident #702 was not responding that they were sent to the hospital, CNA H revealed they were unsure. When queried if they noticed any other changes in Resident #702 prior to the Resident not responding, CNA L stated, Resident #702) slept a lot. Review of staffing/schedule sheets during Resident #702's stay at the facility revealed CNA L worked with Resident #702 on 4/11/26, 4/12/26, and 4/14/26 and CNA H worked with the Resident on 4/11/26 and 4/15/26. An interview was completed with Unit Manager Registered Nurse (RN) D on 5/5/26 at 3:38 PM. When queried if Resident's should have diet orders in the EMR, RN D verbalized they should. RN D was then asked to review Resident #702's EMR for a diet order. After reviewing Resident #702's HCP orders, RN D stated, Ordered on 4/13/26. When queried why Resident #702 did not have a diet order until 4/13/26 when they were admitted on [DATE], RN D was unable to provide an explanation. RN D then stated, There is a kitchen dietary slip that they (nursing staff) send out. When queried if the Resident's diet should be on the Kardex, so staff are aware of any special dietary requirements/restrictions, RN D replied, It should definitely be on the Kardex. Resident #702's Kardex was reviewed with RN D at this time. When queried how staff knew that Resident #702 needed thickened beverages, prior to Monday 4/13/26 when it was not ordered, included on the care plan and/or Kardex, RN D replied that the information should be passed from staff to staff in report. With further inquiry, RN D verbalized they had no way to show what Resident #702 received related to oral intake and stated, I get what you're saying. On 5/5/26 at 6:00 PM, an interview was completed with RN M. When queried regarding Resident #702, RN M verbalized they cared for the Resident on the on midnight shift the day they were admitted . When queried regarding Resident #702's diet and oral intake, RN M responded that they did not recall. A review of Resident #702's hospital Discharge Instructions, Orders, and Medication documentation scanned in the EMR did not include a diet order. A follow-up interview was completed with Witness A on 5/5/26 at 6:30 PM. When queried regarding Resident #702's diet at the hospital, Witness A responded that the Resident was on a mechanical soft diet. Witness A verbalized Resident #702 had to be fed and revealed they fed them the day they went to the hospital. Witness A stated, They are their whole plate at the hospital and drank without difficulty. Review of staffing/schedule sheets revealed LPN N was assigned to Resident #702 on 4/15/26 during the day shift. Resident #702 was transferred to the hospital at 6:46 PM.An interview was conducted with LPN N on 5/6/26 at 9:25 AM. When queried if they recalled Resident #702, LNP N voiced they did and confirmed they were the Resident's assigned day shift (6:00 AM to 2:00 PM) nurse on 4/15/26. When asked how the Resident was during their shift, LPN N replied, (Resident #702) was very tired. They set up in the hall in the Geri chair. LPN N stated, The girls (CNA staff) tried to get (Resident #702) up to clean them up and they could barely stay awake. When asked if that was normal for Resident #702 to be that lethargic during the day, LPN N revealed that was the first time they had taken care of Resident #702 and they did not know. When queried how they determine what a resident's normal is when it is their first time caring for a resident, LPN N revealed they go off of what is charted and what they receive in report. Documentation from Resident #702's EMR was reviewed with LPN N at this time. When asked how they determine if there is a change from a resident's baseline with so little documentation in the EMR, LPN N replied, You don't. I guess you go off of what you get in report. LPN N was asked if they were informed of anything abnormal during report, LPN N responded they had not. When queried if Resident #702 ate during their shift, LPN N replied, They ate a few bites and would fall asleep. When queried if the Resident drank, LPN N stated, Maybe a few sips, maybe. (Resident #702) was not eating or drinking. When queried regarding task documentation in the EMR specifying Resident #702 ate 100% of their meal, LPN N stated, (Resident #702) did not eat 100%, no way. When asked if they assessed the Resident for signs/symptoms of dehydration, LPN N replied, No. Review of staffing/schedule sheets revealed CNA K was assigned to Resident #702 on 4/11/26 and 4/12/26 on the midnight shift.On 5/6/26 at 10:07 AM, an interview was conducted with CNA K. When queried if they assisted Resident #702 to eat, CNA K replied, No. CNA K was then queried regarding how Resident #702 drank and stated, It was in a straw. When asked if Resident #702 had thickened liquids, CNA K replied, I do not think (Resident #702) was on thickened liquids. CNA K was then asked how they know if a resident is on a special diet such as pureed and/or if they need thickened liquids, and replied, I check the Kardex. CNA K verbalized any special diets are listed on the Kardex and stated, That is for sure.Review of staffing/schedule sheets revealed CNA I was assigned to Resident #702 during the afternoon shift on 4/12/26. An interview was completed with CNA I on 5/6/26 at 10:25 AM. When asked, CNA I verbalized they remembered Resident #702. When asked if they assisted the Resident to eat, CNA I replied, (Resident #702) wouldn't really eat themselves, you would have to feed them. When asked how the Resident ate, CNA I replied, (Resident #702) didn't really like the pureed food but really liked pudding. When asked how Resident #702 did with drinking, CNA I stated, Didn't like the straw and would try to take off the lid. CNA I continued, If I gave it (beverage) to them with the spoon, they would drink it. An interview was completed with Family Member Witness B on 5/6/26 at 10:55 AM. When asked, Witness B verbalized they visited Resident #702 at the facility on Monday morning (4/13/26). When queried how Resident #702 was doing, Witness B stated, (Resident #702) was OUT of it. I tried talking to them and they didn't respond at all. When queried if that was a change from how they had been doing, Witness B replied, On Saturday in the hospital (Resident #702) knew we were talking to them and said a couple words. They could respond. Witness B expressed how upset and shocked they were to see (Resident #702) in that condition after the improvements they had made in the hospital. When asked if the Resident had a beverage in their room and/or near them, Witness B stated, (Resident #702) didn't have anything. Witness B was asked if they expressed their concerns to facility nursing staff and responded they told them that Resident #702 was more tired and less responsive than they had been in the hospital. Witness B articulated they are not a health care professional and counted on the facility nursing staff to care for Resident #702. An interview was completed with Therapy Director C on 5/6/26 at 11:00 AM. Director C was asked when Resident #702 was evaluated by therapy service disciples and stated, OT on Saturday (4/11/26), ST (Speech Therapy) on Sunday (4/12/26), and PT (Physical Therapy) on Monday (4/13/26). A review of the Evaluations was completed with Director C and revealed the following:- 4/11/26: OT Evaluation and Plan of Treatment. Patient Goals: become stronger and return home. Functional Skills Assessment. Eating = Substantial/maximum assistance . The evaluation further detailed Resident #702 required substantial/maximum to total assistance for hygiene, bathing, and dressing. - 4/12/26: SLP (Speech-Language Pathologist) Evaluation and Plan of Treatment. Chart Review. Current Intake. Moderately Thick Drinks. Pureed Foods. Patient needs assistance feeding self = yes. Recommendation. Moderately thick (liquids). Pureed (foods). - 4/13/26: PT Evaluation and Plan of Treatment. Transfers. Dependent. Hoyer lift. When queried how Therapy recommendations are communicated to nursing staff, Director C responded that recommendations are compiled and emailed to nursing after all therapy disciplines have evaluated a resident. Director C was informed Resident #702 did not have a diet order in the EMR until 4/13/26. When asked if ST puts diet orders in the EMR after evaluating a resident, Director C responded that they do not. When queried regarding the ST Evaluation indicating Resident #702 was on a pureed diet with nectar thickened liquids prior to their evaluation, Director C indicated the diet recommendations must have came from the hospital. Review of the scanned hospital referral information in Resident #702's EMR was completed with Director C at this time. A Speech Therapy (ST) evaluation and recommendations dated 4/6/26 was located in the referral packet. This evaluation specified, Diet Consistency Recommendation: NDD3 (National Dysphagia Diet level 3- moist foods in bite sized pieces that are easy to chew and swallow). Liquid Viscosity Recommendation: Thin (normal with no thickening) . Supervision Swallow Recommendation: 1:1. Details. Promote below swallow precautions and encourage intake. Upright 90 degrees. Alternate liquids/solids, Slow rate; swallow between bites, small bites of food, small sips of liquid. When queried regarding the ST evaluation recommendations not corresponding with nursing note documentation and ST prior diet documentation, Director C confirmed the inconsistency and indicated they would review the Resident's EMR further. An interview was completed with ST P and Therapy Director C on 5/6/26 at 12:45 PM. When queried how they identify what diet a resident is currently on when completing an evaluation, ST P stated, I go off what modified diet they are on. When asked how they know what diet a resident is on, ST P replied, I look through the hospital discharge and talk to the nurses. If I can't find it, then I do an assessment. When queried if they recalled where they found Resident #702's prior diet information when they completed their evaluation, ST P replied, I don't. When queried if Resident #702 had a beverage when they evaluated them, ST P stated, I can't remember that. When queried what their diet recommendations were for Resident #702 were following their evaluation, ST P replied, Pureed diet and nectar thick (fluids) with feeding assist. Aspiration precautions and supervision. When queried if they recommended a specific cup and/or straw use, ST P replied, Could have been just a spoon. I don't really do the adaptive equipment. Director C then voiced that OT makes recommendation related to adaptative equipment and stated, OT said max assist for feeding. On 5/6/26 at 1:20 PM, an interview was conducted with the DON. When queried regarding Resident #702 not having a diet order and/or care plan/Kardex related to modified diet needs, the DON stated, I don't have an answer for you. When queried regarding documentation of dietary intake without a HCP provider order as well as lack of documentation of fluid intake, the DON did not provide further explanation. When queried regarding lack of clear documentation of Resident #702's urine output and monitoring for signs/symptoms of dehydration due to the Resident's increased risk, the DON indicated facility staff document by exception. When queried how to know if staff were assessing the Resident for signs/symptoms of dehydration when daily assessments were not completed, an explanation was not provided. Review of requested external hospital medical records for Resident #702 revealed an ED Note/Physician / Provider dated 4/15/26 at 11:01 PM. The note detailed, Per EMS, patient coming from facility where he was noted to be altered for at least the last couple hours. more altered compared to the last neurology note from 4 days ago. Multiple diagnoses considered including hypotension, dehydration, sepsis. Final Diagnosis: AMS (altered mental status) . AKI (Acute Kidney Injury).Note: Dehydration, sepsis (body's response to infection causing inflammation in the body), and heart failure are common causes of AKI. Review of laboratory testing results from the ED hospital records revealed the following results on 4/15/26 at 7:43 PM:- BUN (Blood Urea Nitrogen- blood test which measures the amount of urea nitrogen in the blood and is used to assess for kidney function): 38.2 mg/dL (milligrams/decaliter) (Elevated - normal is between 9 and 27 mg/dL. Elevated levels indicated kidney dysfunction and/or dehydration)Note: On 4/11/26 at 5:34 AM, Resident #702's BUN was 17.6 mg/dL prior to discharge to the facility. - Creatinine (waste product filtered by kidneys and excreted in urine, used as an indicator of kidney function): 1.6 mg/dL (High [normal range between 0.6 and 1.5]- elevated levels indicate issues with kidney function)Note: Hospital records showed Resident #702's creatinine level was 0.8 mg/dL on 4/11/26 at 5:34 AM prior to discharge to the facility. - BUN/Creat Ratio (BUN-to-creatinine ratio- blood test used to assess kidney function and hydration): 23.88 (High [normal between 10 and 20]- elevated resulted often indicates dehydration and/or kidney dysfunction).Note: Hospital records showed Resident #702's BUN was 22 mg/dL on 4/11/26 at 5:34 AM prior to discharge to the facility. - Sodium level (test to measure the amount of sodium in the blood used to evaluation hydration and kidney function): 148 mmol (millimoles)/L (liter) (High - commonly caused by dehydration- normal range is 135 to 145 mmol/L)Note: Hospital records showed Resident #702's Sodium Level was 145 on 4/11/26 at 5:34 AM prior to discharge to the facility. - WBC (White Blood Cell - blood test used to detect infection or immune system response): 17.57 (High -normal 4.50 to 10)Note: Hospital records showed Resident #702's WBC was 8.78 on 4/11/26 at 5:34 AM prior to discharge to the facility. Per the ED documentation, Resident #702's family made the decision to admit the Resident to Hospice services at the hospital. Resident #702 was admitted to the hospital on [DATE] at 2:29 AM with orders for comfort care only. Review of facility provided policy/procedure entitled, admission Assessment and Follow Up: Role of the Nurse (Revised: 1/26) revealed, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission. 8. Conduct a physical assessment, including the following system. 12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. The following information should be recorded in the resident's medical record. 3. All relevant assessment data obtained during the procedure. 5. Orders obtained from the Physician. Reporting: 1. Notify the supervisor and the Attending Physician of immediate needs that the resident may have. Review of facility policy/procedure entitled, Charting and Documentation (Reviewed: 7/2025) revealed, Services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of facility provided policy/procedure entitled, Urinary Incontinence - Clinical Protocol (Reviewed 4/2026) did not include documentation and/or assessment/monitoring of urinary output.

This Citation pertains to Intake Number 2709347. Based on interview and record review, the facility failed to implement and operationalize policies and procedures for advance care planning for three residents (#701, #704, and #706) of three residents reviewed, resulting in the lack of timely determination of decision-making capacity and arranging appropriate and legal representation for Resident #701 and Resident #706 and the lack of current guardianship documentation for Resident #704.Findings include:Review of intake documentation revealed a concern that Resident #701 is a vulnerable adult who requires total care. Per the intake, Resident #701 was transferred and admitted to the hospital due to an infection from a pressure ulcer (wound caused by pressure) and was in serious condition. The intake specified the Resident had been at the facility for several months and indicated they had been and were currently unable to make their own medical decisions and did not have guardian or POA (Power of Attorney). Resident #701:Record review revealed Resident #701 was admitted to the facility on [DATE] with diagnoses which included dementia, psychosis, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and was dependent upon staff for all Activities of Daily Living (ADLs) with the exception of supervision for eating. Resident #701's Electronic Medical Record (EMR) revealed the Resident was discharged to the hospital on [DATE] and did not return to the facility. A review of Resident #701's face sheet revealed the Resident was their own responsible party. Their granddaughter (Witness G) was listed as their first emergency contact followed by their two daughters. Review of Hospital documentation dated 8/16/25 to 8/22/25 revealed Resident #701 presented to the emergency room due to altered mental status and was found to have had a heart attack. The hospital documentation detailed Resident #701 was a poor historian, confused, and alert to self only throughout their hospitalization. Review of Resident #701's EMR revealed the Resident was confused and primarily alert to themself throughout their stay at the facility. Documentation from August and September 2025 revealed the Resident also displayed verbal and physical behaviors towards staff. On 12/5/25, a new stage three (full thickness tissue loss) pressure ulcer (wound caused by pressure) was identified on the Resident's coccyx. A detailed review of Resident #701's EMR documentation revealed the following: - 8/25/25 at 10:31 AM: Social Services. spoke to resident concerning advanced directives and reported no wishes to issue any further advanced directives at this time. Resident remains own person. - 8/25/25 at 10:36 PM: Nursing/Clinical. Resident has been agitated first half of this shift. was grabbing staff's arms and would squeezed tight and would not let go and tried to hit staff. - 8/26/25 at 8:47 AM: Care Conference Note. Resident lives with daughter and granddaughter and both were present. (Witness G) reported she is (Resident's) care giver. The patient is their own decision maker. Patient is not exhibiting behavioral symptoms. - 8/26/25 at 1:05 PM: Nursing/Clinical. Resident attempts to climb out of bed and chair numerous. has become aggressive with staff while trying to redirect. - 8/26/25 at 11:27 PM: Physician/Practitioner Progress Note. Review of Systems (ROS): Unable to complete fully due to underlying dementia. - 8/27/25 at 2:44 AM: Nursing/Clinical. Resident is confused during conversation. Resident is laying in reclining chair in hallway. - 8/27/25 at 10:40 AM: Skilled Note. alert and oriented to person (only). - 8/27/25: Psychiatric Evaluation & Consultation. interview was complicated by advanced dementia, leaving them mostly noninteractive and unable to meaningfully participate in the evaluation. An independent history was obtained from the unit nurse, who reported that (Resident#701) is very demented and minimally engaged in their environment. - 8/29/25 at 8:45 AM: Activities Note. Resident is alert and oriented to self with and cognitive impairment. - 8/28/25 at 1:45 PM: Social Services. Resident has been displaying the following behaviors-physical aggression such as hitting, grabbing and throwing food at staff. becomes very agitated and anxious in the evenings and expresses anger without reason towards staff. - 9/2/25 at 9:02 AM: Nursing/Clinical. alert and oriented x 0. unable to verbalize needs. does not follow directions. cannot retain education. - 9/3/25: Psychiatric Evaluation & Consultation. minimally interactive, only able to answer some questions with limited responses. The interview was complicated by advanced dementia, requiring reliance on collateral history from staff and social work. - 9/5/25 at 11:32 AM: Social Services. Resident has been displaying the following behaviors-physical aggression such as hitting, kicking, pushing and attempting to scratch staff. becomes very agitated and anxious in the evenings and expresses anger without reason towards staff. - 9/5/25 at 4:17 PM: Physician/Practitioner Progress Note. Review of Systems (ROS): Unable to complete fully due to underlying dementia. Neuro: Alert, at baseline dementia. - 9/24/25 at 5:48 PM: Social Services. Writer called resident's daughter and presented NOMNC (Notification of Medicare Non-Coverage) . to be mailed to resident's daughter. - 9/26/25 at 9:41 AM: Nursing/Clinical. (Resident #701) is mostly non- verbal with advanced dementia. does not retain education, does not verbalize needs. - 10/1/25: Psychiatric Evaluation & Consultation. The interview was complicated by advanced dementia and limited verbal communication. An independent history was obtained from the unit social worker and nursing staff. spends more time seated in chair and appears calm. They note that (Resident #701) is being prepared for transfer to a memory care facility, and the transition process is underway. - 10/17/25 at 11:13 AM: Skilled Note. alert and oriented to person. - 11/5/25: Psychiatric Evaluation & Consultation. interview was limited due to dementia-related cognitive decline. - 12/3/25: Psychiatric Evaluation & Consultation. interview was significantly limited by severe dementia. Independence with history was impaired, and independent history was obtained from nursing staff and the social worker. alert and oriented to self only. Eye contact was intermittent. Speech was sparse, soft, and concrete. Thought processes were concrete and significantly restricted by dementia. cognition were severely impaired and consistent with baseline dementia. presentation is consistent with advanced dementia, with profound cognitive impairment and limited capacity for engagement. - 12/5/25 at 2:56 PM: Nursing/Clinical. highly cognitively impaired and is unable to make needs known. - 12/5/25 at 8:56 PM: Physician/Practitioner Progress Note. pt (patient) cognitively impaired. Pt unable to make decisions. will need guardianship. sacral wound examined. - 12/7/25 at 1:11 PM: Nursing/Clinical.Resident was alert. does not make needs known. - 12/15/25 at 4:03 PM: Nursing/Clinical. this nurse spoke with (Witness G) regarding, patient's decline and advised her it would be in (Resident #701's) best interest to pursue guardianship, in order to make sound medical decisions . (Witness G) sounded non-committal to do so. - 12/18/25 at 10:38 AM: Nursing/Clinical. Doctor notified of degrading wound and overall health decline. order received to send patient to hospital for evaluation and treatment. (Witness G) regarding, patient's decline and patient being sent to (Hospital) for evaluation and concerns for end-of-life care. Documentation of evaluation of competency for decision-making and/or guardianship was not present in Resident #701's EMR. Additionally, no social service documentation related to designation of a legal decision maker/resident representation was noted. Scanned documentation in Resident #701's EMR included the following consents: - 8/22/25: Advance Directives/Medical Treatment Decisions. I do not choose to formulate or issue any Advance Directives at this time. The form was signed by Licensed Practical Nurse (LPN) F on 8/25/25. Initials were present under the Resident/Patient/Client section of the form and was also dated 8/25/25. - 8/22/25: Informed Consent for Psychotropic Medication. Zyprexa (antipsychotic medication used to treat schizophrenia and bipolar) . The consent form was signed 8/22/25, witnessed by LPN F and illegible initials were present under the Resident Signature section of the form. - 12/5/25: Informed Consent for Psychotropic Medication. Remeron (antidepressant medication known to stimulate appetite) . The consent form was signed 12/5/25, witnessed by the Director of Nursing (DON) and an illegible signature was present under the Resident Signature section of the form. The Resident signature/initials on all the consent forms were noticeably dissimilar, and it was unable to determine, with visual comparison, the name of the individual who had signed/initialed the forms and if the same individual had signed/initialed all three forms. An interview was completed with Licensed Practical Nurse (LPN) F on 1/14/25 at 3:00 PM. When queried if they recalled Resident #701, LPN F verbalized they did. LPN F was asked about the Resident's stay at the facility and responded that the Resident had a decline, developed a pressure ulcer and was transferred to the hospital. When queried regarding if Resident #701 was cognitively intact, LPN F replied, No and indicated they had dementia and were confused. When asked if the Resident had a DPOA (Durable Power of Attorney) or guardian, LPN F indicated they did not. LPN F stated, I talked to (Family Member Witness G) about (Resident's) decline and wounds. LPN F expressed that they informed Witness G they should get guardianship. When asked what happened, LPN F replied, (Witness G) said (Resident #701) was hibernating and would bounce back. LPN F continued, (Witness G) just didn't get it. When queried why guardianship was not discussed with Resident #701's family until 12/5/25 when the Resident had been admitted in August, LPN F indicated they were concerned with the Resident's change in condition and not having a legal decision maker in place. When asked what the change in condition was, LPN F relayed the Resident had developed the pressure ulcer, wasn't eating well, or wanting to get out of bed. On 1/15/26 at 8:26 AM, Witness G was contacted by phone, but an interview was unable to be completed. An interview was conducted with Social Services Director I on 1/15/25 at 10:36 AM. When queried if they recalled Resident #701, Director I verbalized they did. Director I was asked if Resident #701 had a DPOA and/or legal guardian in place and responded they did not. When queried regarding MDS assessments specifying the Resident was rarely/never understood as well as EMR documentation indicating the Resident was confused, Director I confirmed and stated, (Resident #701) lived with their daughter before. When queried if a legal representative/decision maker for medical decisions was discussed with Resident #701's and their family, Director I indicated guardianship had been discussed. When queried where they had documented that it was addressed, Director I reviewed the Resident's EMR and stated, I know (LPN F) stepped in and they made notes about it. When asked to confirm if they were saying they did not discuss/address the Resident not having a legal decision maker/representative, Director I confirmed they did not. When asked why they did not, Director I stated, (Resident #701) was supposed to go home and was not supposed to stay long term. When queried if Resident #701 was able to make informed medical decisions, Director I replied, No. Director I did not provide an explanation when asked how short-term versus long term-stay at the facility pertained to the Resident being cognitively unable to make their own decisions. When queried if the Resident was assessed for competency to make decisions, Director I verbalized they were not. Director I was then asked why a competency assessment had not been completed and stated, the Resident and family had set up in place. When asked what that meant, Director I revealed the Resident was living with their granddaughter (Witness G) and had in home services for care prior to going to the hospital and being admitted to the facility. When queried who was making decisions for the Resident, Director I replied Resident #701 was their own person and made their own decisions and indicated the family was involved. Director I was then asked why they provided Resident #701's NOMNC to the Resident's daughter and not the Resident when they were their own person but did not provide a response. When queried regarding consent for psychotropic medications, Director I indicated the Resident had provided consent. When asked how they were able to provide consent when they were unable to make informed medical decisions, an explanation was not provided. On 1/15/26 at 11:50 AM, an interview was completed with LPN J. When queried if they remembered Resident #701 and if they had provided care to them, LPN J responded they did. LPN J was asked about the Resident's cognitive status and stated, (Resident #701) was very demented and confused right from the beginning. When queried, LPN J indicated the Resident remained very confused throughout their stay at the facility. When queried regarding the Resident not having a DPOA and/or guardian, LPN J stated, We thought the family was going to be very involved and then they weren't. They just never come in. LPN J was then queried regarding facility policy/procedure related to obtaining consent for care/medical decisions when a resident is very confused and does not have a legal representative and revealed they were unsure. Resident #706:A list of facility residents with a BIMS (Brief Interview for Mental Status) score of less than 6, indicating the Resident was severely cognitively impaired was requested and received from the facility Administrator on 1/14/26 at 2:57 PM. Review of the list revealed Resident #706 was listed as having a BIMS score of zero. Record review revealed Resident #706 was originally admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with resulting right sided hemiplegia and hemiparesis (one sided paralysis), dysphagia (difficulty swallowing), and dysarthria (impaired and unclear speech). Review of the MDS assessment dated [DATE] revealed the Resident was rarely/never understood and required moderate to substantial assistance to complete ADLs.A review of Resident #706's face sheet revealed Resident #706's mother was listed as their Responsible Party and Emergency Contact #1. Review of documentation in Resident #706's EMR revealed no documentation of competency assessment, guardianship and/or POA. The following progress note documentation was present in the EMR:- 11/7/25 at 9:05 PM: Nursing/Clinical. Resident arrived to facility via EMS. Resident is Aphasic (acquired language disorder which impairs ability to communicate) can answer question as a yes or no. Resident is alert and hard to understand. - 11/10/25 at 12:05 PM: Social Services. Social worker spoke to resident concerning advanced directives and reported no wishes to issue any further advanced directives at this time. Resident remains own person and expressed wishes to remain a full code status. - 11/11/25 at 11:23 AM: Social Service Assessment &History. Resident is nonverbal but able to indicate needs and answer yes and no questions. SW (Social Work) to contact family for additional information for verification. - 11/11/25 at 1:02 PM: Social Services. Writer contacted resident's mother for information pertaining to resident. Mother let me know that the resident resides with (their aunt) and will return there upon discharge. (Aunt contacted) confirmed that the resident does not have. DME (Durable Medical Equipment) at this time. Note: Resident Aunt was not listed on face sheet as a contact. - 11/12/25 at 8:21 AM: Social Services. Resident's mother refused psych services on resident's behalf. - 12/19/25 at 10:33 AM: Social Services. Resident remains own person. Additional review of documentation in Resident #706's EMR revealed no documentation of competency assessment, guardianship and/or DPOA/legal decision maker.On 1/15/26 at 10:31 AM, an interview was completed with Social Services Director I. When queried if Resident #706 had a legal guardian and/or activated POA, Director I responded that they did not. Director I was then asked who was making the Resident's medical treatment decisions as they were rarely/never understood per their MDS assessment and replied that the Resident was their own person and made their own decisions. When queried if Resident #706 had been assessed for competency to make medical decisions, Director I stated they had not. When asked why they had not been assessed, Director I replied, We try to see if they (residents) are going to do better. When queried how often cognition and ability to make medical decisions is assessed, Director I replied, (Resident #706) will be having a quarterly MDS assessment. When queried who is making medical decisions for the Resident while the facility is waiting to see if they are going to do better, Director I stated, (Resident #706's) family is very involved. When asked if the Resident's family is legally able to make decisions for the Resident, Director I did not provide a response. When queried regarding the facility process/procedure for assessment of competency, Director I revealed residents are assessed by two HCPs including psych. When queried if Resident #706 had been seen and evaluated by psych services, Director I replied, No, (Resident #701's) mother refused psych on their behalf. When queried how the Resident's mother was able to refuse psych services on their behalf, when they were not the Resident's legal representative/guardian, Director I did not provide an explanation. On 1/15/26 at 12:21 PM, an interview was attempted to be completed with Resident #706 in their room. When asked questions, Resident #706 responded verbally with noises, but words were unable to be discerned/understood. The Resident's hands were observed to be visibly shaky when attempting to make purposeful movements. Certified Nursing Assistant (CNA) L was observed in the hallway and asked to enter Resident #706's room. When asked if they knew what Resident #706 was trying to say/communicate, CNA L listened to the Resident and revealed they did not understand either. When asked how they normally communicated with the Resident, CNA L revealed Speech Therapy had provided a paper with pictures to assist in communication and began to look for the paper in the room. CNA L was unable to locate the paper. CNA L left the room at this time and indicated they were going to go and get another picture communication paper. When queried if they would want CPR (Cardiopulmonary Resuscitation) if their heart were to stop, Resident #706 shook their head No and then began to attempt to say something which was unable to be understood. Resident #706 was then provided with a blank word document on a laptop and asked if they were able to type what they wanted to say and shook their head no. Resident #706 was shown how to press the letter keys and continued to shake their head no. When asked if they could write a message with a pen, Resident #706 shook their head no. An image of a communication board for adults was displayed on the laptop screen and Resident #706 was asked to point out what they were trying to say. The Resident's hands were very shaky as they attempted to pick out an image. CNA L returned to the room at this time with an 8 X 10 piece of paper with basic printed images on it. An interview was completed with CNA L after leaving the Resident's room. When queried if they are normally able to understand Resident #706, CNA L responded that they try to get two people in the room but it is hard to know what (the Resident) wants. CNA L then stated, That is the most I have even seen (Resident #706) attempt to communicate. When asked if they are normally able to understand the Resident, CNA L responded that they cannot. Further review of documentation in Resident #706's EMR revealed a scanned document titled, Advance Directives/Medical Treatment Decisions. The form was dated 12/18/25 and detailed the Resident did not choose to formulate or issue any Advance Directives at this time. The form was signed by facility staff LPN K and included Resident #706's name on the Resident, Resident DPOA and/or Guardian Signature line. Resident #706's name was signed on in very clear writing and that was very similar in appearance to LPN K's signature. An interview was completed with LPN K on 1/15/26 at 2:30 PM. When queried regarding the signatures on Resident #706's Advance Directives/Medical Treatment Decisions form, LPN K revealed the Administrator and Director of Nursing (DON) had already spoke to them. LPN K stated it was not their writing for Resident #706's signature on the form. When asked if it was Resident #706's writing and signature on the form, LPN K stated, No LPN K stated, Even the letters don't look like (Resident #706's) because he is so shaky. When queried, LPN K revealed they did not know who signed the Resident's name on the form. When queried regarding facility policy/procedure when a very confused, cognitively impaired Resident is admitted to the facility who does not have a DPOA, guardian, and/or designated legal decision maker for medical and stated, I'm not sure. When queried who was making Resident #706's medical decisions, LPN K replied, I don't know. LPN K was then asked if any family members were present when Resident #706 was admitted to the facility and participated in the admission process and stated, (Resident #706) came alone. Resident #704: Record review revealed Resident #704 was admitted to the facility on [DATE] with diagnoses which included heart disease, and dementia. Review of the MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and required supervision to total assistance to complete ADLs. Review of Resident #704's EMR revealed the Resident had been deemed incompetent to make medical decisions by two HCPs in July 2025. Documentation from the Probate Court was present specifying Witness M was granted Temporary Guardianship of Resident #704 from 7/18/25 to 8/25/25. No permanent guardianship documentation was noted in the Resident's EMR.Review of Resident #704's demographic information and face sheet revealed Witness M was listed as the Resident's Legal Guardian. An interview was completed with Social Service Director I on 1/15/26 at 10:28 AM. When queried if Resident #704 had an active legal guardian, Director I verbalized they did. Director I was asked where the guardianship documentation was maintained and indicated the EMR. Director I proceeded to show the temporary guardianship documentation which expired 8/25/25. When queried regarding the guardianship documentation being expired, Director I stated, (Witness M) had temporary but went back to court. Director I was asked again where current guardianship documentation was and revealed they did not have it. When queried how they knew Witness M was legally able to make decisions for the Resident without proof of guardianship, an explanation was not provided. An interview was completed with the Administrator at 1:30 PM on 1/15/26. When queried regarding Resident #706's cognitive impairment, including being rarely/never understood on their MDS assessment, and lack of a legal representative for decision making, the Administrator did not provide an explanation. When queried regarding facility policy/procedure related to determination of competency, timing, and identification of necessity for legal representative for decision making, the Administrator revealed Social Services is responsible for addressing that. When asked why it was not addressed for Resident #706, the Administrator was unable to provide an explanation. Resident #706's Advance Directives/Medical Treatment Decisions form was reviewed with the Administrator at this time. When queried regarding the signatures of the form, the Administrator confirmed the writing of the signatures looked similar. When asked how Resident #706 would be able to sign so clearly when their hands were visibly shaky, the Administrator replied, I don't think that is his signature. When asked why anyone else would be signing the form, if Resident #706 was their own legal decision maker, the Administrator revealed they should not unless the Resident requested it and then that should be documented. The Administrator was then informed that Resident #706 shook their head no when asked if they wanted CPR if their heart stopped which was opposite of what the form indicated. With further inquiry, the Administrator revealed the Resident may not understand. When queried if Resident #706 was able to read and write, the Administrator revealed they did not know. The Administrator was informed of the Resident shaking their head no when asked to type and/or write what they were trying to say but did not provide further explanation. When asked why advance care planning was not addressed with the Resident/Resident family, the Administrator indicated it should be addressed in Social Services documentation. Resident #706's EMR documentation was reviewed with the Administrator at this time. When queried why advance care planning was not addressed, no further explanation was provided. When queried regarding Resident #701 not having a legal decision maker for medical decisions, being severely cognitively impaired, and no documentation of discussion pertaining to the family obtaining guardianship until after the Resident had been in the facility for approximately four months, no explanation was provided. When queried if the facility should maintain current documentation of resident guardianship, the Administrator verbalized guardianship documentation should be scanned into the EMR. The Administrator was informed of Resident #704's guardianship documentation not being current in the EMR but did not provide further explanation. Review of facility policy/procedure entitled, Advance Directives/Advance Care Planning (Reviewed 1/2026) revealed, Advance directives will be respected in accordance with state law and facility policy. 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. 15. The Interdisciplinary Team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record. Review of facility policy/procedure entitled, Determination of an Advocate's Authority to Act on Behalf of a Resident (Reviewed 6/25) revealed, This policy and procedure outline the process for determining who has health care decision making authority for a resident, and when it is appropriate for a patient advocate/surrogate to act on behalf of a resident who lacks the competency and/or capacity to actively participate in their health care treatment decisions. 2. If no one other than the resident is designated to make the resident's health care decisions, the resident shall maintain the ability to make the resident's health care decisions until it is determined that the resident is longer capable of doing so. 3. Upon admission and on a quarterly basis (or sooner based on an observed change of condition), residents shall be assessed by staff regarding their cognitive status. 4. if it is determined that based on the resident's cognitive status, the resident is unable to participate in medical treatment decisions, or, as applicable, mental health treatment decisions, the building shall determine if a pre-existing Power or Attorney for health care is now activated. 5. If there is not a court appointed Guardian, or activated health care Power of Attorney, the resident's health care decision making decisions shall be made by the resident's patient advocate under state advocacy/surrogacy law. 6. In most, but not all cases, the resident's family member(s) shall be the patient advocate. The facility shall treat the person closest to the resident who participated in the admission as the patient advocate unless those participating in the resident's life mutually agree who shall be designated as the patient advocate. 7. If a dispute should arise amongst multiple potential advocates as to the course of health care decisions, the facility shall treat the responsible party involved in the resident's admission as the patient advocate and direct the other potential patient advocates to seek the court's involvement to appoint a Guardian.

This Citation pertains to Intake Number 2709347. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for the care of pressure ulcers for two residents (#'702 and #703) of three residents reviewed, resulting in a lack of accurate documentation of care and implementation of planned interventions. Findings include:Resident #702: On 1/14/26 at 3:30 PM, Resident #702 was observed laying in bed in their room. The Resident was positioned on their back with their heels directly against the mattress. Heel boots (cushioned, pressure-relieving positioning boots) were observed sitting on a table in the Resident's room. The Resident had one pillow on their bed, under their head. There were no pillows present in the room, including on the floor for positioning use. An interview was completed at this time. When queried if they had any pressure ulcers, Resident #702 replied, Just on my heels. When asked if they had pressure ulcers on both of their heels, Resident #702 revealed they have dressings in place on both feet but only have a pressure ulcer on their right heel. When asked if staff assist them to position their heels off of the mattress for pressure relief, Resident #702 indicated they did not. Record review revealed Resident #702 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, anxiety, and kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required moderate to total assistance to complete Activities of Daily Living (ADLs) with the exception of eating, and had a pressure ulcer. Review of Resident #702's Electronic Medical Record (EMR) reviewed a care plan entitled, I have impaired skin integrity related to admission with pressure ulcers present (Initiated and Revised: 11/26/25). The care plan included the interventions:- Daily skin assessments (Initiated: 11/26/25)- Float my heels while in bed (Initiated: 11/26/25)- Turn and reposition q (every) 2h (hours) (Initiated: 11/26/25)- Low air loss mattress to bed (Initiated: 11/26/25) The Resident did not have a care plan in place pertaining to refusal of care nor did they have an active or discontinued intervention for heel boot use. Review of documentation in Resident #702's Electronic Medical Record (EMR) revealed the Resident was admitted with a pressure ulcer on their right heel. The documentation of the stage of the pressure ulcer was inconsistent. Documentation detailed: - 11/26/25 at 6:43 PM (Signed and Locked on 11/28/25 at 8:37 AM: Nursing Assessment Admission/Readmission. Skin. wound to right heel. - 11/27/25 at 11:58 PM: Physician/Practitioner Progress Note. Late Entry. History and physical. Stage I (intact skin with localized area of non-blanchable redness) R (right) heel pressure injury. - 12/1/25 at 8:24 AM: Nursing/Clinical. admitted . from (hospital). Skin Assessment. Left heel is soft, no open areas. Right heel is soft, red and macerated (skin that is soft and mushy often due to prolonged exposure to moisture) . Treatment Plan: Cleanse bilateral heels with NS (Normal Saline), pat dry, apply skin prep, cover with ABD pad (wound dressing) and wrap with Kerlix dressing QD (every day) and PRN (as needed) . - 12/1/25 at 9:44 AM: SW - Skin Issues. New skin Issue. Location: Right heel. Issue type: Blister (area of underlying tissue damage with unknown depth - often a Suspected Deep Tissue Injury (SDTI) pressure ulcer) . new wound. Wound was present on admission. It is unknown how long the wound has been present. Length (cm- centimeters): 1.9, Width (cm): 1.53. Exudate amount: None. Surrounding tissue: Fragile. - 12/9/25 at 10:46 AM: SW - Skin Issues. Right heel. Blister. Deteriorating. Length (cm): 1.59 Width (cm): 1.59. Slough: 100% . Surrounding tissue: Erythema (redness often from injury, infection, or inflammation) . Fragile. - 12/18/25 at 5:00 AM: External Wound Care Provider Wound Consult. An open wound of the right posterior heel, likely related to pressure. Unstageable Pressure Injury (pressure ulcer with unknown depth) - Right heel Wound . 2cm (length) x 1.8cm (width) x 0.1cm (depth) . Wound Thickness. Unable to Determine based on wound presentation. Wound Bed Tissue. Slough - 100 % . Drainage. Serous. Pressure Redistribution Recommendations. Turn/Repositions Q2H. Offloading heel boots or may alternate w/ floating heels. Note: A weekly SW- Skin Issues note was not present in the EMR for 12/23/25. - 12/29/25 at 1:15 PM: SW - Skin Issues. Location: Right heel. Issue type: Blister. Length (cm): 0.88 Width (cm): 0.45. Surrounding tissue: Erythema. Fragile. - 1/8/26 at 11:02 AM: SW - Skin Issues. Location: Right heel. Issue type: Blister. Progress: Stable: previously deteriorating wound characteristics plateaued. Length (cm): 0.78 Width (cm): 0.56. On 1/15/26 at 8:30 AM, Resident #702 was observed laying in bed on their bed with their eyes closed. The Resident's knees were bent, and their feet were positioned directly against the mattress. The heel boots were in the same place on the table as they were on 1/14/26. An interview was completed with Registered Nurse (RN) A on 1/15/26 at 8:36 AM. When queried regarding Resident #702's skin, RN A verbalized the Resident has a pressure ulcer on their right heel. When queried regarding interventions related to the pressure ulcer, RN A stated, (Resident #702) does like the (heel) boots because they make their feet hot. When queried regarding other interventions to reduce pressure on the Resident's heels, RN A responded that staff float the Resident's heels on a pillow. RN A was asked if they had seen the pressure ulcer and replied, The one is small and scabbed. At 11:15 AM on 1/15/25, Resident #702 was observed in their bed. The Resident was positioned on their back with their heels positioned directly against the mattress. A wound care observation of Resident #702's heel was completed on 1/15/25 at 11:19 AM. Resident #702 was observed in bed with their heels positioned directly against the mattress upon entering the room. RN A removed the dressing in place on the Resident's right heel. A small amount of gray/red colored drainage was observed on the removed dressing. The pressure ulcer was directly over a bony prominence on the heel. The wound bed comprised an oblong area of black colored, necrotic tissue. The edges of the necrotic area were unattached, and the surrounding tissue was red/purple in color. The total wound bed, comprising the necrotic and surrounding red/purple tissue was irregularly circular in shape and approximately the size of a half dollar. Upon request, RN A measured the wound. RN A measured the necrotic, black colored area and stated it was approximately 1 by 0.5 (cm) and the size of the entire wound bed was approximately 2 by 3 (cm). After completing the dressing change, Resident #702 resumed the same position, with their heels positioned directly against the mattress. No pillows for positioning were present in the room. Review of the past 30 days of task documentation in Resident #702's EMR revealed the task, Float heels (as tolerated) while in bed. Review of the documentation revealed No was documented four times and Yes was documented 77 times including three times on 1/14/26 and twice on 1/15/26. On 1/15/26 at 2:30 PM, Resident #702 was observed in their room in bed. They were positioned directly on their back with their heels positioned directly against the mattress. When queried regarding the Resident's heel positioning and pressure reduction, RN A looked around the room and verbalized the Resident did not have an extra pillow to float their heels. RN A exited the room. An interview and review of Resident#702's EMR was conducted with RN A on 1/15/26 at 2:45 PM. When asked, RN A confirmed they also worked and were Resident #702's assigned nurse on 1/14/26. Resident #702's Float heels. task documentation was reviewed with RN A at this time. When queried if they observed Resident #702's heels floated off the mattress yesterday or today, RN A replied, Have not been. RN A was then asked how staff attempted to float the Resident's heels if a pillow/positioning device was not present in the Resident's room and replied, Not attempted. When queried regarding documentation indicating staff had floated the Resident's heels, RN A stated, Will have to talk to them (Certified Nursing Assistants [CNAs]) about that. Resident #702 did not have a task for heel boots. When queried, RN A responded that nurses document if the boots were applied on the Treatment Administration Record (TAR). RN A proceeded to obtain a pillow and enter Resident #702's room to float their heels off the mattress.An interview was conducted with the DON on 1/15/26 at 3:00 PM. When queried regarding lack of implementation of the intervention of floating Resident #702's heels including staff documentation of task completion, interview and observations of task not being completed, the DON reviewed the EMR documentation. The DON then verbalized CNA staff complete the task documentation, and they would receive additional education and training. Resident #703: On 1/14/26 at 3:35 PM, Resident #703 was observed laying in their bed, positioned on their back. Family Member Witness B was present in the room. An interview was completed at this time. When queried if they had any wounds, Resident #703 responded they did on their butt. When asked if they had any pain, Resident #703 responded, Yeah, in my backside. Resident #703 was then asked to rate their pain, on a scale of zero to 10 with 10 being the worst possible pain, and stated, Four. When queried if they are able to turn and reposition themselves in bed, Resident #703 indicated they could not. Resident #703 was then asked how often staff turn and reposition them in bed and replied, Whenever I need to be changed. When queried how often staff provided incontinence care and changed them, Resident #703 replied, Couple times a day. Witness B was asked when they arrived at the facility and replied, Noon to 1:00 PM. Witness B then stated Resident #703 had not moved since I've been here. Record review revealed Resident #703 was admitted to the facility on [DATE] with diagnoses which included Left Below the Knee Amputation (LBKA), diabetes mellitus, and kidney disease with dialysis dependance. Review of the Resident's admission assessment dated [DATE] revealed the Resident was alert and orientated to person, place, time and orientation, non-ambulatory, required assistance with ADL care, and had an open area on their coccyx. Review of Resident #703's EMR revealed they had an unstageable pressure ulcer on their left gluteal area which was being treated with Santyl (debriding wound ointment used to remove dead tissue from wounds) to remove eschar (black colored, necrotic tissue). Review of Resident #703's EMR revealed a care plan entitled, I am at risk for altered skin integrity related to decreased mobility, weakness, debility. (Initiated: 1/9/26; Revised: 1/11/26). The care plan included the interventions:- Encourage me to turn and reposition q2h. (Initiated: 1/9/26)- Float my heels as I tolerate (Initiated: 1/9/26)A second care plan entitled, I have an ADL self-care performance. (Initiated: 1/9/26; Revised: 1/11/26) included the following interventions:- Bed Mobility: I require assistance by (2) staff to turn and reposition in bed (Initiated: 1/9/26)- Dressing: I require assistance by (2) staff to dress (Initiated: 1/13/26)- Transfer: I require mechanical lift with (2) staff assistance for transfers (Initiated: 1/13/26) An interview was completed with Licensed Practical Nurse (LPN) C on 1/15/26 at 8:40 AM. When queried regarding Resident #703's skin, LPN C confirmed the Resident had a pressure ulcer. When queried regarding the appearance of the wound, LPN C stated, A lot (of the wound bed) looks like shearing. There is one area that looks black.On 1/15/26 at 8:45 AM, Resident #703 was observed in their room. The Resident was laying in bed, positioned slightly on their right side. When queried how long they had been laying in that position, Resident #703 revealed they did not remember. Resident #703 was asked if they were having any pain and replied, Little bit in my butt. When asked if staff had assisted them to get cleaned up for the day, Resident #703 stated, No.At 10:42 AM on 1/15/25, a wound care observation for Resident #703 was completed with LPN C and CNA D. Upon entering the room, Resident #703 was observed in bed, positioned on their back, wearing the same shirt as prior observation. CNA D was asked when they last repositioned Resident #703 and responded they were In here 10 minutes ago to change them. LPN C removed the dressing in place on the Resident's left buttocks and cleaned the wound. An area of black, necrotic tissue approximately the size of a nickel with bright red tissue surrounding the necrotic tissue was present. A separate area, approximately the size of a dime with a white colored wound bed was noted proximal to the necrotic area. Directly following the wound care treatment/dressing change, Resident #703 was transferred with a mechanical lift from their bed to sit in a wheelchair. At 2:35 PM, Resident #703 was observed sitting in the wheelchair in their room. When asked how they were, Resident #703 responded sore and tired. When queried if have gone back to bed since they were put in the wheelchair after their dressing change, Resident #703 replied, No. When asked if staff assisted them to move and reposition in the wheelchair while sitting up, Resident #703 replied, No. When queried if any incontinence care had been provided, Resident #703 revealed their brief had not been checked and/or changed since they were put in the wheelchair. An interview was completed with LPN C on 1/15/26 at 2:40 PM. When queried if Resident #7003 has been sitting up in the wheelchair since their wound care observation/dressing change was completed or if they had went back to bed, LPN C stated, Been up. An interview was conducted with the DON on 1/15/26 at 3:00 PM. When queried how often dependent residents should be turned and repositioned, the DON indicated every two hours. The DON was informed of observations of Resident #703 not being repositioned as well as interviews completed, the DON responded, Okay, that is education for staff. Review of facility policy/procedure entitled, Skin Management Guidelines Prevention of Pressure Ulcers/Injuries (Reviewed: 11/2025) revealed, The purpose of this procedure is. to identify specific interventions to assist with prevention and management of skin alterations. 1. Skin is assessed on admission to the facility and at least weekly to identify alterations in skin, and any wound assessments should be documented in the medical record. Pressure Ulcer/Injury Care Plan Considerations. Potential Interventions to Consider: Turning and repositioning, off-loading, Scheduled time out of bed. Mobility Friction/Shearing: Head of bed 30o, unless contraindicated. Heel off-loading - positioning, use of orthotics. Sensory perception: Turning and repositioning, off-loading, Support surfaces - bed, chair etc. Treatment & Monitoring. 3. Wound rounds are completed weekly on pressure ulcers and complex wounds to assess the wound and determine the optimal treatment plan. 4.Review the interventions and strategies for effectiveness on an ongoing basis.

This Citation Pertains to Intake # 2676612.Based on observation, interview and record review, the facility failed to ensure that 1) the sink used for hand hygiene in the kitchen maintained a hot water temperature of at least 85 degrees Fahrenheit and 2) the chemical strips used to test the dish machine were not expired, resulting in the potential for the spread of foodborne illness to all Residents receiving meal service from a census of 99 residents.Kitchen hand washing sinkOn 12/5/2025 at 9:00 AM, during a tour of the Kitchen with Dietary Supervisor B, a sink for employee hand hygiene was noted near the entrance to the kitchen from the service hall. Upon use of the hot water, it was identified to be very cold. The Dietary Supervisor B was asked about the hot water being cold, as she was observed performing hand hygiene and she said sometimes it had to run a bit for it to warm up. The hot water was left to run for approximately 1 minute and it was still cold, not warm or hot. The Dietary Supervisor B was asked if the hot water temperature for the sink was monitored and she said she didn't know.On 12/5/2025 at 9:15 AM, Maintenance staff F was observed obtaining a temperature of the hot water on the kitchen hand washing sink; it was 67 degrees Fahrenheit and did not get any warmer as the water ran.At 10:25 AM, Maintenance staff F provided a list of hot water temperatures for the building that included resident rooms, shower rooms, therapy gym, salon, lobby bathrooms, main dining room, and activities area. There was no monitoring of the kitchen hand washing sink.An interview with Maintenance Director P, on 12/5/2025 at 12:30 PM revealed the facility was not monitoring the hot water temperature of the kitchen hand washing sink. He said it had not been done, but they would begin after they replaced the mixing valve beneath the sink, as it was not working correctly.On 12/5/2025 at 12:55 PM, the Maintenance Director P was interviewed and said the mixing valve on the kitchen hand washing sink had been replaced and the sink temperature was 110 degrees Fahrenheit. A review of the 2022 Food Code: 5-202.12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 29.4 degrees C (85 degrees F) through a mixing valve or combination faucet. Dish MachineOn 12/5/2025 at 9:05 AM, the Dietary Supervisor B was asked about the dish machine that washed the dishes. She was asked how she ensured the dishes were sanitized appropriately and she provided a chemical strip container dated expired 8/2024. She said the dietary staff had not washed any dishes that morning. She was asked if there were additional chemical strips and she said she would look for them. On 12/5/2025 at 9:10 AM, the Dietary Supervisor B returned from her office and said there were no additional strips to test the dish machine. The dietary staff were observed rinsing dishes and preparing to load them into the dish machine. The Dietary Supervisor was asked how she would ensure proper dish sanitization, and she said she would have to get more chemical strips.A review of the Dish Machine Log-Low Temp document used to record dish machine temperatures 3 times a day (Breakfast, Lunch, Supper) indicated Instructions: Record wash temperature and sanitizer PPM (parts per million) and provide initials, three times per day; Notify supervisor immediately if sanitizer PPM is not within acceptable range of 50-100. Each entry on the document dated 12/1- 12/5 December 2025 indicated the Wash temperature was 120 degrees Fahrenheit and the PPM was 50 each time. There was no mention of the Lot number or expiration date of the Test strips. The Dietary Supervisor was asked if anyone was monitoring that the test strips had expired the year before and the test results could be invalid. She said she had never looked at the expiration date on the test strips before.On 12/5/2025 at 9:21 AM, Registered Dietitian/RD J was interviewed and asked about the lack of hot water in the kitchen hand washing sink and the expired dish machine test strips and said she handled the clinical component of dietary needs for resident care and Dietary Supervisor B was responsible for the kitchen. RD J was asked if she was aware there was no hot water for staff to wash their hands in the kitchen hand washing sink and she said was not aware of it.On 12/5/2025 at 10:30 AM, Dietary Supervisor B was interviewed and said she went to the food service store and bought some chlorine test strips for the dish machine. They had an expiration date of 9/2027. Dietary Supervisor B tested the water from the dish machine and the strip turned black indicating 200 parts per million, per the test strip package. A review of the facility policy titled, Dishwashing Machine Use, dated revised March 2010 provided the following, Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. The following guidelines will be followed when dishwashing: 1. a. Wash hands before and after running dishwashing machine, and frequently during the process. 4. Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Type of Solution: Chlorine; Minimum Concentration: 50-100 ppm; Contact Time: 10 seconds.

This Citation Pertains to Intake# 2678077Based on observation, interview and record review the facility failed to develop and implement a comprehensive care plan for one resident (#6) of 3 residents reviewed for wound care, resulting in Resident #6 lacking a care plan for a right leg brace. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: history of right knee replacement and post-surgical right knee infection, reduced circulation right leg, heart disease, and arthritis in knees. The resident had full cognitive abilities and made her own decisions. On 12/4/2025 at 10:00 AM, Resident #6 was observed sitting on the bed in her room, with her right lower leg wrapped in a dressing with a right lower leg brace on. The resident said she had previously had knee surgery, and it became infected. She said she was treated with antibiotics, and her knee was better, but she had other wounds on her right leg. The resident said she wore a right foot boot to protect her foot. A record review of the progress notes and wound notes for Resident #6 identified she had 9 wounds to the right foot and lower leg; including the right front lateral lower leg due to a medical device. A review of the Care Plans for Resident #6 identified the following: Resident has pressure ulcers to: Unstageable pressure ulcers to lateral and posterior aspect of right ankle from hinged leg brace and suspected deep tissue injury to posterior aspect of right ankle and lateral side of right foot proximal to 5th toes, date initiated 8/29/2025 and revised 9/5/2025. The interventions did not mention care of the right leg brace. Further review of the Care Plans for Resident #6 indicated there were several Care Plans mentioning the resident's wounds but did not identify mention of a right foot PRAFO boot to aid in preventing skin breakdown. On 12/4/2025 at 10:49 AM, Wound Nurse A was interviewed, and he said Resident #6 was admitted to the facility after having right knee surgery. The right knee wound became infected and was not healing well. It had since healed, but the resident developed additional wounds, including a wound from the resident's right leg brace on the right lower leg. During the interview with Wound Nurse A on 12/4/2025 at 10:50 AM, he was asked about Resident #6's right leg brace and right foot boot. The resident no longer had a right leg brace but had a right foot boot. Upon review of the Care Plan for Resident #6, there was no mention of a leg brace or a right foot boot. The Wound Nurse A was asked if there were written instructions for the right leg brace or right foot boot to ensure staff were applying them correctly and it was not causing skin breakdown. Reviewed with the Wound Nurse physician orders were identified for a right foot PRAFO boot while the resident was in bed and to remove the PRAFO boot every shift to check for skin breakdown, each dated 10/13/2025. Wound Nurse A confirmed the right foot PRAFO boot was not mentioned on Resident #6's Care Plan, or Kardex. Review of the progress notes with Wound Nurse A revealed neither the right knee brace nor right PRAFO boot was mentioned. A review of a facility policy titled, Assistive Devices and Equipment, dated revised January 2020 and reviewed January 2025 revealed, Our facility maintains and supervises the use of assistive devices and equipment for residents. Recommendations for the use of devices and equipment are based on comprehensive assessment and documented in the resident care plan.

Based on observation, interview and record review, the facility failed to: (1) Ensure proper cleaning of therapy gym equipment for all residents utilizing the equipment; (2) Ensure the timely removal of Resident #2's soiled gown, blanket and linen , (3) Ensure the timely disposal of daily hygiene products of a discharged resident (Resident #15) and the cleaning of the room prior to admittance of a new resident and (4) Ensure the decluttering of residents' items throughout the rooms on the 100 Hall. Findings Include: Therapy Gym During initial tour a resident shared a peddle on the bike in the therapy room gym, was not safe for residents to utilize and requested it be observed for functionality and safety. On 4/24/2025 at 1:10 PM, an observation was conducted of the facility therapy gym. Therapy Director S provided an overview of the equipment and stated each machine is wiped down between each resident, but deep cleaning is completed by housekeeping. The following was observed: 2- Nu Step Machines: -Foot pedals had debris and sand like build up inside both pedals. -In between the foot pedals (at the base of the machine) there were white flecks of debris, hair and sand like particles. -The seat on one machine was ripped and the yellow foam exposed. -The back part of one machine had green particle dusting from the deteriorating handle covering material. 2-Omni Cycles: -Build up unknown particles in the crevices of the pedals on both omni cycles. On 4/24/2025 at 1:20 PM, Director of Environmental Services J stated the therapy gym is deep cleaned once a month. He explained that includes wiping down all the equipment, cleaning the window ledges etc. We went into the gym together to look at the unsanitary state of the Omni Cycles and Nu Steps. When asked exactly what his staff are tasked with cleaning during a deep clean of the machines he stated they would wipe down the machine. Director J was asked to provide the deep cleaning schedule and check off list for the therapy gym. On 4/24/2025 at 1:40 PM, Housekeeper M was interviewed regarding cleaning of the therapy gym. The housekeeper explained the gym is constantly in use, so typically they will sweep the floors, change the trash, clean the bathroom, replenish paper products, and wipe down surfaces. Housekeeper M stated the deep clean must occur after hours. On 4/24/2025 at 2:00 PM, Director J provided the monthly cleaning schedule that indicated the therapy gym was last deep cleaned on 4/1/2025. There were no specific deep cleaning tasks to be performed, so it is unknown exactly what takes place during the therapy gym deep clean. It can be noted that the debris/particle buildup is unlikely to have occurred in three weeks from when it was last cleaned to observation. A discussion was held with the director regarding the cleanliness of the equipment, especially given the amount the resident use. Director J expressed understanding of the concern. 22347 Resident #2: Review of the Face Sheet, care plans and nurses progress notes dated 3/28/25 through 4/23/25, revealed Resident #2 was [AGE] years old, admitted to the facility on [DATE], was totally dependent on staff for all Activities of daily Living/ADL's and was cognitively impaired (BIMS-cognitive assessment score of 3). The resident's diagnoses included, peritoneal abscess, adult failure to thrive, Parkinson, diabetes, lack of normal physiological development, Schizophrenia, Dementia, major depression, Bipolar and anemia. The resident was unable to be interviewed due to their decreased cognition status. Observation was done on 4/23/25 at 11:23 AM of Resident #2 in his bed dressed. He had a soiled gown sitting on the bottom of his bed and the top white blanket had a large brown smear on the top near his face. Also the resident's room walls near the bathroom and the outside of the bathroom door had several black wheelchair marks on it, with paint chipping off the walls and door. 37666 Environment: On 4/23/2025 at 11:20 AM, the bathroom in room [ROOM NUMBER] was observed to have a variety of items on the bathroom sink, including an uncovered toothbrush. There was also a bed pan upside down on the floor underneath a commode chair. One resident was in the 2-resident room and said none of the items were hers and they belonged to her roommate who was in the hospital. On 4/23/2025 at 11:32 AM, room [ROOM NUMBER] was observed to have cluttered items lying on the floor. During the tour of the 100 hall on 4/23/2025, several resident rooms were noted to have resident items stacked on the floor and sometimes large stacks of items were on other surfaces in the rooms. They appeared very cluttered and unkempt. Some of the rooms had space for additional storage or shelving and some had less room.

Based on observation, interview and record review the facility failed to ensure that the clinical staff posting was completed and available for review for multiple days from October 2024- April 2025, resulting in the inability of residents and visitors to know what clinical staff were working on those days. Findings Include: FACILITY Sufficient and Competent Nurse Staffing On 4/24/2025 at 9:17 AM, the Administrator was asked where the posted nurse staffing was located. She said the document was on the wall near the entry to the facility. Upon review of the posted document it said Tuesday, 4/24/2025. The Administrator, viewed the document; discussed with her the dated was correct but the day was wrong. It was not Tuesday; It was Thursday. She said the staff member N responsible for completing the document would correct it. The Administrator said the posted staffing documents were to be posted daily. Requested to review the prior year's posted staffing. The Administrator said Staff N would provide the binder with the documents. The posted nurse staffing binder was reviewed. The posted staffing document was used to identify how many RN's (Registered Nurses), LPN's (Licensed Practical Nurses) and CNA's (Certified Nursing Assistants) were staffed each day on each shift. The document identified how many hours were worked for an RN, LPN and CNA and listed Total Hours per shift) and included the Date and Resident Census (number of residents in the building on that day). The document was required to show how many residents were in the facility on a particular day and how many qualified nursing staff were present to care for them; any visitors or residents would then be able to see it after it was posted. During the review, it was identified there were approximately 60 days of posted staffing sheets that were missing from October 2024 - April 2025. On 4/25/2025 at 9:45 AM, the Administrator was interviewed about the posted staffing documents and said Staff N who was completing the daily posted staffing documents was no longer responsible for ensuring their completion.

Based on observation, interview and record review, the facility failed to provide timely assistance with activities of daily living (ADL) including showers, nail care and hair care for two residents ( #52 and #139), from a sample of 20 residents. Findings Include: Resident #52: Activities of Daily Living On 4/23/2025 at 1:15 PM, Resident #52 was observed lying in bed in her room. She said she had itching on her face and leg and said it was horrible. She said they gave her something for the itching, but the itching would come back frequently. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, depression, anxiety, diabetes, chronic kidney disease, arthritis, blindness right eye and hypothyroidism. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 10/15 and the resident was independent with most care but needed some assistance and oversight with bathing/showering. On 4/24/2025 at 10:30 AM, Resident #52 was observed in the hallway with the same dress that she had on the day before. On 4/25/2025 at 12:45 PM, Resident #52 was observed in the hallway sitting in a wheelchair with the same dress she had worn for the past 3 days. She was rubbing her face and there was a strong odor noticed near the resident. A record review of the electronic medical record/EMR Tasks tab for Shower/bed bath for Resident #52 over a 30 day time period from 3/27/2025 to 4/24/2025, revealed the resident had not had a shower or bed bath since 4/14/2025. It indicated her Shower/Bath days were Monday/Thursday evenings and as needed. There were 2 dates: 4/17/2025 and 4/24/2025 with the heading No bath given attempted x2 and one entry dated 4/21/2025 for Resident Refused. A review of the progress notes for Resident #52 identified the following: 4/14/2025, a nursing clinical note, Pt (patient) receive shower today, today tolerated, offers no concerns up ad lib walking. 4/18/2025 at 11:28 AM, a nursing/clinical note, Pt alert and was encouraged to do adl's (activities of daily living), was given wash cloths and towels and cued to go into restroom to clean up, pt stated 'Am sleeping. Will continue to encourage . 4/19/2025 at 3:18 PM, a nursing/clinical note, Pt encourage to participate in her own adl's, bathing material given to pt and she went in bathroom . 4/19/2025 at 9:54 PM, a nursing/clinical note, Resident participated with her ADL's with help, cueing, and supervision of CNA (certified nursing assistant). Resident accepted help and guidance. 4/21/2024 at 8:57 PM, a nursing/clinical note, Resident encouraged by RN and CNA to take a shower to perform ADLs. Resident adamantly refused each attempt. Not participating with own ADLs. 4/22/2025 at 12:33 PM, Patient was assisted by staff to complete personal hygiene. A review of the Care Plans for Resident #52 identified the following: Resident requires staff oversight for safety and to ensure ADL needs are met due to dementia with severe cognitive deficits. Resident will be clean and dressed appropriately. Often refuses assistance from caregivers . Patient will frequently refuse a shower stating she does not like being cold and does not need a shower too often, date initiated 5/19/2023 and revised 7/27/2023. The interventions were all dated 2023 and were last updated 10/4/2023. On 4/25/2025 at 1:00 PM, during an interview with the Director of Nursing/DON reviewed with her Resident #52 was observed scratching her face in the hallway. The DON reviewed the orders for the resident and said she had Benadryl oral and Cetaphil face cream for the itching. Also discussed the resident had a strong body odor and had been wearing the same dress for 3 days. The DON said the resident refused a bath or shower at times and would put on soiled clothes. Reviewed the care plan , does not suggest alternate options for encouraging the resident to bathe. Does the resident still prefer evening baths/showers. Does she prefer certain staff members. Tasks reviewed: resident's last bath or shower was 4/14/2025. The notes were reviewed, and there were no alternate suggestions for encouraging the resident to bathe and change her clothes. Prior to 4/14/2025 it appeared in the Task charting the resident was bathing/showering twice a week and after 4/14/2024 was not. A review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated reviewed 12/2024 provided, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate . The resident's response to interventions will be monitored, evaluated and revised as appropriate. 22347 Resident #139: Review of the Face Sheet, care plans dated 4/22/25 and 4/23/25, nursing notes dated 4/22/25 through 4/23/25, revealed Resident #139 was [AGE] years old, admitted to the facility on [DATE], was confused, had a tube feeding and was dependent on staff for Activities of Daily Living/ADL's. The resident's diagnosis included diabetes, Dementia, stroke, and hemiplegia and hemiparesis. Observation of the resident was done on 4/24/25 at 10:28 a.m., she was in her wheelchair ready for her facility care conference; staff had gotten her up and got her ready for the conference. The resident's hair was not combed at all, sticking up and her fingernails had black under them. The resident was presented in this manner for the care conference. A second observation of the resident was done on 4/24/25 at approximately 12:20 p.m., the resident was in her room, in her bed and her hair was still not combed and he nails still had black underneath them. Review of the facility Activities of Daily Living (ADL's) policy dated 12/24, stated Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview and record review, the facility failed to monitor weights timely for a Resident who had a hospitalization and return with a Percutaneous Endoscopic Gastrostomy ) (PEG) tube for feeding for one resident (Resident #62) of two residents reviewed for weight loss. Findings include: Resident #62: A review of Resident #62's medical record revealed the Resident had an admission into the facility on [DATE] and readmission on 3/20/25 with diagnoses that included intracerebral hemorrhage (stroke), gastrostomy, abdominal aortic aneurysm, dysarthria, aphasia, hemiplegia and hemiparesis affecting the left non-dominant side, Alzheimer's disease, and muscle wasting and atrophy. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognition and was dependent on staff for activities of daily living. A review of the medical record revealed the Resident had a change in condition on 3/10/25 and was transferred to the hospital and returned on 3/20/25 with a PEG tube for feeding. A review of Resident #62's hospital discharge records of consult to Nutrition Services revealed, Nutrition Diagnosis: Increased Nutrient Needs (Protein) related to increased demand AEB (as evidence by) current medical condition (brain bleed) . Intervention/Plan/Goal: Goal tube feeding is Jevity 1.5 bolus 4 cartons daily with 4 packets protein powder. Providing: 1520 kcal, 84 gm protein. A review of Resident weights revealed a weight on 3/9/25 (prior to discharge to hospital) of 131.6 lbs (pounds) and re-admission weight of 118.4 lbs on 3/21/25 and 18 days later 4/8/25 a weight of 114.2 lbs. A review of Resident #62's Nutritional Evaluation, effective date on 3/24/25 revealed the Resident's Tube Feeding Order: Jevity 1.5; 4 cartons daily; Enteral Composition of Calories: Calories 1420, Calories/Kg (kilograms) 26 kcal/kg, Protein 60; Weight Status: Loss, Enter % of weight loss or gain 12.6 (weight loss); Estimated Nutritional Needs: Calorie needs: 1340-1610, Protein needs: 54-65; Additional detail: Patient with dysphagia and need for nutrition support via PEG to meet nutritional needs; Additional comments/information: .Nutrition/Monitoring Recommendations: Weight per policy-Will monitor weights/PO intake/skin/labs-Monitoring tube feeding tolerance and need to adjust . A review of Resident #62's Nutritional Evaluation, effective date on 4/10/25 revealed the Resident's Tube Feeding Order: Jevity 1.5; 4 cartons daily with Enteral Composition of Calories: 1420 and Protein 60; Weight Status: Loss, Enter % of weight loss or gain 13.6 (weight loss); Estimated Nutritional Needs: Calorie needs: 1554-1813, Protein needs: 67-78; Additional detail: Patient with dysphagia and need for nutrition support via PEG to meet nutritional needs; Additional comments/information: .Nutrition/Monitoring Recommendations: Weight per policy, Recommend increasing tube feeding to Jevity 1.5; 5 cartons total daily 2/2 (due to) continued weight loss. Provides 1775 kcal, 76 gms protein . On 4/24/25 at 3:14 PM, an interview was conducted with Dietitian P who was the interim Dietician at the time of the survey. A review of Resident #62's weight (wt) loss from 3/9/25 of 131.6 lbs. to 3/21/25 of 118.4 lbs (13.2 lbs wt loss) and on 4/8/24 of a weight of 113.2 (an additional 5.2 lbs wt. loss). When asked when a Resident readmitted with a change in nutritional status of enteral feedings and a 13.2 weight loss upon return would weight monitoring be completed, the Dietitian stated, For the first 4 weeks typically we do weights weekly. The Dietitian reported that the Resident should be getting that weight done today. When asked if the Resident got missed with monitoring weights, the Dietician stated, Yeah that's what it looks like. The Dietician indicated that they did not anticipate further weight loss now that the Resident was increased to 5 cartons of the enteral feeding. A review of the enteral orders revealed the Resident was on 4 cartons from 3/21 to 4/10 and the Dietitian reported that with that weight loss, the Dietitian had increased the tube feeding by another carton, we just did not check her weight after that carton. The Resident's weights were not monitored weekly after the 5th carton was started. On 4/24/25 at 3:32 PM, the Dietitian informed the surveyor that the Resident's weight had gone up to 116 pounds today. On 4/25/25 at 12:42 PM, an interview was conducted with the Director of Nursing (DON) regarding concern of Resident #62 returning from the hospital with weight loss and ordered enteral nutrition, weights not monitored timely, and the Resident had additional weight loss. The DON reported she documents all the weights and that they missed the weekly weights on Resident #62. A review of facility policy titled, Weight Policy, reviewed 1/25, revealed, Purpose: Weight changes have significant nutritional implications. The purpose of this policy is to help maintain acceptable parameters of nutritional status. Procedures: .2.Weekly weights are obtained on those residents within the first 4 weeks of admission and those residents deemed appropriate per the assessment of the dietitian, dietary manager, physician or as determined by IDT (Interdisciplinary Team) .

Based on observation, interview, and record review, the facility failed to provide appropriate skin care to prevent the development and failed to implement adequate interventions to avoid the worsening of unstageable pressure ulcer for one resident (Resident #69) of five sampled residents reviewed for pressure ulcer out of a total sample of 18 residents, resulting in the development and worsening of a facility-acquired pressure ulcer resulting in severe pain and suffering, and the potential for infection, delayed wound healing and a deterioration in health status. Findings include: Resident #69 (R69): On 4/17/24 at 10:21 AM, Resident #69 (R69) was observed for wound care. Wound Nurse A and Nurse B were observed to provide wound care for R69. R69 was found lying on his back and his right leg and right heel did not have a pillow or any device to position the heel off the bed. R69's right heel had a protective dressing that was not secure and almost coming off his right heel. While Nurse B attempted to turned R69 towards his left side to prepare him for wound care, R69 screamed in pain. Wound Nurse A continued to remove the dressing from the sacral area and noted a dark blackened area (eschar) with slough in the unstageable sacral ulcer. The wound measured approximately 2 inches in length and half an inch in width. The Wound Nurse A was asked to take wound measurements during the wound observation. However, Wound Nurse A explained that she did not have the camera ready and available. She explained by stating, That is how the facility measured the wound area for accuracy. Wound Nurse A further revealed that they measured the wound yesterday (on 4/16/24), and found that the wound area had significantly increased compared to last week when it was first discovered on 4/10/24, just less than a week ago. During the wound observation, R69 was screaming intermittently due to pain. R69 was observed grimacing and had jerking movement when the Wound Nurse sprayed a wound cleansing solution directly on his sacral area. However, R69 insisted that Wound Nurse A continued the wound treatment despite the pain just to get the treatment done and over. While Nurse B was holding R69 for positioning, Nurse B revealed that R69 had just received his pain medication (a muscle relaxer and Oxycontin) just a few minutes before the wound treatment started. When asked how long she waited for the pain medication to take effect after giving it, Nurse B did not reply. R69, during the wound care observation, indicated that there was increased pain when the sacral wound developed a week ago. R69 indicated that the pain limited his movements necessary for repositioning and offloading. A review of the R69 Electronic Medical Record dated 4/16/24 showed that the sacral wound measured 4.8 centimeters (cm) ( length) X 1.55 cm (width), with a total wound area of 4.72 cm. R69, during an interview conducted on 04/16/24 at 04:31 PM, R69 indicated that he did not have a sore on his bottom when he was admitted to the facility on [DATE]. R69 revealed that his sacral wound developed in the facility. R69 explained that the staff left him soiled for prolonged periods, did not change him, and sometimes waited for over two hours to get cleaned. That is how the wound developed on his bottom. R69 continued to explain and stated, I was asleep a lot because of my pain medication. Last week, they found the wound on my bottom, and the wound nurse told me yesterday that the wound is larger compared to when it was found. R69 further described, The pain has increased every time they move me or do the treatment to the sacral area. R69 revealed that he received wound care only when the wound nurse (named the wound nurse) was working. On 4/16/24 at 10:00 AM, a review of R69's Electronic Medical Record (EMR) revealed R69 was 61 y/o with a primary diagnosis of Traumatic Subarachnoid Hemorrhage without loss of consciousness. R69 was admitted to the facility Post-Motor Vehicle Accident MVA on 3/21/2024. R69 was his own responsible party with a Brief Interview of Mental Status BIMS Score of 14/15 (date assessed 3/28/24), which means R69 is cognitively intact. R69's Minimum Data Set (MDS) assessment dated [DATE] revealed that R69 depended on staff to perform his Activities of Daily Living (ADL's), especially with feeding, personal hygiene, bed mobility, and transfers. Although he had some post-surgical wounds from the MVA, his skin assessment upon admission did not indicate any pressure ulcer or skin alteration in the sacrul area. The following were other observations conducted for R69. On 04/15/24 at 2:22 PM, R69 was observed lying in bed on his back wearing a neck brace, left leg brace, and left arm brace. At 3:30 PM (on 4/15/24), R69 was observed lying on his back in the same position and at 4:00 PM. When queried on 4/15/24 at 4:00 PM, R69 complained about the staff's delayed response to call lights. R69 expressed that he does not think the staff is competent with using the mechanical lift and is fearful of being moved or transferred in an unsafe manner. R69 revealed that he has a wound in his bottom that developed while in the facility. R69 revealed he was in a lot of pain, and although the pain medication worked, it also made him feel drowsy and was usually out of it. On 4/16/24 at 1:30 PM, R69 was observed lying on his back in his room. At 4:30 PM (on 4/16/24), he remained lying on his back and was in the same position for 3 hours (since 1:30 PM). On 4/16/24 at 10:00 AM, a review of R69's care plan dated 3/21/24 revealed: At risk for alteration in skin integrity related to Diabetes with potential for poor wound healing, impaired mobility, incontinence, morbid obesity, recent surgeries, multiple fractures, pain, use of back and neck brace, CVA with residual weakness. The goal specified: 1.) Decrease or minimize skin breakdown risk, and 2.) The skin will remain free of breakdown within limits of disease process . A Care Plan with an Initiated date of 4/10/24 revealed: .the newly developed stage 3 pressure wound to the sacral area with interventions noted such as: 1.) Administer analgesics as needed for pain, 2.) Administer treatment by physician's order 3. ) Daily body audit . Both skin care plans dated 3/21/24 and 4/10/24 did not provide a plan to address poor compliance, poor tolerance to movement and re-positioning. It did not have interventions to offload the pressure areas. It did not address keeping the resident clean and dry and protecting the area from any infection or wound complication. When R69 was asked regarding his skin care plan on 3/16/24 at 4:30 PM, R69 revealed he was left soiled and wet by staff for prolonged periods of up to over two hours, and that caused him to develop the wound on his sacrum. The Wound Nurse A was interviewed on 4/17/24 at 12:15 PM. Wound Nurse A described the sacral wound as unstageable with eschar and slough. Wound Nurse A revealed that R69 was admitted to the facility on [DATE] without a sacral wound. R69 skin assessment upon admission did not show any wound in his bottom. There was no redness or signs of Deep Tissue Injury (DTI). R69 had a history of motor vehicle accident MVA and wore a neck brace. He also has to wear a brace on his left leg and left arm. R69 hated being moved but allowed staff to reposition him during care. The neck brace and pain on movement are what contributed to the development of the unstageable DTI. Wound Nurse A admitted that it was a Facility-Acquired wound developed at the facility. Wound Nurse A further indicated that she was alerted on 4/10/24 about R69 needing skin assessment. Wound Nurse A further described that on 4/10/24, they found a large maroon (deep red) in color, a non-blanchable area at the sacrum, and documented the area as Deep Tissue Injury (DTI) found on the sacrum. Treatment started immediately after the sacral wound was discovered on 4/10/24. Offloading the sacral wound area, applied xeroform and foam protective dressing. When queried about the treatment order, Wound Nurse A indicated it was an effective treatment for DTI based on her experience working as a wound nurse. It was not necessarily a standing order for DTI by the physician. The Wound Nurse A further commented: The wound treatment depends on the presenting situation of the skin. When queried if R69's attending doctor or a wound doctor has assessed and examined R69's wound since 4/10/24, Wound Nurse A replied, No. The Wound Nurse A explained that R69's doctor will see him today (4/17/24) during rounds. Wound Nurse A explained, the facility does not have a wound specialist that comes to the facility. Wound Nurse A further indicated that the wound was on them since he did not have the pressure injury when he was admitted to the facility . When Wound Nurse A was asked when the date and time the physician assessed the sacral wound and addressed the significant change upon the discovery of the wound, Wound Nurse A admitted she could not find it on her record on when the Physician was notified. The Wound Nurse A denied obtaining a Dietary/Nutrition Consult or laboratory testing (blood work) after 4/10/24 when the wound was discovered. An interview with R69's Physician, MD D, was conducted on 4/17/24 at approximately 2:30 PM. The MD D revealed that he has not seen nor assessed the wound of R69 since it was discovered. MD D admitted that he had not talked to the wound nurse to discuss the status of R69 and was not sure of the details at the top of his head about the wound status and the appropriateness of current treatment. MD D indicated that every wound has different characteristics, and treatment may differ for everyone. MD D was queried about R69's pain management. MD D revealed that they had addressed the pain management, and staff must administer the pain treatment 30 minutes up to an hour before the scheduled treatments or during positioning or transfers for R69. MD D emphasized that it is vital for staff to wait for the pain medication to kick in before providing the scheduled wound treatment. MD D Stated, If pain is causing limitations on movement, or not moving at all, there has to be a certain way to turn him and move him. R69's treatment orders were reviewed on 04/17/24 at 02:34 PM. The April 2024 Treatment record revealed the following: 1.Cleanse buttocks with normal saline. Pat dry. Xeroform to the intergluteal area. Peri guard to surrounding buttocks. Cover with protective dressing every shift and as needed for soilage. Every shift for skin care and observation and as needed. Treatment ordered Active on 4/16/2024 05:15 AM 2. Right heel cleanse with normal saline. Pat dry. Cover with foam heel dressing. 1 x daily as protection. Every day shift every 3 day(s) for wound care Treatment ordered Active 4/16/2024 06:15 AM 3. Cleanse neck anterior aspect with normal saline. Pat dry. Assess skin for skin breakdown under cervical collar. 1 x daily . Upon review of the Treatment Administration Record (TAR) dated March 2024 and April 2024, there were days of missing documentation of treatments in the TAR, such as the dates 4/10/24, 4/11/24 for treatment to perform daily and 4/16/23 when R69 only received one treatment that day instead of every shift as ordered. No orders or documentation were found related to pressure relief interventions, offloading pressure areas, or turning or repositioning times daily to ensure adherence and prevent further worsening of skin injuries. There were no body audits documented daily in the progress notes per care plan. On 4/17/24 at 12:45 PM, during the interview with Wound Nurse A, the surveyor requested to provide a copy of R69's Skin Worksheets by nursing staff from the date of admission, 3/21/24 to 4/17/24. A copy of the physician's consult progress notes and recommended treatments for R69. The surveyor also requested a copy of the facility's wound care protocol, which the staff follows for different stages of pressure wounds, including unstageable wounds and DTI's. These documents requested were not received at the time of exit on 4/17/24 at 5:00 PM. The nurse practitioner working for MD D was unavailable for an interview on 4/17/24 at 3:00 PM at the time of request since she had already left the facility for the day. The following policies were reviewed on 4/17/24 at 4:00 PM. Title of Policy: Skin Management Guidelines and Prevention of Pressure Sores/Injuries Date of Policy: July 2017, updated January 2023. It noted: .The purpose of this procedure is: 1) to identify residents at risk for developing alterations in the skin, including pressure ulcer/injury risk factors, and 2) to identify specific interventions to assist with prevention and management of skin alterations . . 3) Nursing assistants use a Skin Worksheet as a communication tool to document skin observations. The worksheet is completed at least once weekly with the resident's shower. Completed worksheets are given to the licensed nurse for validation and action planning as needed. .4) If a new skin injury is identified, a. Notify medical provider and obtain treatment orders b. Notify resident/resident representative c. Nurse to complete incident report including root cause analysis and care plan modification as appropriate d. Nurse to document the above in medical record . Title of Policy: Medication and Treatment Orders Policy (undated) was reviewed on 4/17/24 at 3:00 PM. It noted: .Policy Statement: Orders for medications and treatments will be consistent with the principles of safe and effective order writing. Policy Interpretation and Implementation: 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record . On 4/17/24 at 1:30 PM, the surveyor discussed R69 identified facility acquired pressure ulcers with the facility Administrator during a Quality Assurance and Process Improvement (QAPI) meeting. The Administrator admitted there were two residents currently with pressure ulcers, which were facility-acquired. The Administrator indicated that the Director of Nursing, DON, and the Wound Nurse A are working on these two residents. The Administrator was informed that documents of R69's wound were requested from Wound Nurse A on 4/17/24 at 12:45 PM. These documents requested from Wound Nurse A were not received at the time of exit on 4/17/24 at 5:00 PM.

This Citation Pertains to Intake Number MI 237 Based on observation, interview and record review, the facility was placed in Immediate Jeopardy due to the facility's systemic failure to account for narcotics and controlled substances on a daily basis and resolve discrepancies, including the theft of 41 narcotic tablets/capsules and a vial of [MEDICATION(S)], leading to the likelihood of a serious adverse outcome, including harm and untreated pain and continued diversion. Immediate Jeopardy: On 12/20/21, the Director of Nursing was notified by the pharmacy at 7:13 AM and at 2:39 PM that none of the narcotics sent to the facility on [DATE] for placement into the back-up medication dispensary system (Omnicell) were placed into the back-up system including 41 doses of narcotic medications: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]/acetaminophen, [MEDICATION(S)]/acetaminophen, [MEDICATION(S)]; and an additional vial of liquid [MEDICATION(S)]. The facility did not begin an investigation into the missing narcotics until 12/21/21, one day after the Director of Nursing was notified of missing narcotics by the pharmacy and four days after the narcotics were sent to the facility by the pharmacy for placement into the back-up medication system. The incident was reported to law enforcement by a 911 call after the pharmacy informed them it was required. No officer interviewed the staff or created a report. The incident was not reported to the State Agency. A review of the pharmacy reports from Omnicell, the pharmacy, the narcotics' log and the Medication Administration Records indicated multiple abnormalities, including multiple instances of two nurses not checking in the medications; missed documentation of narcotics administered to the residents on the narcotics log and Medication Administration Records; and inaccurate times of the administration of narcotic medication administration on the narcotic's log. During a review of the Narcotics logs, it was identified the nurses were not consistently reconciling the narcotics log with a 2-person count of the narcotics at the end of or the beginning of the shift, as required per facility policy and standards of practice. The Immediate Jeopardy began on 12/17/21. The Immediate Jeopardy was identified on 1/11/2022. The Administrator was notified on 1/11/22 of the Immediate Jeopardy that began on 12/17/21. The IJ Abatement (Removal) Plan was approved on 1/12/22 with a Removal Date of 1/11/22. Findings Include: On 1/5/22 at 4:45 PM, Nurse J was interviewed related to narcotics medications and said the pharmacy delivered medications, including narcotics twice a day at approximately 5:00 PM (on 2nd shift) and again later in the night approximately 12:00 AM to 1:00 AM on the 3rd shift. She said the nurse had to provide a signature on the pharmacies phone, as a receipt and also on a sheet of paper. She said there was a reconciliation form for general medications and one for narcotics; each in a separate bag. Nurse J stated, If it was a narcotic, I would get another nurse and confirm the count was right and put them away. On 1/5/22 at 5:07 PM Nurse L was observed removing medications from the back-up medication dispensing system for multiple nurses. The nurse asked this Surveyor to stand outside of the medication room while he removed the medications. The Surveyor stayed to observe and he was asked about removal of the medications and stated, I don't pull narcotics for other people, but I take out other meds to help the nurses so they don't have to walk down here. He put them in his pocket and walked out of the medication room. The back-up automated medication dispensing system was located inside a medication room on the C hall. On 1/5/22, the back part of the unit was closed. There was a nurse's desk located in front of the medication room. On 1/6/22 at 12:08 PM, the Director of Nursing (DON) and Corporate Nurse W were interviewed related to missing narcotics and the DON stated, The Pharmacy contacted me by email on that Monday 12/20/21 and said the narcotics were not placed in the Omnicell (back-up medication dispensing system). (Nurse K) said a blue bag of narcotics came up from the pharmacy at 11:45 PM to 12:15 AM on 12/17/21. The DON was asked what the process was for delivery of the narcotics and stated, I don't know what they are doing now. Pharmacy drops them off. When the narcotics come in 2 nurses are to check in the narcotics. The DON said the facility began an investigation of the missing narcotics on 12/21/21, because she was not working on 12/20/21. The DON was asked if the narcotics were located and said, No, they were not. A review of the facility investigation revealed a Pharmacy report dated 12/17/21 with 41 doses of narcotics and a 30 ml bottle of [MEDICATION(S)]- House Briarwood Supply: [MEDICATION(S)] 0.25 mg tablet quantity = 2; [MEDICATION(S)] 0.5 mg tablet quantity = 1; [MEDICATION(S)] 100 mg capsule quantity = 2; [MEDICATION(S)] 300 mg capsule quantity = 9; [MEDICATION(S)] 400 mg capsule quantity = 1; [MEDICATION(S)]-Acet (aminophen) 5-325 mg tab quantity = 5; [MEDICATION(S)]-Acet 7.5-325 mg tab quantity = 7; [MEDICATION(S)]-Acet 10-325 mg tab quantity = 1; [MEDICATION(S)] 100 mg/5ml (20/1) solution quantity = 30 ml; [MEDICATION(S)]-Acet 5-325 mg tab quantity = 4; [MEDICATION(S)]- Acet 7.5-325 mg tab quantity = 3; [MEDICATION(S)] 50 mg tab quantity = 6. The investigation revealed that nurses working from the time the narcotics were delivered 12/17/21 to the time it was reported 12/20/21 were interviewed. Nurse K was the nurse that received the medication from the pharmacy and Nurse U said she saw the narcotics blue bag in the C hall medication room on 12/18/21. A facility interview by Nurse H of Nurse K on 12/21/21 (no time indicated) provided the following: Did you receive Narcotics on 12/17/21 from pharmacy? Yes; What did you do with the narcotics you received? Placed them in the med room unopened in the med room; Where did you last see the narcotics? On the counter, station C's med room; Do you have any knowledge of where the narcotics could be? No. On 12/22/21 (untimed) a phone interview with Nurse K by Corporate Nurse W provided the following: I worked Friday 12/17/21 on 3rd shift. I came in on C wing at 6:00 PM and worked a 12-hour shift. At approx. around 11:45 PM to 12:15 PM pharmacy delivery came. I received regular meds for med cart. Omnicell stuff got purple med bag and blue bag that contained narcotics. Manifest was inside. I signed for delivery of medication. I was dealing with patients in my station and resident's needing attention .The blue bag of narcotics was placed in med room after delivery . I went back to narcotics room a couple of times and bag was still on counter at 3:30 am. Nurse K was asked At any time was med room door propped open, and he replied Yes, I propped open around 12:00 am -1:00 am to put regular medications in Omnicell so (nurse aide T) could call me if needed. I didn't have another nurse with me for regular meds as don't need two nurses for regular meds. I did not take the medication. Nurse K did not mention why he didn't attempt to ask another nurse to assist him in placing the narcotics in the back-up system (Omnicell), so they were not left on the counter. A facility interview via phone with Nurse U on 12/21/21 at 9:30 AM provided: Did you work 12/18 or 12/19/21, Yes; Did you enter the med room on station C 12/18/21 or 12/19/21, Yes; Did you see a blue pharmacy bag in the med room on 12/18/21 or 12/19/21? On Saturday 12/18, I noticed the bag on the counter. I didn't realize it contained narcotics. Did not see the bag on Sunday, 12/19; Do you have any knowledge of the missing blue pharmacy bag that was delivered on 12/17/21, No. On 12/22/21 at 2:45 PM, Nurse U was interviewed by Corporate Nurse W about the missing narcotics and stated, I worked Saturday at 6 am on Station C wing and received report from (Nurse K). (Nurse K) didn't report to me that he needed any help with stocking narcotics or meds. I think I went into the medication room at approx. 9 am because I needed a TB shot . I observed blue bag under the cabinet where TB syringes are . I didn't check it or look at it- think it was zip tied. I don't think I went back into the medication room again on my shift at all . I went back into the med room on Sunday 12/19/21 I think before my first med pass 8 or 9 am and I noticed that blue/purple bag was not on counter at that time. No one told me they stocked medications . Further review of the Narcotic and Controlled Substance Shift to Shift Count Sheets for December 2021 for Stations A and B there were multiple occasions that nurses did not sign that they completed a narcotics count at the beginning or end of their shift: A hall- 12/15/21 no signature of the off going nurse on the 3rd shift and on 12/20/21 no signature of the off going nurse on the 2nd shift. B hall- 12/5/21 no signature of the oncoming dayshift nurse or off going 2nd shift nurse; 12/16/21 no signature of the oncoming days shift nurse and on 12/21/21 no signature of the on coming day shift nurse on 3rd shift. Review of the Controlled Substance Record for a Resident on the C hall that received [MEDICATION(S)] 0.25 mg tablet by mouth every 6 hours scheduled, had conflicting documented times when the medication was pulled from the narcotics drawer. On 12/19/21 the nurse removed medication at 4:30 AM and then 11:00 PM (2300), 11:00 AM and then 5:00 PM- in that order. The times were documented by 2 different nurses and out of sequence. The nurse then documented 11:00 PM again and then 12/19/21 5:00 AM. There was no logical order to the documentation. Another Resident on the B hall that received [MEDICATION(S)] 300 mg capsule, Take 1 capsule by mouth every 12 hours, had conflicting documentation. On 12/14/21 the medication was given at 9:00 PM and the next entry was dated 12/22/21 at 9:00 am. The entry after that was dated 12/15/21 at 9:00 PM and then 12/16/21 at 9:00 AM. The 12/22/21 9:00 AM entry was incorrect. Many of the Controlled Substance Records had entries that were crossed off, written over and not dated/timed in order. A phone interview with Nurse U on 1/6/22 at 2:08 PM provided, I saw bags, but I didn't know what was in them. I went in the med room to get syringes for a TB test. I now know the bags I saw were narcotics. Sometimes I see the empty bags in the garbage, but not on the counter. Nurse U was asked if she had received education from the facility on how to handle narcotics and responded, We received 1:1 education about controlled substances- When they come in they are to be immediately locked up. Med cart, change of shift narc box count, oncoming book, off going book, count sheet by sheet, count total amount of cards, check stickers on the cards and they should match the sheets. On 1/6/22 at 3:06 PM, Nurse H was interviewed about the process for handling narcotics deliveries and stated, Two nurses count it and lock it up. On 1/6/22 at 3:16 PM during an interview with Nurse A related to narcotics provided, They (nurses) go over the count sheets together if it is a narcotic. They can do it themselves if it is not a narcotic. On hire they receive education on narcotics deliveries. An interview with Nurse X on 1/6/22 at 4:50 PM revealed, They deliver to each of the nurses stations. If it is a narcotic, you have to count off/reconcile the meds with the sheet from pharmacy with another nurse. Then you place them in your cart/lock box. On 1/7/22 at 10:25 AM, Nurse K was interviewed about the narcotics that were delivered to the facility on [DATE] and stated, There is a courier from the Pharmacy. Medications are provided in sealed plastic bags; like a bank deposit bag- glued to itself. Regular medications are in a green bag and narcotics are in a separate blue bag. They inform me of how many bags they have and then a manifest. You sign a pda (electronic signature)- then we proceed to put the medications away in the medication carts. The Omnicell is located on Station C and delivery is only on 3rd shift. I would call down to the other stations (A and B) to let them know to help me put the Omnicell medications away. They would come down to Station C and we would proceed to put away the medications. One of us would log into the Omnicell first and open the blue bag. The 2nd nurse would sign into the system; count the meds in the bin you are trying to replenish. The machine requires you to scan the barcode of the med your are trying to replenish to ensure it is correct. You have to check to make sure the number of medications on the manifest matches the pills delivered and what the Omnicell expects ex. '[MEDICATION(S)] 1 mg- Omnicell will say 'I expect [MEDICATION(S)] 5 pills.' We check to make sure they match. Occasionally the manifest will say the sent you something and they didn't- We correct the count on the manifest- I would either write 0 or leave it blank. The manifest does not go back. We put it in the book. Nurse K was asked if he would inform the Director of Nursing if there were missing narcotics or a discrepancy on the Manifest and he stated, No. I put the manifest in the book. Nurse K was asked what the process was for reconciling (counting) narcotics on the medication carts at the beginning and end of a shift and stated, We have Report between nurses, go to medication cart, go to lock box, off going nurse looks in the narc book, oncoming nurse looks at medication cards- compare correct number, card and count sheet- when it is done there is a sign off sheet, both nurses sign, record number of blister packs in the cart. During the interview on 1/7/21 at 10:25 AM, Nurse K was asked about the December 17th- narcotics shipment and stated, I received an Omnicell shipment of narcotics to the C station. I put the shipment in the medication room. Locked the door. Called Station A- nobody answered. I proceeded to continue working on my assignment at station C- did not call station B, but she did not have access to the Omnicell- If she needs a medication from the Omnicell including a narcotic the station C nurse gets it. Put the regular meds in the Omnicell. Doesn't require 2 nurses. Put them away after helping a patient and then put those away. The narcotic bag was sitting on the counter in the medication room. I stepped out of the med room. Someone from Station A called for help and I went down there. Nurse K was asked when he should put away the narcotics and said, Normally we put them away right away. I did not ask (the nurse at Station A) her for help to put them away. I found out Monday from the DON that pharmacy sent her an email that the narcotics were not put into the Omnicell. I told her I intended to put them away with the dayshift nurse and I forgot. I hung up the phone and went to work that night (12/20/21) On 12/21/21 I saw the DON after my shift. I really screwed up. On the way home the DON called and said I was suspended until further notice. The next shift I worked was 12/24/21. Nurse K worked on 12/17/21 when the narcotics shipment was delivered, and his next shift was 12/20/21 6 PM -12/21/21 6:30 am. He was not removed from work until after he finished his shift on 12/21/21. On 1/7/22 at 2:00 PM, Pharmacy Coordinator Y was interviewed related to narcotics delivered to the facility on [DATE], I came in the 20th (Monday December 20, 2021) and noticed (via report) they hadn't restocked the controls (narcotics). I sent an email to the facility. I sent my first email 20th 0715 and then 1447. On the 21st at 0619 am (the DON) responded and said they couldn't find them. I told them it would be reported to the DEA (Drug Enforcement Administration) and told the facility they needed to contact the police. It was reported to the DEA on 12/22/21. The protocol is they are supposed to sign for the shipment and then load it into the Omnicell that shift or the next shift. On the 23rd resent all of the medication. When I run a restock, I have to verify if they were issued to verify a restock. During the interview, the Pharmacy Coordinator Y provided a copy of the emails sent to the Director of Nursing on 12/20/21: 12/20/21 at 7:13 AM- Your assistance is greatly needed. The controls from your restock bag sent on 12/17/21 still have not been loaded into the Omnicell. These must be stocked prior to 1 PM in order to receive your restock bag today. These controls are considered missing . 12/20/21 at 2:47 PM- Urgent Action: The controls from your restock bag on 12/17 have not been loaded into the Omnicell. These controls are missing and will be reported as missing to the DEA. Please respond to this email if you have the controls in your possession and how you would prefer to resolve this matter. On 1/7/22 at 2:13 PM, contact was attempted via phone with Officer Z . No return call was received. 1/10/22 at 1:00 PM, Nurse O was interviewed and asked if she worked the night of 12/17/21 and said, Yes, on Station A. Nurse O was asked if (Nurse K) had asked for help in placing the pharmacy shipment of narcotics into the Omnicell and she stated, No, he didn't ask me for help. You have to have two nurses to put them away. 1/12/22 at 10:40 AM, an interview with Medical Director BB related to the missing narcotics provided, I was informed, but I was on vacation. Reviewed with the Physician that the nurses were not consistently using 2 nurses to check in narcotics, they were not always signed out timely on the narcotics logs, on the electronic medication administration record (MAR) or consistently documenting shift to shift narcotics counts. Physician BB said he was not aware of this. A review of the facilities policies revealed the following: Omnicell-Restocking, dated 10/2021 The pharmacy will send medications to be restocked on a mutually agreed upon schedule. The Omnicell should be restocked the same shift replacements are received to maintain medication accountability . Controlled Substances: Will require a witness to restock. Medication Administration: Master Controlled Substance Log, dated 11/2017 The Master Controlled Substance Log and Controlled Substance Record are use to aid in ensuring controlled substance accountability on medication carts and refrigerators containing controlled substances: Procedure- Medication Carts containing controlled substances will have the Master Controlled Substance Log; Date received; 2 Nurses signature; Prescription information . Each controlled substance received by Nursing . will be logged onto the Master Controlled Substance Log by the receiving nurse and witnessed by a second licensed nurse. Both nurses will sign the Master Controlled Substance Log for each entry . Document controlled substance administration on the Medication Administration Record (MAR) and on the Controlled Substance Record immediately . Off going and oncoming licensed nurses will conduct a shift-to-shift count to verify controlled substance counts whenever there is an exchange of medication cart keys including in between shifts, breaks, or meals . A review of the Narcotics Diversion Plan of Correction on 1/26/21 at 12:34 PM with the Administrator, DON and Corporate Clinical Nurse revealed the following: 1/11/22: A Full Narcotic Count of all unit's medication carts was completed with no missing medications. 1/11/22: Omnicell reviewed to ensure all medications were accounted for. No Narcotics were missing. 1/11/22: Licensed Nurses received education on medication management specific to narcotics. Emphasis on validation to ensure that available narcotics reflect delivery receipts, accuracy of patient specific controlled substance records, completing initials and reasons for removal of narcotics and monitoring and management of narcotic controlled substances shift to shift count sheet with discrepancy to be reported immediately to DON and no propping of medication room door at any time. 1/11/22: Licensed nurses inservices on validating that delivery manifest reflects accuracy of what was received from pharmacy and if not to notify pharmacy and DON immediately, accuracy of patient specific controlled substance records without writing over top of dates, two nurses signing for receipt of narcotics and removal of narcotics, shift to shift sheet is signed each shift with count and no nurse asks another nurse to pull medication from the Omnicell for them. 1/11/22: Administrator and Director of Nursing began education related to reporting to the State Agency (SA) and law enforcement any possible diversion of narcotics. 1/26/22 at 12:34 PM, this surveyor confirmed the facility had enacted their Plan of Correction for Narcotics Diversion.

This Citation pertains to Intake Number MI 977. Based on interview and record review, facility failed to prevent the development of a Stage III pressure ulcer for one resident (Resident #200) out of 3 residents reviewed for pressure ulcer care and treatment, resulting in development of Stage III pressure ulcer to the sacrum requiring multiple treatments, hospitalization , surgical debridement, and infection treatment. Findings include: Review of the 'Skin Practice Guide' dated 01/2013, shows that The purpose of the Skin Practice Guide is to describe the process steps for identification of patients at risk for development of pressure ulcers, identify prevention techniques and interventions to assist with the management of pressure ulcers and skin alterations. Review of clinical record, on 12/29/21 at 2:35 PM, reflected that Resident #200 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (MDS) indicator, dated 11/24/21, R #200 scored a 13 on the Cognition Assessment, indicating minimal cognition impairment. According to facility developed care plan dated 11/19/21, Resident #200 was documented at risk for alteration in skin integrity related to: impaired mobility, morbid obesity, weakness, debility, high risk for falls that could result in skin alterations. The goals were identified as decrease/minimize skin breakdown risks and Skin will remain free of breakdown within limits of disease process. Interventions were documented as Encourage reposition as needed; use assistive devises as needed, Observe skin condition with ADL care daily, Use pillows/positioning devices as needed, and Provide preventative skin care routinely and prn (as needed). On 12/29/21 at 1:14 PM, during interview with the complainant, she stated that her husband was hospitalized on [DATE], with a Stage III pressure injury to sacrum, which developed during his stay in the facility and became infected. He (Resident#200) had to undergo surgical debridement of the wound and received antibiotic therapy to treat the infection. She also said that she visited her husband in a facility during his stay on multiple occasions (almost every day after work) and spoke to the staff about his care. Every visit she saw him lying on his back and did not see staff positioning him on his sides or moving him. She stated on his admission on 11/18/21, her husband did not have any open areas on his buttocks or back. Skin on his buttocks and back was intact. He was admitted to the facility initially for rehabilitation and recovery after his hospitalization with heart failure. Complainant stated that staff in a facility failed to turn him every 2 hours and that is why he developed his pressure wound. She (Wife) explained that upon discharge from the acute setting, Resident #200 was discharged to a different Long Term Care facility, per wife's request, on 12/22/21, due to the development of pressure ulcers while residing in the facility. During an interview with Registered Nurse H on 12/29/21 at 2:16 PM, RN H stated that she did initial skin assessment of Resident #200 on admission. RN H remembers a man that came from hospital with left sided weakness, and [CONDITION(S)] of his lower extremities. RN H noted multiple blisters to his legs and some ulcers that RN H thinks resulted from rapid diuresis for his heart failure treatments. RN H recorded all her assessment findings in electronic medical records (EMR). RN H said Resident #200 had no pressure sores on admission. RN H mentioned that resident was sensitive to touching and repositioning and was screaming when staff was moving him. RN H discussed this with his wife several times and wife advised the facility staff to continue providing necessary treatments even if Resident #200 continued to scream. On 12/29/21 at 2:10 PM, review of Resident #200's electronic medical records revealed admission assessment note by RN H documented Patient observed resting in bed without distress noted. Patient alert and talking with staff. Skin audit completed at this time. Left outer lateral leg previous blister site. Area measures 12 cm x 9 cm. No depth to the area. Red tissue noted to wound bed surface. Scab forming to multiple areas of the abrasion. Small amount of blood drainage noted on the dressing removed from the area. Area cleansed with normal saline, Xeroform applied to the wound. Covered with abdomen dressing, wrapped with Kerlix. Right anterior foot previous blister 2 cm x 2.5 cm. Skin intact to the area. No drainage from the area. Area cleansed with normal saline and left open to air. Left foot anterior aspect previous blister 5 cm x 2.8 cm. Skin intact to the area. No drainage from the area. Area cleansed with normal saline and left open to air. No [CONDITION(S)] noted to lower legs or feet at this time. Staff will assist the patient with daily personal care. Patient alert and able to express his needs to staff. Staff will assist the patient with daily personal care. Staff will assist the patient with frequent position changes could shift [SIC]. Pressure relieving mattress on bed to promote comfort. Preventive skin care provided by staff as needed. Treatments will be done as ordered. Patient noted to scream out during treatment and assessment of skin. Patient denied pain associated with the treatment or assessment. Patient cooperative with the treatment and stated: Just do your thing, I just scream. Staff will assist the patient with bathroom or incontinence needs. Review of minimum data set (MDS) section M (skin assessment) on admission 11/24/21 showed answers No to questions if a resident has a pressure ulcer/injury and any other open [CONDITION(S)], skin tears, [CONDITION(S)] or surgical wounds. According to Skin Practice guide used by the facility The approaches for skin management are clear, specific and individualized for the patient's needs. Managing skin risk can be complex as there may be a combination of risk factors and causes. Regardless of the interventions that are put in place, a key factor to success is the timely review of the interventions as the patient's condition and needs change. On 12/29/21 at 3:10 PM, review of Resident #200's progress notes reflected an entry by Nurse I dated 11/21/21 at 1:35 PM, as Pt noted to have a blister approximately the size of a dime on the inside right buttock. Zinc cream applied and an Optifom dressing. Note left for wound care nurse. ( 4 days after admission into the facility, one blister noted) Further, review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Progress notes by Registered Nurse J on 11/22/21 at 5:44 AM, revealed Pt alert and able to make all needs and wants known to staff; compliant with all care provided. Also noted on 11/22/21 at 1:22 PM, Registered Nurse H progress note reflected Charting for 8 AM this morning. Right inner buttock 2 previous blisters noted. Each size 1 cm x 1 cm. Non fluid filled. Skin intact to the area. No drainage from the area. Treatment completed as tolerated by the patient without acute distress noted. Patient updated on current skin condition and current treatments. Patient cooperative with care. ( 2 blisters noted) Social services note on 11/26/21 at 10:00 AM reads Therapy- Resident is a Hoyer lift at this time and an extensive 2pa (2 person assist). General progress note documented by Nurse in care of Resident #200 on 11/27/21 at 3:12 PM, reflected Wound care completed as ordered. Resident A+O (alert and oriented) and able to voice his needs. Needs assist with personal care and bed mobility. Nursing progress note on 11/29/21 at 11:01 AM, by RN H documented Right inner buttocks previous blister sites dry peeling skin noted to the area. Red tissue noted to wound bed surface. No drainage from the area. Treatment completed as ordered. a. Patient continues to yell out whenever touched, care provided, or position changed. Progress note written by nurse on 11/30/21 on 8:51 PM shows Ate well with evening meal; fed by his wife. He is dependent for most ADLs. Incontinent of B&B (bowel and bladder). Participated in therapies. Review of Progress noted documented by RN H on 12/01/21 at 10:54 AM, revealed Buttocks/sacrum inter buttocks wound measures 6.3 cm x 7 cm. Red/ purple tissue noted to wound bed surface. No measurable depth to the area. Wound is a stage 2 pressure wound. Dry peeling skin noted to surrounding tissue. Treatments completed as ordered. Revision to care plan on 12/01/21 shows the note by the Registered nurse (H): Resident has a pressure ulcer to buttocks/sacrum area. Patient incontinent of bowel and bladder. Patient resistant to turning and having treatment done. Patient will scream out during all direct care procedures. Wife and doctor aware of patient's current condition. The goal column for this assessment reads free from odor. (2 previous dime size blisters have significantly progressed in size) Review of Progress notes over a 13-day period, from admission 11/18/21 - 12/1/21, did not reflect any documentation entered in medical record that Resident #200 refused to be repositioned while in bed. Progress note dated 12/02/21 reflected that Sacrum wound improvement noted to wound bed surface. Red tissue noted to 90 percent of the wound bed. 10 percent brown peeling tissue. No drainage from the area. No odor from the wound. Treatment done as ordered. Review of Progress note dated 12/05/21 at 7:42 PM, Wound care completed. Sacral wound noted now having a pungent odor which had not been previously noted. Wound bed mixture of yellow slough and beefy red tissue. Wound edges friable. Peri wound tissue appears healthy. Progress note on 12/06/21 at 11:19 AM, revealed Sacral wound measures 6.3 cm x 7 cm x 1.5 cm. Superior aspect of wound bed gray tissue noted. Distal to mid medial aspect red tissue noted. Scant amount of yellow drainage noted on the dressing removed from the wound. No odor noted from the wound after cleansing the wound with Remedy wound cleanser. Dry skin noted to surrounding tissue. Treatment completed as ordered. (Wound worsening) On 12/06/21 at 3:56 PM, progress note Patriot EMS here to pick pt up and transfer him to Hospital. Review of Emergency Department Hospital notes revealed Patient was sent in by facility for concern for wounds on his feet and sacral decubitus ulcer. He has had purulent drainage along with fever, same note reveals physician assessment The patient had a stage III decubitus ulcer at his sacral area, purulent drainage. Resident was admitted to the hospital on 12/06/21. Plan of care revealed OR (operating room) debridement of the sacral decubitus ulcer 12/8, Sacral wound culture positive for mixed bacterial culture with prominent negative rods, [MEDICATION(S)] and [MEDICATION(S)], de-escalated to [MEDICATION(S)] 875 mg BID (twice a day). Resident #200 spent 17 days in a hospital and was discharged to a different facility for rehabilitation. During interview with complainant on 12/29/21 at 1:14 PM, she stated that it was heartbreaking to see her husband suffer so much through all this experience. She wishes facility could provide a better care for him and reposition him in bed more often. She shared her concerns and informed the facility he would not be returning and would be going to another facility. During an interview with Registered Nurse H on 12/29/21 at 2:16 PM, RN H said she was surprised how quickly Resident #200 wounds progressed and were difficult to heal. According to International NPUAP/EPUAP (National Advisory Panel/ European Pressure Ulcer Advisory Panel; a group of experts who serve as the authoritative voice in pressure injuries) defined pressure injury stages. (A) Stage I- non-blanchable [CONDITION(S)]. (B) Stage II- partial thickness skin loss with exposed dermis. (C) Stage III- full thickness skin loss. (D) Stage IV- full thickness skin and tissue loss. (E) Unstageable pressure injury- obscured full thickness skin and tissue loss. (F) Deep tissue pressure injury- persistent non-blanchable deep red, maroon, or purple discoloration. (2016 NPUAP Pressure Injury Staging Illustration from http://www.npuap.org/recources/educational-and-clinical-recources/pressure-injury-stagingillustartions/. Used with permission of the National Pressure Ulcer Advisory Panel March 2018. NPUAP) Nursing and Patient Care Considerations: Prevent Ulcer Development- 1. Provide meticulous care and positioning for immobile patients. 2. Inspect skin several times daily. 3. Wash skin with mild soap, rinse, and pat dry with a soft towel. 4. Lubricate skin with a bland lotion to keep skin pliable. 5. Avoid poorly ventilated mattresses that is covered with plastic or impermeable material. 6. Encourage ambulation and exercise. 7. Promote nutritious diet with optimal protein, vitamins, and iron.

Based on observation, interview and record review the facility failed to prevent an accidental shock, thoroughly investigate an incident, and accurately document following the incident for 1 resident (401) resulting in Resident 401 receiving an electrical shock from a faulty wire from a NEMS unit with complaint of pain. Findings include: Upon entry to the facility the facility was having difficulty with Internet access. According to Resident #401's Electronic Medical Record (EMR) and a hard copy of medical records, Resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Hospital discharge records, dated 2/14/19, revealed resident #401 had a total knee arthroplasty, wore a knee stabilizer as needed for pain, and had an incision to the right knee with instructions to leave soft dressing in place for one week and keep dry. Review of Resident #401's Incident Report, dated 2/18/19 at 4:17 PM, revealed Equipment failure resulting in injury: Location of injury other; Description of incident: Therapist was adjusting e-sim pads to pt rt lower ext and lead came out of pad and pt felt a painful jolt. Was patient seen by a physician at the center No. Describe care and medications, if any provided to patient following incident and by whom provided: Equipment turned off and removed immediately. Lead was take off machine and disposed of. Pain and skin assessment completed. Was patient taken to a hospital? no. Incident Cause: Describe cause of incident, if known: Faulty lead to e-stim pad. Corrective Action: Describe corrective action taken following incident, if applicable: Equipment was turned off and removed immediately and disposed of. Pt examined for injury, non noted. Physician statement: 1. Extent of injuries: As indicated in incident report. 2. Treatment ordered No new orders. 3. Disposition of Patient. Remains at center. The incident report included one statement that included Physical Therapist Assistant (PTA) H present at the time of the incident 4:10 PM, which stated Patient was sitting on mat in therapy room I applied e-stem pads 2 on quads (upper thigh muscle) and 2 on hamstrings (posterior thigh muscle) Turned on e-stim machine and dialed amps on hamstring slowly; until patient said ok that's good at 30 MA to (patient's tolerance). Then dialed up slowly for quads and patient kept saying, I can't feel it. It read 45 MA then made sure (inspected pads with with [MEDICATION NAME] wire in cord, when I touched the white [MEDICATION NAME] wire which was in cord there was a surge & I immediately turned machine off. Patient hollering. When asked if patient okay, she said It felt like I was electrocuted. Skin was observed intact and no red or any other marks. She immediately began walking back to her room with her walk(er) with this therapist ensuring she got back to her room okay. Asked patient how she was feeling and stated, I still can feel it down my leg. Witness statements were inconsistent. Review of Resident #401's Progress note, dated 2/18/19 at 16:29 (4:29 PM), revealed Therapist was adjusting e-stim pads to pt (patient) rt (right) lower ext (extremity) and lead came out of pad and pt felt a painful jolt, Equipment was turned off and removed immediately and disposed of. Pt examined for injury, none noted. MD made aware. Review of Resident #401's physician progress notes [REDACTED]. she still feels that tingling intermittently (he) did is no irritation at the contact pointed the skin patient also wants to be transferred since this morning she wanted to be transferred. Review of Review of Resident #401's physician progress notes [REDACTED]. meanwhile will continue to provide care I did offer that we can have heart failure site wrist (sp) (specialist?) evaluate her to really assess also the above-mentioned incident. Inconsistent with interview of no cardiac issues or concerns. Review of Resident #401's Medication Administration Record (MAR) revealed resident had received Perocet tablet 5-325 (2) tablets on 2/18/19 Pain level was documented as a (5) out of 10 at 00:50 and 06:00 AM, at 12:00 noon, prior to the incident Resident #401's pain level was at a (4) and at 18:21 (6:21 PM) pain level was at a (9) following the incident. Review of Resident #401's Skin worksheet (shower sheet), dated 2/18/19 at 16:30 (4:30 PM), revealed surgical scars on the right leg at the knee and ankle, and discoloration on right arm from brace. Review of Progress note dated 2/18/19 at 13:12 (1:12 PM) [MEDICATION NAME] tablet 5-325 MG Give 2 tablet by mouth every 6 hours as needed for Pain PRN administration was: Effective follow-up Pain Scale was: 0. Review of Resident #401 pain assessment completed at 16:19 revealed a pain scale of Highest level 10 current pain level at 13:12 0. Specific event causing pain locomotion/ROM, Right knee, right lower leg. This information was inconsistent with the incident report, staff statements and progress notes. Inaccurate documentation related to incident on 2/18/19 at 4:19 PM, electrical shock related to faulty lead to e-stim pad of NEMS unit. Review of Resident #401's Vital summary revealed Blood pressure was taken at 12:43 PM, and at 15:13 (2:13 PM) and not again until 23:51 (11:51 PM) On 3/7/19 at 9:04 AM, Director of PT E reported she had not been in the facility when the incident occurred and the faulty leads were on her desk the following day. Director of PT E was informed the following day that PTA H had informed Unit Manager D who had completed the incident report and there was no mark left on her. Director of PT E reported that PTA H had informed her the resident had reported it had felt like she got a shock or increased charge due to the faulty wire. PTA H therapist took the wires off that NMES (neuromuscular electrical stimulation) Unit and it was sent back to the company and it is out of service. PT Director E reported there were 3 other NMES units they are new. They have not been checked over, just had that one that was replaced. They were all purchased at the same time. The inspections are not due until 7/19. Director of PT agreed the NMES units had not been inspected to ensure there were no other faulty wires at this time. On 3/7/19 at 9:31 AM, PTA H, reported the incident with Resident #401 occurred on a Monday 2/18/19 a couple weeks ago. Received Training with the NMES unit from the sales rep for the (company) and through CEU (Continuing Education) on the computer. PTA reported that Resident #401 had come to PT and she had explained some testing was needed for Resident's insurance. PTA H reported resident had completed some of the exercises on the mat and only completed 1-2 the previous Friday (2/15/19) she had done 5-8 repetitions. PTA H stated, Resident had stated aren't you going to put those [MEDICATION NAME] on me. PTA H stated, she was very dramatic. PTA H reported had then then applied the [MEDICATION NAME] on 2 on hamstrings on back of leg/thigh (posterior leg) and 2 pads on front quad(quadriceps) (anterior upper leg) and did the channel with the hamstring and dialed that slowly and she said that is fine. PTA H reported she then switched to the other channel and Resident 401 said she was not feeling anything and continued to dialing slowly. PTA H reported had touched her leg. Felt the pads. PTA H reported had make sure the white cord on the [MEDICATION NAME] was in place and touched that to ensure and that was when the machine surged, shut the machine off immediately. PTA H reported removed the pads. PTAH stated, I looked at the the connections on the machine but do not think I touched them. PTA H reported she was unable to recall what number setting the NMES unit was dialed to and stated, I would have to look at my statement. PTA H was queried you could have dialed it up to a high number and not realized it, and responded, I am not sure. When Resident #401 stated she did not feel anything, did you shut the machine off, PTA H responded No. I checked the pads. Everything looked like it was connected, when I touched it, it surged. I felt the tingle. PTA H was queried if she had checked the connections and stated, I looked at the ones at the machine and did not physically check them, when I pushed on the one at the pad with my hand it surged, and I felt the tingle. PTA H was queried multiple times who removed the pads prior to Resident leaving the physical therapy room and repeatedly stated she had removed the pads, then finally stated .It was all a whirlwind, she (Resident) was pulling, your instinct was to grab. I was pulling it off. PTA H was queried of Resident #404's pain level when she came to therapy and stated, her knee was hurting prior to PT like after her surgery and had pain medicine just prior to coming down to PT, she said she was hurting really bad, after the incident the way she was crying probably a 9. On 3/7/19 at 3:50 PM, PTA H reported she had completed vitals before the incident and thought she had completed them post incident, PTA H then stated she was upset and thought the nurse would have completed the vital signs later. Surveyor requested to review documentation and the documentation dated 2/18/19 was blank for vital signs. On 3/6/19 at 5:45 PM, Confidential Witness I reportedly was present during the incident that happened on 2/18/19 at approximately 4:30 PM. Witness K reported Resident #401 did the first part of therapy-went up and down stairs. Did a lap around cone, moved over to table and did measurements of how leg was doing flexing and bending. Then, PTA H applied the NMES unit. Put 2 pads on lower part and 2 pads on top, started cranking up and Resident #401 stated that was a tolerable hurt. PTA H then switched to the other patch and Resident stated feel nothing. PTA H kept dialing up on the NEMS unit and Resident #401 continued to feel nothing. PTA H kept dialing on the unit, and hit level that had dialed at on the back of the leg. PTA H stated, you should have felt something by now. PTA H stopped dialing on the unit. PTA H went to fiddling to device where the cord connected to the (e-sim) patch at the connecter piece and messed with dial, then messed with the cord that connected to the machine and that didn't do anything. From there PTA H went to the patch and moved the connector lightly and went back to the machine and Resident #401 screamed bloody murder. No one came to help. Resident #401 yanked the patch off. PTA H looked at Resident #401 like she was a freak, like why are you screaming. Resident #401 started to get up and we started to leave the therapy room. PTA H kept saying I am sorry. PTA H said I need to fill out an incident report she hurt her self. Witness I stated Resident #401 was having excruciating pain, which was described to Witness I as constant pulse that is still causing pain. Witness I reported that Attending Physician J came in and could not do anything as there was no mark, because Resident was in the process of being discharged , he could not monitor Resident. Witness I reported Witness L was present at that time and stated, We understand and the physician just kept getting louder and repeating could not do anything because Resident #401 was being discharged . On 3/7/19 at 10:00 AM, PT Director E stated, discussed with my Regional Manager of rehab Services K and it was decided that it was not necessary that the other 2 NEMS units be out of service as they have been serviced annually and they are not consecutive serial numbers. On 3/7/19 at 12:33 PM, Unit Manager D reported that on 2/18/19 UM D was standing at the nurses station and was informed of the incident with Resident #401 with the NEMS faulty lead. Unit Manager D reported Resident #401 had reported had pain to the area, had proceeded to her room, the incident report was initiated, and the physician was contacted . Unit Manager D reported the second shift Unit Manager C completed the assessments. Unit Manager D reported Resident #401 Resident stated it was very painful, it was a shocking pain, but not a number. Physician was coming in to see the patient and reportedly had then left for the day. Unit Manager reported Resident #401's pain at worst had been a 10, and thought she had surgery for [REDACTED]. Unit Manager D was queried as to were there any other questions for Resident #401, witnesses or staff, did you ask any further questions to complete the incident report? Did you look at the NEMS units? UM D responded, No, just got the model and serial number for the incident report. On 3/7/19 at 1:17 PM, during an interview, Unit Manager M stated that they were in the facility on 2/18/19 on the day of the incident with Resident #401, reportedly had completed assessment, looked skin over, and reported there was no mark present. Pain level was reported at a 9, called doctor to see if he was coming in, and completed a skin record. Unit Manager M reported she did not document on the pain. Unit Manager M reported was not aware there was a change, it was always that right leg and it was described as tingling on the right leg, had not assessed pain earlier so did not know if it was different. Unit Manager M was queried if the surgeon responsible for the knee arthroplasty had been notified and responded, no I did not. Unit Manager M stated, Not sure on the order for the TENS unit that is done by therapy. Unit Manager M reported did not complete a pain assessment or document the incident in the progress notes just completed a skin assessment. (shower sheet). Unit Manager U was queried if she had assessed Resident #401 for headache, chest pain or vital signs following the incident. UM M responded, just looked at the skin on her leg, understand that PTA H did vitals. Unit Manager M was queried if the vitals were reviewed and responded, No. Review of Resident #401's vital signs were reviewed and there were no vital signs documented at 4:30 PM. Unit Manager M was queried if a SBAR (Situation, Background, Assessment, Recommendation) with a change of condition was completed. UM M responded It was not required there was no change of condition. On 3/7/19 at 3:00 PM, during an interview, Attending Physician J reported he was not an expert on TENS or NEMS units and had Resident #401's medical record in front of him for reference, denied resident had any cardiac issues and was not at risk for cardiac concerns or arrhythmia. Resident was documented with [DIAGNOSES REDACTED]. Attending Physician J reported following the assessment of Resident's skin on her leg, he had offered to the Resident to speak to the Rehab physician. Resident was leaving the facility and was reported to have declined. Attending Physician J had not explained to Resident #401 what a physiatrist physician specialty was. Attending Physician J stated there was not any skin irritation, the nerves the superficial whether the deep nerve was involved could not be sure there as was tingling down the whole leg when it happened and was complaining when she was seen after the incident. Attending Physician J reported the incident was on the same leg as the (knee surgery) knee pain. Resident was going to another rehab unit so assumed would be evaluated at the facility and denied any cardiac issues and was not at risk for cardiac concerns. 3/7/19 at 1:46 PM, DON reportedly was in and out the week Resident #401 was at the facility, reviewed the incident report reported Administrator was taking care of it, signed and reviewed the form. DON reported had not discussed the incident with the Resident. DON requested to review documentation including vitals, pain assessments, progress notes, DON agreed there were no vitals at the time of the incident, agreed there was no pain level nursing documentation. DON reported physician was notified so an SBAR was not needed. Pain assessment reviewed and Reviewed MAR and stated she received [MEDICATION NAME]. DON walked out of the office and was not cooperating at that time, so inconsistencies of the documentation was not discussed at that time. Policy for investigating incidents other than falls was requested and DON responded, I do not know what you are talking about. On 3/7/19 at 5:30 PM, Administrator, during an interview, reported he had not discussed the incident with Resident #401. She was more concerned with discharging from the facility. There was no further investigation into the incident documented by the facility. There were no other witness statements completed by the facility. The 3 NMES units were still in service and had not been examined for safety by any staff. Administrator reported they followed the Fall Practice Guideline. Discussed that the fall practice guideline used by the corporation was not specific for documentation. Administrator stated, we usually use a different guideline for other types of incidents and provided a copy of Trigger Events guideline used by the corporation. According to Trigger Events -Actual, no date, revealed Examples: Equipment failure resulting in injury, Report: Report rigger events immediately to the Administrator and Director of Nursing Establish Facts: Upon the occurrence of an incident that may have caused injury to a patient, the patient is evaluated, observe the patient condition. Determine injury prior to moving patient. Note patient location, position vital signs, level of consciousness, range of motion, presence of pain, skin alterations. Ask patient to describe what happened, if able. Validate and Investigate: Initiate an investigation. Identify who may have witnessed the event, has knowledge of event or in the vicinity. Track precipitating events and surrounding circumstances. Evaluate and Expand: Collect patient and witness statements. Identify who else may be involved or could have like circumstances. Evaluate expanded patient situations Track and Document: Complete the Incident Report. Report the nature and extent of the injury or the results of the patient assessment, e.g., skin tear, bruise, hematoma, etc. Describe the injury and the affected body part noting the level of consciousness, pain, swelling, lethargy, shortness of breath, vital signs and any changes in condition According to http://www.electrotherapy.org/assets/Downloads/NMES%20Muscle%20Stimulation%20march% 3.pd, There is an increasing application of long term (i.e. chronic) electrical stimulation in order to modify or change muscle function. This work was initially concentrated around athlete strengthening and function, but in recent years, the intervention has crossed the boundary into clinical practice with an increasing range of applications. There are numerous studies that indicate that such stim is capable of changing muscle function parameters e.g. strength and endurance. There are MANY different terms that are employed to describe this type of intervention, and it is suggested that a general term - like Neuro Muscular Electrical Stimulation (or NMES) is preferable to modality names based on specific machines. According to https://www.livestrong.com/article/ 8-muscle-stimulation-dangers/Research published in the European Journal of Applied Physiology in 2011 shows that certain types of muscle injury can be caused by electrical muscle stimulation if the tissue becomes too tense during the electrically induced contraction. Muscles are most easily injured at the musculotendinous junction and can tear at these sites if the stimulator is turned up too high. Electrical stimulation can also cause pre-existing muscle injuries, such as tears and deep bruises, to get worse and may even prevent full tissue healing. If a muscle begins to hurt more when stimulation is applied, turn off the machine and consult a medical provider for guidance on appropriate parameters. Improper use of a muscle stimulation unit can easily lead to skin burns, according to research published in The Journal of Arthroplasty in 2005. Dr. Daryl Lawson states that if a strong electrical current is delivered through a small [MEDICATION NAME], the skin is exposed to a higher concentration of electricity per unit of area, which can cause burns. Be wary of skin pain and discomfort at the area under the [MEDICATION NAME] during stimulation. While stimulation often causes a strong tingling sensation, it should not be painful or cause distress of any sort. If the stimulation is painful, turn off the machine and remove the [MEDICATION NAME] so your skin can recover.

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place to prevent the development of a Stage 4 Pressure Ulcer (Full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer) on the coccyx/sacral area for 1 Resident (#67) of 3 residents reviewed for pressure ulcers, resulting in Resident #67 developing a Stage 4 Pressure Ulcer, infection at the ulcer site, readmittance to the hospital and Intravenous (IV) antibiotic treatment in the hospital and at the facility. Findings Include: Resident #67: On 10/17/18 at 12:00 PM, the resident was observed up in a wheelchair in the dining room for lunch, per staff the resident usually is up once daily for about 1 hour because of a facility acquired Stage 4 Pressure Ulcer. A record review of the Face Sheet and Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #67 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS indicated Resident #67 was confused and unable to be assessed for cognitive function and At risk for developing a pressure ulcer, but did not have a pressure ulcer on admission. Resident #67 required extensive 1-person assistance with bed mobility, dressing, eating, personal hygiene and bathing and extensive 2-person assistance with transfers and toileting. A Significant Change MDS assessment was completed on 9/23/18 due to the resident developing a Stage 4 pressure ulcer. On 10/17/18 at 12:00 PM, Unit Manager CC, was queried about the treatment of [REDACTED]. Usually the nurse does it. On 10/18/18 at 8:00 AM, Unit Manager's CC and KK were interviewed prior to observing the dressing change for Resident #67; Nurse CC stated The wound started in (MONTH) as a Suspected Deep Tissue Injury (SDTI- Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister) and then opened and she went to the hospital. They said she had an abscess (an infected collection of pus under the SDTI) and she received an IV. She's been on Antibiotics here too. We changed the treatment order yesterday, because we were basically doing a wet to dry and now we added (a wound gel). On 10/18/18 at 8:05 AM, during an observation of the dressing change for Resident #67, there was a small amount of serosanguinous (yellow/red) drainage on the dressing removed. There was a large open wound on the coccyx/sacrum area with 3 areas of exposed bone and scant yellow slough (stringy dead skin) distal from the exposed bone. Nurse CC was queried about the 3 white areas and stated, It's bone. The wound was cleansed by Nurse CC and the wound gel a 4 x 4 inch gauze pad and a foam dressing were applied. Nurse CC said the resident was using a special wound care mattress, Since she got back from the hospital (in (MONTH) (YEAR)). A review of a General Progress Note, written 10/16/18 at 7:13 AM revealed the Stage 4 pressure ulcer measured, 8 centimeters (cm) length by 7.6 cm width by 3.3 cm depth and said, Undermining 3 o clock to 8 o clock 3.3 cm .Bone palpable not visible to center of wound surface . The overall undermining had increased. A review of the Progress Notes from 7/19/18-10/17/18 revealed the following: 7/19/18- Resident noted to have split in the skin located at coccyx measuring 1 cm length by <0.1 cm width with no depth. Orders received for (a zinc-based ointment) to coccyx every shift and as needed. Braden score 11 High Risk for skin breakdown. 7/31/18- The first documented physician progress notes [REDACTED]. 8/8/18- Skin assessment completed 8/6/18-No changes in size or condition 1 cm length by 0.5 cm width by 0.1 cm depth-wound bed pink. The wound had increased in depth since 7/19/18. 8/15/18- Resident presents with a split in the skin located at the cleft of the coccyx between the right and left buttock measuring 1 cm length by 0.5 cm width by 0.1 cm depth- wound bed is pink. 8/23/18- Areas to coccyx measures 4 cm by 2 cm with no measurable depth to the wound- wound bed surface 80% covered with brown/black tissue. 8/26/18- Pt. (patient) up in Geri-chair for several hours in hall. 8/30/18- A Medical Practitioner note does not mention the wound, treatment or preventive measures. 8/31/18- Coccyx wound 5.2 cm length by 3.5 cm width by 2 cm depth, visible wound bed with gray/black tissue noted. Tissue mushy to the touch. Wound bed not visible .Left buttocks directly lateral to the wound 5 cm length by 5 cm width raised firm .tissue purple/brown in color .odor noted .wound is not showing signs of healing . An oral antibiotic was ordered. 9/2/18- The resident was discharged to the hospital. 9/16/18- The resident was readmitted to the facility after debridement (surgical removal of dead tissue) of the wound and IV antibiotic treatment. 9/17/18- Wound measurement- 10 cm length by 10 cm width by 5 cm depth. No signs and symptoms of infection .Staff will observe the patient frequently each shift and provide frequent position changes every shift. Preventive skin care provided by staff as needed . 9/26/18- Coccyx/sacral wound Measurement 8 cm length by 8 cm width by 3 centimeters depth with undermining (a pocket beneath the skin at the wound's edge) at 6 o clock 2.5 cm and 3 o clock 2.5 cm. The wound had further deteriorated and while smaller was not healing due to the undermining. 10/2/18- Wound to coccyx/sacral area Stage 4 currently measures 8 cm length by 8 cm width by 3.5 cm depth. Undermining at 3 o clock-2.5 cm and 8 o clock at 3.5 cm .Center of wound bed visible, lifting of bone fragment noted, bone loosely attached to wound bed. There was no change in wound treatment or interventions provided. A review of the Care Plans for Resident #67 indicated the original care plans created prior to discharge to the hospital (9/2/18), were discontinued on 9/17/18 after the resident was readmitted . New Care Plans were created on 9/17/18. An At risk for skin breakdown care plan, dated 1/2/18 revealed, Encourage to reposition as needed, use assistive devices as needed. There were no updated interventions from 1/2/18 until 9/16/18. There were no documented interventions after the 7/19/18 identification of the split in the resident's skin on the coccyx. A care plan titled, Resident noted to have a split in the skin at the coccyx, created 7/19/18 was not updated with new interventions with the decline in the wound. The wound measurement on 8/8/18 indicated the wound had declined and measured a depth of 0.1 cm. No new interventions were added after 8/7/18. The care plan was discontinued on 8/23/18. An Activities of Daily Living-ADL Care Plan, dated 9/17/18, Staff to assist the patient with frequent position changes every shift, 9/17/18- The intervention was not added until after the resident's wound continued to decline. An Incontinent of Bowel and Bladder Care Plan, Staff to position patient off buttocks as much as possible, dated 9/17/18. This was not added to the care plan until the wound continued to decline. At Risk for alteration in skin integrity, Encourage to reposition as needed; use assistive devices as needed, dated 9/17/18. This intervention was also listed on the 1/2/18 Skin care plan. The resident is unable to reposition self and needs assistance to routinely reposition. The care plan does not indicate this. On 10/18/18 at 8:35 AM, during an interview with the Director of Nursing (DON) and Nurse CC, they were queried about the onset of Resident #67's wound, the progression and preventive measures prior to and after the Pressure Ulcer developed and the DON stated, We will review the chart and get you that information. On 10/18/18 at 3:00 PM, during an interview the DON, she was queried again about preventive measures prior to the Stage 4 Pressure Ulcer forming and replied, I have to go get the care Plan. We found the split in the skin on 7/19/18, prior to that we had at risk for skin breakdown. We had reposition as needed. When queried if the resident could reposition herself she stated, No she didn't reposition herself. I believe she had a stroke. The staff does every 2 hours check and change. We document when they change them. Repositioning is not documented. Previously she was up more in her chair, at that time she had falls from bed and was up in the chair more-it was a balance between the two. The DON said she received corporate education on skin care/preventive measure on 8/20/18 and Staff Education started, 9/11/18 and 9/13/18- I did not provide education to 100% of the staff/Nurses and CNA's (Certified Nursing Assistants). When queried why preventive and treatment measures were not administered sooner, the DON replied, It was a split in the skin. We wouldn't do it for that. A review of the facility policy titled, Skin Practice Guide, dated 1/2013 revealed, The purposes of the Skin Practice Guide is to describe the process steps for identification of patients at risk for the development of pressure ulcers, identify prevention techniques and interventions to assist with the management of pressure ulcers and skin alterations .A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or in combination with shear .page 17, Care Plans and risk factors need to be individualized to meet patient specific need .centers may develop and utilize a system for monitoring patient turning and repositioning while continuing to incorporate individualized patient turning and positioning needs .

This pertains to Intake # Based on observation, interview and record review, the facility failed to properly assess, including obtaining vital signs, with a change of condition for 2 (#'s 702 and 703) residents reviewed for assessment with change of condition from a total sample of 3 residents, resulting in Resident # 702 becoming hospitalized for [REDACTED].#703 developing a progressively worse cough without any documented assessment. Findings Include: Resident #702 A record review on 12/4/17 at 9:50 am revealed, Resident #702 was initially admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident needed extensive 1 person assistance with transfers, dressing and bathing and extensive 2 person assistance with toileting. The resident needed 1 person assistance with eating. The resident had memory problems and could not be assessed for cognitive status. On 12/4/17 at 11:34 am, an interview with Confidential Person (CP) A, revealed Resident #702 had a Certified Nursing Assistant call CP A on 11/23/17, because the resident was having left hip and knee pain; CP A stated, I asked the nurse (Nurse C) to call the ambulance, (Nurse C) said we can't call the ambulance for pain. (Nurse C) said the vitals (vital signs- blood pressure (BP), heart rate (pulse), respiratory rate (RR), temperature (Temp.) and oxygen saturation rate) were fine. (Nurse C) stated, We don't call the ambulance unless the vitals are out of whack. The doctor saw her (11/23/17) and ordered an x-ray. It showed severe arthritis and Pain medications were ordered. On 11/24/17, I talked to the nurse (Nurse D) she said, Your mom, she's been sick. The vital signs were fine. She's acting confused. When I saw her there were no blankets, she was wearing a brief and t-shirt and the fan was blowing. Her voice was light and she was breathing shallow. They took the vital signs and said they were fine. I asked for her to go to the hospital. In the ER (emergency room ) they said she had a temperature of 100.6 degrees (Fahrenheit- F) and the doctor said she was really sick and needed to be in the hospital. They said she has pneumonia and is septic. She's still in the hospital and still on antibiotics. Confidential Person A was queried if the nurses at the facility told her what the vital signs were on 11/23/17 or 11/24/17 and she stated, They never told me what the vitals were. A record review on 12/4/17 at 11:55 am revealed, there were no vital signs or assessment documentation, other than a pain assessment and x-ray results of the left hip and leg, in Resident #702's medical record for 11/23/17 or 11/24/17, until immediately prior to transfer to the hospital. There was one set of vital signs charted by the Director of Nursing at 3:07 pm on 11/24/17: BP 92/51 (low), Pulse 96 (High for the resident), RR 31 (high), and Temp. 98.1. A review of a facility physician's progress note, written by Doctor G and dated, 11/23/17, did not indicate any vital signs were obtained or documented. The resident was assessed for left hip and knee pain. X-rays and pain medication (Tylenol and [MEDICATION NAME]) was ordered. The hospital records indicated Resident #702 received a chest x-ray on 11/24/17 after admission, which revealed, bibasilar atelectasis-airspace disease, left side worse than right with Dyspnea (shortness of breath), chills and joint aches. Blood Cultures, obtained from the hospital grew Streptococcus (Strep) pneumoniae on 11/24/17. On 12/4/17 the following facility staff were interviewed: 2:12 pm- Nurse C stated, I had her (Resident #702) on Thanksgiving, 11/23/17. She was complaining of left knee pain up to the thigh. There was no change in ROM (range of motion). I normally do vitals. I looked to see. I thought I put them in the notes. There was none there. Nurse C looked at Doctor G's progress note and stated, No he didn't chart any vitals. Just the pain. 2:30 pm- Nurse D provided, I took care of her the day after Thanksgiving (11/24/17 6:00 am to 2:30 pm), the daughter wanted her to go to the hospital, because of change of pain. She wasn't having any breathing issues, no change in mentation. Nothing out of the ordinary. I think it was the end of my shift when the daughter came in. I don't know if I talked to the daughter that day. When queried if Nurse D obtained an assessment or vital signs for Resident #702 on 11/24/17, she stated, No I didn't. I would only take them if there was a change of status. Nurse D indicated her shift was from 6:00 am to 2:30 pm. 3:30 pm- Nurse E indicated she worked the 2:00 pm to 10:30 pm shift on 11/24/17, (Nurse D) gave me report. The daughter came up and said She's (Resident #702) breathing shallow. The DON was walking down the hall and she took over and talked to her. One of the aides (Certified Nursing Assistants) got vitals. Resident #703 A record review on 11:25 am indicated, Resident #703 was admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities and needed supervised to minimal assistance with care. On 12/4/17 at 11:45 am, an interview with Resident #703 revealed, I'm not very good. I've got a cold or infection. I've been taking cough syrup and cough drops. It's been worse the past few weeks. I use oxygen when I sleep. I have [MEDICAL CONDITION] and [MEDICAL CONDITION]. A record review on 12:50 pm, indicated the last progress note in Resident #703's chart was dated 11/26/17 and didn't include any assessment information. The resident had a Blood Pressure taken daily related to use of heart medications and a temperature was taken on 12/1/17-97.4, as part of the weekly vitals. There was no assessment of lung sounds. The cough syrup order was dated 1/5/16 and there was no mention that the resident was using it more often. Twice on 12/2/17 and once on 12/3/17. An interview with Nurse E on 12/4/17 at 3:35 pm provided, (The resident) will let us know. If (a resident) has a cold I would ask for symptoms, when did it start and get vital signs. Nurse E was queried why there was no assessment documentation for the resident and stated I will get that now. An interview with the DON, on 12/4/17 at 3:40 pm revealed, A Change of Condition is based on signs and symptoms. We would follow the policy. I don't know why vital signs weren't taken sooner. On 12/4/17 at 3:45 pm, a review of the facility policies titled, Change in Condition, dated 11/2016, provided, To provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention and notifications .a significant change in the resident's physical, mental or psychosocial status (that is a deterioration in health .in either life-threatening conditions or clinical complications . and Alert Charting Log, dated 4/2014, Documentation in the electronic medical record may include, but is not limited to: patient evaluation findings .initiation of a care plan including the patient's problem or focus, goal and interventions .

Based on observation, interview and record review, the facility failed to implement and operationalize a Restorative Nursing Program and failed to document Restorative activities for three (#'s 903, 908, and 915) of three Residents reviewed for Restorative Nursing, from a total sample of 21, resulting in functional decline, decreased independence, lack of monitoring and documentation of Resident contractures, and development of foot drop (contracture of the ankle). Findings include: Resident # 903 Record review on 9/11/17 at 12:00 PM revealed Resident # 903 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required extensive assistance to perform Activities of Daily Living (ADL's), and had no impairment related to Range of Motion (ROM) in bilateral upper extremities and lower extremities. During the initial tour on 9/11/17 beginning at 9:00 AM, Resident #903 was observed lying in bed on their back. When queried, Resident # 903 stated, I always lay on my back. On 9/11/17 at 2:20 PM, an interview was conducted with Nurse E. When queried regarding Resident #903, Nurse E stated, (The Resident) doesn't ever get out of bed. With further inquiry, Nurse E stated, I can't tell you the last time (the Resident) got out of bed. They don't want to. On 9/11/17 at 2:30 PM, observation of ADL care for Resident #903 occurred with Nursing Assistant N and Nursing Assistant O. During care, Resident #903's feet were observed to be pointed down (toes were pointed away from the Resident's head). When queried regarding their feet, Resident #903 stated, They're (feet) numb. When asked if they were able to move their feet, Resident #903 replied, Not much. The Resident then attempted to move their feet upward. Resident #903 was unable to move either of their feet upward greater than approximately two centimeters. The Resident was unable to point their toes straight at the ceiling. When queried regarding getting out of bed, Resident #903 stated, I don't get up because I was told before that there weren't enough nursing assistants to put me back to bed and I'd have to wait. I don't know how long I would have to wait but I can't stand sitting up too long so I don't get up. Nursing Assistant N stated, We can get you up on our shift if you want. I can come back. Resident #903 replied, As long as you can put me back to bed. Record review on 9/11/17 at 3:40 PM of Resident #903's care plans revealed the Resident did not have a care plan in place that addressed decreased Range of Motion (ROM), foot drop, and/or contractures. On 9/12/17 at 10:30 AM, Resident #903 was observed lying in bed, positioned on their back. An interview was conducted with Resident #903 at this time. When queried if they got out of bed yesterday, Resident #903 laughed and stated, No, they (staff) never came back. With further inquiry, Resident #903 stated, They (staff) never asked me if I wanted to get out of bed. On 9/12/17 at 10:35 AM, an interview was conducted with Nurse E. When queried further regarding Resident #903's status and getting out of bed, Nurse E stated, (Resident #903) used to walk. Then they went on Hospice, got better, and came off of Hospice. (The Resident) hasn't walked since then. When queried regarding the Resident's decline in functional status, Nurse E was unable to provide an explanation. On 9/13/17 at 10:40 AM, Resident #903 was observed lying in bed, positioned on their back. When queried, Resident #903 stated, No one has offered to get me up. With further inquiry, Resident #903 stated, No one offers to get me up very often. The only time I get offered is if it is someone (staff) from another floor (working here). When asked if they want to get up and out of bed, Resident #903 stated, Sometimes, yes but I don't want to be up all the time. On 9/13/17 at 11:00 AM, an observation occurred of Nursing Assistant L providing care to Resident #903. When queried regarding their feet, Resident #903 stated, They are still numb. Nursing Assistant L then touched both of the Resident's feet including the toes. When queried if they were able to feel Nursing Assistant L touching their feet, Resident #905 replied, Not really. When queried if they were able to move their feet, Resident # 903 attempted to move their feet upward. Resident #903 demonstrated minimal ability to move their feet. The Resident was unable to point their toes straight at the ceiling. At this time, Nursing Assistant L stated, (Resident #903's) feet have been dropping for a couple months. With additional inquiry, Nursing Assistant L stated, (Nurse E) noticed it a couple months ago. When queried regarding Restorative Nursing, Resident #903 stated, They were going to have someone come in and see me about it but no one ever did. Now it just keeps getting worse. When queried if the Resident's feet have gotten worse since noticed, Nursing Assistant L stated, Yes. When asked about a Restorative Nursing program within the facility, Nursing Assistant L stated, I don't think we have one. On 9/13/17 at 11:10 AM, an interview was conducted with Nurse E. When queried regarding Resident #903's feet and contractures, Nurse E stated, I did notice they had some foot drop a couple months ago. I let the manager know. On 9/13/17 at 12:20 PM, an interview was completed with the Director of Nursing (DON). When queried regarding facility policies and/procedures pertaining to a Restorative Nursing Program, the DON stated, We don't have a Restorative program. With further inquiry regarding maintenance of Resident's functional status and prevention of contractures, the DON stated, If someone is discharged from therapy, they (Physical Therapy) provide recommendations for staff. When asked if the facility had a policy and/or procedure in place, the DON stated, I don't think so but I will look. When queried regarding Resident #903's feet, the DON stated, Yes, we are going to have it looked at. When queried regarding documentation in the Resident's medical record pertaining to foot drop, the DON replied, There is none. The manager forgot to document it. With further inquiry regarding monitoring the Resident and interventions in place to prevent the development and worsening of foot drop/contractures, the DON did not provide an explanation. On 9/13/17 at 1:05 PM, an interview was conducted with Physical Therapy Staff M. When queried regarding a restorative program within the facility, Therapy Staff M stated, There is not really a program. With further inquiry Therapy Staff M stated, We (Therapy Staff) fill out a follow up form when someone is discharged from therapy with recommendations. When queried regarding recommendations, Therapy Staff M replied, Like walk to dining room every day or use the lift to transfer. When queried if Therapy Staff follow up to make sure that recommendations are being completed and that Resident's functional abilities are not decreasing, Therapy Staff M replied, No. Therapy Staff M then stated, If nursing staff see a decline or change (in a Resident's functional abilities), they are supposed to let us know. We can be consulted (on the Resident). When queried regarding recommendations for Resident #903, Therapy Staff M reviewed the Resident's medical record and stated, There were no recommendations after they were taken off of Hospice. Therapy hasn't seen (Resident #903), we have not been asked to see (the Resident). When queried if Restorative Therapy assists in the prevention of contractures and foot drop, Therapy Staff M replied, Yes, nursing is supposed to do ROM. On 9/13/17 at 1:50 PM, an interview was completed with Unit Manager Nurse D. When queried regarding Restorative Nursing within the facility, Nurse D stated, There isn't a program. With further inquiry, Nurse D stated, Therapy makes recommendations when a Resident is discharged (from Therapy) and the staff are supposed to follow the recommendations. When queried regarding documentation of completion of recommendations, Nurse D stated, There isn't any documentation. When queried how staff monitor the status of a Resident's contracture if there is no documentation, Nurse D stated, You wouldn't. There is no way to know if the contracture gets worse. When queried regarding Restorative Nursing for Resident #903, Nurse D stated, There is none. When queried regarding Resident #903's feet, Nurse D stated, They have foot drop now. When queried if the Resident had foot drop previously, Nurse D replied, No. Resident # 908 Record review on 9/11/17 at 11:50 AM revealed Resident #908 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required extensive to total assistance to perform Activities of Daily Living (ADL's), and had impaired Range Of Motion (ROM) in both lower extremities. Review of the Annual MDS assessment dated [DATE] revealed Resident # 908 had impaired ROM in one upper extremity and one lower extremity. On 9/12/17 at 11:00 AM, Resident #908 was observed lying in bed in their room. The Resident was positioned on their back. When queried regarding getting out of bed, Resident #908 stated, I don't get up. They don't get me up. With further inquiry, Resident #908 stated, They don't offer much anymore. They have to use the lift to get me out of bed and not all the girls do it right. When queried if they got out of bed this week, Resident #908 replied, No. When asked if staff offered to assist the Resident to get out of bed this week, Resident #908 replied, No. Both the Residents feet were observed lying directly on the bed. Each foot was pointing outward. When queried regarding their ability to move their legs and feet, Resident #908 stated, I can't move them myself. With further inquiry, Resident #908 stated, They (feet) keep getting worse. Record review on 9/12/17 at 2:10 PM of Resident #908's care plans revealed a care plan entitled, At risk for loss of range of motion R/T (related to) physical limitations, [MEDICAL CONDITION], existing contractures of left upper extremity and bilateral lower extremities . (Initiated 1/11/16, Reviewed 4/18/17 and 8/24/17). The care plan included the following interventions: -Active ROM (right upper extremity) with care/ADLs (Initiated: 1/11/2016, Revised: 1/11/16) -Passive ROM (all extremities) with care/ADLs (Initiated: 1/11/2016, Revised: 1/11/16) On 9/13/17 at 10:45 AM, observation occurred of Resident #908 lying in bed, positioned on their back. The Residents feet were lying directly on the bed. Each foot was pointing outward. When queried if they had gotten out of bed, Resident #908 replied, No. When queried regarding Restorative Nursing and ROM activities performed by nursing staff, Resident #908 was unaware of staff performing ROM activities. When queried if staff repositioned them in bed, Resident #908 stated, When I need to be cleaned up after I go to the bathroom they do. On 9/13/17 at 12:20 PM, an interview was completed with the Director of Nursing (DON). When queried regarding facility policies and/procedures pertaining to a Restorative Nursing Program, the DON stated, We don't have a Restorative program. With further inquiry regarding maintenance of Resident's functional status and prevention of contractures, the DON stated, If someone is discharged from therapy, they (Physical Therapy) provide recommendations for staff. When asked if the facility had a policy and/or procedure in place, the DON stated, I don't think so but I will look. When queried regarding documentation related to assessment of Resident #908's limited ROM and documentation of therapy recommended activities, the DON stated, That isn't documented. On 9/13/17 at 1:05 PM, an interview was conducted with Physical Therapy Staff M. When queried regarding Restorative Nursing for Resident #908, Therapy Staff M reviewed the Resident's medical record and stated, (The Resident) was screened on 8/24/17 and the note states to follow the previous plan. When queried regarding the previous plan, Therapy Staff M reviewed the Residents chart and stated, Staff are to complete ROM on (the Residents) bilateral upper extremities and bilateral lower extremities and use the Hoyer lift for transfers. With additional inquiry, Therapy Staff M stated, I believe (The Resident) has contractures. Review of Rehabilitation Screening form at this time did not reveal assessment of the Resident's contractures. On 9/13/17 at 1:50 PM, an interview was completed with Unit Manager Nurse D. When queried regarding documentation of Restorative Nursing including completion of ROM activities for Resident #908, Nurse D stated, There is no documentation. When queried regarding inconsistent documentation of ROM impairment noted in Resident #908's MDS assessments and care plans, Nurse D was unable to provide an explanation. No documentation of ROM activities was located within the Residents medical record. Resident # 915 Record review on 9/12/17 at 4:30 PM revealed Resident #915 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed the Resident was moderately cognitively impaired, required total assistance to perform Activities of Daily Living (ADL's), was always continent of urine, and had no impairment related to Range of Motion (ROM) in bilateral upper extremities and lower extremities. On 9/13/17 at 10:05 AM, Resident #915 was observed lying in bed in their room. Both the Resident's hands were observed to be bend at a 90 degree angle at the first joint of the hand. When queried, Resident #915 stated, I can't do nothing with these hands. That is why I want my motorized wheelchair. I can move that myself. I'd feel more at home with my power chair. With further inquiry regarding their hands, Resident #915 stated, They ain't getting no better. I don't even want to get in that wheelchair (Resident pointed at a regular wheelchair in their room). I can't move myself around in it anymore because of my hands so I gotten to depend on somebody else to push me. I like my independence. If I'm in that wheelchair and I got to go to the bathroom, I got to wait and wait for someone to help me so I wet myself. I don't like that. If I had my power-chair I could come back to my room and use the urinal. I know when I got to go. I have been asked about it over a year ago but never heard nothing back. When queried if they were receiving therapy or if staff were helping them to exercise their hands, Resident #915 stated, No. On 9/13/17 at 12:20 PM, an interview was completed with the Director of Nursing (DON). When queried regarding facility policies and/procedures pertaining to a Restorative Nursing Program, the DON stated, We don't have a Restorative program. With further inquiry regarding maintenance of Resident's functional status and prevention of contractures, the DON stated, If someone is discharged from therapy, they (Physical Therapy) provide recommendations for staff. When asked if the facility had a policy and/or procedure in place, the DON stated, I don't think so but I will look. When queried regarding documentation related to assessment of Resident #915's hands and documentation of completion of therapy recommended activities, the DON stated, That isn't documented. When queried regarding Resident #915's hand contractures and request for their motorized wheelchair, the DON stated, We just got a concern about it Monday when (survey staff) was completing the initial tour. Social work is looking into to that. I really doubt (the Resident) has a motorized wheelchair at home anyway. On 9/13/17 at 1:20 PM, an interview and record review was completed with Physical Therapy Staff M. Review of provided Rehabilitation Screening form dated 8/24/17 revealed an evaluation and/or re-screen was not needed and included the following documentation: Per nursing report there is no significant change in functional status. Patient continues to require Hoyer lift for transfers and is able to propel wheelchair short distances. Has been requiring max/total assist for self care task . Continue with previous follow up program including ROM to BUE (Bilateral Upper Extremities) and BLE (Bilateral Lower Extremities). When queried if the contractures in Resident #915's hands had worsened, Therapy Staff M did not provide an explanation. On 9/13/17 at 2:00 PM, an interview was completed with Social Worker F and Social Worker G. When queried regarding Resident #915's request regarding his motorized wheelchair and lack of independence related to his hands, Social Worker G stated, I just found out that (the Resident) wanted his motorized wheelchair. I left a message with (the Resident's) family. When queried regarding past requests regarding the wheelchair, Social Worker G indicated they and Social Worker F had only been working at the facility two weeks. Record review of Resident #915's care plans on 9/13/17 at 3:00 PM revealed a care plan entitled ADL Self care deficit as related to disease process, physical limitations and generalized weakness . Patient generally prefers to remain in bed. (Created: 10/12/15, Initiated: 1/18/16, Revised: 8/30/17). The following interventions were included in the care plan: -Active-assisted range of motion of upper and lower extremities during ADL's. (Initiated: 7/19/16, Revised: 7/27/16) -2 person assist with Hoyer lift for all transfers (Initiated: 7/19/2016, Revised: 7/27/16) No documentation of ROM activities was located within the Residents medical record. Review of facility provided policy entitled ADL/Functional Rehabilitation Restorative Nursing Practice Guide (Dated 2011) revealed The initial review for restorative nursing is completed by the licensed nurse. This is documented in PCC entitled Restorative Nursing status. Upon completion of the initial status report, the restorative care needs identified will trigger the ADL Functional Rehabilitation care plan. The policy further revealed, The nursing assistant providing the daily care, documents the care provided using the Point of Care documentation system. Specific restorative interventions require the nursing assistant to document the number of times of service provided daily.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one (#706) of five sampled residents reviewed for accidents from a total sample of 20, resulting in a fall, fractured clavicle (collar bone), pain, a skin tear, and a bruise. Findings include: On 8/13/14 at 10 AM, resident #706 was observed laying flat across the bed, attempting to sit up. The resident stated that he was unable to sit up without assistance due to severe pain from the left side of the neck radiating down the left arm and into the left hand. The resident rubbed the left collar bone area and stated the following: "I went to the doctor's (surgeon's) office to get the staples removed (following hernia surgery). I came out of the office by myself (in a wheelchair), went down the ramp, and it (wheelchair) took off on me fast. I hit the curb. I couldn't stop it. I fell out of the chair and broke this (rubbing left collar bone) and hit my head right here (rubbing the left forehead). It scraped the skin right off (looking at his left hand that was bandaged). I was going to go to therapy, but it's too rough." Nurse 'B' then entered the room. The resident asked the nurse to pull him up to a sitting position. Once in a sitting position, the nurse left the room and the resident grimaced and said, "It's (pain) shooting up my neck! Oh, oh, there it goes again! I tried to drink coffee this morning, but the pain shot up into my neck and I spilled the coffee all over me." The resident said, "I go to dialysis (every Tuesday, Thursday, and Saturday) with no problem. At the dialysis center, everything there (the ground surface) is flat. I've never been to this (surgeon's) office before. I never used a wheelchair before on a ramp." The resident indicated that he was not told by office staff not to go outside alone or to wait for assistance. At 10:30 AM, nurse 'B' re-entered resident #706's room to look at the left hand and inform the resident that he was going to be picked for transport to dialysis because he missed his regularly scheduled session the previous day on 8/12/14. The resident was observed with a faint yellow/gray bruise to the left forehead/temple area. When the gauze wrap was removed from the left hand by nurse 'B', there was a large amount of blood on the wrap. The resident had numerous steri-strips adhering to a large, raw area on the top of the hand. The wound was covered in blood that could be seen through a thin, transparent dressing. The resident stated that he was in pain at level "9" on a scale of 1(mild) to 10 (high). On 8/14/14 at 11 AM, resident #706's clinical record was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS also noted that the resident was not steady during transitions and was only able to transfer surface-to-surface with human assistance to stabilization. An "At Risk for Falls care plan initiated 7/28/14 for resident #706 noted: The resident was at risk due to impaired balance/poor coordination, syncope/vertigo, and history of falls (prior to admission). The goal-"Minimize risk for injury related to falls." Interventions included: Assist to transfer and reinforce wheelchair safety. The care plan did not address supervision during appointments or mobility over uneven surfaces. A "Renal Insufficiencies" care plan initiated 7/29/14 noted: "Patient has periods of confusion due to fatigue, weakness, and end-stage renal disease." Resident #706 had the following physician's orders [REDACTED]." At 11:15 AM, when asked to clarify this order, the Director of Nursing (DON) said the order was, "for all of our residents who go outside on the grounds of the facility to keep them safe here on the grounds." The DON indicated that the order did not apply to residents who were off the grounds. When asked how the resident fell at the physician's office, the DON did not respond and stated that she had not interviewed the resident about the incident. The DON indicated that she was unaware of the ramp at the surgeon's office and that there were no inquiries regarding the grounds/surfaces at the office prior to sending the resident there for the first time. On 8/14/14 at 12 noon, the therapy director was interviewed regarding supervision during outside appointments for resident #706. The therapy director stated that the resident was able to go to dialysis appointments without facility staff supervision because the dialysis staff were trained in surface-to-surface transfers, the transportation company staff were not, so they would hand off the resident directly to dialysis staff. Now that the resident had fallen, the therapy director stated that the resident would go to appointments through a different company that had trained staff. On 8/14/14 at 1:30 PM, per review of physical/occupational therapy notes dated 8/6/14 thru 8/9/14: "Resident very lethargic this session;" "Very sleepy....demonstrates mild confusion;" "Resident complained of blurry vision and feeling dizzy;" "fell asleep twice;" "Very tired and weak today;" Ambulation attempted, but "only able to stand....weakness and fatigue;" "Very sleepy....difficult time staying awake." Per the resident's weekly "Physical Therapy Summary" dated 7/29/14, 8/5/14, and 8/13/14, resident #706 had not been tested for mobility over uneven surfaces. Per review of progress notes in resident #706's record: On 8/6/14-The resident was "very lethargic" and "unable to arouse" even after a sternal rub. The resident was transported to the hospital emergency room . He became "aggressive and attempting to hit staff" at the hospital. On 8/12/14 (the day after the fall at the surgeon's office)-The resident was again "very difficult to arouse," was transported back to the hospital, and returned the following morning (8/13/14) with a hospital [DIAGNOSES REDACTED]." On 8/15/14 at 11:25 AM, nurse unit manager 'A' was queried regarding interventions to keep the resident safe during outside appointments. The manager said, "If the resident is alert and oriented, we don't go with them to appointments. We call for transportation and they take them for appointments." The resident's fall care plan, which was revised by the manager on 8/14/14, noted that the resident fell while at the appointment, but did not add interventions regarding future transports by the other company or supervision for off the grounds appointments. Manager 'A' created a care plan dated 8/14/14 that noted: Resistive/noncompliant with treatment/care.... related to pain, weakness." On 8/15/14 at 10 AM, review of the facility's policy on "Leave of Absence: Patient" dated 3/2010 did not address supervision during outside appointments. The "Falls Practice Guide" dated 2011 noted: "The care plan is revised as clinically indicated to meet the patient's current needs." ( )

This citation pertains to intake number MI 559 Based on observation, interview and record review, the facility failed to provide adequate and appropriate care to treat and prevent pressure sores for one (#508) of two sampled residents reviewed for pressure sores from a total of ten sampled residents, resulting in a newly developed Left Heel Stage II pressure ulcer with complaints of pain, and the worsening of a Stage II pressure ulcer to a Stage III pressure ulcer. Findings include: On 10/1/13 at 1:00 p.m., the Director of Nursing (DON) reported Resident # 508'S left heel pressure ulcer was acquired at the facility. The DON reported, "She (#508) has a history of non-compliance and she can't really move her legs. She is paralyzed and has been bedridden for 2-3 years." The DON was asked whether a wound specialist was involved with the resident's care and stated, "We don't have a wound care specialist. The nurses do daily treatments and we do wound rounds weekly, but "RN G" is wound certified." On 10/1/13 at 3:09 p.m., Resident #508 was observed in her room sitting in a wheelchair and a bulky dressing was observed on her left foot. Both of the resident's feet rested on and against the foot rest of the wheelchair. Resident #508's heels were not elevated. During an interview, Resident #508 reported, "I had no problems with my heel before I came here. I got it (pressure sore) from my feet pressing on the bed." When asked if she refused to be repositioned or refused to wear protective heel boots to minimize/reduce pressure to the area, Resident #508 said "No, I just do whatever they tell me to do." On 10/1/13 at 3:50 p.m., during a wound care observation, Resident #508 was observed in bed laying on her back and the heels of her foot were resitng on the bed--Resident #508 was not wearing protective heel boots and her heels had not been not elevated. "RN E" removed the dressing from Resident #508's left heel to reveal a scant amount of serosanguinous (blood tinged) drainage. There was no odor noted and described the area as a Stage II pressure sore to her left heel which measured 5 cm (centimeters) x (by) 5.4 cm with a pink base. "RN E" used a 4 x 4 gauze dressing and normal saline solution to cleanse the wound. As the wound was being cleaned, Resident #508 grimaced and said "Ouch! That hurts." "RN E" proceeded to apply Z-Guard (skin protectant) to the wound and covered it with a dry dressing. When asked how Resident #508 acquired a Stage II pressure ulcer to her left heel, "RN E" reported, "I honestly think she (#508) got it from her heels not being elevated." On 10/2/13 at 9.32 a.m., during an interview, the Director of Nursing (DON) reported, resident #508 was provided with a specialty mattress and a special cover that was placed over her mattress to absorb moisture. The DON stated, "She had Prevalon boots but she doesn't really care for them. She favors one side over the other and she resists care and is non-compliant." When asked to provide documented evidence of Resident #508's history of non-compliance, the DON was unable to do so. During the onsite investigation, the DON acknowledged changing and updating Resident #508's "Skin" care plan. When asked why the care plan had been altered prior to submitting it, the DON reported, "I'm sorry. I just made changes because we were conducting our own investigation of her pressure sores." A review of the facility's "Admitting Record" revealed that Resident #508 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The "Minimum Data Set" ((MDS) dated [DATE] revealed that #508 had no cognitive impairments for decision making and required extensive assistance of staff with all activities of daily living including bed mobility, transfers, dressing, hygiene, bathing and toileting. A review of #508's "Nursing Admission Assessment" dated 8/21/13 documented that #508 was admitted to the facility with, "two small open areas approximately 1.5 cm (centimeters) x (by) 1.5 cm and 1 cm x 0.5 cm buttocks reddened. Groin and inner thighs have red appearance. No open areas noted." The Nursing Admission Assessment revealed that #508 had no open areas to her left ischium or left heel on admission and had a Braden scale score of "13 = Moderate risk for skin breakdown." On 10/2/13 at 2:30 p.m., during an observation of #508's sacral pressure sore revealed that Resident #508's Stage II pressure sore had progressed--increasing in size and depth to a Stage III pressure ulcer. The wound had an irregular shape and measured 4 cm x 6 cm over the sacral area with a necrotic grayish center which "RN H" measured at 3 cm x 2.4 cm x 1.0 depth. The sacral wound's necrotic center was bordered by pink tissue. Resident #508 was identified with a third pressure ulcer, described as a Stage II pressure ulcer to her left ischium which revealed pink tissue and was measured by "RN H" at 3 cm x 1 cm. There was a slight odor emitted from #508's sacral wounds. When asked if #508's sacral wound had improved or worsened since her admission on 8/21/13, "RN H" replied, "It got worse but it's actually improving now." When queried about the left ischium pressure ulcer, "RN G" who was present during the dressing change reported, "It's a pressure ulcer. We'll take care of it right now." Review of the physician's orders dated 8/21/13 documented, "Clean coccyx with normal saline, pat dry, spray [MEDICATION NAME] to buttocks allow to dry, apply DuoDerm every five days and as needed." A physician's order dated 8/23/13 documented, "Discontinue weekly body assessment, start daily body assessment related to increased pressure sore risk." A physician's order dated 9/25/13 documented, "Clarify: Cleanse open area to sacral with normal saline, pat dry, apply Santyl (wound treatment) to necrotic ara and Z-Guard to surrounding open area and cover with Allevyn sacrum dressing daily and as needed." There was no physician's order which directed care of #508's newly developed Stage II left heel pressure sore or the newly identified pressure sore to #508's left ischium. Further, none of the above mentioned physician's orders had been signed by the physician. A physician's progress note dated 9/26/13 documented, "she (#508) has sacral ulcer and left heel ulcer." There was no assessment of #508's wounds and no legible orders written. A review of an "ADLs/RESTORATIVE CARE" document (Certified Nursing Assistant (CNA) care guide), undated, documented, "Pt (patient) to be turned and repositioned frequently to aide with pressure reduction, Dressing to left heel - alert nurse if dressing missing or soiled, Prevalon boots to bilateral feet." Resident #508 was not observed with Prevalon boots to her bilateral feet during the entirety of the investigation. Further, #508 had not been repositioned frequently, in order to offload pressure. On 10/3/13 at 3:00 p.m., a review of the facility's "Skin Practice guide" dated 1/2013 documented, "Prevention Interventions: Reposition frequently in bed and chair, Complete thorough skin observations, Elevate heels."

REFER TO INTAKE MI 363. BASED ON INTERVIEWS AND CLOSED RECORD REVIEW, THE FACILITY FAILED TO ASSESS AND MONITOR THE CONDITION OF THE SKIN UNDER A KNEE IMMOBILIZER FOR 1 (#500) OF 4 SAMPLED RESIDENTS REVIEWED FOR WOUNDS FROM A TOTAL SAMPLE OF 8, RESULTING IN THE DEVELOPMENT OF A NECROTIC PRESSURE SORE ON RESIDENT #500'S RIGHT POSTERIOR LOWER LEG. FINDINGS INCLUDE: RESIDENT #500, AN [AGE] years OLD FEMALE, WAS admitted to the facility on [DATE], ACCORDING TO THE ADMISSION RECORD. THE RESIDENT WAS discharged HOME WITH HOSPICE CARE ON 11/24/12, ACCORDING TO A NURSING PROGRESS NOTE. THE RESIDENT WAS NOT IN THE FACILITY DURING THE COMPLAINT INVESTIGATION. RESIDENT #500, ACCORDING TO A 10/31/12 HOSPITAL TRANSFER FORM, HAD BEEN admitted TO THE FACILITY AFTER SUSTAINING A FRACTURED OF THE RIGHT FEMUR (THIGH BONE) THAT REQUIRED surgery for [REDACTED]. A PHYSICIAN'S HISTORY & PHYSICAL (H&P) REPORT FOR RESIDENT #500, DATED 11/5/12, DOCUMENTED ADDITIONAL DIAGNOSES, INCLUDING HYPERTENSION, A HEART ARRHYTHMIA, [MEDICAL CONDITION], A HISTORY [MEDICAL CONDITION] IN THE 1990'S, [MEDICAL CONDITION], KYPHOSCOLIOSIS (CURVATURE OF THE SPINE), A HISTORY OF DEEP VEIN [MEDICAL CONDITION] (CLOT), [MEDICAL CONDITION], AND DEMENTIA. AT THE TIME OF THIS H&P REPORT, DESPITE RESIDENT #500'S HISTORY OF DEEP VEIN [MEDICAL CONDITION], THE H&P DOCUMENTED THAT THE COLOR AND CIRCULATION OF RESIDENT #500'S LOWER EXTREMITIES WERE WITHIN NORMAL LIMITS. SENSATION, ALSO, WAS WITHIN NORMAL LIMITS. A NURSING PROGRESS NOTE, DATED 11/4/12, DOCUMENTED THAT RESIDENT #500 WAS ALERT WITH CONFUSION. A NURSING ADMISSION ASSESSMENT, DATED 11/3/12, DOCUMENTED THAT RESIDENT #500 REQUIRED ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING, REQUIRED SCHEDULED PAIN MEDICATION, HAD "BILATERAL SOFT HEELS," AND THAT HER "LEFT LEG HAS INCISION WITH 42 STAPLES" (SURGERY ON RIGHT LEG). A BRADEN SCALE INDICATED THAT THE RESIDENT WAS AT MODERATE RISK FOR PRESSURE SORES. THE NURSING ADMISSION ASSESSMENT INCLUDED NO ASSESSMENTS OF RESIDENT #500'S LOWER EXTREMITIES, DESPITE THE RECENT SURGERY OF THE RIGHT LEG AND THE PRESENCE OF A RIGHT KNEE IMMOBILIZER AND PRESSURE RELIEF ANKLE FOOT ORTHOTIC (PRAFO) BOOTS. ACCORDING TO RN (REGISTERED NURSE) #4, INTERVIEWED ON 12/7/12 AT 3 P.M., RESIDENT #500 WAS admitted WITH A KNEE IMMOBILIZER AND BILATERAL PRAFO BOOTS. (PRAFO BOOTS ARE BRACES THAT EXTEND FROM THE TIP OF THE TOES TO THE MID-CALF. THEY ARE MADE OF A [MEDICATION NAME] CALF SEGMENT WITH A CHANNEL INTO WHICH AN ANATOMICALLY FORMED UPRIGHT STRUCTURE OF ALUMINUM OR STAINLESS STEEL FITS. THE UPRIGHT AND THE CALF SEGMENTS ARE ATTACHED WITH BRASS SCREWS AND RETAINERS.) THE KNEE IMMOBILIZER, ACCORDING TO RN #4, EXTENDED FROM RESIDENT #500'S MID-THIGH TO MID-CALF. (THE USE OF A DEVICE, SUCH AS A KNEE IMMOBILIZER OR PRAFO BOOTS, CAN RESULT IN PRESSURE POINTS AND WOUNDS, IF ASSESSMENTS ARE NOT ONGOING.) RN #4 COULD NOT FIND A physician's orders [REDACTED]. A NURSING "TASK LIST" DATED 11/4/12 INDICATED THE FOLLOWING: "WEIGHT BEARING STATUS - SPECIFY ANY WEIGHT BEARING REQUIREMENTS REMOVE DAILY WITH CARE AND REPLACE (WEIGHT BEARING AS TOLERATED WITH RIGHT LEG IMMOBILIZER)." THIS WAS IDENTIFIED ON THE TASK LIST AS A NURSING ASSISTANT AND LICENSED NURSE RESPONSIBILITY. ONE NURSING PROGRESS NOTE FOR RESIDENT #500 DATED 11/5/12 DOCUMENTED, "RESIDENT WAS LETHARGIC MOST OF SHIFT MD (PHYSICIAN) CHANGED SCHEDULED [MEDICATION NAME] TO PRN (AS NEEDED), AND ALSO WANTS BRACE TO RIGHT LEG LEFT ON AT ALL TIMES." THE ORDER FOR THE "BRACE" (PROBABLY THE KNEE IMMOBILIZER) WAS NOT WRITTEN AS A physician's orders [REDACTED]. RESIDENT #500 HAD A CARE PLAN, DATED 11/4/12, ADDRESSING "AT RISK FOR ALTERATION IN SKIN INTEGRITY RELATED TO INCONTINENCE, NUTRITIONAL DEFICIT, IMPAIRED MOBILITY." RESIDENT #500 ALSO HAD A CARE PLAN DATED 11/4/12 ADDRESSING "RIGHT KNEE SURGICAL INCISION RELATED TO RECENT SURGERY." NEITHER CARE PLAN INCLUDED ANY INTERVENTIONS ADDRESSING THE KNEE IMMOBILIZER. ACCORDING TO RN #4, INTERVIEWED ON 12/7/12 AT 3 P.M., THERE WERE NO NURSE'S NOTES FOR RESIDENT #500 DOCUMENTING ANY ASSESSMENTS OF HER LOWER EXTREMITIES, CONSIDERING THE RECENT FEMUR FRACTURE AND SURGICAL REPAIR AND THE RISK OF PRESSURE SORES RELATED TO THE KNEE IMMOBILIZER AND PRAFO BOOTS. (ASSESSMENTS WOULD INCLUDE SKIN COLOR AND TEMPERATURE, SWELLING, SKIN DISCOLORATION OR WOUNDS, PULSES, PAIN OR TENDERNESS, CAPILLARY REFILL, AND MOVEMENT.) RN #4 SAID THAT ON 11/6/12, SHE (#4) PERFORMED HER "SKIN SWEEP" ON RESIDENT #500, OBSERVING FOR WOUNDS AND PRESSURE SORES. RN #4 SAID THERE WERE NO WOUNDS AT THAT TIME. NO WOUNDS WERE DOCUMENTED ON THE "SKIN WORKSHEET" ALTHOUGH RESIDENT #500'S RIGHT BUTTOCKS AREA WAS DESCRIBED AS "PINK" AND HER BILATERAL HEELS WERE DESCRIBED AS "DRY." RN #4 SAID THAT ON 11/13/12, SHE (#4) ASSESSED THE SKIN ON RESIDENT #500'S UPPER BODY, BUT THAT SHE DID NOT ASSESS THE RESIDENT'S LOWER EXTREMITIES. RN #10, INTERVIEWED ON 12/10/12 AT 11:15 A.M., SAID SHE PROVIDED CARE FOR RESIDENT #500 ON 11/10/12, 11/11/12, AND 11/12/12 DURING THE DAY SHIFT. SHE SAID SHE REMOVED THE KNEE IMMOBILIZER AND PRAFO BOOTS EACH DAY AND OBSERVED THE SKIN UNDER BOTH DEVICES. SHE SAID THAT SHE (#10) DID NOT FIND ANY SKIN BREAKDOWN. SHE SAID SHE DID NOT DOCUMENT HER ASSESSMENTS. RN #11, INTERVIEWED ON 12/10/12 AT 11:45 A.M., SAID SHE PROVIDED CARE FOR RESIDENT #500 ON 11/13/12 DURING THE DAY SHIFT. THE NURSE SAID SHE DID NOT ASSESS THE RESIDENT'S LOWER EXTREMITIES PRIOR TO A COMMUNITY APPOINTMENT WITH HER ORTHOPEDIC SURGEON ON 11/13/12. ACCORDING TO THE ORTHOPEDIC SURGEON'S DOCUMENTATION FOR RESIDENT #500'S VISIT ON 11/13/12, HE REMOVED THE STAPLES FROM RESIDENT #500'S SURGICAL INCISION. THE DOCUMENTATION FURTHER READ THAT THE SURGEON DID NOT SEE EVIDENCE OF ANY BLOOD CLOTS IN THE RIGHT LOWER EXTREMITY, AND THE CIRCULATION IN THE LEG APPEARED WITHIN NORMAL LIMITS. THE ORTHOPEDIC SURGEON DID DOCUMENT THAT AT THE TIME OF THAT COMMUNITY APPOINTMENT, RESIDENT #500 HAD A "STAGE 2 ULCER POSTERIOR LEG, 2 CM X 3 CM, NO CLINICAL SIGNS OF INFECTION." THE SURGEON WROTE an order for [REDACTED]. A FAMILY MEMBER WHO ACCOMPANIED RESIDENT #500 TO THE ORTHOPEDIC SURGEON'S OFFICE ON 11/13/12 WAS INTERVIEWED BY TELEPHONE ON 12/12/12 AT 4:30 P.M. THE FAMILY MEMBER SAID THAT RESIDENT #500'S RIGHT LOWER EXTREMITY WOUND WAS LOCATED AT THE LOWER EDGE OF THE KNEE IMMOBILIZER. THE BOTTOM OF THE KNEE IMMOBILIZER HAD BLOOD ON IT WHERE IT HAD RUBBED AGAINST THE WOUND. THE FAMILY MEMBER REPORTED THAT THE ORTHOPEDIC SURGEON HAD SAID THAT RESIDENT #500 SHOULD NOT CONTINUE WEARING THE KNEE IMMOBILIZER BECAUSE IT HAD CAUSED A PRESSURE SORE ON HER LEG. RN #11, INTERVIEWED ON 12/10/12 AT 11:45 A.M., SAID SHE PARTIALLY TOOK THE DRESSING OFF RESIDENT #500'S WOUND, WHICH HAD BEEN PLACED DURING THE APPOINTMENT WITH THE ORTHOPEDIC SURGEON, AND OBSERVED A "NICE-SIZED AREA OF ESCHAR (DEAD, DEVITALIZED TISSUE) ON THE WOUND BED." (A WOUND COVERED BY ESCHAR IS DESCRIBED AS A NON-STAGEABLE WOUND. IT IS NOT A STAGE 2 WOUND.) RN #11 SAID SHE NOTIFIED RESIDENT #500'S PHYSICIAN AND THE NURSE MANAGER ABOUT THE WOUND. RN #11 SAID SHE DID NO ASSESSMENTS OF THE WOUND AND PROVIDED NO TREATMENT TO THE WOUND ON RESIDENT #500'S RIGHT LEG. RN #4, INTERVIEWED ON 12/7/12 AT 3 P.M., SAID SHE ASSESSED AND DOCUMENTED RESIDENT #500'S RIGHT LOWER EXTREMITY WOUND ON 11/14/12 (A DATE OF 11/14/12 WAS WRITTEN OVER A DATE OF 11/15/12) ON THE PRESSURE ULCER HEALING RECORD. THE DOCUMENTATION WAS A "PUSH SCORE" WHICH IS DETERMINED BY CATEGORIZING THE ULCER WITH RESPECT TO ITS SURFACE AREA, EXUDATE, AND THE TYPE OF WOUND TISSUE. THE SURFACE AREA OF THE WOUND BED IS DETERMINED BY MULTIPLYING THE LENGTH OF THE WOUND BY THE WIDTH OF THE WOUND. THE EXACT MEASUREMENT OF THE WOUND BED WAS NOT DOCUMENTED. THE SURFACE AREA OF THE WOUND WAS BETWEEN 12.1 CM AND 24.0 CM, GIVING THE WOUND SURFACE AREA A SCORE OF "9" OF A POSSIBLE "10". A SCORE OF TEN SIGNIFIES THE LARGEST SURFACE AREA FOR A WOUND. THERE WAS NO EXUDATE FROM THE WOUND. THE WOUND BED WAS "NECROTIC TISSUE." THE TOTAL PUSH SCORE (SURFACE AREA, EXUDATE AMOUNT, AND TISSUE TYPE) WAS SCORED AS "13" OF A POSSIBLE TOTAL OF "17". A TREATMENT ORDER FOR RESIDENT #500'S RIGHT LOWER EXTREMITY WOUND WAS WRITTEN ON 11/15/12. THE TREATMENT TO BE PROVIDED TO RESIDENT #500 WAS TO CONSIST OF THE APPLICATION OF A LIQUID SKIN PROTECTOR AFTER CLEANSING THE WOUND WITH NORMAL SALINE. THE TREATMENT WAS ORDERED EVERY THREE DAYS. DIRECTOR OF NURSING (DON) #3, INTERVIEWED ON 12/7/12 AT 3 P.M., SAID THAT RESIDENT #500'S EXACT WOUND MEASUREMENTS SHOULD HAVE BEEN DOCUMENTED IN THE DAILY PROGRESS NOTES, IN ADDITION TO DOCUMENTING ON THE PRESSURE ULCER HEALING RECORD. THE DON SAID SHE ASSESSED THE WOUND ON 11/21/12. ACCORDING TO SKIN ALTERATION RECORD, DATED 11/21/12, THE WOUND BED MEASUREMENT AT THAT TIME WAS 6.8 CM BY 3.2 CM BY LESS THAN 0.1 CM. THE WOUND BED WAS DESCRIBED AS DESCRIBED AS "BLACK NECROTIC TISSUE." THERE WAS NO DRAINAGE. THE SURROUNDING SKIN WAS DESCRIBED AS BEING "REDDENED" WITH "[MEDICAL CONDITION] OR SWELLING." THE TOTAL PUSH SCORE WAS "14". THE DON, INTERVIEWED ON 12/7/12 AT 3 P.M., SAID RESIDENT #500'S RIGHT LOWER EXTREMITY WOUND WAS OBLONG IN SHAPE, BELOW THE KNEE, POSTERIOR, MID MUSCLE, IN AN AREA WHERE THE PRAFO BOOTS AND THE IMMOBILIZER MET. THE DON SAID THE WOUND WAS CONSIDERED A VASCULAR WOUND, ALTHOUGH THERE WAS NO PHYSICIAN DOCUMENTATION TO SUPPORT THE DON'S ASSERTION THAT THE WOUND WAS VASCULAR IN NATURE. THE DON DOCUMENTED THE FOLLOWING ON AN UNDATED "HIGH RISK NOTE" FOR RESIDENT #500: "DOPPLER (NON-INVASIVE TEST WHICH USES REFLECTED SOUND WAVES TO SEE HOW BLOOD FLOWS THROUGH A BLOOD VESSEL) COMPLETED ON 11/1/12 WAS VERY LIMITED AND THEY WERE UNABLE TO LOOK AT POPLITEAL VEIN AND LEG FOR FLOW. ASSESSMENT OF AREA SHOWED IRREGULAR, SHALLOW WOUND WITH [MEDICAL CONDITION], AND VENOUS STAINING PRESENT, COOL EXTREMITY, WITH LACK OF PULSE ON RIGHT, AND NO HAIR ON THE EXTREMITY. PATIENT (#500) HAD ANOTHER DOPPLER COMPLETED AT FACILITY THAT SHOWED BAKER'S CYST WITH FLUID IN RIGHT LOWER LEG CONSTRICTING FLOW. PER INVESTIGATION AND REVIEW WITH DOCTOR WOUND APPEARS TO BE ARTERIAL/VENOUS IN NATURE." FINDINGS FROM THE HOSPITAL DOPPLER STUDY FOR RESIDENT #500, DATED 11/1/12, CONCLUDED THAT "ALL IMAGED VESSELS DEMONSTRATE NORMAL COMPRESSION, FLOW AND DISTAL AUGMENTATION. CONTRALATERAL COMMON FEMORAL VEIN DEMONSTRATES NORMAL COMPRESSION, FLOW AND DISTAL AUGMENTATION." THERE WERE SIX IMAGED VESSELS WHICH DEMONSTRATED NORMAL FUNCTION. THE REPORT INDICATED THAT THE STUDY WAS UNABLE TO VISUALIZE THE POPLITEAL VEIN DUE TO AN INABILITY TO MANIPULATE THE EXTREMITY. THE FINAL IMPRESSION OF THE STUDY WAS "RIGHT LOWER EXTREMITY NEGATIVE FOR ACUTE [MEDICAL CONDITION] (DEEP VEIN [MEDICAL CONDITION]) TO THE EXTENT VISUALIZED." FINDINGS FROM THE DOPPLER STUDY FOR RESIDENT #500 DATED 11/21/12 CONCLUDED, "NEGATIVE RIGHT LEG VENOUS ULTRASOUND ...FINDINGS: NORMAL VENOUS FLOW AND GOOD COMPRESSIBILITY ARE SEEN IN ALL OF THE DEEP VEINS OF THE RIGHT LEG. NO [MEDICAL CONDITION] OR VENOUS OCCLUSION IS IDENTIFIED. THE LEFT COMMON FEMORAL VEIN IS NORMAL AS WELL. A 13 X 10 X 4 MM IN DIAMETER FLUID COLLECTION IN THE RIGHT POPLITEAL FOSSA REPRESENTS A BAKER'S CYST." THE REPORT DID NOT INDICATE THAT THE BAKER'S CYST CONSTRICTED BLOOD FLOW. BASED ON A LACK OF CLEAR EVIDENCE CONSISTENT WITH ARTERIAL VENOUS DISEASE, RESIDENT #500'S WOUND WAS CITED AS A PRESSURE ULCER. IN AN INTERVIEW ON 12/7/12 AT 3 P.M., THE DON SAID SHE UNDERSTOOD WHY THERE WERE CONCERNS WITH THE DEVELOPMENT OF A PRESSURE SORE WITH RESIDENT #500. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO DEVELOP EFFECTIVE INTERVENTIONS TO PREVENT FALLS FOR 4 RESIDENTS FROM 6 RESIDENTS REVIEWED FOR FALLS (#3, 7, 13 AND 10) FROM A TOTAL SAMPLE OF 15 RESIDENTS AND 1 OF 4 SUPPLEMENTAL RESIDENTS ( #18). THIS RESULTED IN THE IMMEDIATE JEOPARDY FOR RESIDENT #7 WHO SUSTAINED 15 FALLS FROM 2/11/11 TO 5/30/11 RESULTING IN THE POTENTIAL FOR HARM AND INJURY RELATED TO FALLS WITH FRACTURES NECESSITATING SURGERY, OR LOSS OF CONSCIOUSNESS, OR HEAD INJURY. THE TEAM IDENTIFIED THE IMMEDIATE JEOPARDY THE MORNING OF 6/17/11 AND THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 6/17/11 AT 1:04 P.M. THE IMMEDIATE JEOPARDY STARTED ON 2/27/11. THE IMMEDIATE JEOPARDY WAS REMOVED BUT NOT CORRECTED ON 6/20/11 AT 4:10 P.M. WHEN THE FACILITY'S REMOVAL PLAN WAS ACCEPTED. THE REMOVAL PLAN CONSISTED OF THE FOLLOWING: PROVIDING A SCOOP MATTRESS, 1:1 CONTINUOUS NURSING ASSISTANT CARE/SUPERVISION UNTIL THE RESIDENT IS DEEMED SAFE, REVISION OF THE RESIDENT #7'S FALL CARE PLAN, STAFF EDUCATION AND QUALITY ASSURANCE MONITORING. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED , THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AT HARM FOR PATTERN BECAUSE OF THE FALLS IDENTIFIED FOR 3 RESIDENTS #3, 10 AND 18 AND THE INVOLVEMENT OF THE QUALITY ASSURANCE COMMITTEE TO ADDRESS, CORRECT AND SUSTAIN CORRECTION FOR FALLS. FINDINGS INCLUDE: ACCORDING TO THE SIGNED PHYSICIANS ORDERS DATED 6/8/11, RESIDENT #7 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. THE FACILITY'S CARE PLAN FOR FALLS INITIATED ON 1/26/11 FOR RESIDENT #7, REFLECTED FOCUSES RELATED TO RISK FOR FALLS DUE TO PSYCHOTROPIC MEDICATIONS, IMPAIRED BALANCE/POOR COORDINATION, UNSTEADY GAIT, COGNITIVE IMPAIRMENT, POOR SAFETY AWARENESS AND LATE STAGE DEMENTIA. THE FACILITY'S CARE AREA ASSESSMENT (CAA) SIGNED, DATED, AND COMPLETED ON 2/1/11 REFLECTED THE RESIDENT HAD IMPAIRED BALANCE DURING TRANSITIONS, DISTURBANCES OF BALANCE, GAIT, POSTIONING ABILITY, SEDATION MANIFESTED BY SHORT-TERM MEMORY LOSS, DECLINE IN COGNITIVE ABILITY, SLURRED SPEECH, AND DROWSINESS. IN ADDITION, THE ADMINISTRATOR'S VOICE MESSAGE FROM 6/17/11 REVEALED THE RESIDENT HAD FALLEN AT HOME ON 1/3/11 RESULTING IN A BLACK AND BLUE LEFT EYE. ACCORDING TO SIGNED physician's orders [REDACTED]. BOTH MEDICATION'S SIDE EFFECTS CAN INCREASE THE RISK OF FALLS. THE RESIDENT HAD FIFTEEN FALLS BETWEEN 1/25/11 AND 6/17/11; A PERIOD OF 5 MONTHS. THE INCIDENT REPORTS (IR)FOR EACH DATE REFLECTED THE FOLLOWING: 1. 2/11/11 AT 2:30 A.M. PRESSURE SENSITIVE ALARM (PSA) SOUNDING. PATIENT (PT) IN DOORWAY OF BATHROOM (BR) SITTING ON FLOOR GRIPPER SOCKS ON PT STATED SHE HAD TO GO TO THE BR AND LOST HER BALANCE. CORRECTIVE ACTION (CA) RE-EDUCATED ON USE OF CALL LIGHT (CL) AND WAITING FOR HELP. THE FALLS CARE PLAN DID NOT HAVE ANY INTERVENTIONS NOTED AFTER THE FALL AND THERE WERE NO NOTES FOUND RELATED TO INTERVENTIONS IMPLEMENTED FROM THE FACILITY'S INTERDISCIPLINARY TEAM (IDT). 2. 2/27/11 AT 2:57 P.M. PT GOT UP FROM WHEELCHAIR (W/C) SLID ON FLOOR, ALARM SOUNDING. CA: WHEELCHAIR W/C WILL BE CHANGED FOR SMALLER W/C THAT FIT RES SUFFICIENT. INTERDISCIPLINARY PROGRESS NOTES (IDT REVIEW 3/2/11) RECOMMENDED THE RESIDENT TO BE ON A LAY DOWN SCHEDULE AFTER MEALS AND ANTI-TIPPERS FOR W/C. DYCEM (A NON-SKID PAD) AND W/C CUSHION IN PLACE. THE FALLS CARE PLAN (CP) DID NOT REFLECT RES SHOULD HAVE A SMALL W/C THAT WOULD FIT RES SUFFICIENTLY, LAY DOWN SCHEDULE AFTER MEALS, NOR DID IT REFLECT ANTI-TIPPERS FOR W/C OR DYCEM AS INTERVENTIONS. THE FACILITY DID NOT INTEGRATE THE CORRECTIVE ACTION INTO THE CARE PLAN FOR CONSISTENT IMPLEMENTATION. 3. 3/13/11 AT 4:00 P.M. PT WAS TRYING TO GET HER WATER AND SLID OUT OF CHAIR ON TO FLOOR ON HER BUTTOCKS. CA: VITAL SIGNS (VS), RANGE OF MOTION (ROM), AND ASSISTED BACK TO W/C. THE IDT NOTES 3/14/11 RECOMMENDED WATER TO BE KEPT WITHIN REACH WHILE AT NURSES STATION AND AT BEDSIDE. PSA ALARM TO W/C AND DYCEM ALREADY IN PLACE. THE FALLS CP DID NOT REFLECT THAT WATER SHOULD BE KEPT AT BEDSIDE, OR DYCEM AS AN INTERVENTION. THE RECOMMENDATIONS WERE NOT INTEGRATED INTO THE CARE PLAN FOR CONSISTENT IMPLEMENTATION. 4. 4/3/11 AT 3:27 P.M. ALARM SOUNDING RESIDENT (RES) ROOMMATE CALLING OUT RESIDENT (RES) FOUND ON KNEES ON SAFETY FLOOR MAT BED LOW. CA: ASKED BOTH RES TO USE CALL LIGHTS FOR HELP. THE IDT NOTES 4/4/11 REFLECTED PIW (PATIENT INFORMATION WORKSHEET USED BY NURSING ASSISTANTS WHEN GIVING CARE) TO BE UPDATED. NO OTHER INTERVENTIONS WERE LISTED. THERE WAS NO EVALUATION WHETHER THE USE OF THE CALL LIGHT WHICH WAS LISTED AS AN INTERVENTION FROM THE FALL OF 2/11/11 WAS EFFECTIVE AND NO RATIONALE WHY THIS WAS CONTINUED SINCE RESIDENT #8 HAS ADVANCED DEMENTIA. 5. 4/6/11 AT 10:33 A.M. RESIDENT INTENTIONALLY PUT SELF ON FLOOR AFTER SHOWER, NO INJURIES NOTED WHEN ASK WHY SHE DID THIS "I DON'T WANT TO LIVE". CA: SENT TO HOSPITAL FOR PSYCH EVAL. FAMILY AND DR. AWARE. IDT NOTES 4/6/11 INTERVENTION REFLECTED RES TO HAVE BED BATH AND NO SHOWERS, WHICH WAS NOT FOUND ON THE FALLS CP. THERE WAS NO FOLLOW THROUGH FROM CORRECTIVE ACTIONS TO THE CARE PLAN FOR ALL STAFF TO BE AWARE AND IMPLEMENT. 6. 4/23/11 AT 10:00 A.M. RESIDENT STATES. I LAY ON THE FLOOR. EVERY TIME I AM UP IN CHAIR. I AM GOING TO LAY ON THE FLOOR. I WANT TO DIE. CA: VS TAKEN SKIN ASSESSMENT DONE. NO INJURIES. DENIES PAIN. FAMILY DOCTOR CALLED. IDT NOTES 4/27/11: INTERVENTION WILL BE PUT IN PLACE TO ASSIST TO BED OR UP IN CHAIR WHEN REQUESTED. THE INTERVENTION WAS NOT ADDED TO THE FALLS CP. NO INTEGRATION BETWEEN THE IDT NOTES TO THE CARE PLAN. 7. 5/1/11 AT 2:30 P.M. OBSERVED PT WITH KNEE ON MAT ON FLOOR AND ARMS ON THE BED. ROM DONE. NO COMPLAINTS OF (C/O) PAIN. CA: CONTINUE BILATERAL MATS TO FLOOR, LOW BED, AND PSA ALARMS TO BED AND W/C. 8. 5/1/11 AT 10:15 P.M. ALARM SOUNDING. PT OBSERVED LYING ON MAT ON FLOOR. CA: PT IN W/C AT NURSES STATION. PSA CONTINUES TO W/C AND BED. LOW BED AND BILATERAL MATS TO FLOOR. IDT NOTES 5/2/11: INTERVENTIONS ARE PSA IN BED AND W/C, LOW BED WITH MATS (PREVIOUSLY IN PLACE NOT A NEW INTERVENTION), SENIOR WELLNESS MEDICATION CHANGE RECOMMENDATION. THE INTERVENTION NOT FOUND ON THE FALLS CP. NO INTEGRATION OF IDT NOTES TO CARE PLAN. THERE WAS NO ANALYSIS OF WHY RESIDENT #7 ENDS UP ON FLOOR MAT OR WHETHER THIS MAY BE CORRELATED TO HER VERBALIZATION FROM 4/6/11 OF WANTING TO DIE. 9. 5/9/11 AT 8:00 A.M. IN DINING ROOM (D. RM) FOR BREAKFAST AND GOT OUT OF W/C ATTEMPTED TO WALK AND fell on FLOOR BY DINING RM. CA: CHECKED FOR INJURIES AND PLACED BACK IN BED. IDT NOTES 5/9/11: IF IN DINING ROOM, PLACE W/C UP TO TABLE WITH W/C LOCKED WILL BE IMPLEMENTED. THE INTERVENTION WAS NOT FOUND ON THE FALLS CP; NO CORRELATION BETWEEN THE CA AND CP. 10. 5/14/11 AT 5:30 A.M. OBSERVED ON FLOOR LYING ON RIGHT SIDE WITH W/C BEHIND HER. ALARM ON AND SOUNDING. W/C WAS NOT LOCKED. A CA REPORT WAS NOT FOUND. AN IDT REPORT WAS NOT AVAILABLE IN THE INTERDISCIPLINARY PROGRESS NOTES (IPN). THERE WAS NO ROOT CAUSE ANALYSIS FOR THIS INCIDENT. 11. 5/15 AT 3:30 P.M. ALARM SOUNDING FOUND ON MAT BESIDE BED LAYING ON HER STOMACH. CA: ASKED RES TO USE CL FOR HELP BEFORE TRYING TO GET OUT OF BED (CL USE INTERVENTION NOT EFFECTIVE) . AN IDT REPORT WAS NOT AVAILABLE IN THE IPN. 12. 5/17/11 AT 9:30 P.M. OBSERVED LYING ON FLOOR ON RIGHT SIDE OF THE BED ON FLOOR MAT. A CA REPORT WAS NOT FOUND. IDT NOTES 5/18/11: WILL REQUEST FAMILY, HOSPICE AND CENTER MEETING TO DISCUSS CURRENT RECOMMENDATIONS FROM BOTH PSYCH GROUPS AND SAFETY ISSUES. ON 6/20/11 AT 12:20 P.M. ACCORDING TO RESIDENT'S #7 HOSPICE NURSE (STAFF "Y" WHO HAS CARED FOR HER SINCE 12/2010 TO CURRENT), THE FACILITY HAD NEVER INFORMED STAFF "Y" OF ANY FALLS THAT HAD OCCURRED WITH THE RESIDENT. 13. 5/19/11 AT 4:00 P.M. NA WAS ABOUT TO TRANSFER RES FROM W/C TO BED WHEN RES JUST SLID OUT OF THE W/C TO THE FLOOR WITH THE HELP OF CNA. CA: AS DESCRIBED IN REPORT. THERE WAS NO FURTHER INVESTIGATION OF WHETHER THE CNA COULD HAVE PREVENTED HER OR STOPPED RESIDENT # 7 FROM SLIDING; WAS THE TRANSFER TECHNIQUE APPROPRIATE? 14. 5/21/11 AT 8:30 A.M. ALARM GOING OFF, OBSERVED RES HAD SLID OUT OF THE BED ONTO HER RIGHT SIDE/BOTTOM. CA: FALL PRECAUTIONS ALREADY IN PLACE. THE IDT NOTE FOR BOTH 5/19/11 AND 5/21/11: PHYSICAL THERAPY TO SCREEN REGARDING DECLINES. SCOOP MATTRESS IMPLEMENTED. WILL EVALUATE FOR GERI CHAIR FOR POSITIONING. ON 6/20/11 AT 12:20 P.M. STAFF "Y" STATED, "THE RESIDENT HAD NEVER HAD A SCOOP MATTRESS (A MATTRESS WITH HIGHER/RAISED SIDES USED TO MAKE IT HARDER FOR RESIDENTS TO GET UP ALONE) SINCE ADMISSION". 15. 5/30/11 AT 1555 FOUND ON MAT BESIDE LOW BED ALARM NOT SOUNDING DUE TO RES LEG STILL ON BED. RES STATED I WAS JUST GOING TO GET UP. CA: ASKED RES TO USE CL FOR HELP BEFORE TRANSFERRING SELF OUT OF BED. IDT NOTES 5/31/11: "...NURSING WILL MONITOR HER UP IN CHAIR, DOWN IN BED SCHEDULE TO DETERMINE RESIDENT'S TOLERANCE OF BEING UP IN CHAIR OR IN BED". THE FALLS CP DID NOT REFLECT THE INTERVENTION. DURING THE INITIAL TOUR THAT STARTED AT 10:49 A.M. ON 6//14/11, THE RESIDENT WAS OBSERVED IN BED WITH HER EYES CLOSED. RESIDENT #7'S BED HAD A METAL FRAME, BILATERAL MATS (CUSHION FLOOR DEVICE USED TO HELP DECREASE THE IMPACT OF FALLS) ON THE FLOOR, AND NO SCOOP MATTRESS. THE SCOOP MATTRESS WAS OBSERVED ON 6/20/11 AT 9:50 A.M. ON 6/16/11 AT 11:55 A.M., RESIDENT #7 WAS IN BED AND COULD NOT BE SEEN FROM THE HALLWAY, BECAUSE HER PRIVACY CURTAIN WAS CLOSED. UPON ENTERING THE ROOM, THE RESIDENT'S CL WAS OBSERVED ON THE FLOOR OUT OF THE RESIDENT'S REACH. LATER ON THE SAME DAY AT 12:21 P.M., RESIDENT #7 WAS IN BED AND COULD NOT BE SEEN FROM THE HALLWAY, BECAUSE HER PRIVACY CURTAIN WAS CLOSED. . UPON ENTERING HER ROOM, HER CL WAS STILL ON THE FLOOR. AFTER EXITING THE RESIDENT'S ROOM, THE DIRECTOR OF CARE DELIVERY (STAFF "R") WAS INFORMED THAT THE RESIDENT'S CL WAS ON THE FLOOR AT 12:25 PM. THE CURRENT NURSING ASSISTANT PLAN OF CARE (KARDEX), THAT WAS PRINTED FROM THE COMPUTER BY THE DIRECTOR OF NURSING (DON) 6/14/11 AT 5:00 PM REFLECTED THE FOLLOWING: "SAFETY/RESTRAINTS" SECTION: ENSURE THAT ALARM/DEVICE (PSA) IS IN PLACE WHEN IN W/C BED, LID FOR HOT LIQUIDS, LOW BED WITH MATS, LOW BED WITH SCOOP/PERIMETER MATTRESS". THE KARDEX DID NOT REFLECT THE OTHER INTERVENTIONS LIKE TO KEEP WATER ON BEDSIDE TABLE IN REACH, DYCEM/CUSHION FOR WHEELCHAIR, resident had a history of [REDACTED]. THESE WERE NOTED AS CORRECTIVE ACTIONS THAT WERE NOT INTEGRATED THROUGHOUT THE DIFFERENT DOCUMENTS USED BY STAFF TO KNOW ABOUT HER CARE PLAN. BASED ON THE FACILITY'S CORRECTIVE ACTIONS/RECOMMENDATIONS NOTED ABOVE, THE FACILITY FAILED TO REVIEW THE INTERVENTIONS FOR THE FALLS FOR THEIR EFFECTIVENESS, CONSISTENT IMPLEMENTATION OF INTERVENTIONS, ASSESSMENT OF THE ROOT CAUSE/PATTERN/TREND OF THE RESIDENT'S REPEATED FALLS (I.E., 10 OF 15 FALLS OCCURRED DURING SECOND SHIFT), AND DEVELOP DIVERSIONAL ACTIVITIES TO ENGAGE THE RESIDENT TO PREVENT REPEATED FALLS. BASED ON OBSERVATION (6/14/11 TO 6/20/11), THE RESIDENT'S ROOM WAS WITHOUT ANY VISUAL STIMULATION. THE RESIDENT HAD NO PHOTOS, PICTURES, OR RADIO IN HER ROOM. THE CLOCK THAT WAS IN THE RESIDENT'S ROOM REFLECTED INACCURATE TIMES. ON 6/16/11 THE ACTUAL TIME WAS 11:55 AM, AND THE CLOCK REFLECTED 7:18. ON 6/20/11 THE ACTUAL TIME WAS 11:38 AM, AND THE CLOCK REFLECTED 8:45. THE FACILITY'S PHYSICIAN'S PROGRESS NOTES DATED 1/24/11 TO 6/8/11, HAD ONLY ONE NOTE RELATED TO HER FALLS THAT WAS DATED 5/15/11. ON THAT DATE THE DOCTOR WROTE, "PT. HAS BEEN FALLING REPEATEDLY. THESE ARE NOT REAL FALLS BUT BEHAVIORAL MANIFESTATIONS. OFTEN SHE CHOOSES TO GO TO THE FLOOR..." UPON REVIEW OF THE INCIDENT ACCIDENT REPORTS FOR THE RESIDENT, THEY REFLECTED TIMES WHEN SHE WAS TRYING TO REACH FOR WATER AND ATTEMPTING TO STAND , NOT JUST CHOOSING TO GO TO THE FLOOR. NONE OF THE FIFTEEN INCIDENT ACCIDENT REPORTS REFLECTED A SIGNATURE FROM A PHYSICIAN TO INDICATE THE PHYSICIAN'S INVOLVEMENT TO ANALYZE AND ADDRESS THE RESIDENT'S REPEATED FALLS OR REVIEWED THE REPEATED FALLS. ON 6/16/11 AT 5:25 PM THE ADMINISTRATOR WAS ASKED FOR INVESTIGATIONS RELATED TO RESIDENT #7'S REPEATED FALLS. THE ADMINISTRATOR STATED THAT THEY DID NOT DO A GOOD JOB WITH INVESTIGATIONS AT THE FACILITY. HOWEVER, SHE ADDED THAT THEY DID IDT REVIEWS, FALLS OFF CYCLE ASSESSMENT, AND PROVIDED A COPY OF THE FALLS PROCESS FLOW SHEET. THE FACILITY'S INVESTIGATION PROTOCOL WAS LOCATED IN FRONT OF THE INCIDENT ACCIDENT BINDER PRESENTED ON 6/15/11. SOME COMPONENTS OF THE OCCURRENCE INVESTIGATION FLOW CHART WERE AS FOLLOWS: EVENT OCCURS, COMPLETE PATIENT EVALUATION/ASSESSMENT, PRELIMINARY INVESTIGATION AND INCIDENT REPORT WITH NOTIFICATION TO FAMILY AND PHYSICIAN, IS THIS A TRIGGER EVENT? YES, THEN CONDUCT A: TRIGGER EVENT INVESTIGATION COMPLETE: INCIDENT REPORT WITNESS STATEMENTS. NONE OF THE STATEMENT OF WITNESS FORMS FOR ANY OF RESIDENT #7'S FALLS WERE AVAILABLE FROM 6/14/2011 TO 6/20/11. THE FORM WAS TO BE COMPLETED BY STAFF, INDICATING DATE OF INCIDENT AND INTERVIEW, PLACE OF INTERVIEW, AND STATEMENT OF WITNESS. THE ADMINISTRATOR DID NOT PRESENT ANY DOCUMENTATION RELATED TO STATEMENTS FROM STAFF WHO HAD WITNESSED FALLS, OR INVESTIGATIONS TO DETERMINE TIME FRAME AND/OR ROOT CAUSE FOR FALLS. THE FACILITY'S PROCEDURES WERE NOT CONSISTENTLY FOLLOWED FOR RESIDENT #7'S INCIDENT/ACCIDENT REPORTS. ( ) RESIDENT #13 WAS A [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE]. ACCORDING TO HIS FALLS CARE PLAN CREATED ON 4/8/11, THE RESIDENT HAD [DIAGNOSES REDACTED]. SINCE THE RESIDENT'S ADMISSION HE HAS HAD A TOTAL OF 7 FALLS (4 FALLS WERE WITH INJURY). THE FACILITY'S ADMISSION PHYSICIANS ORDERS DATED 6/13/11 REFLECTED THE RESIDENT WAS RECEIVING RISPERDAL 0.5 MG HALF A TABLET (ANTIPSYCHOTIC CENTRAL NERVOUS SYSTEM SIDE EFFECT: DIZZINESS, CARDIOVASCULAR SIDE EFFECT HYPOTENSION, BOTH SIDE EFFECTS CAN INCREASE THE RISK OF FALLS) ORALLY AT NIGHT. THE [DIAGNOSES REDACTED]. THE RESIDENT HAD FALLS BETWEEN 5/23/11 AND 5/29/11. THE INCIDENT REPORTS (IR)FOR EACH DATE REFLECTED THE FOLLOWING: ON 5/23/11 AT 0530 RESIDENT #13'S HEAD WAS BUMPED AGAINST A HEAD BOARD WHILE THE NURSING ASSISTANT (NA) LIFTED HIM UP IN BED. LUMP TO LEFT SIDE OF HEAD. NO CA OR IDT REVIEW REPORT WAS AVAILABLE. NO INVESTIGATION WAS AVAILABLE, ALTHOUGH THE RESIDENT MAY HAVE BEEN INJURED DURING A TRANSFER BY NURSING ASSISTANT (NA) 5/26/11 AT 1830 FALL WITH INJURY, THE TYPE OF INJURY WAS NOT INDICATED ON FORM. 5/28/11 AT 2300 FOUND LYING ON HIS RIGHT SIDE ON THE FLOOR IN FRONT OF WHEELCHAIR (W/C). TWO ABRASIONS NOTED ON RIGHT SIDE OF BACK. CA: NO INTERVENTIONS. 5/29/11 AT 1430 FOUND JUST INSIDE OF ROOM ON FLOOR. THE TYPE OF INJURY WAS NOT INDICATED, OTHER THAN POSSIBLE HEAD TRAUMA. THE CORRECTIVE ACTION (CA) FOR THE INCIDENT NOT AVAILABLE. AN INTERDISCIPLINARY TEAM (IDT) REVIEW SHEET WAS NOT PROVIDED. ACCORDING TO THE FACILITY'S "OCCURRENCE INVESTIGATION FLOW CHART" DATED 4/27/07, ONCE AN EVENT OCCURS AN INCIDENT REPORT SHOULD BE COMPLETED. THE INCIDENT REPORTS (IR) DATED 5/26/11, 5/28/11, AND 5/29/11 "CENTER ACTION: PATIENT FAMILY/GUARDIAN NOTIFICATION" SECTION WERE NOT COMPLETED. THE IR'S WITHOUT THE PREVIOUSLY NOTED INFORMATION, REFLECTED THE FOLLOWING: THE NURSE (STAFF "N") ON DUTY 5/23/11, NURSE (STAFF "BB") ON DUTY 5/26/11, NURSE (STAFF "CC") ON DUTY 5/28/11, AND NURSE (STAFF "F") ON DUTY 5/29/11 A.M. THE TIME FAILED TO COMPLETE THE IR FOR DATES LISTED. THE RESIDENT'S FAMILY MEMBER WAS NOT INFORMED OF THE INCIDENT. THE ADMINISTRATOR WAS NOT INFORMED OF THE INCIDENT. THE ADMINISTRATIVE DIRECTOR OF NURSING WAS NOT INFORMED OF THE INCIDENT THE MEDICAL DIRECTOR WAS NOT INFORMED OF THE INCIDENT THE FACILITY FAILED TO FOLLOW THEIR POLICY OF IR COMPLETION, AND FAILED IMPLEMENT CORRECTIVE ACTIONS/INTERVENTIONS AFTER A FALL, AND FAILED TO INVESTIGATE FALLS RELATED TO INJURIES. ( ) ACCORDING TO THE ADMITTING RECORD, PRINTED ON 6/16/2011, RESIDENT #10 WAS AN [AGE] year-old FEMALE ORIGINALLY admitted to the facility on [DATE] WITH A CURRENT admission date of [DATE]. THE [DIAGNOSES REDACTED]. THE PHYSICIAN'S PROGRESS NOTES, DATED 9/11/2010, REFLECTED THAT RESIDENT #10 WAS SEEN AND EXAMINED REGARDING A FALL WITH ABRASIONS BY A BOARD CERTIFIED FAMILY NURSE PRACTITIONER ON THAT DATE. THE NOTE REFLECTED THAT RESIDENT #10 HAD FALLEN IN ANOTHER RESIDENT'S ROOM WHERE SHE HAD BEEN FOUND PINNED BETWEEN THE HEATER AND HER WHEELCHAIR. THE PROGRESS NOTE ADDITIONALLY REFLECTED THAT RESIDENT #10 HAD SUSTAINED ABRASIONS ON HER LEFT LOWER BACK AND LEFT ELBOW. THE DIRECTOR OF NURSING WAS ASKED FOR DOCUMENTATION ABOUT THIS INCIDENT AND PRODUCED AN INCIDENT REPORT ON 6/20/2011 AT ABOUT 9:30 AM. THE ONE PAGE INCIDENT REPORT, DATED 9/11/2010, REFLECTED THAT THE RESIDENT HAD BEEN FOUND ON THE FLOOR AT 4:30 PM. THE FORM DID NOT RECORD THE VITAL SIGNS OF THE RESIDENT AT THE TIME OF THE INCIDENT. THE FORM DID NOT REFLECT AN EVALUATION OF THE CIRCUMSTANCES SURROUNDING THE FALL, AN EVALUATION OR ANALYSIS OF RESIDENT #10'S RISK FOR FALLS, INCLUDING MEDICAL CONDITIONS AND MEDICATIONS, AND DID NOT INCLUDE ANY INTERVENTIONS TO REDUCE THE FURTHER RISK OF FALLS. THE PHYSICIAN 'S PROGRESS NOTES, DATED 9/11/2011, REFLECTED THAT THE RESIDENT WAS TAKING THE MEDICATIONS HYDROCHLOROTHIAZIDE AND SEROQUEL AT THE TIME OF THE INCIDENT. ACCORDING TO THE NURSES' PERSONAL DIGITAL ASSISTANT DRUG REFERENCE SOFTWARE SUPPORTED BY EPOCRATES.COM AND UPDATED 6/13/2011, THE DRUG HYDROCHLOROTHIAZIDE REMOVES FLUID FROM THE BODY THROUGH THE KIDNEYS RESULTING IN INCREASED URINATION AND BOTH THE DRUGS HYDROCHLOROTHIAZIDE AND SEROQUEL CAN CAUSE A DROP IN BLOOD PRESSURE WITH AN ASSOCIATED DIZZY OR FAINTING SPELL. THE INCIDENT REPORT, DATED 9/11/2011, DID NOT REFLECT AN ASSESSMENT AS TO WHETHER OR NOT THE RESIDENT HAD BEEN REPORTING A NEED TO URINATE AT THE TIME OF THE INCIDENT AND DID NOT RECORD THE BLOOD PRESSURE OF RESIDENT #10 AT THE TIME OF THE INCIDENT. AN INCIDENT REPORT, DATED 1/12/2011, REFLECTED THAT AT 3:15 PM STAFF NOTED AN ALARM SOUNDING AND RESIDENT #10 WAS OBSERVED AMBULATING IN FRONT OF HER WHEEL CHAIR. THIS INCIDENT REPORT FURTHER REFLECTED THAT WHEN THE NURSE ATTEMPTED TO STOP THE RESIDENT, RESIDENT #10 SAT ON THE FLOOR. THIS FORM REFLECTED THAT THE CORRECTIVE ACTION WAS "AMBULATION PROGRAM; AMB(AMBULATE OR WALK) TO AND FROM DR (DINING ROOM) ALSO". HOWEVER, THIS INTERVENTION WAS ALREADY LISTED ON THE CARE PLAN AS: AMBULATE RESIDENT WITH WALKER EVERY SHIFT AND AS NEEDED WHEN RESTLESS. TAKE TO DINING ROOM WHEN IT IS TIME TO EAT. THIS INTERVENTION WAS INITIATED ON 12/19/2007. A COMPUTERIZED FORM TITLED "FALL(S) (OFF-CYCLE)", DATED 1/20/2011, REFLECTED THAT RESIDENT #10 SUSTAINED A FALL ON 1/20/2011 AT 2:00 PM. THE DOCUMENTATION SECTION OF THIS FORM REPORTED THAT RESIDENT #10 "WAS NEEDING TO USE THE BATHROOM, ATTEMPTING TO GO BY HERSELF" AND SHOULD BE PUT ON A TOILETING PATTERN NEEDS SCHEDULE. STAFF "D", THE REGISTERED NURSE UNIT MANAGER FOR THE B UNIT, ACCESSED THE COMPUTERIZED CHARTING SYSTEM ON 6/20/2011 AT ABOUT 3:00 PM, AND LOCATED A NOTATION THAT RESIDENT #10 WAS TO UNDERGO A THREE DAY OBSERVATION OF HER TOILETING PATTERN, BUT COULD NOT LOCATE THE RESULTS. STAFF "D" STATED THAT RESIDENT #10 CURRENTLY HAD NO TOILETING PLAN. THERE WERE TWO ENTRIES ON THE NURSE'S NOTES FOR RESIDENT #10 ON 1/21/2011. ONE OF THE ENTRIES WAS UNTIMED, THE OTHER TIMED 7:00 PM AND NEITHER ENTRY MENTIONED TOILETING. A NURSES NOTE ENTRY FOR 1/22/2011 AT 9:00 AM REFLECTED THAT TOILETING WAS OCCURRING EVERY TWO HOURS BUT DID NOT INDICATE IF THE RESIDENT HAD REMAINED CONTINENT OR IF THIS INTERVENTION WAS EFFECTIVE IN KEEPING RESIDENT #10 FROM ATTEMPTING TO TRANSFER HERSELF TO THE BATHROOM. AN ENTRY ON THE NURSE'S NOTES FOR RESIDENT #10 AT 6:00 AM DID NOT MENTION TOILETING. AN ADDITIONAL NOTE ON THAT DATE AT 9:00 AM REFLECTED THAT RESIDENT #10 WAS TOILETED EVERY TWO HOURS BUT DID NOT REFLECT THE OUTCOME OF THE TOILETING INTERVENTION. AN INTERDISCIPLINARY (IDT) PROGRESS NOTE FOR RESIDENT #10, DATED 1/31/2011, REFLECTED THAT RESIDENT #10 WAS OBSERVED TO STAND FROM HER WHEEL CHAIR AND THEN START TO BEND AT THE KNEES AND WAS ASSISTED TO SIT ON THE FLOOR. THE IDT NOTE RECOMMENDED THAT THE WALKING PROGRAM BE TEMPORARILY STOPPED FOR RESIDENT #10 AND THAT SHE BE REFERRED TO THE THERAPY PROGRAM FOR INTERVENTIONS. THE PHYSICAL THERAPY SUMMARY FORM, DATED 2/7/2011 REFLECTED THAT RESIDENT #10 WAS TREATED BY THE THERAPY DEPARTMENT FROM 1/31/2011 TO 2/4/2011 AND DID NOT MAKE ANY FUNCTIONAL GAINS. THE SECTION ON THE PHYSICAL THERAPY SUMMARY FORM FOR RECOMMENDATIONS WAS BLANK. A FORM TITLED "FALLS(S) (OFF-CYCLE)" REFLECTED THAT RESIDENT #10 HAD SUSTAINED A FALL ON 2/2/2011 AT 1:30 PM. THE FORM REFLECTED THAT RESIDENT #10 HAD STOOD UP FROM HER WHEEL CHAIR WHILE ATTEMPTING TO TRANSFER TO ANOTHER CHAIR AND LOST HER BALANCE AND fell BACKWARDS SITTING ON THE FLOOR AND PULLING THE CHAIR ON TOP OF HER. THE NEW INTERVENTION LISTED THAT A GAIT BELT WAS TO BE WORN AT ALL TIMES, AND THE RESIDENT WAS TO BE WALKED USING A WALKER AND A GAIT BELT TO THE DINING ROOM FOR MEALS. A CARE PLAN INTERVENTION HAD ALREADY BEEN INITIATED ON 12/19/2007 TO WALK RESIDENT #10. A FORM TITLED "FALLS(S) (OFF-CYCLE)" REFLECTED THAT RESIDENT #10 HAD SUSTAINED A FALL ON 2/2/2011 AT 2:00 PM. THE FORM REFLECTED THAT RESIDENT #10 HAD USED THE RAIL IN THE HALLWAY TO PULL HERSELF FORWARD AND HAD LOWERED HERSELF TO THE FLOOR. AN IDT REVIEW OF THESE TWO FALLS WAS RECORDED ON 2/3/2011 IN THE INTERDISCIPLINARY PROGRESS NOTES. THE NOTE DID NOT REFLECT AN ANALYSIS OF POSSIBLE CAUSES FOR THE FALLS, AN EVALUATION OR ANALYSIS OF RESIDENT #10'S RISK FOR FALLS, INCLUDING MEDICAL CONDITIONS AND MEDICATIONS, AND DID NOT INCLUDE ANY INTERVENTIONS TO REDUCE THE FURTHER RISK OF FALLS. THERE WAS NO NOTE THAT THE MEDICATIONS, VITAL SIGNS, TOILETING SCHEDULE, OR ACTIVITY INVOLVEMENT WERE REVIEWED. AN ACTIVITY PROGRESS NOTE OF 2/1/2011 REFLECTED THAT THERE HAD BEEN NO CHANGES IN PARTICIPATION SINCE HER READMISSION (ON 1/28/2011 ACCORDING TO THE ADMITTING RECORD PRINTED ON 6/16/2011). AN INCIDENT REPORT DATED 2/3/2011 REFLECTED THAT AT 4:30 PM ON THAT DATE, RESIDENT #10 WAS OBSERVED LYING ON HER RIGHT SIDE IN FRONT OF HER WHEEL CHAIR WITH THE WHEEL CHAIR PERSONAL ALARM SOUNDING AND THE GAIT BELT AROUND HER WAIST. THE CORRECTIVE ACTIONS RECORDED WERE BOWEL AND BLADDER TRAINING, WALKING WITH THE RESIDENT WITH THE GAIT BELT AND A WHEELED WALKER, AND A MEDICATION REVIEW AND UPDATE. HOWEVER, THERE WAS NO NEW CARE PLAN ENTRY FOR THE BOWEL AND BLADDER TRAINING, RESIDENT #10 ALREADY HAD AN INTERVENTION FOR AMBULATION AND A MEDICATION REVIEW. THE NURSE'S NOTES FOR RESIDENT #10 FROM 2/4/2011 TO 2/21/2011 DID NOT REFLECT ANY TOILETING SCHEDULE, AMBULATION PROGRAM, ACTIVITY PARTICIPATION, ORTHOSTATIC BLOOD PRESSURE MEASUREMENTS (TO EVALUATE FOR DIZZINESS DUE TO A DROP IN BLOOD PRESSURE WHEN SITTING UP OR STANDING). THERE WAS NO physician progress notes [REDACTED]. AN INCIDENT REPORT REFLECTED THAT ON 2/21/2011 AT 3:25 PM, RESIDENT #10 WAS OBSERVED LYING ON HER RIGHT SIDE ON THE FLOOR. THE NOTE REFLECTED THAT RESIDENT #10 DID NOT HAVE ON SHOES AND HER SOCKS WERE NOT THE "GRIPPER" TYPE. NEITHER OF THESE INTERVENTIONS HAD BEEN MENTIONED IN ANY OF THE PREVIOUS INCIDENT REPORTS OR ADDRESSED AS REVISIONS TO THE CARE PLAN. THE CORRECTIVE ACTION LISTED ON THIS INCIDENT REPORT REFLECTED THAT THE "SAFETY INTERVENTIONS IN PLACE AND WORKING" BUT, "EDUCATION WAS NOT ABLE TO BE DONE" WITH THE RESIDENT BECAUSE OF HER DIAGNOSIS. THE CLINICAL ASSESSMENT REPORT DATED 2/21/2011 DID NOT REFLECT AN ANALYSIS OF THE RESIDENT #10 ' S RISK FOR FALLS, OR AN EVALUATION OF THE EFFECTIVENESS OF THE CURRENT INTERVENTIONS OR A MODIFICATION OF THE CURRENT INTERVENTIONS. NO INTERDISCIPLINARY PROGRESS NOTE WAS LOCATED THAT ADDRESSED THIS INCIDENT. A CONSULTATION REPORT FROM THE PHARMACIST THAT WAS DATED 2/28/2011, COMMENTED THAT RESIDENT #10 HAD BEEN REPORTED TO HAVE FALLEN OR BE AT HIGH RISK FOR FALLS. THE PHARMACIST SUGGESTED THE FACILITY MONITOR POSTURAL BLOOD PRESSURES AT LEAST MONTHLY BECAUSE SOME ANTIPSYCHOTIC MEDICATIONS HAD BEEN ASSOCIATED WITH ORTHOSTATIC HYPOTENSION. THIS INTERVENTION HAD NOT BEEN ADDED TO THE CARE PLAN. DURING AN INTERVIEW WITH STAFF "D", THE REGISTERED NURSE UNIT MANAGER FOR THE B WING ON 6/20/2011 AT ABOUT 11:35 AM AT THE B WING NURSES STATION, SHE STATED THAT ORTHOSTATIC BLOOD PRESSURES HAD NOT BEEN MONITORED FOR RESIDENT #10. AN INTERDISCIPLINARY PROGRESS NOTE DATED 4/20/2011, REFLECTED A REVIEW OF CURRENT SAFETY INTERVENTIONS AT 4:00 PM. THE RECOMMENDATIONS WERE TO CONTINUE WITH THE LOW BED WITH MATS, A PERSONAL SAFETY ALARM TO THE BED AND THE WHEELCHAIR AND SELF LOCKING WHEEL CHAIR BRAKES. AN ADDITIONAL RECOMMENDATION WAS MADE TO DISCONTINUE THE "GAIT BELT TO BE WORN AT ALL TIMES". THE NOTE FURTHER RECOMMENDED THAT RESIDENT #10 SHOULD AMBULATE WITH ASSISTANCE EVERY SHIFT AND AS NEEDED WHEN SHE WAS RESTLESS. NONE OF THESE RECOMMENDATIONS WERE INTERVENTIONS THAT HAD NOT BEEN LISTED PREVIOUSLY. OTHER INTERVENTIONS SUCH AS A TOILETING PLAN, A MEDICATION REVIEW, OR USE OF GRIPPER SOCKS AND SHOES WERE NOT MENTIONED. AN INCIDENT REPORT DATED 4/28/2011 REFLECTED THAT RESIDENT #10 WAS OBSERVED KNEELING ON THE MATS NEXT TO HER BED AT 7:55 PM AND WHEN ASKED, STATED THAT SHE WAS PRAYING. THE CORRECTIVE ACTION REFLECTED NO ANALYSIS OF THE INCIDENT AND DID NOT EVALUATE THE EFFECTIVENESS OF CURRENT INTERVENTIONS OR ADD INTERVENTIONS TO PREVENT FURTHER INCIDENTS. THE DOCUMENT TITLED "FALL(S) (OFF-CYCLE)", DATED 5/1/2011, NOTED THAT RESIDENT #10 RECEIVED A DIURETIC, CARDIOVASCULAR MEDICATION, AND SEROQUEL, A MIND ALTERING DRUG. THE NOTE DID NOT CORRELATE THESE MEDICATIONS TO A CERTAIN INTERVENTION, SUCH AS TOILETING, OR CORRELATE THEM TO AN EVALUATION OF THE POSSIBILITY THE SIDE EFFECTS MAY HAVE CONTRIBUTED TO THE FALL, SUCH AS LOW BLOOD PRESSURE OR SLOW PULSE THAT MAY CAUSE DIZZINESS OR FAINTING. AN INCIDENT REPORT DATED 5/18/2011 REFLECTED THAT RESIDENT #10 WAS FOUND SEATED ON HER BOTTOM ON THE FLOOR AT 7:30 PM. THE CORRECTIVE ACTION LISTED WAS THAT RESIDENT #10 WAS PRIVATELY ASSESSED FOR INJURY. THE DOCUMENT TITLED "FALL(S) (OFF-CYCLE)", DATED 5/18/2011, COMMENTED, CONTINUE WITH PLAN OF CARE AND DID NOT MAKE ANY EVALUATION OR ASSESSMENT OF THE RESIDENT OR ANY FACTORS THAT MAY HAVE CONTRIBUTED TO FALLS. AN INTERDISCIPLINARY PROGRESS NOTE THAT REVIEWED THIS FALL AT 3:00 PM, REFLECTED THAT THE CURRENT INTERVENTIONS WOULD BE CONTINUED. RESIDENT #10 WAS DOCUMENTED TO BE AT RISK FOR FALLS ON 12/19/2007. RESIDENT #10 SUSTAINED NINE FALLS FROM 1/12/2011 THROUGH 5/18/2011. THE DOCUMENTATION AS PRESENTED REFLECTED NO ANALYSIS OR EVALUATION OF THE FALLS OR THE RESIDENT'S RISK FOR FALLS, INCLUDING MEDICAL CONDITIONS AND MEDICATIONS, DID NOT MONITOR THE EFFECTIVENESS OF INTERVENTIONS ALREADY IN PLACE TO PREVENT FALLS, AND DID NOT MODIFY THE INTERVENTIONS OF THE CARE PLAN IN A MANNER THAT WOULD HAVE PREVENTED THE FALLS. THE COMPUTERIZED CARE PLAN THAT FOCUSED ON RESIDENT #10'S RISK FOR FALLS WAS DATED AS CREATED ON 12/19/2007, INITIATED ON 2/21/2011, REVIEWED ON 4/28/2011 AND 5/19/2011. THE GOAL TO MINIMIZE RISK FOR INJURY RELATED TO FALLS WAS DATED AS CREATED ON 12/19/2007, INITIATED ON 6/22/2010, AND REVISED ON 11/17/2010. THE GOAL TO MINIMIZE RISK FOR FALLS WAS INITIATED ON 6/8/2010, AND REVISED ON 11/17/2010. THE COMPUTERIZED CARE PLAN THAT FOCUSED ON RESIDENT #10'S FALLS LISTED THE FOLLOWING INTERVENTIONS AND DATES: RESOLVED: AMBULATE RESIDENT WITH WALKER EVERY SHIFT AND AS NEEDED WHEN RESTLESS. TAKE TO DINING ROOM WHEN IT IS TIME TO EAT. THIS INTERVENTION WAS INITIATED ON 12/19/2007 AND RESOLVED ON 5/19/2011. THIS INTERVENTION WAS REWRITTEN ON 5/19/2011 AS AMBULATE PATIENT EVERY SHIFT WHILE AWAKE WITH STAFF ASSISTANCE AND AS NEEDED WHEN RESTLESS. EVALUATE EFFECTIVENESS AND SIDE EFFECTS OF SEROQUEL WITH PHYSICIAN FOR POSSIBLE DECREASE IN DOSAGE/ELIMINATION OF MEDICATION. THIS INTERVENTION WAS INITIATED ON 12/19/2007 AND HAD NO REVISION DATE. MINIMIZE ENVIRONMENTAL CLUTTER WAS DATED AS INITIATED ON 12/19/2007 AND HAD NO REVISION DATE. PROVIDE ADEQUATE LIGHTING WAS AN INTERVENTION THAT WAS INITIATED ON 12/19/2007 AND CANCELLED ON 5/3/2010. REASSESS FOR FALL RISK AS NEEDED WAS AN INTERVENTION INITIATED ON 12/19/2007 AND REVISED ON 11/7/2010. (THERE WERE NO INSTRUCTIONS LISTED AS TO WHAT FORM TO USE FOR THE ASSESSMENT OR WHAT CONDITIONS WERE TO BE ASSESSED.) THE INTERVENTION FOR A PHYSICAL THERAPY SCREEN WHEN CHANGES WERE NOTED IN GAIT AND SAFETY WAS INITIATED ON 4/2/2008 AND REVISED ON 5/3/2010. THE INTERVENTION TO ENCOURAGE TO TRANSFER AND CHANGE POSITIONS SLOWLY WAS CANCELLED 5/3/2010. THE INTERVENTION TO ADMINISTER PAIN MEDICATION AS ORDERED AND TO MONITOR FOR EFFECTIVENESS WAS INITIATED ON 4/30/2009. THE INTERVENTION TO PROVIDE ASSIST TO TRANSFER AND WALK AS NEEDED AS THE RESIDENT ALLOWS WAS INITIATED ON 4/30/2010 AND REVISED ON 11/7/2010. THE INTERVENTION TO ENSURE THAT THE PERSONAL SAFETY ALARM WAS IN PLACE WHEN IN BED AND WHEELCHAIR AND FOR A WHEEL CHAIR WITH SELF LOCKING BRAKES AND SENSOR ALARM WAS INITIATED ON 6/1/2010 AND REVISED ON 1/20/2011. AN INTERVENTION TO ANALYZE PERVIOUS FALLS TO DETERMINE WHETHER PATTERN OR TREND COULD BE ADDRESSED WAS INITIATED ON 6/8/2010. AN INTERVENTION TO PUT THE BED IN THE LOW POSITION AND USE BILATERAL MATS WAS INITIATED ON 11/17/2010. AN INTERVENTION TO ESTABLISH TOILETING NEEDS THROUGH TOILETING PATTERNS FOR THREE DAYS WAS INITIATED ON 1/21/2011 AND REVISED ON 4/20/2011. ( ) ACCORDING TO THE HISTORY AND PHYSICAL DATED 4/22/2011 RESIDENT #3 WAS A [AGE] year OLD ALERT AND ORIENTED FEMALE. THE MINIMUM DATA SET ((MDS) dated [DATE] REFLECTED A SUMMARY SCORE OF 14 (A SCORE OF 13-15 INDICATES COGNITIVELY INTACT). RESIDENT #3 WAS INITIALLY admitted to the facility on [DATE] FOR DEBILITY AND REHABILITATION FROM PNEUMONIA AND DEEP VEIN THROMBOSIS (BLOOD CLOT). ACCORDING TO THE HISTORY AND PHYSICAL (H&P), DATED 6/2/2011, RESIDENT #3 WAS REadmitted on [DATE] AFTER BEING hosptalized on [DATE] FOLLOWING A FALL IN THE FACILITY, ON 4/14/2011, WHICH RESULTED IN THE NEED FOR A SKIN GRAFT TO THE LEFT LOWER LEG (SHIN) WOUND. THE CURRENT [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #3'S NURSING NOTES DATED 4/14/2011 INDICATED THE RESIDENT fell TO THE FLOOR WHEN BEING TRANSFERRED BY A CERTIFIED NURSE AIDE (CNA). A FORM PRESENTED WITH THE INCIDENT REPORT DATED 4/14/2011 TITLED "STATEMENT OF WITNESS" WAS CONDUCTED ON 5/14/2011 AND INDICATED RESIDENT #3 STATED SHE WAS ABLE TO TRANSFER WITH ONE PERSON ASSIST AFTER BEING ASKED BY A CERTIFIED NURSE AIDE HOW SHE IS TO BE TRANSFERRED, BECAUSE THE FORM TITLED 'PATIENT INFORMATION WORKSHEET' (A WORKSHEET USED BY NURSING AIDES WHEN GIVING CARE) WAS ABSENT OF REQUIREMENTS NEEDED TO TRANSFER THE RESIDENT." THE FALL ON 4/14/2011 RESULTED IN A LEFT LOWER LEG (SHIN) AREA BRUISE. RESIDENT #3'S CARE PLAN WHICH FOCUSED ON FALLS INDICATED IT WAS CREATED AND INITIATED ON 4/14/2011 WITH THE FOLLOWING INTERVENTIONS: TO ADMINISTER PAIN MEDICATION AS ORDERED AND OBSERVE FOR EFFECTIVENESS; ENCOURAGE AND ASSIST AS NEEDED TO WEAR PROPER NON-SLIP FOOTWEAR; ENCOURAGE TO TRANSFER AND CHANGE POSITIONS SLOWLY; HAVE COMMONLY USED ARTICLES WITHIN EASY REACH; MINIMIZE ENVIRONMENTAL CLUTTER; OT (OCCUPATIONAL THERAPY) EVALUATION AND TREATMENT PER ORDERS; PT (PHYSICAL THERAPY) EVALUATION AND TREATMENT PER MD ORDERS. A REVIEW OF RESIDENT #3'S NURSING NOTES DATED 5/10/2011 INDICATED THE RESIDENT WAS OBSERVED ON THE FLOOR AND DENIED PAIN AND INJURIES. THE NURSES NOTES REFLECTED

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ENSURE THE RIGHT TO REFUSE TREATMENT WAS RESPECTED FOR 1 OF 15 SAMPLED RESIDENTS (#6) AND 4 EXTENDED SAMPLE RESIDENTS RESULTING IN RESIDENT #6 HAVING CARDIOPULMONARY RESUSCITATION (CPR) PERFORMED DESPITE A WRITTEN ADVANCED DIRECTIVE FOR NO RESUSCITATION IN THE EVENT OF A CARDIOPULMONARY ARREST. FINDINGS INCLUDE: RESIDENT #6 WAS AN ALERT AND ORIENTED [AGE] year OLD FEMALE WHOSE [DIAGNOSES REDACTED]. AND A HISTORY OF [MEDICAL CONDITION]. THE RESIDENT HAD RECEIVED HOSPICE SERVICES PRIOR TO ADMISSION WHICH CONTINUED DURING HER STAY IN THE FACILITY. THE MDS ASSESSMENT IN PROGRESS DOCUMENTED THE RESIDENT'S COGNITIVE SCORE AS 15 OF 15 WHICH MEANT SHE WAS COGNITIVELY INTACT AND ABLE TO MAKE HER OWN DECISIONS. ON [DATE] THE CLINICAL RECORD REFLECTED THE RESIDENT WAS admitted to the facility on [DATE] FOR REHABILITATION SERVICES BEFORE RETURNING TO HER SON'S HOME WHERE SHE HAD BEEN LIVING. THE ADVANCED DIRECTIVE SECTION OF THE CLINICAL RECORD CONTAINED A "DURABLE POWER OF ATTORNEY (FOR CARE, CUSTODY AND MEDICAL TREATMENT DECISIONS) (DPOA) AND INSTRUCTIONS TO HEALTH CARE PROVIDERS" SIGNED BY THE RESIDENT ON [DATE]. THE RESIDENT'S SON WAS NAMED AS HER PATIENT ADVOCATE AND WAS GIVEN THE AUTHORITY TO ACT ON THE RESIDENT'S BEHALF AT ANY TIME TO "...REFUSE OR WITHDRAW FOR ME ANY MEDICAL CARE...". THE DOCUMENT FURTHER REFLECTED "...MY LIFE SHALL NOT BE ARTIFICIALLY PROLONGED UNDER THE CIRCUMSTANCES SET BELOW..." SECTION B OF THE DPOA "LIFE SUSTAINING PROCEDURES" ITEM 1 REFLECTED "I DO NOT WISH TO UNDERGO CARDIOPULMONARY RESUSCITATION." ON THE SAME DAY THE PHYSICIAN ORDERS [REDACTED].", DATED [DATE] AND NOT YET SIGNED BY THE FACILITY PHYSICIAN. THE "COMPREHENSIVE ASSESSMENT DRUG PROFILE-PHYSICIAN ORDER" FORM FROM THE HOSPICE SERVICE REFLECTED A COLUMN FOR DO NOT RESUSCITATE (DNR) STATUS WITH A Y/N (YES/NO) CHOICE TO BE CIRCLED. THE Y (YES) WAS CIRCLED AND "DNR" WAS HAND WRITTEN AFTER THE CIRCLED Y. THIS INDICATED THE RESIDENT DID NOT WANT TO BE RESUSCITATED IF HER HEART OR BREATHING STOPPED. THE HOSPICE SECTION OF THE CLINICAL RECORD CONTAINED THE HOSPICE "DO NOT RESUSCITATE (DNR) REQUEST FORM" SIGNED BY THE RESIDENT'S SON ON [DATE], AND THE "INPATIENT DISCHARGE AND TRANSFER SUMMARY", DATED [DATE], WHICH HAD THE "YES" BOX FOR DNR STATUS CHECKED. ON [DATE] AT 4:15 PM RESIDENT #6 WAS INTERVIEWED RELATED TO HER LIFE IN THE FACILITY. THE RESIDENT WAS VERY CLEAR ABOUT HER ANSWERS AND WHAT SHE THOUGHT OF THE CARE SHE HAD RECEIVED. RESIDENT #6 STATED SHE WAS A RETIRED NURSE AND HAD WORKED MANY YEARS IN THE SURGERY DEPARTMENT OF A HOSPITAL BEFORE RETIREMENT. ( ) ON [DATE] AT APPROXIMATELY 4:55PM., THE FACILITY ANNOUNCED OVER THE SPEAKER "CODE BLUE" (CARDIOPULMONARY ARREST) FOR RESIDENT #6. UPON ENTERING THE RESIDENT'S ROOM AT ABOUT 5:05P.M., CARDIOPULMONARY RESUSCITATION (CPR) WAS IN PROGRESS DONE BY THE NURSING STAFF. THE RESIDENT WAS NOT BREATHING AND DID NOT HAVE A PULSE ACCORDING TO THE STAFF. THE DIRECTOR OF CARE DELIVERY NURSE (STAFF "R") WAS GIVING BREATHS VIA AN OXYGEN AMBU BAG, AND ANOTHER DIRECTOR OF CARE DELIVERY NURSE (STAFF "Q") WAS ADMINISTERING 12 TO 15 CHEST COMPRESSIONS PER TWO BREATHS. THE STAFF WAS HEARD TO INFORM THE PARAMEDICS WERE CALLED. THE CPR CONTINUED TO BE PREFORMED ON RESIDENT #6. AT 5:20PM, THE PARAMEDICS ARRIVED AND TOOK OVER THE CPR. RESIDENT #6 WAS GIVEN AN OXYGEN MASK AND ATTEMPTED TO ELICIT A PULSE RATE. AT 5:29PM, THE SON OF RESIDENT #6 CAME INTO THE ROOM AND WITNESSED HIS MOTHER BEING GIVEN CPR. HE STATED, "NO, NO.. STOP! STOP! SHE IS A DNR". THE SUPERVISOR OF THE PARAMEDICS WHO HAD THREE PIECES OF DOCUMENT INFORMED THE SON THAT THE INFORMATION HE HAD IN HIS HANDS SHOWED FULL CODE AND THE BOX FOR DNR WAS NOT CHECKED. THE SON ANGRILY LEFT THE ROOM AND THE NURSING STAFF TRIED TO APPEASE HIM. THE SON WAS OVERHEARD TO ASK THE STAFF WHERE THE DNR FORM WAS AND WHEN STAFF COULD NOT LOCATE IT, THE SON VOLUNTEERED TO GET A COPY FROM HIS CAR. THE SON RETURNED WITHOUT A COPY AND ANGRILY REDIRECTED THE STAFF TO CHECK HIS MOTHER'S CHART FOR THE DNR PAPERS. THE FORM WAS RETRIEVED AND AT 5:35PM, THE SUPERVISOR OF THE PARAMEDICS ASKED HIS STAFF TO STOP ADMINISTERING CPR. RESIDENT #6 APPEARED TO HAVE EXPIRED. LATER AT 6:20 P.M. RESIDENT #6'S SON CAME TO THE CONFERENCE ROOM WHERE THE SURVEYORS AND THE FEDERAL SURVEYORS MET PRIVATELY DURING THE SURVEY. THE SON WAS CALM YET UPSET, BECAUSE HIS MOTHER HAD JUST EXPIRED. THE SON REVEALED TO THE SURVEYORS THAT HE WAS VERY UPSET BECAUSE HIS MOTHER WAS GIVEN CPR WHEN SHE WAS A "DO NOT RESUSCITATE (DNR)" RESIDENT. THE SON STATED UPON HER ADMISSION HE PROVIDED THE FACILITY WITH A COPY OF HER DURABLE POWER OF ATTORNEY (DPOA), WHICH CLEARLY STATED CPR WAS NOT TO BE INITIATED DURING A LIFE EMERGENCY SITUATION. HE STATED IT WAS HIS MOTHER'S DESIRE TO NOT HAVE CPR PERFORMED AND THAT THE FACILITY KNEW SHE WAS A DNR. WHEN THE FACILITY CALLED THE SON BY PHONE TO INFORM HIM HIS MOTHER HAD CODED, HE STATED HE TOLD THEM THAT SHE WAS A DNR, AND NOT TO DO CPR. THE FACILITY THEN REPLIED TO HIM THAT THEY DID NOT HAVE ANY DOCUMENTATION TO PROVE SHE WAS A DNR, AND HE RESPONDED SAYING CHECK THE CHART FOR THE DPOA. HE REITERATED THAT HE CLEARLY INFORMED STAFF OF HIS MOTHER'S DNR STATUS WHENEVER SHE WAS admitted TO A HOSPITAL, THE [MEDICAL TREATMENT] UNIT AND THE NURSING HOME. HE RECALLED THAT ONCE ARRIVING AT RESIDENT'S #6 ROOM, THE SON SAID HE TOLD THEM "STOP" CPR, HIS MOTHER WAS A DNR, AND TO CHECK THE CHART FOR THE DPOA. THEY CONTINUED TO DO CPR, AGAIN STATING THEY COULD NOT FIND ANY DOCUMENTATION PROVING SHE WAS A DNR. HE REITERATED HOW UPSET HE WAS THAT HIS MOTHER HAD TO GO THROUGH THAT, WHEN THE FACILITY KNEW HER CODE STATUS. THE SON FURTHER ASKED THE FACILITY TO CHECK THE CHART AND WERE ABLE TO FIND THE DOCUMENTATION INDICATING HIS MOTHER WAS A DNR. HE SENSED HIS MOTHER HAD EXPIRED. APPLYING THE REASONABLE PERSON CONCEPT, THE FACILITY'S FAILURE TO ADHERE TO RESIDENT'S #6'S SPECIFIC DNR WISHES WAS HARMFUL. SHE WAS GIVEN CPR FOR APPROXIMATELY ,[DATE] MINUTES WITH INTERVALS OF RECEIVING DEFIBRILLATION BOTH FROM THE NURSING STAFF AND PARAMEDICS AND INTRAVENOUS INFUSION BY THE PARAMEDICS. THE DURABLE POWER OF ATTORNEY FORM DATED AND SIGNED, ,[DATE] BY HER SON WHO IS RESIDENT #6'S PATIENT ADVOCATE INCLUDED SPECIFIC INSTRUCTIONS OF NOT TO GIVE CPR AND NOT ARTIFICIALLY PROLONG HER LIFE. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 213. BASED ON INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE PREVENTIVE MEASURES AND TREATMENTS FOR PRESSURE ULCER (COMPLETE AND TIMELY ASSESSMENTS OF PRESSURE ULCER FOR DECREASED HEALING AND INFECTION, AND PROVIDE WOUND TREATMENTS) FOR 1 (RESIDENT #100) OF 6 SAMPLED RESIDENTS, RESULTING IN SEVERELY INFECTED PRESSURE ULCER, TISSUE TRAUMA WITH NARCOTIC TISSUE (DEAD TISSUE), OSTEO[DIAGNOSES REDACTED] (INFECTION IN BONE), AND THE POTENTIAL FOR INFECTION TO 6 OTHER RESIDENTS WITH EXISTING PRESSURE ULCERS. FINDINGS INCLUDE: REVIEW OF THE FACILITY ROSTER REVEALED RESIDENT #100 DID NOT RESIDE AT THE FACILITY AT THE TIME OF THE INVESTIGATION (4/18/11 TO 4/29/11). REVIEW OF THE FACILITY FACE SHEET, NURSES NOTES DATED 12/16/10 THROUGH 1/25/11, NURSING ADMISSION assessment dated [DATE], physician progress notes [REDACTED]. HISTORY AND PHYSICAL DATED 12/16/10, HOSPITAL emergency room NOTES DATED 1/25/11, PHYSICIAN CONSULTS DATED 1/26/11, AND physician progress notes [REDACTED]., TURNING, AND RE-POSITIONING WITH COMPLAINTS OF SEVERE PAIN. THE RESIDENTS [DIAGNOSES REDACTED]. RESIDENT #100'S SACRAL PRESSURE ULCER BECAME SEVERELY INFECTED AT THE FACILITY, HE DEVELOPED OSTEO[DIAGNOSES REDACTED] AND WAS TRANSFERRED TO THE hospital on [DATE]. RESIDENT #100 DID NOT RETURN TO THE FACILITY. REVIEW OF THE HOSPITAL EXTENDED CARE FACILITY TRANSFER FORM DATED 12/16/10, THE DATE RESIDENT #100 WAS admitted TO THE FACILITY STATED "PT (RESIDENT #100) HAS OPEN AREAS ON COCCYX WITH [MEDICATION NAME] INTACT, CHANGED PRN (AS NEEDED)". THE RESIDENT HAD 2 PRESSURE ULCERS ON HIS COCCYX AREA. REVIEW OF THE RESIDENTS FACILITY ADMISSION PHYSICIAN ORDERS [REDACTED]. REVIEW OF RESIDENT #100'S FACILITY PRESSURE ULCER CARE PLAN DATED 12/17/10, REVEALED STAFF WERE TO EVALUATE AND RECORD WOUND STATUS PER FACILITY GUIDELINES UNTIL HEALED, MONITOR FOR AND REPORT ANY NEW DISCOLORATION, OPEN AREAS, MONITOR FOR AND REPORT ANY EVIDENCE OF INFECTION (INCREASED TEMP., FOUL ODOR, PURULENT (WHITE/YELLOW/GREEN) DRAINAGE, INCREASED PAIN/TENDERNESS, INCREASED CONFUSION AND SWELLING, WARMTH OR REDDEN SKIN SURROUNDING SITE). REVIEW OF THE HOSPITAL HISTORY AND PHYSICAL (H & P) DATED 1/26/11; REVEALED RESIDENT #100 WAS TRANSFERRED TO THE emergency roiagnom on [DATE], DUE TO CHANGES IN MENTAL STATUS. THE HOSPITAL HISTORY AND PHYSICAL DATED 1/26/11, STATED "THE PATIENT (RESIDENT #100) HAS FULL THICKNESS DECUBITUS (A DEEP PRESSURE ULCER ON HIS SACRAL AREA). LESION IS ODIFEROUS (HAS A FOUL ODOR, A SIGN OF INFECTION), LESION IS FULL THICKNESS THROUGH THE DERMIS, THE EPIDERMIS, THROUGH THE MUSCLE AND THE PATIENT'S VERTEBRAE (BONE) ARE VISIBLE THROUGH THE LESION (THE PRESSURE ULCER WAS DEEP ENOUGH TO SEE BONE). ASSESSMENT: INFECTED SEVERE DECUBITUS ULCER". REVIEW OF THE HOSPITAL PHYSICIAN CONSULT DATED 2/11/11, STATED "THE PATIENT DEVELOPED NECROSIS (DEAD TISSUE) OF THAT AREA (THE SACRAL AREA) AND BAD SMELL." REVIEW OF A PICTURE TAKEN AT THE HOSPITAL OF RESIDENT #100'S SACRAL PRESSURE ULCER DATED 1/25/11, SHOWED EVIDENCE OF A DEEP, ROUNDED WOUND WITH A DARK BLACKISH COLORED AREA IN THE CENTER. REVIEW OF THE HOSPITAL PHYSICIAN CONSULT DATED 1/26/11 AT 1:30 P.M., AND physician progress notes [REDACTED].M., REVEALED RESIDENT #100 HAD AN INFECTED STAGE 4 (TO THE BONE) PRESSURE ULCER ON HIS SACRAL AREA, WITH NARCOTIC TISSUE, SUGGESTING OSTEO[DIAGNOSES REDACTED]. REVIEW OF THE physician progress notes [REDACTED].M., STATED "STAGE IV (A PRESSURE ULCER EXTENDING TO THE BONE) SACRAL DECUB, THIS MOSTLY HAS BEEN EXISTING FOR SEVERAL DAYS". REVIEW OF THE SECOND physician progress notes [REDACTED].M., STATED THE COCCYX PRESSURE ULCER INFECTION "OCCURRED OVER SEVERAL DAYS TO WEEKS". REVIEW OF THE HOSPITAL physician progress notes [REDACTED].M., STATED "COCCYX BONE OSTEO[DIAGNOSES REDACTED], DOES NOT WANT TO RETURN TO HIS PRIOR ECF (EXTENDED CARE FACILITY)". REVIEW OF THE HOSPITAL physician progress notes [REDACTED].M., STATED "OSTEO[DIAGNOSES REDACTED] COCCYX SEVERELY INFECTED DECUBITUS ULCER SACRAL/COCCYX, VANCO.,[MEDICATION NAME] (IV ANTIBIOTIC'S) EXTENDED COURSE 6-8 WEEKS". REVIEW OF THE physician progress notes [REDACTED].M., STATED "NOT SURGICAL CANDIDATE (DO TO TISSUE DAMAGE CAUSED BY HIS PRESSURE ULCER)". REVIEW OF THE HOSPITAL HISTORY AND PHYSICAL DATED 1/26/11, STATED "WOUND CULTURE SHOWS NUMEROUS GRAM-NEGATIVE RODS (THE RESIDENTS PRESSURE ULCER WAS INFECTED)". REVIEW OF THE FACILITY NURSING ADMISSION assessment dated [DATE], REVEALED RESIDENT #100 WAS admitted WITH 2 WOUNDS/PRESSURE ULCERS ON HIS COCCYX AREA, PRESSURE ULCER #1 WAS 2 CM X 3.5 CM AND PRESSURE ULCER #2 WAS 2 X 3 CM. REVIEW OF NURSING ASSESSMENTS DATED 12/17/10, 12/23/10 AND 1/7/11, REVEALED HE HAD LIMITED SENSORY PERCEPTION, OCCASIONALLY MOIST SKIN, WAS BEDFAST, HAD VERY LIMITED MOBILITY, PROBABLY INADEQUATE NUTRITION, AND FRICTION AND SHEARING WAS A PROBLEM (DUE TO SLIGHT MOVEMENTS, BEDDING CAUSING SKIN DAMAGE), RESULTING IN THE RESIDENT BEING A HIGH RISK FOR PRESSURE ULCERS. A TELEPHONE INTERVIEW WAS DONE ON 4/25/11 AT 9:40 A.M., WITH RESIDENT #100'S FAMILY MEMBER. FAMILY MEMBER #1 STATED "THE FACILITY CALLED ME AND TOLD ME HE (THE RESIDENT) WAS DYING. THEY TOLD ME THEY WERE GOING TO PUT AN IV IN HIM. I SAID NO; SEND HIM TO (THE HOSPITAL). HE WAS OUT OF HIS BRAIN, HE WAS SHAKING TOO. THE DOCTOR AT THE HOSPITAL SAID IT (THE SACRAL PRESSURE ULCER) WAS INFECTED AND IT LOOKED LIKE GANGRENE (DEAD TISSUE). THEY SAID THE INFECTION GOT DOWN INTO HIS TAILBONE (OSTEO[DIAGNOSES REDACTED]). I WOULD SMELL SOMETHING WHEN I WAS THERE (AT THE FACILITY); THEY KEPT A PATCH ON IT. THEY SAID THEY CHANGED IT EVERY 3 DAYS, I WAS AT (THE FACILITY) AT LEAST TWICE A DAY, I NEVER SAW THEM CHANGE IT. THE DOCTOR AT THE HOSPITAL TOLD ME TO CALL THE STATE AND REPORT THEM. I CALLED THE HOSPITAL MYSELF BEFORE HE WAS SENT (TRANSFERRED TO THE hospital on [DATE]) TO GET SOME HELP. I TALKED WITH THE WOUND CLINIC. I THEN CALLED (THE ADON/DCD-ASSISTANT DIRECTOR OF NURSING/DIRECTOR OF CARE DELIVERY) ON 1/17/11, AND TOLD HER I WANTED HIM REFERRED TO (THE HOSPITAL) WOUND CARE CLINIC. SHE SAID SHE HAD NOT SEEN HIS PRESSURE ULCER ON HIS COCCYX. SHE SAID SHE WAS GOING TO LOOK AT HIS PRESSURE ULCER AND CALL ME BACK. SHE CALLED ME BACK (ON 1/19/11), AND SAID IT WAS WORSE AND WHERE DID I WANT HIM TO GO. I WENT OUT THERE THE DAY AFTER HE LEFT AND HAD A MEETING. (THE ADON/DCD) SAID SHE SAW HIM EVERY WEEK, LOOKED AT HIS PRESSURE ULCER ON HIS COCCYX AND SHE WAS THE ONE WHO GAVE HIS WOUND CARE EVERY WEEK. SHE HAD NOT SEEN HIS PRESSURE ULCER UNTIL I CALLED HER ON 1/16/11 AND ASKED HER TO LOOK AT IT. I HAVE HER MESSAGE ON MY PHONE. HE WAS ON ANTIBIOTICS FOR 6 WEEKS BECAUSE OF HIS INFECTED PRESSURE ULCER. HE STILL HAS A WHOLE IN HIS COCCYX, THE DOCTOR AT THE HOSPITAL SAID IT WILL NEVER HEAL". REVIEW OF A FACILITY RESIDENT CONCERN FORM DATED 3/3/11, SIGNED BY THE ADON/DCD, REVEALED ON 1/26/11 RESIDENT #100'S FAMILY MEMBER HAD COMPLAINED REGARDING THE RESIDENTS CONDITION AND STATED "(THE FAMILY MEMBER) REPORTED THAT SHE WORRIES ABOUT HOW LONG THE WOUNDS WERE IN NEED OF INTENSE TREATMENT. RESIDENTS (FAMILY MEMBER) REPORTED THAT SHE FELT IT (THE INFECTED PRESSURE ULCER) WAS DETECTABLE ESPECIALLY FROM THE SMELL. RESIDENT IS CURRENTLY BEING tested (AT THE HOSPITAL) TO SEE HOW FAR THE INFECTION HAD SPREAD AND HAS BEEN diagnosed AS GANGRENE (DEAD TISSUE)". AN INTERVIEW WAS DONE ON 4/19/11 AT 10:30 A.M., WITH SOCIAL WORKER #1 (SW, ASSIGNED TO THE HALL RESIDENT #100 WAS ON). SW #1 STATED "(THE RESIDENTS FAMILY MEMBER) CAME IN AFTER HIS DISCHARGE ON 1/25/11. (THE FAMILY MEMBER) SAID HIS WOUNDS WERE INFECTED AND WANTED TO KNOW WOUND CARE ISSUES. (THE ADON/DCD) TALKED WITH HER. I DID NOT MAKE ANY NOTES". AN INTERVIEW WAS DONE ON 4/25/11 AT 10:45 A.M., WITH THE ADON/DCD NURSE. THE ADON/DCD REVEALED RESIDENT #100 WAS admitted TO THE FACILITY WITH 2 PRESSURE ULCERS ON HIS COCCYX AREA. REVIEW OF THE ADON/DCD'S WOUND CARE NOTES DATED 12/29/10, REVEALED A DESCRIPTION OF RESIDENT #100'S (2) SACRAL PRESSURE ULCERS AND STATED THAT SHE HAD DONE WOUND CARE AND DRESSING CHANGES ON BOTH OF THEM. THE ADON/DCD STATED "I SAW HIM (RESIDENT #100) ON 12/29/10, 1/10/11, 1/13/11, 1/24/11 AND 1/25/11, I DID WOUND CARE ON HIM ON HIS PRESSURE ULCERS ON HIS COCCYX. I DID NOT DO A FULL BODY ASSESSMENT OF THE RESIDENT. I INFORMED THE CHARGE NURSE (NURSE #2) ABOUT HIS INFECTED PRESSURE ULCER, I DID NOT FOLLOW-UP OR TELL THE DOCTOR OR RE-LOOK AT THE WOUND. I THOUGHT THE CHARGE NURSE WOULD BE COMPETENT AND TAKE CARE IT. I DID NOT INFORM HIS FAMILY". THE ADON/DCD WAS UNABLE TO RECALL THE DATE SHE INFORMED NURSE #2 OF THE INFECTED PRESSURE ULCER AND WAS UNABLE TO FIND ANY DOCUMENTATION OF INFORMING NURSE #2 IN THE RESIDENTS CLOSED CLINICAL RECORD. REVIEW OF RESIDENT #100'S NURSING assessment dated [DATE], REVEALED AN ADDED HAND WRITTEN ENTRY DATED 1/24/11 (THE DAY BEFORE HE WAS TRANSFERRED TO THE HOSPITAL), SIGNED BY THE ADON/DCD STATING "FURTHER DECLINE IS UNAVOIDABLE R/T (RELATED TO) CANCER WITH METS (SPREAD TO OTHER AREAS), DECREASED APPETITE, WT LOSS, HX (HISTORY) OF PRESSURE ULCER". AN INTERVIEW WAS DONE ON 4/21/11 AT 1:45 P.M., WITH NURSE #2 (ASSIGNED TO THE HALL THE RESIDENT WAS ON). NURSE #2 DENIED THE ADON/DCD INFORMED HER OF RESIDENT #100'S INFECTED SACRAL PRESSURE ULCER AND SAID THE CHARGE NURSES WERE DOING WEEKLY ASSESSMENTS OF ALL PRESSURE ULCERS PRIOR TO RESIDENT #100 BEING admitted TO THE FACILITY AND WERE INSTRUCTED BY THE PREVIOUS DIRECTOR OF NURSING TO STOP DOING THEM, THE ADON/DCD NURSE WAS TO TAKE OVER THE WEEKLY ASSESSMENTS. NURSE #2 STATED "WE (THE CHARGE NURSES) STOPPED DOING WOUND ROUNDS FOR AWHILE, THE OLD DON (PREVIOUS DIRECTOR OF NURSING) SAID THE DCD (ADON/DCD) WAS TO DO THE PUSH TOOLS (PRESSURE ULCER ASSESSMENT AND MONITORING DOCUMENTATION TOOLS) ON ALL PRESSURE ULCERS WEEKLY. WE WENT BACK TO DOING THE ASSESSMENTS AND MONITORING OF THE PRESSURE ULCERS EVERY WEDNESDAY STARTING IN FEBRUARY (2011). I DON'T REMEMBER HER (THE ADON/DCD NURSE) TELLING ME TO CALL THE DOCTOR OR WOUND CLINIC, OR OF THE WOUND CONDITION. THERE SHOULD BE TREATMENT SHEETS (AN ADMINISTRATION RECORD OF WOUND CARE/TREATMENTS DONE) FOR 12/10". NURSE #2 WAS UNABLE TO FIND TREATMENT SHEETS OR DOCUMENTATION OF WOUND CARE GIVEN IN 12/10, IN THE RESIDENTS CLOSED CLINICAL RECORD AND STATED, "I CAN'T FIND IT AND I DON'T KNOW WHAT TO SAY". REVIEW OF THE FACILITY PHYSICIAN ORDER [REDACTED]. REVIEW OF RESIDENT #100'S FACILITY TREATMENT SHEET DATED 12/10, REVEALED NO DOCUMENTATION OF WOUND CARE GIVEN. REVIEW OF RESIDENT #100'S PHYSICIAN ORDER [REDACTED].#1 WITH NS APPLY SANTYL TO SLOUGH, COVER WITH 4 X 4 AND HYPOFIX QD AND PRN" AND "CLEANSE WOUND #2 SACRUM WITH NS APPLY [MEDICATION NAME], CHANGE Q 3 DAYS AND PRN". REVIEW OF THE FACILITY TREATMENT SHEET DATED 12/10, STATED "CLEANSE WOUND #2 WITH NS APPLY SANTYL (TOPICAL MEDICATION) TO SLOUGH, COVER WITH 4 X 4 AND HYPOFIX QD (EVERY DAY) AND PRN (AS NEEDED)", AND "CLEANSE WOUND #1 SACRUM (A SECOND PRESSURE ULCER ON THE COCCYX AREA) WITH NS APPLY [MEDICATION NAME], CHANGE Q (EVERY) 3 DAYS AND PRN". REVIEW OF THE PHYSICIAN ORDER [REDACTED]. THE TREATMENT ORDER FOR WOUND #1 WAS WRITTEN FOR WOUND #2 AND THE TREATMENT ORDER FOR WOUND #2 WAS WRITTEN FOR WOUND #1. THE FACILITY NURSING NOTES FOR RESIDENT #100 DATED 12/16/11 THROUGH 12/23/11, ARE AS FOLLOWS: 12/24/11 AT 8:00 P.M.: "[MEDICATION NAME] (PRESSURE ULCER DRESSING) CHANGED TO L (LEFT) BUTTOCK". 1/1/11 (NO TIME): "CHECKED [MEDICATION NAME] PATENT (DRESSING INTACT)". 1/13/11 AT 12:50 P.M.: "TX (TREATMENT) TO SACRUM". 1/14/11 AT 3:00 P.M.: "AREA TO SACRUM D/C'D-HEALED (PRESSURE ULCER #1, HEALED)". NO DOCUMENTATION OF PRESSURE ULCER #2 WAS FOUND. 1/15/11 AT 3:15 P.M.: "TX DONE PER ORDER ON L BUTTOCK (THE SACRAL PRESSURE ULCER). GREENISH YELLOW DRAINAGE NOTED WITH FOUL ODOR. YELLOW SLOUGHING NOTED TO WOUND BED (SIGNS OF INFECTION)". NO DOCUMENTATION OF INFORMING THE RESIDENTS PRIMARY PHYSICIAN, ADON/DCD, FAMILY OR OF AN ORDER REGARDING THE INFECTED PRESSURE ULCER WAS FOUND. A PHONE INTERVIEW WAS DONE ON 4/29/11 AT 2:10 P.M., WITH NURSE #1 (DOCUMENTED IN THE NURSE'S NOTES ON 1/15/11 AT 3:15 P.M., THE CONDITION OF RESIDENT #100'S PRESSURE ULCER). NURSE #1 STATED "I PASSED IT ON IN THE 24 HOUR REPORT THAT DAY (1/15/11). I TOLD THE DOCTOR, BUT I CAN NOT REMEMBER WHEN I TOLD THE DOCTOR". 1/16/11 AT 4:30 P.M.: "TX TO SACRAL AREA". NO DOCUMENTATION OF ASSESSMENT OR MONITORING THE RESIDENTS SACRAL PRESSURE FOR INFECTION WAS FOUND. 1/19/11 AT 10:00 A.M.: "TX TO SACRAL AREA". NO DOCUMENTATION OF ASSESSMENT OR MONITORING THE RESIDENTS SACRAL PRESSURE FOR INFECTION WAS FOUND. 1/21/11 AT 4:45 P.M.: "NEW ORDER DR (PRIMARY PHYSICIAN) PT. TO GO TO WOUND CLINIC RE: SACRAL DECUB-UNIT CLERK TO SCHEDULE APPT". AN INTERVIEW DONE WITH THE WARD CLERK ON 4/21/11 AT 1:50 P.M., REVEALED RESIDENT #100'S APPOINTMENT TO GO TO THE WOUND CLINIC WAS MADE FOR 2/1/11; THE RESIDENT WAS TRANSFERRED TO THE hospital on [DATE]. THE WARD CLERK WAS UNABLE TO RECALL THE DATE SHE MADE THE RESIDENTS APPOINTMENT FOR THE WOUND CLINIC, AND SAID SHE DID NOT DOCUMENT IT. 1/25/11 AT 11:00 A.M. (THE DAY RESIDENT #100 WAS TRANSFERRED TO THE HOSPITAL): "LATE ENTRY, NEW ORDERS WRITTEN FOR NEW PRESSURE AREAS NOTED ON 1/24/11 TO BIL (BOTH) HIPS, BIL FEET. SPOKE WITH (FAMILY MEMBER) AT 6:00 P.M. ON 1/24/11 RE (REGARDING) FOLEY CATHETER R/T (RELATED TO) ADVANCEMENT OF SACRUM WOUND TO STAGE IV (STAGE 4) AND POSSIBLE TUBE FEED". 1/25/11 AT 11:00 A.M.: "CALL PLACED TO DR (PRIMARY PHYSICIAN) AT 9:15 A.M. RE: CONDITION. PT FOUL ODOR COMING FROM SACRAL WOUND. (FAMILY MEMBER) WANTS PT SENT TO HOSPITAL FOR EVALUATION INSTEAD OF PT GETTING TX DONE HERE. DR (PRIMARY PHYSICIAN) CALLED RE (FAMILY MEMBER) CONCERN AND WANTS N.O. (NEW ORDER) TO SEND TO ER (emergency room ) FOR EVAL". REVIEW OF THE PHYSICIAN ORDER [REDACTED]. THE SURVEYOR REQUESTED ALL RESIDENT #100'S CHANGE IN STATUS/24 HOUR NURSING REPORT SHEETS. NO CHANGE IN STATUS/24 HOUR REPORT WORKSHEET DATED 1/15/11, WAS GIVEN TO THE SURVEYOR. REVIEW OF THE RESIDENTS 24 HOUR REPORT SHEETS (DATED 12/17/10, 12/18/10, 12/20/10, 12/21/10, 12/23/10, 12/30/11, 1/1/11, 1/4/11, 1/5/11, 1/7/11, 1/8/11, 1/9/11, 1/11/11, 1/16/11, 1/18/11, 1/20/11, 1/21/11, 1/22/11, 1/23/11, 1/24/11 AND 1/25/11), REVEALED NO DOCUMENTATION FOUND OF THE CONDITION OF THE RESIDENTS SACRAL PRESSURE ULCER, OR OF INFORMING THE PRIMARY PHYSICIAN. REVIEW OF THE CLOSED CLINICAL RECORD REVEALED TWO PRIMARY PHYSICIAN DICTATED PROGRESS NOTES DATED 12/28/10 AT 6:13 P.M. AND ON 1/4/11 AT 6:49 P.M. NO DOCUMENTATION OF RESIDENT #100'S PRESSURE ULCERS, SKIN CONDITION OR WOUNDS WAS FOUND. AN INTERVIEW WAS DONE ON 4/19/11 AT 2:00 P.M, WITH THE ADMINISTRATOR AND THE DIRECTOR OF NURSING (DON). THE ADMINISTRATOR AND DON AGREED RESIDENT #100'S CLOSED CLINICAL RECORD DID NOT HAVE DOCUMENTATION OF COMPLETE NURSING ASSESSMENTS AND MONITORING OF HIS SACRAL PRESSURE ULCER, MONITORING FOR SIGNS/SYMPTOMS OF INFECTION, AND UP-DATING THE PHYSICIAN ON THE CONDITION OF HIS PRESSURE ULCER. THE DON REVEALED THE PREVIOUS DON HAD CHANGED THE PRESSURE ULCER PROGRAM AT THE TIME THE RESIDENT WAS AT THE FACILITY (12/16/10 TO 1/25/11). REVIEW OF THE FACILITY CHARTING: ALERT POLICY DATED 8/11/06 FOUND IN THE NURSING POLICY BOOK AT THE 300/400 HALLS NURSING STATION, STATED "PURPOSE: TO PROVIDE A GUIDELINE FOR THE CLINICAL DOCUMENTATION PROCESS THAT MAY BE NEEDED FOLLOWING A CHANGE IN PATIENT CONDITION OR STATUS. INCLUDES DOCUMENTATION OF A PATIENT'S CONDITION THAT WARRANTS ALERT CHARTING, THE DECISIONS AND ACTIONS OF STAFF RELATED TO THE PATIENT'S CONDITION AND THE PATIENT'S RESPONSE TO INTERVENTIONS IMPLEMENTED. SITUATIONS FOR ALERT CHARTING TYPICALLY INCLUDE SIGNS AND SYMPTOMS OF INFECTION, SKIN ALTERATIONS". REVIEW OF THE FACILITY SKIN PRACTICE GUIDE GIVEN TO THE SURVEYOR BY THE ADMINISTRATOR ON 4/19/11 DATED 7/08, STATED "THE PURPOSE OF THE GUIDE IS TO DESCRIBE THE PROCESS STEPS FOR PREVENTION TECHNIQUES AND INTERVENTIONS TO MANAGE PRESSURE ULCERS AND SKIN ALTERATIONS". THE SKIN PRACTICE GUIDELINES REVEALED A COMPREHENSIVE EVALUATION WAS TO BE COMPLETED WEEKLY AND DOCUMENTED IN THE PATIENT'S CLINICAL RECORD FOR EACH PRESSURE ULCER AND INCLUDED THE APPEARANCE OF SURROUNDING SKIN, PRESENCE AND LOCATION OF TUNNELING OR UNDERMINING, EVIDENCE OF INFECTION, DEPTH AND PAIN. REVIEW OF THE FACILITY IN-SERVICE GIVEN ON 11/4/10, REVEALED THE NURSES WERE EDUCATED ON THE SKIN PRACTICE GUIDELINES PRIOR TO RESIDENT #100'S ADMISSION ON 12/16/10. ( )

Based on observation, interview and record review the facility failed to prevent and protect 2 of 6 sampled Residents (#102, #104) from sexual and mental abuse, resulting in 2 Residents (#102, #104) being touched inappropriately. Findings include: Resident #101 was a [AGE] year old male, admitted to the facility on [DATE]. According to his Admitting Record he had the following Diagnoses: [REDACTED]. According to the Social Services Department Process Note dated 2-24-2011, "Checked in on Resident #101 following a concern from [MEDICAL TREATMENT] about his interaction with another patient on (Name of City Bus Service), Resident #101 was sleeping and was not easily aroused. Social Worker #2 left Resident #101 sleep. Social Worker #2 informed nursing staff (station B) of recent behavior reported from [MEDICAL TREATMENT] Social Worker #3. Administration notified of reported behavior." During an interview with the Nursing Home Administrator (NHA) on 3-17-2011, at 10:20 AM the Surveyor asked to speak with Social Worker #3 to get more information regarding her note in Resident #101's chart dated 2-24-2011. The NHA said that Social Worker #3 was on vacation out of State and could not be reached this week. The NHA was asked the information the Social Worker had reported to the Administration. The NHA said she was leaving work on 2-24-2011 and the Social Worker had told her that Resident #101 had something happen at [MEDICAL TREATMENT] or on the bus but she was not sure. The NHA said the Social Worker did get more information from [MEDICAL TREATMENT] later and she would look for the information. The NHA returned with an note with a FAX cover sheet dated 2-28-2011. The note was dated 2-28-2011, at 11:48 AM. The note summary stated, "Issue on (Name of City Bus Service)." The note stated, "Patient report that on her transportation today another rider put his hand on her leg. She stated she was not sure what it was and repositioned herself away from the touch. She stated after moving she then felt the touch on her thigh then she swung her arm out to remove the item to find it was the other rider next to her that had touched her. She reported this to the driver who stated he would report it to his supervisor. Ms. (name of patient) was very upset and concerned of the return trip with this other person. (Person working at [MEDICAL TREATMENT]) called the City Bus Service and talked to the supervisor and reported the complaint. The City Bus Service Supervisor ensured us that this would be taken care of and that the return trip the 2 would be separated and that the other rider would not have access to her. This information was reported to the (Patient Name) but she was still concerned and upset. (Patient Name) did not get picked up with the other patients and (City Bus Service Name) was called to see why she was not picked up and they reported that the driver thought she was not going to ride with the other patient today. (Name of Patient) daughter was called and picked her up today". During a telephone interview with the [MEDICAL TREATMENT] Social Worker #3 on 3-17-2011, at 10:30 AM, Social Worker #3 was asked if she sent the note described above to the facility. Social Worker #3 said she had sent the note and told Social Worker #2 about the incident on 2-24-2011. Social Worker #3 assured the surveyor that she had shared everything that was in the note dated 2-28-2011 with Social Worker #2 on 2-24-2011. Social Worker #3 added that the female patient on the bus was Blind had described the touch as, "putting his hand on my tight and sliding it up to her groin." Social Worker #3 said the patient is still afraid to ride the same bus as Resident #101. She said, Resident #101 and the female involved in the incident continue to go to [MEDICAL TREATMENT] but ride different buses. During a telephone interview with CNA #5, on 3-17-2011, at 3:25 PM. CNA #5 said she was on 2-24-2011 and at about 4:35 PM the Social Worker and the Charge Nurse met with all the Certified Nurse Aides (CNA's). CNA #5 said that the Social Worker educated them on sexual abuse and what to watch for with Resident #101. CNA #5 said at Resident #101 was placed on 1:1 that night. During an interview with the Nursing Home Administrator (NHA) on 3-17-2011 the surveyor informed the NHA that she was told that Resident #101 was placed on 1:1 on 2-24-2011 at 4:35 PM and wanted to see the documentation and have the name and telephone number of the nurse working at that time. The NHA said she thought the the person giving the information was confused because 1:1 care was not started until after the facility incidents on 2-25-2011. The NHA said she had tried to call the nurse that was working that night several times and she could not be reached. The NHA did not provide the name of the nurse or the telephone number. The surveyor was not provided any information that showed nursing had address the behavior concerns that were documented in the Social Services Progress Note dated 2-24-2011. During an interview with CNA #1, on 3-17-2011, at 8 AM, CNA #1 was asked what she knew about Resident #101's inappropriate behaviors. CNA #1 said she was not assigned to Resident #101 on 2-25-2011 but when she was passing trays in the Main Dinning Room (MDR) at about 7:55 AM and she saw Resident #101 wheel himself into the MDR . Resident #101 come up to Resident #104 he put his hands on her breast and tied to pull up her shirt. CNA #1 said she went over to Resident #101, moved his hand away and said you are not supposed to do that and he responded, "Ya, Ya." She did not see any response from Resident #104. CNA #1 said she moved Resident #101 to the table where he usually sat and set up his breakfast tray. After setting up the breakfast tray she reported the incident to Registered Nurse (RN) #1. CNA #1 stated RN #1 said she would get to it and kept passing her medications. When CNA #1 returned to the MDR, CNA #2 told her Resident #101 was pulling up Resident #102's shirt and Resident #102 said, "he sure was" . CNA #2, said she reported this to RN#1 and this time removed Resident #101 from the MDR. During an interview with CNA #2 on 3-17-2011, at 9:05 AM, CNA#2 , said Resident #101 was in the MDR on 2-25-201 when she saw him put his hand on Resident #102 breast. She said his hand was under the Residents bib and over her shirt. CNA #2 said Resident #102 said, "what are you doing" and was red in the face. CNA #2 said that CNA #1 took Resident #101 out of the MDR and she stayed to comfort Resident #102. Resident #102 was a [AGE] year old female admitted to the facility on [DATE]. According to her Admitting Record she had the following Diagnoses: [REDACTED]. During an interview with Resident #102, on 3-17-2011, at 12:45, Resident #102 was asked if she remembered anyone touching her where she did not want to be touch recently. Resident #102 was unable to recall the incident. CNA #2 said in an interview, 3-17-2011, at 9:05 AM that Resident #102 was red in the face when Resident #101 had his had on her breast. Resident #104, was a [AGE] year old female admitted to the facility on [DATE]. According to her Admitting Record she had the following Diagnoses: [REDACTED]. During an interview with Resident #104, on 3-17-2011, at 12:35 PM, Resident #104 did not have any verbal or physical response to questions from this surveyor. The facility 5 day Report stated, "On 2-25-2011 at approximately 7:15 AM, (name of Resident #101) was in the Main Dining preparing for breakfast. It was witnessed that on his way down to his table he had inappropriately touched Residents. (Name of Resident #101) was removed from the dining room and taken to the nurse responsible for his care. The CNA's and RN's interviewed above were asked if they were given training on abuse after the incidents on 2-25-2011. They all said they were given additional information on abuse since the incidents on 2-25-2011. They were all asked if they would do any thing differently if the incident happened today and most of them replied they would not do anything different and felt that the situation was handled well. ( )

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 790, MI 905, AND MI 996. BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO FOLLOW PRIMARY CARE PROVIDERS' (PCP) ORDERS IN 4 OF 9 SAMPLED RESIDENTS (#102, #103, #104, AND #109), RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #102 WHO DID NOT RECEIVE 4 DOSES OF [MEDICATION NAME] RESULTING IN SUB-THERAPEUTIC INR LEVELS, INFARCTED/ISCHEMIC BOWEL, SURGICAL INTERVENTION, SEPTIC SHOCK, AND PLACEMENT ON A VENTILATOR IN THE INTENSIVE CARE UNIT, AND THE POTENTIAL FOR WORSENING OF THE MEDICAL CONDITION FOR RESIDENT #103 WHO DID NOT RECEIVE [MEDICATION NAME] FOR PAIN RELATED TO [MEDICAL CONDITION] WITH ABDOMINAL ORGAN METASTASIS, RESIDENT #104 WHO DID NOT RECEIVE [MEDICATION NAME] (NUTRITIONAL STIMULANT) TO SUPPORT WEIGHT STABILIZATION EFFORTS, AND RESIDENT #109 WHO DID NOT RECEIVE LABORATORY WORK FOR 2 DAYS FROM DATE OF ORDER. , FINDINGS INCLUDE: THE PROFESSIONAL STANDARD OF QUALITY FOR DOCTOR'S ORDERS STATES, "NURSES MUST OBEY THE ORDERS OF THE PHYSICIAN IN CHARGE OF A PATIENT, UNLESS AN ORDER WOULD LEAD A REASONABLE PERSON TO ANTICIPATE INJURY IF IT WERE CARRIED OUT" (LAW EVERY NURSE SHOULD KNOW, 5TH EDITION, HELEN CREIGHTON). RESIDENT #102: THE FACE SHEET REVEALED RESIDENT #102 WAS AN [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE PRIMARY CARE physician's orders [REDACTED]. THERE WERE NO ORDERS PRESENT IN THE RESIDENT'S MEDICAL FILE TO WITHHOLD ANY DOSES OF [MEDICATION NAME] FOR THE PERIOD 10/22/10 (DATE OF ADMISSION) THROUGH THE DATE OF THE RESIDENT'S TRANSFER TO A LOCAL hospital on [DATE]. ACCORDING TO THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. ACCORDING TO LAB WORK OBTAINED ON RESIDENT #102 DATED 11/3/10, INR LEVELS (INTERNATIONAL NORMALIZED RATIO) WERE REPORTED AS 1.58 OR SUB-THERAPEUTIC (BELOW DESIRED LEVELS) FOR ANTICOAGULANT EFFECT (THERAPEUTIC LEVEL IS 2.0-3.0). ACCORDING TO NURSES NOTES DATED 11/6/10 AT 12:00 P.M., RESIDENT #102 EXPERIENCED ABDOMINAL PAIN FOR WHICH HER PHYSICIAN WAS NOTIFIED; SHE WAS TRANSFERRED TO A LOCAL HOSPITAL FOR EVALUATION AT 3:00 P.M. THE EMERGENCY DEPARTMENT SURGICAL CONSULTATION RECORD DATED 11/6/10 AT 4:20 P.M., REVEALED RESIDENT #102 WAS ASSESSED AS HAVING AN "ACUTE ABDOMEN; POSSIBLE DEAD BOWEL." OBTAINING AN INR LEVEL, AND SURGICAL INTERVENTION, WERE INCLUDED IN THE PLAN OF APPROACH. THE HOSPITAL REPORT DATED 11/6/10 AT 8:35 P.M., REVEALED RESIDENT #102'S INR WAS 1.57; BELOW DESIRED LEVELS FOR ANTICOAGULANT EFFECT. THE CONSULTATION REPORT OF A PHYSICIAN SPECIALIST IN CARDIOLOGY (HEART-RELATED CONDITIONS) DATED 11/7/10 AT 4:00 P.M., REVEALED THE CONSULTANT PHYSICIAN ASSESSED RESIDENT #102 WITH "COLONIC INFARCTION SECONDARY TO ISCHEMIA, RULE OUT CARDIAC [MEDICAL CONDITION] GIVEN HER LOW INR ON PRESENTATION." THE OPERATIVE REPORT DATED 11/11/10 AT 11:06 A.M., DOCUMENTED #102'S POSTOPERATIVE [DIAGNOSES REDACTED]." THE RESIDENT WAS REPORTED TO HAVE UNDERGONE AN "EXPLORATORY LAPAROTOMY, SUBTOTAL COLECTOMY WITH END [MEDICAL CONDITION]." THE REPORT INCLUDED THE RESIDENT WAS IN CRITICAL CONDITION, AND CONTINUED CARE ON A VENTILATOR IN THE INTENSIVE CARE UNIT. DURING A PHONE INTERVIEW ON 12/7/10 AT 10:10 A.M., RESIDENT #102'S ATTENDING PHYSICIAN (WITNESS #19) SAID, "I'VE CARED FOR THIS RESIDENT FOR [AGE] years. SHE HAD MANY COMPLEX PROBLEMS. MISSED DOSES OF [MEDICATION NAME] WOULD HAVE COMPROMISED CLOTTING AND CIRCULATION. THIS WOULD AFFECT OVERALL MEDICAL COVERAGE AND EXPOSE HER TO THROMBUS (BLOOD CLOT) FORMATION. SHE WAS ALREADY AT HIGH RISK FOR THROMBI (CLOTS FREELY TRANSPORTED VIA BLOOD TO THE BRAIN AND/OR ORGANS OF THE BODY) DUE TO HER OTHER DIAGNOSES." DURING A PHONE INTERVIEW ON 12/7/10 AT 12:05 P.M., THE MEDICAL DIRECTOR (WITNESS #22) SAID, "IF A RESIDENT DOESN'T MAINTAIN THERAPEUTIC LEVELS OF [MEDICATION NAME], THERE'S AN INCREASED RISK OF STROKE AND EMBOLISM (BLOOD CLOTS). THE RISK FOR RESIDENTS WITH [MEDICAL CONDITION] FIBRILLATION IS A CLOT THAT GOES TO THE BRAIN, CAUSING A STROKE. EMPIRICALLY, THE BOWEL COULD BE EXPOSED TO CLOTS AS WELL." RESIDENT #103: THE FACE SHEET REVEALED RESIDENT #103 WAS A [AGE] year OLD MAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO PHYSICIAN ORDERS [REDACTED]. ACCORDING TO THE MAR FOR NOVEMBER 2010, RESIDENT #103 DID NOT RECEIVE [MEDICATION NAME], AS ORDERED BY HIS PRIMARY CARE PHYSICIAN, ON 11/13/10 AT 8:00 P.M., ON 11/14/10 AT 8:00 A.M. OR 8:00 P.M., ON 11/15/10 AT 8:00 A.M. OR 8:00 P.M., OR ON 11/16/10 AT 8:00 A.M. DURING AN INTERVIEW ON 11/29/10 AT 12:20 P.M., RESIDENT #103 SAID, "I NEED PAIN MEDICATION FOR PAIN ALL AROUND MY STOMACH. MOST TIMES IT'S SEVERE; AN 8 OR 9 OUT OF 10 ON THE PAIN SCALE. I DIDN'T GET MY [MEDICATION NAME] FOR ABOUT 3 DAYS. I COULDN'T HARDLY STAND THE PAIN. I DIDN'T FEEL LIKE EATING ANYTHING. I TOLD NURSES I WAS IN SEVERE PAIN. THEY SAID THEY DIDN'T HAVE THE [MEDICATION NAME]. THE SET BACK CAME WHEN THE PAIN WAS SO BAD I DIDN'T FEEL LIKE I'M GOING TO MAKE IT. I NEED TO FIGHT TO LIVE. I NEED TO FIGHT [MEDICAL CONDITION]. I NEED TO EAT, REST, BE COMFORTABLE WITHOUT PAIN; IT'S VERY HARD TO DO WITHOUT PAIN RELIEF. EVERYDAY I ASKED FOR THE [MEDICATION NAME]; I DIDN'T GET IT, BUT I DID GET EXCUSES. THIS SHOULDN'T BE HAPPENING." DURING AN INTERVIEW ON 11/29/10 AT 12:00 P.M., THE DIRECTOR OF NURSING SAID, "I WAS AWARE HE (RESIDENT #103) WENT WITHOUT [MEDICATION NAME]; THEY (STAFF) WERE UNABLE TO GET HOLD OF HIS ATTENDING PHYSICIAN FOR A FEW DAYS AND WERE OUT OF THE MEDICATION. I TRIED TO GET HOLD OF HIS DOCTOR, TOO. I DID NOT CALL THE MEDICAL DIRECTOR. EVERY NURSE KNOWS THEY CAN CALL THE MEDICAL DIRECTOR IF THEY CAN'T GET HOLD OF AN ATTENDING PHYSICIAN. SOMEHOW, WE HAD an order for [REDACTED]. RESIDENT #104: THE FACE SHEET REVEALED RESIDENT #104 WAS A [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO PHYSICIAN ORDERS [REDACTED]. ACCORDING TO THE MAR INITIATED 11/19/10, RESIDENT #104 DID NOT RECEIVE [MEDICATION NAME], AS ORDERED BY HER PRIMARY CARE PHYSICIAN FOR THE DATES 11/28/10, 11/29/10, AND 11/30/10. THE MAR indicated [REDACTED]. DURING AN INTERVIEW ON 11/29/10 AT 10:05 A.M., RESIDENT #104 SAID, "THEY (FACILITY) RAN OUT OF [MEDICATION NAME] A FEW DAYS AGO. MY SISTER'S GOING TO BRING SOME FROM HOME THAT I HAD BEFORE COMING HERE. I [MEDICAL CONDITION] IN MY STOMACH. I'VE HAD [MEDICAL CONDITION]. I'M LOSING WEIGHT AND LOSING MY HAIR. I NEED THIS MEDICATION." DURING AN INTERVIEW ON 11/29/10 AT 10:15 A.M., A REGISTERED NURSE (WITNESS #8) SAID, "SHE'S (RESIDENT #104) BEEN WITHOUT [MEDICATION NAME] FOR 2 DAYS. I DON'T KNOW IF IT'S BEEN RE-ORDERED. WE DON'T HAVE ANY [MEDICATION NAME] IN OUR BACK UP BOX, AND THERE'S NONE IN HER DRAWER ON THE MED CART." RESIDENT #109: THE FACE SHEET REVEALED RESIDENT #109 WAS A [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH DEBILITY AND SEVERE [MEDICAL CONDITION]. ACCORDING TO THE PRIMARY CARE physician's orders [REDACTED].M., RESIDENT #109 WAS TO HAVE A PT AND INR DRAWN (LAB WORK OBTAINED TO TRACK SUCCESS OF ON-GOING ANTICOAGULANT THERAPY) ON 12/4/10 TO MONITOR THE EFFECT OF AN INCREASED DOSE OF [MEDICATION NAME]. INCLUDED IN THE ORDER WAS "MAKE SURE LAB PICKS UP (PT/INR DRAWN ON SPECIFIED DATE, 12/4/2010)." THE REPORT OF THE PT/INR (LAB WORK ORDERED BY THE PCP) WAS DATED 12/6/10, NOT 12/4/10, AS SPECIFIED. DURING AN INTERVIEW ON 12/7/10 AT 11:15 A.M., THE DIRECTOR OF CARE DELIVERY (REGISTERED NURSE, WITNESS #3) SAID, "THE ORDER FOR THIS LAB WORK (PT/INR) SAID IT WAS SUPPOSED TO BE OBTAINED ON 12/4/10. I HAVE NO IDEA WHY IT WASN'T DRAWN ON 12/4/10. IT'S WRITTEN DOWN IN THE LAB DRAW BOOK FOR 12/4/10. IT WAS EVENTUALLY DRAWN ON 12/6/10, 2 DAYS AFTER THE DATE IT WAS SUPPOSED TO BE DONE. I CHECKED WITH THE LAB AND NO LAB WORK WAS OBTAINED ON THIS RESIDENT ON 12/4/10." DURING AN INTERVIEW ON 12/7/10 AT 1:50 P.M., THE DIRECTOR OF NURSING SAID, "I EXPECT ALL STAFF TO FOLLOW ORDERS, AS WRITTEN." DURING AN INTERVIEW ON 12/7/10 AT 2:00 P.M., THE NURSING HOME ADMINISTRATOR SAID, "OUR STANCE HERE (FACILITY) ON STAFF FOLLOWING PCP ORDERS IS WE WILL FOLLOW ALL PRIMARY CARE physician's orders [REDACTED]. ON 12/2/10 AT 3:55 P.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 10/25/10 WHEN STAFF DISREGARDED A PRIMARY CARE PROVIDER'S ORDER TO ADMINISTER [MEDICATION NAME] DAILY TO RESIDENT #102 WHO SUBSEQUENTLY DID NOT RECEIVE 4 DOSES OF [MEDICATION NAME] RESULTING IN SUB-THERAPEUTIC INR LEVELS, INFARCTED/ISCHEMIC BOWEL, SURGICAL INTERVENTION, SEPTIC SHOCK, AND PLACEMENT ON A VENTILATOR IN THE INTENSIVE CARE UNIT. ON 12/3/10, THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. ON 11/29/10 THE FACILITY REVIEWED THE CLINICAL RECORDS OF 7 RESIDENTS ON [MEDICATION NAME] TO VALIDATE THE PROPER [MEDICATION NAME] DOSE WAS BEING ADMINISTERED, THAT APPROPRIATE PT/INR HAD BEEN ORDERED AND COMPLETED, AND THAT TRACKING SHEETS WERE PRESENT IN THE MAR. 2. ON 11/30/10, THE FACILITY INITIATED NEW [MEDICATION NAME] TRACKING LOGS FOR EACH OF 7 RESIDENTS ON SCHEDULED [MEDICATION NAME]. 3. ON 12/1/10, NURSES WHO WERE IMPLICATED IN ERRORS OF OMISSION, AND/OR FOLLOW UP CARE TO MISSED DOSES OF MEDICATION OF [MEDICATION NAME] RECEIVED ONE-TO-ONE EDUCATION REGARDING ORDERS MANAGEMENT. 4. ON 12/1/10, RECORDS OF RESIDENTS ON [MEDICAL TREATMENT]/LOA (LEAVES OF ABSENCE) WERE REVIEWED TO VALIDATE ADMINISTRATION OF MEDICATIONS DURING LOA; 4 RESIDENTS WERE IDENTIFIED. ON 12/3/10, ALL RESIDENT RECORDS WERE REVIEWED FOR PARTICIPATION IN ANTICOAGULANT THERAPY; A TOTAL OF 23 RESIDENTS WERE IDENTIFIED. 5. ON 12/3/10, 23 OF 27 REGISTERED NURSES WERE INSERVICED ON MEDICATION ADMINISTRATION, ORDERS MANAGEMENT, ANTICOAGULANT THERAPY, MEDICATION MANAGEMENT OF [MEDICAL TREATMENT] RESIDENTS AND PROVISION OF CLINICALLY INDICATED FOLLOW-UP CARE TO MISSED DOSES OF MEDICATION/MISSED LAB WORK, AND CARE AS ORDERED. TWO REMAINING NURSES WILL RECEIVE EDUCATION PRIOR TO START OF NEXT SCHEDULED SHIFT. ONE NURSE HAS BEEN SENT A CERTIFIED LETTER DATED 12/3/10 INFORMING OF MANDATORY EDUCATION PRIOR TO RETURN TO WORK. ONE NURSE, IN OFF-SITE ORIENTATION, WILL RECEIVE EDUCATION BY DON. 6. ON 12/3/10 14 OF 18 LPN'S WERE INSERVICED ON MEDICATION ADMINISTRATION, ORDERS MANAGEMENT, ANTICOAGULANT THERAPY, MEDICATION MANAGEMENT OF [MEDICAL TREATMENT] RESIDENTS AND PROVISION OF CLINICALLY INDICATED FOLLOW-UP CARE TO MISSED DOSES OF MEDICATION/MISSED LAB WORK, AND CARE AS ORDERED. THREE LPN'S ON LEAVE WERE SENT CERTIFIED LETTERS OF MANDATORY INSERVICE PRIOR TO RETURN TO WORK. ONE LPN, IN OFF-SITE ORIENTATION, WILL RECEIVE EDUCATION BY DON. 7. NEWLY HIRED NURSES WILL RECEIVE INSERVICE ON MEDICATION ADMINISTRATION, ORDERS MANAGEMENT, ANTICOAGULANT THERAPY, MEDICATION MANAGEMENT OF [MEDICAL TREATMENT] RESIDENTS AND PROVISION OF CLINICALLY INDICATED FOLLOW-UP CARE TO MISSED DOSES OF MEDICATION/MISSED LAB WORK, AND CARE AS ORDERED, AS PART OF NEW EMPLOYEE ORIENTATION. 8. PROCEDURE FOR OBTAINING, PROCESSING, AND NOTING PHYSICIAN ORDERS [REDACTED]. NURSING ORDERS ARE REVIEWED BY THE NURSING MANAGERS TO VALIDATE ACCURATE TRANSCRIPTION OF MEDICATIONS. [MEDICATION NAME] TRACKING SHEETS ARE IN THE MAR, REVIEWED DAILY BY NURSE SUPERVISORS TO VALIDATE COMPLETION OF ORDERED BLOOD DRAWS, AND DOSAGES OF [MEDICATION NAME] ADMINISTERED AS ORDERED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 12/3/10, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE AND SEVERITY OF ISOLATED WITH NO ACTUAL HARM, BUT POTENTIAL FOR MORE THAN MINIMAL HARM, BUT NO IMMEDIATE JEOPARDY DUE TO ALL STAFF WERE INSERVICED, AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY.

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 790 AND MI 905. BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES IN 2 OF 9 SAMPLED RESIDENTS (#102 AND #103) RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #102 WHO DID NOT RECEIVE THE NECESSARY FOLLOW-UP CARE (PRIMARY CARE PROVIDER NOTIFICATION AND REPORT TO ONCOMING SHIFTS) TO 4 MISSED DOSES OF [MEDICATION NAME] RESULTING IN SUB-THERAPEUTIC INR LEVELS, INFARCTED/ISCHEMIC BOWEL, SURGICAL INTERVENTION, SEPTIC SHOCK, AND PLACEMENT ON A VENTILATOR IN THE INTENSIVE CARE UNIT, AND FOR INCREASED IN PAIN IN RESIDENT #103 WHO DID NOT RECEIVE THE NECESSARY FOLLOW-UP CARE TO MISSED DOSES OF [MEDICATION NAME] FOR 3 DAYS (7 DOSES) FOR PAIN RELATED TO [MEDICAL CONDITION] WITH ABDOMINAL ORGAN METASTASIS. FINDINGS INCLUDE: RESIDENT #102 THE FACE SHEET REVEALED RESIDENT #102 WAS AN [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE PRIMARY CARE PHYSICIAN'S (PCP) ORDERS DATED 10/22/10 THROUGH 11/4/10 SPECIFIED RESIDENT #102 WAS TO RECEIVE [MEDICATION NAME], DAILY. THERE WERE NO ORDERS PRESENT IN THE RESIDENT'S MEDICAL FILE TO WITHHOLD ANY DOSES OF [MEDICATION NAME] FOR THE PERIOD 10/22/10 (DATE OF ADMISSION) THROUGH THE DATE OF THE RESIDENT'S TRANSFER TO A LOCAL hospital on [DATE]. ACCORDING TO THE MEDICATION ADMINISTRATION RECORD (MAR), RESIDENT #102 DID NOT RECEIVE [MEDICATION NAME] FOR THE DATES 10/25/10, 10/29/10, 11/3/10, AND 11/5/10. ACCORDING TO LAB WORK OBTAINED ON RESIDENT #102 DATED 11/3/10, INR LEVELS (INTERNATIONAL NORMALIZED RATIO) WERE REPORTED AS 1.58 OR SUB-THERAPEUTIC (BELOW DESIRED LEVELS) FOR ANTICOAGULANT EFFECT (THERAPEUTIC LEVELS ARE 2.0-3.0). ACCORDING TO NURSES NOTES DATED 11/6/10 AT 12:00 P.M., RESIDENT #102 EXPERIENCED ABDOMINAL PAIN FOR WHICH HER PHYSICIAN WAS NOTIFIED; SHE WAS TRANSFERRED TO A LOCAL HOSPITAL FOR EVALUATION AT 3:00 P.M. THE OPERATIVE REPORT DATED 11/11/10 AT 11:06 A.M., DOCUMENTED #102'S POSTOPERATIVE [DIAGNOSES REDACTED]." THE RESIDENT WAS REPORTED TO HAVE UNDERGONE AN "EXPLORATORY LAPAROTOMY, SUBTOTAL COLECTOMY WITH END [MEDICAL CONDITION]." THE REPORT INCLUDED THE RESIDENT WAS IN CRITICAL CONDITION, AND CONTINUED CARE ON A VENTILATOR IN THE INTENSIVE CARE UNIT. DURING AN INTERVIEW ON 11/29/10, THE DIRECTOR OF NURSING SAID, "THE RESIDENT (#102) WAS ON [MEDICAL TREATMENT]. SINCE DOSES OF [MEDICATION NAME] MISSED WERE ON HER [MEDICAL TREATMENT] DAYS, WE WOULD'VE RECEIVED ORDERS FROM THE [MEDICAL TREATMENT] CENTER TO HOLD [MEDICATION NAME] IF IT WERE NECESSARY, BUT THERE ARE NO ORDERS IN HER CHART TO HOLD THE [MEDICATION NAME]. [MEDICATION NAME] WOULD BE EXPECTED TO BE GIVEN AT 4 P.M. OR 5 P.M., OR LATER THAT EVENING IF [MEDICAL TREATMENT] WERE DONE LATER IN THE DAY. IF A NURSE HAD A QUESTION ABOUT GIVING THE [MEDICATION NAME], SHE WOULD BE EXPECTED TO CALL THE PHYSICIAN OR PCP." AFTER REVIEWING RESIDENT #102'S MEDICAL FILE, THE DON VERIFIED 4 DOSES OF [MEDICATION NAME] HAD NOT BEEN ADMINISTERED. "THE MEDICATION WAS TO BE GIVEN AND THE PCP'S ORDERS FOLLOWED." DURING AN INTERVIEW ON 12/1/10 AT 1:15 P.M., A REGISTERED NURSE (WITNESS #7) SAID SHE HAD BEEN ASSIGNED TO THE CARE OF RESIDENT #102 ON 11/5/10 FROM 6:00 P.M. TO 6:00 A.M. ON 11/6/10. "MOST [MEDICAL TREATMENT] RESIDENTS ARE BACK HERE (FACILITY) BY 5:00 P.M. AND WE WOULD GIVE THE [MEDICATION NAME] ON RETURN. IF THE RESIDENT CAME BACK TO THE FACILITY AFTER 5:00 P.M., I COULD GIVE THE [MEDICATION NAME] AFTER I START MY SHIFT. WE ALWAYS HAVE [MEDICATION NAME], AND THERE'S ALWAYS SOME IN THE BACK UP BOX IF WE RUN OUT. RESIDENT #102'S [MEDICATION NAME] NOT BEING GIVEN AT 5:00 P.M., BY FIRST SHIFT, WAS NOT PASSED ON TO ME IN REPORT. IF IT'S NOT PASSED ON, I WOULDN'T HAVE ASSUMED I NEEDED TO GIVE IT. THERE'S NO REASON SHE (RESIDENT #102) SHOULD'VE MISSED HER [MEDICATION NAME]." DURING AN INTERVIEW ON 12/1/10 AT 1:55 P.M., A REGISTERED NURSE (WITNESS #9) SAID, "I WORK 6:00 A.M. TO 6:00 P.M. I WAS ASSIGNED TO HER (RESIDENT #102) ON 11/3/10. SHE WAS A [MEDICAL TREATMENT] PATIENT AND RECEIVED [MEDICAL TREATMENT] ON MONDAY, WEDNESDAY, AND FRIDAY AT 1:45 P.M., THEN RETURNED TO THE FACILITY ABOUT 4 TO 5 HOURS LATER. I WAS GONE WHEN SHE GOT BACK. I LEFT A BLANK SPOT ON THE MAR ON 11/3/10 FOR HER 5:00 P.M. DOSE OF [MEDICATION NAME]. I DIDN'T PASS ON TO THE ONCOMING SHIFT THAT THE RESIDENT MISSED HER MED. WE CAN CHANGE THE TIME AND GIVE IT LATER IF WE NEED TO. I DON'T RECALL PASSING ON THAT THE RESIDENT MISSED HER MED TO THE ONCOMING SHIFT. IF THE [MEDICATION NAME] WAS NOT GIVEN, THE INR WOULD HAVE BEEN AFFECTED." DURING AN INTERVIEW ON 12/1/10 AT 12:30 P.M., A REGISTERED NURSE (WITNESS #10) SAID, "I TOOK CARE OF HER (RESIDENT #102) ON 11/3/10 FROM 6:00 P.M. TO 6:00 A.M. ON 11/4/10. SHE CAME BACK FROM [MEDICAL TREATMENT] ON 11/3/10 BEFORE THE START OF MY SHIFT. I WASN'T TOLD SHE NEEDED TO HAVE A DOSE OF [MEDICATION NAME]; DIDN'T GET THAT IN REPORT. I COULD'VE GIVEN IT TO HER LATE. THE ONLY WAY WE'D KNOW TO GIVE A MED THAT WAS MISSED, IS TO HEAR IT IN REPORT." DURING AN INTERVIEW ON 12/1/10 AT 3:15 P.M., A REGISTERED NURSE (WITNESS #8) SAID SHE HAD BEEN ASSIGNED TO RESIDENT #102 ON 11/5/10 FROM 6:00 A.M. TO 6:00 P.M. "SHE DIDN'T GET HER 5:00 P.M. DOSE; NOT SURE WHY." DURING AN INTERVIEW ON 12/6/10 AT 11:55 P.M., THE DIRECTOR OF NURSING (DON) SAID, "WE DON'T HAVE A POLICY OR PROCEDURE ABOUT THE TIMING OF [MEDICATION NAME] ADMINISTRATION. WE GIVE IT AT 5:00 P.M. BECAUSE THAT ALLOWS TIME FOR LAB WORK TO GET HERE (FACILITY)." RESIDENT #103: THE FACE SHEET REVEALED RESIDENT #103 WAS A [AGE] year OLD MAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO PHYSICIAN ORDERS [REDACTED]. ACCORDING TO THE MAR FOR NOVEMBER 2010, RESIDENT #103 DID NOT RECEIVE [MEDICATION NAME], AS ORDERED BY HIS PCP, ON 11/13/10 AT 8:00 P.M., ON 11/14/10 AT 8:00 A.M. OR 8:00 P.M., ON 11/15/10 AT 8:00 A.M. OR 8:00 P.M., OR ON 11/16/10 AT 8:00 A.M. DOCUMENTED ON THE MAR FOR THE DATES 11/14/10 AND 11/15/10 WAS THE UNAVAILABILITY OF THE MEDICATION, AND THE NEED FOR A "NEW PRESCRIPTION." DURING AN INTERVIEW ON 11/29/10 AT 12:20 P.M., RESIDENT #103 SAID, "I NEED PAIN MEDICATION FOR PAIN ALL AROUND MY STOMACH. MOST TIMES IT'S SEVERE; AN 8 OR 9 OUT OF 10 ON THE PAIN SCALE. I DIDN'T GET MY [MEDICATION NAME] FOR ABOUT 3 DAYS. I COULDN'T HARDLY STAND THE PAIN. I DIDN'T FEEL LIKE EATING ANYTHING. I TOLD NURSES I WAS IN SEVERE PAIN. THEY SAID THEY DIDN'T HAVE THE [MEDICATION NAME]. THE SET BACK CAME WHEN THE PAIN WAS SO BAD I DIDN'T FEEL LIKE I'M GOING TO MAKE IT. I NEED TO FIGHT TO LIVE. I NEED TO FIGHT [MEDICAL CONDITION]. I NEED TO EAT, REST, BE COMFORTABLE WITHOUT PAIN; IT'S VERY HARD TO DO WITHOUT PAIN RELIEF. EVERYDAY I ASKED FOR THE [MEDICATION NAME]; I DIDN'T GET IT, BUT I DID GET EXCUSES. THIS SHOULDN'T BE HAPPENING." DURING AN INTERVIEW ON 11/29/10 AT 12:00 P.M., THE DON SAID, "I WAS AWARE HE (RESIDENT #103) WENT WITHOUT [MEDICATION NAME]; THEY (STAFF) WERE UNABLE TO GET HOLD OF HIS ATTENDING PHYSICIAN FOR A FEW DAYS AND WERE OUT OF THE MEDICATION. I TRIED TO GET HOLD OF HIS DOCTOR, TOO. I DID NOT CALL THE MEDICAL DIRECTOR. EVERY NURSE KNOWS THEY CAN CALL THE MEDICAL DIRECTOR IF THEY CAN'T GET HOLD OF AN ATTENDING PHYSICIAN." DURING AN INTERVIEW ON 12/7/10 AT 1:50 P.M., THE DON SAID, "I EXPECT ALL STAFF TO FOLLOW ORDERS, AS WRITTEN. IF THERE ARE MISSED DOSES OF MEDICATION, OR MEDICATION NEEDS TO BE RE-ORDERED, THEN I EXPECT THE PCP IS TO BE NOTIFIED AND NEW ORDERS FOLLOWED IMMEDIATELY." DURING AN INTERVIEW ON 12/7/10 AT 2:00 P.M., THE NURSING HOME ADMINISTRATOR SAID, "OUR STANCE HERE (FACILITY) ON STAFF FOLLOWING PCP ORDERS IS WE WILL FOLLOW ALL PCP ORDERS. WHEN LAB WORK OR MEDICATIONS ARE MISSED, I EXPECT STAFF TO NOTIFY PCP'S, GET CLARIFICATION OF ORDERS WITH CLARIFICATION, CIRCLE OMISSIONS, AND DOCUMENT REASON ON BACK OF MAR WITH DATE AND TIME INCLUDED. I EXPECT STAFF TO CARRY OUT NEW ORDERS, AND TO COMPLETE AN INCIDENT REPORT, IF APPLICABLE. STAFF SHOULD VERIFY WITH OUR LAB WORK BOOK THAT LAB WORK HAS BEEN COMPLETED AS ORDERED, WITH RESULTS REPORTED TO THE PCP IMMEDIATELY." ON 12/2/10 AT 3:55 P.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 10/25/10 WHEN STAFF DISREGARDED A PRIMARY CARE PROVIDER'S ORDER TO ADMINISTER [MEDICATION NAME] DAILY TO RESIDENT #102 WHO SUBSEQUENTLY DID NOT RECEIVE 4 DOSES OF [MEDICATION NAME] RESULTING IN SUB-THERAPEUTIC INR LEVELS, INFARCTED/ISCHEMIC BOWEL, SURGICAL INTERVENTION, SEPTIC SHOCK, AND PLACEMENT ON A VENTILATOR IN THE INTENSIVE CARE UNIT. ON 12/3/10, THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. ON 11/29/10 THE FACILITY REVIEWED THE CLINICAL RECORDS OF 7 RESIDENTS ON [MEDICATION NAME] TO VALIDATE THE PROPER [MEDICATION NAME] DOSE WAS BEING ADMINISTERED, THAT APPROPRIATE PT/INR HAD BEEN ORDERED AND COMPLETED, AND THAT TRACKING SHEETS WERE PRESENT IN THE MAR. 2. ON 11/30/10, THE FACILITY INITIATED NEW [MEDICATION NAME] TRACKING LOGS FOR EACH OF 7 RESIDENTS ON SCHEDULED [MEDICATION NAME]. 3. ON 12/1/10, NURSES WHO WERE IMPLICATED IN ERRORS OF OMISSION, AND/OR FOLLOW UP CARE TO MISSED DOSES OF MEDICATION OF [MEDICATION NAME] RECEIVED ONE-TO-ONE EDUCATION REGARDING ORDERS MANAGEMENT. 4. ON 12/1/10, RECORDS OF RESIDENTS ON [MEDICAL TREATMENT]/LOA (LEAVES OF ABSENCE) WERE REVIEWED TO VALIDATE ADMINISTRATION OF MEDICATIONS DURING LOA; 4 RESIDENTS WERE IDENTIFIED. ON 12/3/10, ALL RESIDENT RECORDS WERE REVIEWED FOR PARTICIPATION IN ANTICOAGULANT THERAPY; A TOTAL OF 23 RESIDENTS WERE IDENTIFIED. 5. ON 12/3/10, 23 OF 27 REGISTERED NURSES WERE INSERVICED ON MEDICATION ADMINISTRATION, ORDERS MANAGEMENT, ANTICOAGULANT THERAPY, MEDICATION MANAGEMENT OF [MEDICAL TREATMENT] RESIDENTS AND PROVISION OF CLINICALLY INDICATED FOLLOW-UP CARE TO MISSED DOSES OF MEDICATION/MISSED LAB WORK, AND CARE AS ORDERED. TWO REMAINING NURSES WILL RECEIVE EDUCATION PRIOR TO START OF NEXT SCHEDULED SHIFT. ONE NURSE HAS BEEN SENT A CERTIFIED LETTER DATED 12/3/10 INFORMING OF MANDATORY EDUCATION PRIOR TO RETURN TO WORK. ONE NURSE, IN OFF-SITE ORIENTATION, WILL RECEIVE EDUCATION BY DON. 6. ON 12/3/10 14 OF 18 LPN'S WERE INSERVICED ON MEDICATION ADMINISTRATION, ORDERS MANAGEMENT, ANTICOAGULANT THERAPY, MEDICATION MANAGEMENT OF [MEDICAL TREATMENT] RESIDENTS AND PROVISION OF CLINICALLY INDICATED FOLLOW-UP CARE TO MISSED DOSES OF MEDICATION/MISSED LAB WORK, AND CARE AS ORDERED. THREE LPN'S ON LEAVE WERE SENT CERTIFIED LETTERS OF MANDATORY INSERVICE PRIOR TO RETURN TO WORK. ONE LPN, IN OFF-SITE ORIENTATION, WILL RECEIVE EDUCATION BY DON. 7. NEWLY HIRED NURSES WILL RECEIVE INSERVICE ON MEDICATION ADMINISTRATION, ORDERS MANAGEMENT, ANTICOAGULANT THERAPY, MEDICATION MANAGEMENT OF [MEDICAL TREATMENT] RESIDENTS AND PROVISION OF CLINICALLY INDICATED FOLLOW-UP CARE TO MISSED DOSES OF MEDICATION/MISSED LAB WORK, AND CARE AS ORDERED, AS PART OF NEW EMPLOYEE ORIENTATION. 8. PROCEDURE FOR OBTAINING, PROCESSING, AND NOTING PHYSICIAN ORDERS [REDACTED]. NURSING ORDERS ARE REVIEWED BY THE NURSING MANAGERS TO VALIDATE ACCURATE TRANSCRIPTION OF MEDICATIONS. [MEDICATION NAME] TRACKING SHEETS ARE IN THE MAR, REVIEWED DAILY BY NURSE SUPERVISORS TO VALIDATE COMPLETION OF ORDERED BLOOD DRAWS, AND DOSAGES OF [MEDICATION NAME] ADMINISTERED AS ORDERED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 12/3/10, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE AND SEVERITY OF ISOLATED WITH ACTUAL HARM, BUT NO IMMEDIATE JEOPARDY DUE TO ALL STAFF WERE NOT INSERVICED, AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY.

REFER TO INTAKE # MI 008 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY AND APPROPRIATE CARE AND SERVICES OF THE PICC LINE WOUND SITE AND DECUBITUS ULCERS TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING, IN ACCORDANCE WITH THE COMPREHENSIVE ASSESSMENT AND PLAN OF CARE FOR ONE RESIDENT (#502) OF 5 SAMPLED RESIDENTS RESULTING IN hospitalization DUE TO INFECTION OF WOUND SITE ON THE LEFT ARM (PICC LINE) AND INFECTION OF STAGE 2 DECUBITUS ULCER OF THE COCCYX AND SACRAL AREA. FINDINGS INCLUDE: RESIDENT 502 WAS [AGE] years OLD, ALERT AND ORIENTED RESIDENT, admitted to the facility on [DATE]. ACCORDING TO HISTORY AND PHYSICAL DATED 9/19/10, RESIDENT #502 HAD [MEDICAL CONDITION] AND HAD A FRONTAL LOBE MASS RESECTION. HOSPITAL TRANSFER FORM DATED 9/17/10, SPECIFIED SKIN CONDITION: LEFT ARM SKIN TEAR DRESSING WITH CLEAR, DRY AND INTACT DRESSING, BILATERAL ARMS BRUISING AND LEFT FRONTAL AREA STAPLES. NO PRESSURE SORE OR RASH WAS NOTED. NO INFECTION WAS NOTED. THE FACILITY NURSING ADMISSION assessment dated [DATE], INDICATED THAT RESIDENT #502 DID NOT HAVE ANY PRESSURE SORE HOWEVER FOUND BRUISING TO BILATERAL ARMS, AND LEFT ARM SKIN TEAR. RESIDENT #502 ' S CLINICAL RECORD DID NOT SHOW EVIDENCE THAT A CARE PLAN FOR ALTERATION OF SKIN INTEGRITY AND PREVENTING INFECTION WAS INITIATED FROM ADMISSION. THERE WAS NO WEEKLY SKIN ASSESSMENT AND NO BRADEN SCALE ASSESSMENT FOUND. RESIDENT #502 DID NOT HAVE A BATH /SKIN ASSESSMENT SHEET. THERE WAS NO EVIDENCE THAT THE PICC LINE WAS MONITORED AND ASSESSED NOR PICC LINE DRESSING WAS CHANGED, FROM 9/17/10 THROUGH 9/28/10. THE PICC LINE WAS PULLED OUT ON 9/22/10, PER DOCTOR ' S ORDER AND DRY DRESSING WAS APPLIED. THERE WAS NO ASSESSMENT RECORDED AFTER THE PICC LINE WAS REMOVED. ON 9/28/10, NURSE ' S NOTES DESCRIBED THAT THE LEFT ARM AS SWOLLEN, RED, WEEPING WITH PUS. RESIDENT #502 WAS SENT OUT TO THE hospital on [DATE] PER FAMILY ' S REQUEST FOR FURTHER EVALUATION OF THE LEFT ARM. DISCHARGE TRANSFER SHEET DID NOT INDICATE ANY PRESSURE SORE ON THE BUTTOCKS AND COCCYX AREA. HOSPITAL emergency room (ER) RECORD DATED 9/28/10, REVEALED A [DIAGNOSES REDACTED]. ER SKIN assessment dated [DATE] AT 5:04 PM, NOTED: PATIENT ' S LEFT ARM SWOLLEN, RED AND WARM TO TOUCH. PATIENT ' S TESTICLES STAGE 1 DECUBITUS, RED, AND TENDER TO TOUCH. PATIENT ' S BUTTOCKS RED, INFLAMED WITH STAGE 1 AND 2 DECUBITUS ULCERS PRESENT. WOUND CONSULT DATED 9/29/10, FURTHER DESCRIBED: " THERE ARE 2 LINEAR DECUBITUS ULCERS. ONE ON THE LEFT BUTTOCKS ABOUT 9.0 CM X 0.4 CM X 0.1 CM AND OTHER IN THE COCCYX AREA OF 4.0 CM X 0.4 CM X 0.1 CM " . RESIDENT #502 STARTED ON IV (INTRAVENOUS) ANTIBIOTICS, [MEDICATION NAME] ORALLY AND SANTYL (TOPICAL) TO BUTTOCKS AND COCCYX ULCER DAILY. NURSE # 4 WAS INTERVIEWED BY TELEPHONE ON 10/25/10 AT 1:45 PM, SHE admitted THAT SHE WAS THE NURSE THAT DID THE ADMISSION SKIN ASSESSMENT ON 9/18/10, AND ALSO WAS THE NURSE WHO discharged RESIDENT #502 ON 9/28/10. SHE RECALLED THE STAPLES ON RESIDENT #502' S HEAD, BRUISING ON BOTH ARMS AND A SKIN TEAR ON LEFT ARM. THE PICC LINE WAS INTACT ON THE LEFT ARM AND THERE WAS A DRESSING ON. RESIDENT DID NOT HAVE ANY PRESSURE SORE FOUND UPON ADMISSION. ON 9/28/10, SHE RECALLED THAT HIS LEFT ARM WAS SWOLLEN RED AND WARM TO TOUCH. PUS WAS COMING FROM THE PICC LINE SITE. ABOUT 3 DAYS AFTER IT WAS REMOVED. THE DRESSING WAS SATURATED WITH PUS. NURSE #4 NOTIFIED THE PHYSICIAN AND ORDERED TO START ANTIBIOTICS. NURSE #4 RECALLED THAT THE FAMILY INSISTED FOR RESIDENT #502 TO BE SENT TO THE HOSPITAL. NURSE DENIED AWARENESS OF ANY PRESSURE SORE ON THE BUTTOCKS OR COCCYX AREA. SHE DID NOT KNOW HE HAD ANY OPEN SORE OTHER THAN HIS LEFT ARM BEFORE DISCHARGE. THE DIRECTOR OF NURSING (DON) ON 10/25/10 AT 12:00 PM admitted THAT THERE WAS NO CAREPLAN FOR SKIN CARE AND PREVENTION OF INFECTION FOR RESIDENT #502. SHE AGREED THAT RESIDENT #502 HAD STAPLES (27) ON THE HEAD UPON ADMISSION AFTER A BRAIN (FRONTAL LOBE) MASS RESECTION. BASING ON THE ADMISSION SKIN assessment dated [DATE], HE ALSO HAD A SKIN TEAR AND A PICC LINE ON THE LEFT ARM. THE DON DID NOT FIND ANY EVIDENCE OF WEEKLY SKIN ASSESSMENT, OR BATH/SHOWER SKIN SHEET. NO SKIN ASSESSMENT WAS RECORDED IN RESIDENT #502 ' S "TREATMENT ADMINISTRATION RECORD" (TAR). NURSE ' S NOTES FROM 9/17/10 TO 9/28/10, EXCEPT WHEN HIS PICC LINE WAS REMOVED ON 9/21/10, STAPLES REMOVED ON 9/24/10 AND RESIDENT #502 ' S LEFT ARM WAS FOUND SWOLLEN AND INFECTED. RESIDENT #502 ' S RECORD DID NOT SHOW EVIDENCE THAT HE HAD OPEN AREA ON THE BUTTOCKS AND COCCYX. THE DON DENIED ANY AWARENESS OF THE STAGE 2 ULCERS FOUND AT THE emergency room . BLOOD CULTURE WAS ordered on [DATE], AFTER PICC LINE WAS DISCONTINUED. FINAL LABORATORY REPORT DATED 9/23/10, SHOWED: POSITIVE BLOOD CULTURE GRAM STAIN. NO NEW physician's orders [REDACTED].( )