Every finding on record at Brittany Manor

Based on interview and record review, the facility failed to provide medication according to professional standards of practice for 2 residents (R89 and R94) of the 6 residents reviewed. Findings include:R89 Review of an admission Record revealed R89 originally admitted to the facility on [DATE] with pertinent diagnoses which included acute cholecystitis (inflammation of the gall bladder), muscle wasting, and urinary tract infections. Review of R89's Physician's Orders revealed an active order started 4/8/2026 for one midodrine (used to treat low blood pressure) 10 milligram (mg) tablet by mouth every 8 hours as needed for hypotension (low blood pressure) and to administer to R89 when SBP (systolic blood pressure) was less than 100. Review of R89's Blood Pressure Summary and Medication Administration Record (MAR) revealed the following blood pressures readings with no midodrine administered: 4/9/2026 at 7:29 AM -92/48 millimeters of mercury(mmHg) 4/9/2026 at 6:46 PM -95/45 mmHg 4/12/2026 at 6:22 PM -91/41 mmHg 4/13/2026 at 11:04 AM -99/54 mmHg 4/14/2026 at 6:23 PM – 97/52 mmHg 4/23/2026 at 6:13 PM – 98/51 mmHg 4/24/2026 at 6:35 PM – 98/48 mmHg 4/26/2026 at 7:16 PM – 98/48 mmHg In an interview and record review on 5/12/2026 at 12:01 PM, Unit Manager (UM) C reported that the midodrine 10 mg tablet was not administered for the eight blood pressures documented when the systolic blood pressure was less than 100 following the active date of the midodrine order of 4/8/2026. UM C reported that the midodrine order was not followed per physician's order. Review of facility policy/procedure Medication Administration revised on 10/17/2023, revealed . Medications are administered in accordance with written orders of the attending physician. Review of the medical record reflected R94 originally admitted to the facility 12/28/2022 with pertinent diagnoses that included Diabetes Mellitus and Chronic Pain Syndrome. Review of the Minimum Data Set (MDS) for R94 dated 2/24/2026 reflected a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the Resident was cognitively intact. Review of the Doctor's Orders for R94 revealed a current order for Humalog Kwikpen per sliding scale before meals following Fasting Blood sugar (FBS) scheduled for 7:00 AM. And Lantus (insulin) 15 units one time a day. Additionally, a Doctor's Order for a Lidocaine External Patch 4% to be applied to Upper Right arm topically one time a day. Lastly, a current order for Biofreeze external gel 10% as needed was initiated 2/21/2026. On 5/13/2026 at 8:02 AM at the medication cart with Registered Nurse (RN) L an observation and interview were conducted. R94 approached the medication cart in a wheelchair and requested the Lidocaine patch be applied to her right upper arm as she was in pain. RN L checked the medication cart and reported no patch was available. RN L proceeded to check the Resident's blood sugar without donning gloves or sanitizing the hands. R94 reported she had eaten breakfast in her room earlier. The test reflected a blood sugar result of 192 milligrams per deciliter which the sliding scale called for 2 units of insulin. RN L then administrated both insulins (the to scale and long-acting insulins) by exposing the Residents abdomen while in the hall with other staff and residents about. RN L did not wear gloves during the administration of insulin but held an ongoing conversation with the Resident that the insurance company would not send the lidocaine patch until the last minute. On 5/13/2026 at 11:18 AM an interview was conducted with R94 in her room. R94 reported that she did not have a Lidocaine patch applied and that RN L did not offer her other pain medication. R94 reported pain in her right upper arm at a current pain level of 8 on a 1 to 10 pain scale. On 5/13/2026 at 11:48 AM RN L reported that R94 refused the Lidocaine patch and took Biofreeze (a topical analgesic) instead. RN L reported he had put in an order for the Lidocaine patch and had spoken to the Medical Provider. RN L was asked about the checking of a fasting blood sugar level and administration of to scale insulin after a resident had eaten. RN L indicated that the assigned Hall had approximately twenty residents on insulin and that it was physically impossible to meet that Doctor ordered standard. Review of R94's Medication Administration Record (MAR) for May 2026 reflected that the Lidocaine Patch 4% had been signed out by RN L as administered. The MAR did not reflect that Biofreeze had been applied. Review of the Progress Notes for R94 did not reflect an entry on 5/13/2026 by RN L regarding a conversation with the Medial Provider of the Lidocaine patch or the complaint of pain by R94. The policy provided by the facility titled Blood glucose monitoring, long-term care was reviewed. The policy reflected Equipment.Gloves. And Implementation.Put on gloves to comply with standard precautions (in italics) .Provide privacy. The undated document provided by the facility titled Charge Nurse Job Description was reviewed. The Position Summary reflected that the Charge Nurse manages nursing care, nursing services.to nursing home residents. And The position requires patience, compassion, and a desire to care for the residents in a gentle and empathetic manner. The document reflected Essential Functions and job responsibilities that included, Provides safe and accurate Medication Related interventions to residents. (2) a. Administers and documents medications and treatments according to each resident's medication schedule using current standards of medication pass technique. (2) f. Promptly responds to resident requests for pain intervention and documents such in the medical record. The document reflected Resident Rights promotes and protects resident's rights. treats residents with dignity and respect. And Infection Control.demonstrates understanding of. standard precautions. The policy provided by the facility titled Resident Dignity and Personal Privacy effective 3/12/2025 was reviewed. The policy reflected Policy, The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality and right to personal privacy, And 2. Examine and treat residents in a manner that maintains their privacy.a. Use a closed door, a drawn curtain, or both to shield the resident during all personal care and treatment procedures.

Based on observation, interview, and record review, the facility failed to ensure adherence to standard infection control practices during medication administration for one Resident (R24) and failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). Findings:Medication Administration Review of the medical record reflected R24 originally admitted to the facility 8/27/2025 with diagnoses that included congestive heart failure. Review of the Doctor's Orders for R24 reflected the Resident received medications daily from facility staff. The policy provided by the facility titled Medication Administration last revised 10/17/2023 was reviewed. The policy reflected Procedure, 1. Follow infection control practices. A. Perform hand hygiene prior to medication preparation for each medication pass. c. Place medications into a souffle or medication cup without touching the inside of the cup. A. If medications come into contact with the bare hands of the nurse/QA med tech, or with the cart, the medication should be disposed of per policy and new medications obtained. On 5/13/2026 at 7:40 AM an observation was conducted with Registered Nurse (RN) L during a medication administration. RN L was observed setting up medications for R24 by retrieving stock and prescriptions medications by placing them in his bare hands before placing them in a medication cup. RN L was observed opening a stock medication container of aspirin 81 milligram (mg) and pouring into a bare hand several aspirin tablets, selecting one pill, pouring the unneeded doses from the bare hand back into the stock (community used) container and placing the selected tablet into the medication cup bare-handed. This was repeated with the stock magnesium oxide 400 mg and Vitamin D3 oral capsules. Other prescribed medications that were directly deposited into the hand of RN L after being removed from the package before being placed in the medication cup included: pyridostigmine bromide 60, Lyrica capsule 100 mg, linaclotide oral capsule 72 microgram, and Lexapro oral tablet 5 mg. The medications were then administered to R24. On 5/13/2026 at 11:48 AM an interview was conducted with RN L. RN L was asked about touching resident medications with his bare hands from the container or pack and placing the medication in the cup. RN L stated that's usually what I do, is that not right? I guess I do do that. On 5/13/2026 at 12:03 PM an interview was conducted with RN Unit Manager (UM) C in his office. RN UM C was informed of the observation of the method RN L implemented for setting up oral resident medications. RN UM C indicated this method was not consistent with facility policy or standards of practice. No additional information was provided as of survey exit. Water Management On 05/11/2026 at 1:34PM, during review of the water management plan, it was discovered there was no documentation of a water management team meeting, water management plan risk assessment or review of policy or assessment for 2025 or 2026. On 05/11/2026 at 1:40PM, a copy of the 2025 and 2026 documents regarding the water management team meeting agenda or minutes and review of the risk assessment was requested from Maintenance Director (MD) I On 05/11/2026 at 3:25PM, observed in the bathing room on [NAME] hallway, a spa tub surrounded by stored bathing chairs and bathing beds. When asked, MD I was not sure if the spa tub was in use or not. MD I indicated the spa tub is currently not on the flushing schedule. On 05/11/2026 at 3:27PM Certified Nursing Assistant (CNA) J was asked if they knew if the spa tub was working, CNA J stated that they had worked at the facility for over a year and have never seen the tub in operation. CNA J did not know if lack of use was because the tub was broken or if residents chose not to use it. On 05/12/2026 at 8:00AM, during interview with MD I regarding the documents that were requested on 05/11/2026, MD I stated that they were unable to locate water management team meeting minutes, agenda or completed risk assessment forms for 2025. MD I stated they have been with facility for two months and the former Maintenance Director did not leave documentation of the requested items for 2025. On 05/12/2026 at 12:00 PM, Nursing Home Administrator (NHA) indicated that the water management team meeting and risk assessment had not been completed for the current year.

Based on observation, interview, and record review, the facility failed to ensure appropriate urinary catheter care for one resident (R4) of three residents reviewed for catheter care.Findings include:Review of an admission Record revealed R4 admitted to the facility on [DATE] with pertinent diagnoses which included chronic interstitial cystitis (bladder pain syndrome) and acute cystitis (bladder infection).Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R4, with a reference date of 3/30/2026 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R4 was cognitively intact. Review of a current incontinence Care Plan for R4, created 3/4/2025, revealed R4 was incontinent of bowel and staff were instructed to check her for incontinence and wash, rinse, and dry perineum after episodes of incontinence. Review of a current urinary catheter Care Plan for R4, created 2/26/2025, revealed R4 was at risk for urinary tract infection and instructed staff to cleanse her perineum front to back and provide catheter care per policy.In an interview on 5/11/2026 at 2:09 PM, R4 reported staff did not clean around her urinary catheter regularly.In an observation and interview on 5/12/2026 at 8:35 AM in R4's room, Certified Nursing Assistant (CNA) E performed catheter care for R4. R4 had not recently been incontinent of bowel and was complaining of burning down there. While cleaning around R4's urinary catheter, CNA E cleaned stool out of her vagina from in between her labia. Stool was visible on the washcloth as CNA E cleaned the perineum. CNA E reported the stool should not have been there and should have been cleaned the last time R4 had a bowel movement. R4 was not sure when she had her last bowel movement and reported it might have been the previous day. R4 stated, They never clean down there. R4 reported staff will leave stool when they find it on her, stating it's not much. R4 reported the burning sensation improved after CNA E cleaned her.In an interview on 5/12/2026 at 8:50 AM, Registered Nurse Unit Manager C reported stool should never be left on resident's skin. Review of facility policy/procedure Catheter Associated Urinary Tract Infection Prevention, effective 2/28/2025, revealed .Clean around the catheter insertion site daily with soap and water.

Based on interview and record review, the facility failed to ensure dignified care was provided for 1 resident (R72) of 3 residents reviewed for dignity. Findings include: Review of an admission Record revealed R72 originally admitted to the facility on [DATE] with pertinent diagnoses which included absence of right leg below knee amputation, chronic congestive heart failure, and muscle wasting and atrophy (shrinking). Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R72, with a reference date of 4/28/2026 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R72 was cognitively intact. In an interview on 5/11/26 at 11:47 AM, R72 reported that she waited for assistance to the bathroom for over an hour early this morning until a certified nursing assistant came in at 2am and had been incontinent in her bed soaking through her brief, pad and sheet requiring a total bed change. R72 stated that made her feel embarrassed. R72 reported that same occurrence happened at least weekly. Review of 72's Urinary Continence documentation dated 4/29/26 through 5/11/26 revealed that R72 had been incontinent 20 times out of 25 times continence was documented. Further documentation revealed Personal Hygiene documentation that R72 required moderate to complete assistance with personal hygiene 22 times out of 26 times assistance had been documented. In an interview on 5/12/26 at 12:30 PM, the Director of Nursing (DON) reported that Sunday the facility had three call offs for certified nursing assistants for the evening shift in which all of the 3 shifts had been covered with other staff members except for a four-hour shift from 10pm to 2am. Review of a facility/procedure Resident Dignity & Personal Privacy, revised 3/28/2024, revealed .the facility provides care for residents in a manner that respects and enhances each resident dignity. staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth.

Based on interview and record review, the facility failed to follow up with pressure ulcer wound clinic recommendations for two residents (R3 and R4) of two residents reviewed for the treatment of pressure ulcers.Findings include:R3Review of an admission Record revealed R3 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and muscle wasting.Review of R3's Physician's Orders revealed an order, started 5/1/2026 and still active 5/13/2026, .Right heel wound: Clean wound with wound cleanser, pat dry, apply xeroform to wound bed.Review of R3's community wound clinic right heel wound treatment recommendations, dated 5/5/2026, revealed .Cleanser: Dakin 0/125% . Primary dressing: Triple Helix Collagen Dressing. Secondary dressing: Xeroform Petrolatum gauze. Further review of the electronic medical record (EMR) revealed no indication these wound clinic recommendations were reviewed or initiated by facility staff.In an observation and interview on 5/13/2026 in R3's room, right heel dressing change was observed. Registered Nurse (RN) Wound Nurse C reported the current dressing order was for xeroform, but he planned to discuss updating the treatment order due to the progress of the wound.In an interview on 5/13/2026 at 9:29 AM, RN Wound Nurse C reported he was not aware of R3's 5/5/2026 right heel wound treatment recommendations and these recommendations had not been reviewed by facility clinical staff. RN Wound Nurse C reported wound clinic recommendations should be addressed by facility staff.R4Review of an admission Record revealed R4 admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcer of sacral region and muscle wasting.Review of R4's EMR revealed community wound clinic sacral ulcer wound treatment recommendation dated 5/4/2026 which recommended to apply a pad of Prisma (or equivalent collagen) to the center of the wound bed, then black foam, for her VAC (negative pressure wound therapy) dressing. Further review of the EMR revealed no indication these wound clinic recommendations were reviewed or initiated by facility staff.Review of R4's Physician's Orders revealed an order, started 5/9/2026 and active 5/13/2026, to apply black foam/wound vac to wound bed, with no direction to use collagen under the black foam.In an interview on 5/12/2026 at 10:40 AM, RN Wound Nurse C reported he was not aware of R4's wound clinic treatment recommendations. RN Wound Nurse C reported he should have reviewed these recommendations when they were received by the facility and the recommended changes to the treatment plan should have been reviewed by the clinical team and medical provider. RN Wound Nurse C reported he was not sure why wound clinic recommendations were not being received by the clinical team, or why communication documentation was not being sent to the facility from the wound clinic when the resident returned from appointments.In an interview on 5/13/2026 at 9:20 AM, the DON reported she did not believe clinical staff were receiving wound clinic recommendations from medical records staff when they were faxed to the facility or they would have been followed up with.In an interview on 5/13/2026 at 11:00 AM, the DON reported wound clinic treatment recommendations should be addressed in real time and documented in the EMR. Review of facility policy/procedure Skin Management, revised 1/28/2026, revealed .Residents with wounds and/or pressure injury. are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. The licensed nurse will notify the practitioner with any changes as needed.

Based on observation, interview, and record review, the facility failed to ensure appropriate assessments and monitoring were implemented for 1 resident with a PICC (Peripherally Inserted Central Catheter) (R45) out of 2 residents reviewed for PICC lines. Findings include:Review of an admission Record reflected R45 admitted to the facility with diagnoses that included Methicillin Resistant Staphylococcus Aureus (MRSA) infection as the cause of diseases classified elsewhere, Shiga toxin-producing Escherichia coli (E.Coli) as the cause of disease classified elsewhere, Pseudomonas (aeruginosa mallei pseudomallei) as the cause of diseases classified elsewhere, chronic osteomyelitis with draining sinus, left ankle and foot, non-pressure chronic ulcer of left ankle with muscle involvement, non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin.During an observation on 6/17/2026 at 8:36 AM, R45 was observed in her room, in bed. R45's PICC line was visible, a transparent dressing in place, dated 6/13/2026. R45's right arm did not show signs of infection or swelling. There was no drainage visible under the transparent dressing. During an interview on 6/17/2026 at 2:12 PM, Licensed Practical Nurse (LPN) A reported he was familiar with PICC line use and maintenance. LPN A reported that the PICC line should be measured weekly with dressing changes. LPN A said that the measurement obtained during the dressing change should match the measurement recorded by the previous nurse. During an interview and observation on 6/17/2016 at 2:23 PM, agency LPN H reported she was familiar with PICC lines and believed the PICC line should be measured daily. LPN H said she had administered an IV antibiotic to R45 that day but could not report the PICC measurement. LPN H obtained a paper ruler and measured R45's PICC line and reported the length of the PICC line was 11 cm. During an interview on 6/17/2026 at 2:56 PM, the Director of Nursing reported that if a resident is admitted with or received a PICC line while living at the facility, orders for the care and maintenance of the PICC line are selected in batches from the Electronic Medical Record (EMR) program. The DON said the PICC should be measured from the insertion point to the end of the hub weekly with the dressing change. If the measurements differ, the physician should be notified, and the licensed nurse would follow orders obtained after physician notification. The DON said she would refer to hospital records or to the cardiovascular consultation/insertion report for a baseline measurement. The DON reviewed the cardiovascular consultation notes for R45's PICC line insertion on 5/14/2026 and 5/22/2026 and could not determine what the baseline measurement would be. The DON reported it would be important to include the baseline measurement in the actual order so all the nurses were working from correct information. The DON reviewed the PICC line orders for R45 and could not explain why dressing changes were ordered on a different day than the PICC line measurement. Review of a Resident At Risk note dated 5/14/2026 reflected, (R45) Continues with wound care to left foot-lateral, heel and plantar, diabetic in nature. Areas are stable. Follows with wound clinic. Recently diagnosed with non-refractory osteomyelitis (a bone infection that successfully respond to standard treatment). Will be receiving a PICC line for IV (intravenous) abx (antibiotic) treatment. Interventions in place and ongoing.Review of Progress Notes dated 5/14/2026 - 5/15/2026 reflected a PICC line was placed in R45 on 5/14/2026; the placement was verified with a chest x-ray. On 5/15/2026 the chest x-ray results were reported and confirmed appropriate placement of the PICC line, ensuring safe use of the device. Review of R45's Medication Administration Record (MAR) for the month of May 2026 reflected the following orders:- Measure PICC catheter length every day shift every 7 day(s) for IV maintenance ordered by ID (Infectious Disease) -Start Date- 5/14/2026 -D/C Date- 6/11/2026. The MAR also included an as needed measurement order. Neither order specified what measurement was expected or what to do if the measurement deviates from an established baseline.- Change transparent dressing to PICC every day shift every 7 day(s) for IV maintenance - Start Date- 5/15/2026. The MAR also included a corresponding as needed dressing change order. Review of a Nurses Notes dated 5/15/2026 indicated, PICC lumen 3 cm (centimeters) .Review of an eMAR (electronic Medication Administration Record)- Medication Administration Note dated 5/16/2026 at 6:40 PM, reflected Changed CVA (Central Vein Access) dressing at this time. Due 5/15/26. Kit came in this AM (morning). Writer completed task at this time. Progress Notes leading up to this dressing change did not reflect the PICC dressing was compromised, and it is unclear why the dressing needed to be changed due to the PICC was originally placed on 5/14/26, two days prior. The note did not reflect a measurement of the PICC line. Review of another eMAR progress note, dated 5/16/2026 at 7:05 PM reflected Measurements 6 cm to lumen and 6 cm to entrance total length 12 cm. This measurement conflicted with the measurement recorded in the Nurses Notes dated 5/15/2026 by 9 cm.Review of Nurses Notes from 5/17/2026 and 5/18/2026 reflect the same measurements as were obtained and documented on 5/16/2026 (12 cm).Review of a Nurses Note dated 5/21/2026 reflected, Medication held due to loss of IV access. Provider (name of provider) and cardiovascular team notified. The note does not include a measurement of the PICC line, nor does it include a physical assessment of R45's PICC site. Review of a Peripherally Inserted Central Catheter (PICC)/Midline Insertion Documentation consultation form dated 5/22/2026 reflected a specialty nurse from an outside company replaced R45's PICC line. Notes on the consultation form reflected Pt. (patient, R45) w/ (with) PICC line, not flushing & partially dislodged on assessment, replacement recommended. Staff nurse removed PICC line RUE (right upper extremity) - new PICC inserted, confirmed tip location w/ECG (electrocardiogram) & OK to use. Please change dressing Q (every) 7 days or PRN (as needed) if loose/moisture present. Please no BP (Blood Pressure) or tourniquets on R (right) (even by wrist) while line in indwelling.Review of R45's May 2026 MAR did not reveal orders had been discontinued after the removal of the PICC from R45's RUE and a new PICC was placed pertained to the PICC in R45's left upper extremity. Review of an eMAR - Medication Administration Note dated 6/11/2026 at 9:04 AM reflected, 8.1 cm. Prior to this documentation, there was not a recorded PICC line measurement on the record from the date the new PICC was inserted on 5/22/2016. No additional measurements were noted in the clinical record from 6/11/2026 - 6/17/2026.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Peripherally inserted central catheter (PICC) lines enter a peripheral arm vein and extend through the venous system to the superior vena cava, where they end. Other central lines enter a central vein such as the subclavian or jugular vein or are tunneled through subcutaneous tissue before entering a central vein. Central lines are more effective than peripheral catheters for administering large volumes of fluid, PN (parenteral nutrition), and medications or fluids that irritate veins. Proper care of central line insertion sites is critical for the prevention of central line-associated bloodstream infection (CLABSI) (Box 42.6) (Centers for Disease Control and Prevention [CDC], 2020; [NAME] et al., 2021; [NAME] et al., 2019). Nurses and health care providers must have specialized education regarding care of CVCs (Central Venous Catheters) and implanted infusion ports (The Joint Commission [TJC], 2021b). Nursing responsibilities for central lines include careful monitoring, flushing to keep the line patent, and site care and dressing changes to prevent CLABSIs ([NAME] et al., 2021; [NAME] and [NAME], 2019). [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book. Elsevier. Kindle Edition.

Based on interview and record review, the facility failed to offer and maintain education of pneumococcal immunizations for two Residents (R2 and R18) of five residents reviewed for their status of pneumococcal vaccinations. Findings:The policy provided by the facility titled Immunizations: Pneumococcal Vaccinations (PPV) of Residents, last revised 11/4/2024 was reviewed. The policy reflected Recognizing the major impact and mortality of the pneumococcal vaccine on residents in nursing homes and the effectiveness of vaccines. the facility has adopted the following policy statements. These adopted policy statements included, All residents of our facility should receive the pneumococcal vaccine if they are [AGE] years of age or older or younger than 65 years with underlying conditions that are associated with increased susceptibility to infection or increased risk for serious disease or its complications.And II, Administrative Procedure: Each resident's pneumococcal immunization status will be determined upon admission or soon afterwards, and will be documented in the resident's medical record. Current residents will have their immunizations status determined by reviewing available past and present medical records.And B. All residents with undocumented or unknown pneumococcal vaccination status will be offered the vaccine.And C. Informed consent in the form of a discussion regarding risks and benefits of vaccination will occur prior to vaccination (This may be with the resident's authorized representative when appropriate.And D. Residents may refuse vaccination. Vaccination refusal and reasons why .should be documented by the facility. If the resident/family/legal representative chooses to exercise the right to decline the vaccination, it will be re-evaluated annually.R2Review of the medical record reflected R2 admitted to the facility 3/21/2025 with diagnoses that included Diabetes Mellitus and Vascular Dementia. Review of the Minimum Data Set (MDS) dated [DATE] reflected that R2 was severely cognitively impaired. The electronic Medical Record (EMR) reflected R2 had in place a Power of Attorney (POA) for medical and financial decisions.Review of the EMR Immunization record for R2 did not reflect current or historical data for either the PCV20 or PVC21 (Pneumococcal) vaccines. Review of the pneumococcal Immunization notes for the PCV20 and PVC21 for R2 dated 3/21/25 (date of Resident's admission reflected, Confused - waiting on DPOA.On further review of the EMR for R2 no other documentation was identified that indicated that the pneumococcal immunizations of R2 had been revisited or reviewed with the responsible party for R2, that education had been provided, or that a signed consent for administration or declination of the vaccination had been obtained. R18Review of the MDS dated [DATE] reflected R18 admitted to the facility 1/24/2024 and had current diagnoses that included Renal Insufficiency and Pulmonary conditions. The MDS reflected R18 was cognitively intact.Review of the electronic Medical Record (EMR) immunization documentation for R18 reflected the Resident refused the pneumococcal vaccination 2/6/2024 and that No education was provided. No other documentation was located in the EMR that R18 had since been offered (minimally annually per facility policy) a pneumococcal vaccination or that education was provided on the risks or benefits of vaccination for residents (this resident who had a) with a documented history of pulmonary conditions.On 5/12/2026 at 12:56 PM an interview was conducted with Infection Preventionist (IP) K. IP K reported she had been in the IP position for approximately three months. IP K acknowledged that the facilities' immunization program to maintain resident immunizations and education was incomplete. IP K reported she only recently obtained approval to access the state immunization data base and updating the status of new and current residents was ongoing.

Based on interview and record review, the facility failed to adhere to principles of antibiotic stewardship for 1 resident with a fungal infection (R24), out of 15 residents reviewed. Findings Include:Review of an admission Record reflected R24 admitted to the facility with diagnoses that included urinary tract infection, sepsis, a body mass index (BMI) of 39.0-39.9 (severe obesity), and type 2 diabetes. R24 was their own responsible party. Review of a late entry Nurse Practitioner Note dated 5/14/2026 reflected R24 had been seen due to itching to labia . No redness, discharge or burning with urination.Review of a Nurses Notes dated 5/14/2026 at 4:07 PM reflected the Nurse Practitioner (NP) had assessed R24 that day and ordered Miconazole 2% cream (an over the counter and prescription antifungal medication used to treat vaginal yeast infections) BID (twice a day) x 2 weeks for vaginal itching. Review of R24's May 2026 Medication Administration Record (MAR) reflected the order Miconazole 7 Vaginal Cream 2% (Miconazole Nitrate Vaginal) Insert 1 dose vaginally every day and night shift for vaginal itching for 14 days - Start Date - 5/14/2026. Further review of the MAR reflected that the medication was NOT given as ordered on the following dates:-5/14/26 - medication not given as evidenced by (AEB) the number 5 (The number 5 is a chart code for Hold/See Nurse Note) on the MAR. The eMAR (electronic MAR)-Medication Administration Note reflected the medication was on order. -5/15/26 - medication not given in the evening, the MAR for this date and time is blank; -5/16/26 - medication not given all day AEB the number 5 on the MAR for both doses. The corresponding eMAR note reflected not available, awaiting pharmacy delivery, and Med not available. -5/17/26 - medication not given in the evening AEB the number 5 on the MAR. The eMAR note reflected med not available. -5/18/26 - medication not given in the morning, the MAR for this date and time is blank;-5/21/26 - medication not given in the evening AEB the number 5 on the MAR. There was NOT an eMAR progress note to explain why the medication was not given. -5/22/26 - medication not given in the evening AEB the number 5 on the MAR. The corresponding eMAR note reflected med not available.-5/25/26 - medication not given in the morning, the MAR on this date and time is blank.Further review of all available Progress Notes for the duration of the prescribed treatment for R24's vaginal itching did not indicate the physician had been notified of the medication unavailability. The Progress Notes did not reflect R24 had been assessed for ongoing vaginal itching, discomfort and/or worsening of symptoms due to multiple missed doses of medication and incomplete duration of therapy. There was no documentation indicating R24 refused the medication administration or was not available for the medication administration.During an interview on 6/17/2026 at 2:23 PM, the Director of Nursing (DON) reviewed the clinical record for R24 and confirmed the Miconazole Vaginal Cream 2% was not given as ordered. The DON said she did not know whether the antifungal was house stock or if pharmacy would have to send it. The DON reported she did not know how a dose of the medication could have been given in the morning on 5/15/2026 if the medication was not available and could not explain the sporadic administration of the prescribed treatment for R24's vaginal yeast infection. According to the DON, once the medication became available, the order should have been modified to ensure R24 received the prescribed vaginal cream for the entire 14 days of the course of treatment, which was not done. The DON said that typically the Infection Control Nurse and/or Unit Manager would monitor antibiotic/antifungal orders.

Based on observation, interview, and record review the facility failed to promptly assess and treat a new skin concern for one resident (R1) of 3 residents reviewed for skin concerns.Findings include: Review of an admission Record revealed R1 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and chronic respiratory failure. In an observation and interview in R1's room on 5/11/2026 at 11:05 AM, Certified Nursing Assistant (CNA) D found a new wound on R1's right gluteal fold while performing incontinence care and reported she would notify nursing staff. Review of R1's Electronic Medical Record (EMR) on 5-/12/26 revealed no assessment of his new right gluteal fold skin condition. In an interview on 5/12/2026 at 7:52 AM, Registered Nurse (RN) Wound Nurse C reported he had not been notified of R1's new wound identified the previous day and would investigate this. In an observation and interview on 5/12/2026 at 8:13 AM in R1's room, RN Wound Nurse C reported he had reviewed R1's chart and his new wound had not been assessed by nursing staff on 5/11/2026 when it was identified by the CNA. RN Wound Nurse C assessed R1's wound and initiated a treatment plan. RN Wound Nurse C reported new wound concerns should be evaluated by nursing staff at the time they are identified and a treatment plan initiated. Review of R1's Electronic Medical Record (EMR) reflected that after being notified of the of the unreported new wound, RN Wound Nurse C documented an assessment of this on a Skin Check progress note. Review of R1's Skin Check progress note, dated 5/12/2026 at 10:50 AM, revealed .New skin issue. Right gluteal fold. Moisture associated skin damage (MASD). Wound acquired in house. Review of R1's Physician's Orders, started 5/12/2026, revealed .Right gluteal fold MASD: Clean area with soap and water, pat dry, apply barrier cream to affected area. every shift for MASD. In a telephone interview on 5/12/2026, CNA D reported she told Registered Nurse (RN) B about R1's new skin concern when she found it on 5/11/2026. In an interview on 5/12/2026 at 11:50 AM, RN B reported she was not notified of R1's new skin concern on 5/11/2026. RN B reported she would have contacted the medical provider and initiated a treatment plan had she been notified. In an interview on 5/12/2026 at 11:45 AM, the Director of Nursing (DON) reported nursing staff should immediately assess new skin concerns and initiate a treatment plan. Review of facility policy/procedure Skin Management, effective 1/28/2026, revealed .Residents with wound and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. The licensed nurse will initiate documentation in the electronic health record, which includes a description of the skin impairment. The CNA. will report any new skin impairment to the licensed nurse that is identified during daily care.

This citation pertains to intakes #: 2808141, 2749047, and 2977070Based on interview and record review, the facility failed to 1.) ensure comprehensive nursing assessments were completed and 2.) identify and notify the provider of a change in condition for 2 residents (Resident #7 and #8) out of 3 residents reviewed for quality of care resulting in a delay in treatment, the worsening of symptoms, and hospitalization.Findings:Resident #7 (R7)Review of an admission Record revealed R7 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure and chronic obstructive pulmonary disease. Further review of the record revealed R7 did not receive hospice services.During an interview on 04/13/2026 at 10:37 AM, Responsible Party (RP) J reported that at 5:00 AM on 3/22/2026 a facility nurse informed her R7's oxygen level had dropped down into the 80's and R7 was diaphoretic (sweaty) and was given supplemental oxygen. Wen RP J called to check on R7 an hour and a half later, the nurse indicated R7 had not been reassessed, and no additional orders were requested because R7 was a DNR and on Hospice. RP J had to clarify with the nurse that DNR did NOT mean do not treat and that R7 was NOT on Hospice but Palliative Care which are not the same thing. (Palliative care is specialized medical care focusing on relieving symptoms while incorporating curative treatments. Hospice care focuses on comfort and quality of life while ceasing curative treatments). RP J reported that it wasn't until she reached the Director of Nursing (DON) to report the nurse's dismissal of R7's change in condition was R7 ordered bloodwork, a urinalysis, an EKG (electrocardiogram, used to assess the heart's electrical function and rhythm), and a chest x-ray. The chest x-ray was obtained and results reported to the facility several hours later which showed R7 had a pleural effusion (fluid buildup in the lungs). R7's provider ordered a diuretic (Lasix) to be given IM (intramuscularly) and undergo outpatient thoracentesis (removal of fluid or air in the plural spaces around the lung, to improve breathing and identify the root cause of the buildup) without ever physically evaluating R7. During an interview on 04/14/2026 at 12:20 PM, Nursing Home Administrator (NHA) reported that when a DNR form was completed there was no specification for the type of treatment to be administered (antibiotic therapy, hospitalization, surgical interventions, etc). NHA reported that the facility treats the resident and/or informs the family and allows them to make the decision for treatment/hospitalization at the time of a change in condition.Review of R7's Palliative Care Progress Note dated 4/8/26 revealed, Her (R7's) care goals have been discussed a lot with her and her daughter, who is her legal guardian. They want aggressive treatment for conditions that can be reversed and hospitalizations if needed .Review of R7's Care Plan initiated on 11/5/24 revealed, (R7) is at risk for complications r/t (related to) diagnosis of Congestive Heart Failure .Observe & report to MD (medical doctor) PRN (as needed) any s/sx (signs or symptoms) of Congestive Heart Failure: dependent edema of legs and feet, periorbital edema, SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, Orthopnea (shortness of breath when lying down), weakness and/or fatigue, increased heart rate (Tachycardia), lethargy or disorientation .Obtain weight as ordered .Review of R7's Heart Failure Clinic (HFC) handwritten consultation report dated 3/4/26 revealed, Heart failure follow up. Euvolemic (balanced/normal) on exam. No cardiac complaints. Labs stable. No changes needed from a cardiac standpoint. The HFC printed report revealed, .weight relatively stable between 164-166 pounds. Dry weight approximately 164-166 lbs (pounds). R7's weight on 3/4/26 was 163 pounds.Review of R7's Order Summary dated 8/22/25 revealed, Weigh every morning , if there is a weight gain of > (greater than) 2 lbs in one day or >5 lbs in one week , call HFC clinic.or fax weight log to HFC.Review of R7's Weight Summary (pounds) revealed:3/16/2026 163.13/17/2026 162.8No weight 3/183/19/2026 172.43/20/2026 171.03/21/2026 169.83/22/2026 170.03/23/2026 171.2(8.1 pounds in 1 week)Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Daily weights are an important indicator of fluid status. Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid retained or lost.Weigh patients with heart failure daily. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1059). Elsevier Health Sciences. Kindle Edition.Review of R7's Electronic Medical Record (EMR) revealed no documentation that the facility provider or the HFC were notified of R7's weight gain per the provider order.Review of R7's Order Summary dated 11/2/26 revealed, oxygen at 2 liters per minutes for pulse OX below 90% every day and night shift for pulse ox less than 90%.Review of R7's Oxygen Saturation Summary revealed:3/16/2026 06:35 AM 85.0% Room Air3/19/2026 06:16 AM 74.0% Room Air3/22/2026 12:00 AM (SBAR) 84.0% Room Air3/22/2026 04:42 AM 94.0% @ 3 L/MinReview of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Vital Signs Acceptable Ranges for Adults. Pulse oximetry (SpO2) Normal: SpO2 95% . Pulse 60 to 100.beats/min, strong and regular.Review of R7's EMR revealed no documentation that the facility provider was notified of the abnormal low oxygen saturation level on 3/16/26 or 3/19/26Review of R7's Nurses Note dated 3/22/2026 at 04:47 AM revealed, Patient desaturation this shift down to 84% on room air. Put on oxygen at 3 lpm (liters per minute). SPO2 94% on 3 lpm of oxygen. Vitals as follows: BP (blood pressure) 159/83, (temperature) 98.2, Pulse 116. Patient is DNR and is on palliative care .Notifying Hospice for further instruction for cared (sic). (R7's order was to apply oxygen at 2 lpm if needed.)Review of R7's SBAR Change in Condition revealed, Other change in condition: Drop in oxygen saturation to 84% on room air. Elevated pulse of 116. Elevated RR (respiratory rate) 22 Temp 98.2, BP 159/83. Applied oxygen at 3 liter per minute SPO2 up to 94%. Patient is calmy (clammy) at this time. Per patient's statement she feels okay.Respiratory Evaluation: Not clinically applicable to the change in condition being reported. 5. Cardiovascular Evaluation: Not clinically applicable to the change in condition being reported .Primary Care Clinician Notified: Yes Date: 03/22/2026 Time: 12:00 AM .Notified (name omitted) Palliative Care at this time . Name of Family/Health Care Agent Notified: (RP J) Date: 03/22/2026 Time: 5:00 AM. Confirming a cardiac and respiratory assessment were not completed and the facility provider was not notified at the time of R7's change of condition.Review of R7's Nurses Note dated 3/22/2026 at 05:10 AM revealed, Notified (name omitted) on call (facility) Provider for direction .Awaiting call back from (name omitted) Palliative Care at this time. Change in Condition completed. Concern: Wounds with Vital with possible sepsis indicators.Review of R7's Nurses Note dated 3/22/2026 at 05:25 AM revealed, Per (name omitted) Palliative continue to monitor patient for pain and await orders from on-call provider.Review of R7's Nurses Note dated 3/22/2026 at 10:33 AM revealed, The writer was contacted by DON to process CBC (complete blood count), CMP (comprehensive metabolic panel), Urine analysis and C&S (culture and sensitivity) if indicated. RN (registered nurse) drew blood work and did in and out to collect urine sample, both will be delivered to (name omitted) ER (emergency room).During an interview on 4/14/26 at 11:45 AM, the DON reported R7's laboratory and diagnostic tests were generated from the facility's Sepsis Protocol and were not ordered by the facility provider. The Sepsis Protocol included a BMP (basic metabolic panel), blood culture, CBC, lactate level, UA and culture, and chest xray. An ECG was not part of the order set.Review of R7's Nurses Note dated 3/22/2026 at 2:16 PM revealed Lab results are faxed to (medical doctor) for review. Results are reviewed by (medical doctor), no new orders are given. DON is aware and will update resident's daughter (RP J) and at 2:24 PM, Chest xray results are faxed to (medical doctor) for review.Review of R7's Provider Communication dated 3/22/26 (no time) revealed a fax with laboratory/diagnostic results (resulted on 3/22/26 at 1:00 PM) and the following handwritten note, Please review as per daughter's request.Review of R7's Provider Communication dated 3/22/26 (unknown time) revealed a fax with laboratory/diagnostic results and the following handwritten note by the provider revealed, Reviewed (labs), no new orders. Is there a special concern from her? Indicating the facility provider had not been made aware of R7's respiratory symptoms/change in condition or need for laboratory/diagnostic testing.Review of R7's Provider Communication dated 3/22/26 at 4:21 PM revealed a fax with laboratory/diagnostic results and the following handwritten note by the nurse, .Resident's SaO2 (low) 84% during the night. Resident is put on oxygen via nasal cannula in am. As per report from night nurse, resident was diaphoretic, During the day today resident is more lethargic & tired than her baseline. As per primary nurse, chest is clear. I am not a primary nurse of this resident today & I was requested by DON to do CBC, CMP, UA, Chest x-ray, & ECG (ECG will be done tomorrow).Review of R7's Nurses Note dated 3/22/2026 at 5:14 PM revealed, Chest xray and lab results refaxed to MD x2. Waiting for response from MD. DON is made aware.Review of R7's Provider Communication dated 3/22/26 (no time) which revealed, Lasix 40 mg (IM) twice a day for 2 days and monitor oxygen level if she drops oxygen below 90% please let me know. We may have to transfer her to the emergency room.Review of R7's Nurses Note dated 3/22/2026 at 6:16 PM revealed, Received order from (medical doctor) .Will continue to monitor oxygen level if resident drops oxygen below 90% and notify MD on call. May have to transfer resident to emergency room.Review of R7's Oxygen Saturation Summary revealed an oxygen assessment on 3/22/26 at 6:12 PM. R7's oxygen level was not assessed again until 3/23/26 at 6:35 AM.Review of R7's EMR revealed no documentation of any comprehensive or focused respiratory/cardiac assessments from the time of symptom onset until the time paramedics arrived on 3/23/26 at 10:14 AM. There was no documentation on R7's condition throughout the night and into the morning of 3/23/26 or of the date, time, or rationale for her transfer to the hospital.During an interview on 04/14/2026 at 1:10 PM, the DON confirmed there was no documentation related to R7's transfer to the hospital and her condition on 3/23/26.Review of the EMS (Emergency Medical Services) Report dated 3/23/26 revealed, The patient is an [AGE] year-old female with a medical history of congestive heart failure, chronic obstructive pulmonary disease, hypertension, and type 2 diabetes .The patient reports experiencing difficulty breathing, which began on March 22, 2026 at 1600 (4:00 PM) and has persisted for one day .ECG shows pt is in atrial fibrillation. Per her medical record this is a new onset. The patient presents with shortness of breath as the primary impression.Upon assessment, lung sounds are decreased in the left upper and lower chest areas, while no abnormalities are noted in the right upper and lower chest areas. R7 was transported to the hospital on 3/23/26 at 10:32 AM.Review of R7's emergency room Report dated 3/23/26 revealed, History of Present Illness-This is an [AGE] year-old female with a history of dementia, COPD, congestive heart failure, and new onset atrial fibrillation presenting via EMS with dyspnea for several days. She does not typically use home oxygen but has it available at her facility and is currently requiring 3 L nasal cannula. She received intramuscular Lasix yesterday. The patient is not on any anticoagulation. She is accompanied by her daughter, who is her guardian. Earlier this week, the patient was placed on supplemental oxygen at her facility due to difficulty breathing. Yesterday morning, she experienced a drop in oxygen saturation into the 80s, accompanied by clamminess and an increased heart rate. She did not report any pain but stated she did not feel well and was experiencing difficulty with respirations. After being placed on oxygen, her saturation improved to the 90s and she was reportedly resting comfortably in bed. A chest x-ray performed between 3:00 and 4:00 PM yesterday showed a moderate left pleural effusion. An EKG was not performed as the facility was awaiting an outside company. The patient is followed by clinicians at the CHF clinic, with her last visit approximately one week ago. Following the identification of the pleural effusion, intramuscular Lasix was administered and an outpatient thoracentesis was scheduled, but her daughter felt she was not in suitable condition for outpatient management this morning. The patient has developed atrial fibrillation, which is new for her, as she typically has a normal sinus rhythm. Clinical Impression as of 03/23/26 1450: Acute exacerbation of chronic heart failure, New onset atrial fibrillation, Pleural effusion.Lab result for R7's aminoterminal pro B-type natriuretic peptide (NT-proBNP) revealed a result of 12,300 (Reference Range: less than 300). Indicating R7 was experiencing profound heart failure.Resident #8 (R8)Review of an admission Record revealed R8 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Adult failure to thrive, severe protein-calorie malnutrition, symptoms and signs concerning food and fluid intake, and muscle wasting.Review of R8's Care Plan initiated 3/31/25 revealed, (R8) has potential for Dehydration and fluid deficit R/T: History of constipation, Decreased Mobility, and Diuretic usage. Date Initiated: 03/31/2025 .Will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor through the next review date .Observe and report to physician PRN s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, To determine whether a patient is dehydrated, assess the patient's oral mucous membranes .The overall condition of the skin reveals a patient's level of hydration-Skin Turgor-Failure of skin to return to normal position after several seconds indicates FVD (fluid volume deficit) .Dehydration Results in decreased skin elasticity and turgor. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.Review of R8's Care Plan revealed, (R8) has Actual impairment to skin integrity r/t , Coccyx (Stage 3).Unstageable, Unstageable pressure injury to sacrum.Observe for s/sx of infection of area (ie temperature increases, increased drainage, odor or redness etc and report to physician as needed. Date Initiated: 03/25/2025. Observe location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to physician. Date Initiated: 03/24/2025.Review of R8's Order Summary dated 9/22/25 revealed, Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth in the morning for infection prevention for wounds. (Used prophylactically for R8's wounds).Review of R8's Skin Issues dated 3/4/2026 at 10:21 AM revealed:Skin Issue: #001:Location: Sacrum.Pressure ulcer/injury.Progress: Deteriorating: wound characteristics deteriorated.Pressure ulcer staging: Unstageable.due to slough and/or eschar.Signs and symptoms of infection: Smell increased.Signs and symptoms of infection: Non-healing.Staged by: In-house nursing. Length (cm): 3.51 Width (cm): 4.11 Depth (cm): 2.5 Area (cm2): 13.78 Undermining: Yes. Undermining length (cm): 2.from: 12 o'clock to: 6 o'clock.Tunneling: Yes. Tunnel length (cm): 4 Tunnel location 1: 6 o'clock.Granulation: 10%. Slough: 80%. Eschar: 10%.Exudate amount: Heavy.Sanguineous: Indicates active bleeding, typically bright red.Odor after cleansing: Strong.Other wound bed: boggy.Periwound: Rolled edge (Epibole).Surrounding tissue: Fragile.Maceration & Erythema. Periwound temperature: Warm.Dressing appearance: Saturated. Dressing saturation: Heavy > 75% .Skin Issue: #003:Location: Coccyx. Pressure ulcer/injury.Progress: Improving: overall wound characteristics improved.Pressure ulcer staging: Stage 4 Pressure ulcer/injury - full thickness skin and tissue loss.Staged by: In-house nursing. Length (cm): 1.34 Width (cm): 0.86 Depth (cm): 0.2 Area (cm2): 0.93Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 40%. Slough: 60%. Eschar: 0%.Exudate amount: Moderate. Exudate type: Serous: clear watery fluid, which is separated from solid elements.Odor after cleansing: None. Other wound bed: pink or red.Periwound: Attached. Surrounding tissue: Maceration. Surrounding tissue: Fragile.Induration: Induration, < 2cm around wound. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact.Dressing appearance: Saturated. Dressing saturation: Moderate 26-75%During an interview on 04/14/2026 at 1:21 PM, the DON reported that wound management and treatments was completed by the facility wound nurse. They did not contract with an outside entity for wound management unless it was specifically ordered by the provider. Treatment changes, laboratory and diagnostic testing, and oversite was conducted by the facility provider.Review of R8's Physician Communication dated 3/4/26 may we obtain an (sic) wound culture & sensitivity r/t foul odor and copious exudate to sacrum wound.Review of R8's Order Summary dated 3/4/26 revealed, Obtain culture and Sensitivity to sacrum wound R/T foul odor and copious amounts of drainage.Review of R8's Order Summary revealed no initiation of the Sepsis Protocol-Order Set.Review of R8's Laboratory Services revealed that the wound culture was collected on 3/5/26.On 3/6/26 at 5:06 PM a preliminary result revealed MODERATE WBCs SEEN, MANY GRAM NEGATIVE RODS, MANY GRAM POSITIVE RODS, MODERATE GRAM NEGATIVE COCCI, and Pending final culture.On 3/7/26 at 12:54 PM a preliminary result revealed MODERATE WBCs SEEN, MANY GRAM NEGATIVE RODS, MANY GRAM POSITIVE RODS, MODERATE GRAM NEGATIVE COCCI, and culture in progress.On 3/8/26 at 11:14 AM a preliminary result revealed MODERATE WBCs SEEN, MANY GRAM NEGATIVE RODS, MANY GRAM POSITIVE RODS, MODERATE GRAM NEGATIVE COCCI, and culture result MODERATE SKIN FLORA.On 3/11/26 at 11:20 AM a final result revealed MODERATE WBCs SEEN, MANY GRAM NEGATIVE RODS, MANY GRAM POSITIVE RODS, MODERATE GRAM NEGATIVE COCCI, culture result MODERATE SKIN FLORA, and FEW MIXED ANAEROBES.During an interview on 04/14/2026 at 1:10 PM, the DON reported that the facility provider did not review preliminary culture results and would review only the final result to determine the next course of action. The DON reported that the final result of R8's wound culture was resulted/printed off following R8's transfer to the hospital on 3/11/26.Review of R8's EMR revealed no documentation that the facility provider assessed R8 following the notification of the deterioration of the wound. There were no other laboratory or diagnostic studies/tests ordered to rule out systemic infection despite the documentation of the presence of infection: increased foul odor, non-healing, deteriorating, and copious exudate. There was no documentation that a risk versus benefit assessment had been completed to determine if the use of empiric antibiotics to prevent systemic infection was necessary, despite the availability of the preliminary culture results and the current use of prophylactic antibiotics for his wounds. There were no additional wound assessments completed prior to hospital transfer on 3/11/26 to identify the further deterioration of R8's wounds.Review of R8's Dietary Note dated 2/26/2026 revealed, Some decline in intake is noted since last review. Resident currently being treated for oral thrush; likely plays role in intact/wt loss.Review of R8's EMR revealed no documentation of interventions implemented to promote fluid intake following the identified concern of thrush.Review of R8's Skin Check dated 3/7/26 revealed Skin Baseline-Skin warm & dry, skin color WNL, turgor normal. Not Met . (This assessment excludes R8's known wounds/pressure injuries). Indicating a change in R8's skin baseline and potential dehydration.Review of R8's EMR revealed no documentation that a comprehensive assessment was completed or that the physician was notified of the change in R8's skin baseline.Review of R8's Nurses Notes dated 3/11/2026 revealed, Resident was transferred to the emergency department per request of daughter, who is the resident's POA (power of attorney), after presenting to the facility and expressing concern that the resident may be experiencing pain related to his wounds and requesting further evaluation. Resident is followed by wound care nurse weekly on Wednesdays, with daily and PRN wound treatments performed by nursing staff per physician orders. Vital signs obtained prior to transfer were within normal limits for the resident with no acute changes noted. Per POA request, resident was transferred to the emergency department for further evaluation.Review of R8's EMS Report dated 3/11/26 revealed the paramedics arrived to the facility at 9:07 AM.Once in the ambulance, vitals were found to be unstable. Blood pressure and O2 saturation were quite low. Monitor showed Afib controlled.Review of R8's emergency room Notes dated 3/11/26 at 9:50 AM revealed, .Patient has pending wound cultures, collected 3/5/26, which show many Gram positive and negative rods, moderate gram negative cocci, with few mixed anaerobes.Micro: Moderate skin flora, mixed anaerobes.As the source of his infection appears to be his decubitus ulcer patient was given Zosyn and vancomycin IV (intravenously) (Treatment initiated prior to the final result of the wound culture (3/11/26 at 11:20 AM).Patient presented to the emergency room from (facility) via EMS for multiple pressure ulcers. Daughter at bedside answering questions at this time. Daughter reports that her father's wound on the right heel and sacrum have been getting worse over the last couple of months. (facility) has been taking care of the sacral wound.Due to these wounds getting worse she brought him in to be evaluated today.On arrival of EMS, BP was measured 60/40. EMS administered one 500cc bolus of saline, with increase of BP to 92/51.He is toxic-appearing.Mucous membranes are dry.Skin is pale.Skin tenting present.Odorous, right sided sacral and coccygeal ulcer present, which appear to have merged subcutaneously (indicating the worsening of the wound into 1 sacrococcygeal wound and not 2 separate wounds).Given HPI and findings in presence of multiple advanced ulcers I am concerned for sepsis secondary to soft tissue infections. Large sacral decubitus ulcer with wound bed noted to have some pink and red tissue with scattered areas that appear necrotic with grey/green sloughing to the most distal aspect which is malodorous.CT pelvis with sacral decubitus ulcer with associated osteomyelitis of the inferior sacrum and coccyx. The hospital records did not reflect wound measurements but included pictures of the deterioration of R8's pressure injuries for reference.At approximately 2:30 PM on 04/14/2026, the NHA and DON were notified of the deficient practice related to R7 and R8. A request for any additional supporting documentation to dispel the concerns listed above for R7 and R8 was requested. No additional documentation was received by close of business on 04/14/2026.Review of the facility policy Change in status, identifying and communication, long term care last revised 9/15/25 revealed, In a long term care setting, it's essential to identify and address any change from baseline in a resident's status. A resident is more likely to return to baseline status and avoid complications if a nurse recognizes a condition early when treatment is still possible. When a nurse recognizes a potentially life-threatening condition or significant change in a resident's status, the nurse must communicate with other health care team members to meet the resident's needs.at a minimum, assessment should include: *reviewing the resident's medical record *asking how the resident feels and what symptoms the resident has *obtaining vital signs *observing the residents overall condition, including function and cognition *exploring the resident's complaints.Recognizing status changes, assessing the resident, and intervening early on allow the resident to receive appropriate care, decreasing the need for transfer to an acute facility or emergency department.Review of the facility policy Notification of Change last revised 2/14/24 revealed, The facility must inform the resident; consult with the resident's practitioner; and notify, consistent with his or her authority, the resident representative(s) when there is a change in status. Even when a resident is mentally competent, his or her designated resident representative or family, as appropriate, should be notified of significant changes in the resident's health status unless the resident does not want the notification. A change in status would include the following.A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). DEFINITIONS A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (such as an adverse drug reaction), or commence a new form of treatment to deal with a problem (for example, the use of any medical procedure, or therapy that has not been used on that resident before). PROCEDURE 1. Changes in the resident status, including but not limited to, those identified above, or any unusual occurrence, the licensed nurse will notify the resident attending practitioner. Any new orders or directives will be implemented by the licensed nurse. 2. Changes in the resident status, including but not limited to, those identified above, or any unusual occurrence, the licensed nurse will notify the resident's representative, unless otherwise dictated by the resident. 3. The licensed nurse will document in the resident electronic medical record the notification and the information that was provided, including any additional orders from the practitioner. DOCUMENTATION 1. Progress Notes.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, (Nurses) are accountable to report any significant changes in your patient's condition in a timely manner to the health care provider and to document these changes in the patient's electronic health record (EHR). Timely and truthful documentation is important to provide communication necessary among health care team members. Documentation must be accurate. In the EHR, ensure that assessments are complete and consistent with those completed previously. Ensure that you conduct your own assessment rather than copying the previous assessment in the patient's medical record to ensure accuracy of information.Notify other team members in a timely manner when changes in condition are triggered within the record. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

This citation refers to Intake 2748888. Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 8 sampled residents (R4). Findings include:A review of R3's admission Record, dated 4/14/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's admission Record revealed they had multiple diagnoses that included encephalopathy, anxiety, dementia, and repeated falls. A review of R3's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/3/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 6 which revealed R3 was severely cognitively impaired. A review of R4's admission Record, dated 4/13/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R4's admission Record revealed they had multiple diagnoses that included dementia and anxiety. A review of R4's MDS, dated [DATE], revealed a BIMS score of 7 which revealed R4 was severely cognitively impaired. A review of the Incident and Accident Investigation Form, dated 1/29/26, revealed on 1/28/26 at 7:44 PM, staff near the nurse's station heard a banging noise. When they went to investigate they saw R3 lying on the floor of his room with blood coming from his nose. They also observed R4 standing with his left fist balled up. Both residents were making threatening statements to each other when staff intervened. The Incident and Accident Investigation Form also revealed that R3 stated R4 walked up to him and struck him causing R3 to fall to the floor. R4 did not recall the incident when interviewed soon after the incident occurred. A review of R4's electronic medical record (EMR), dated 12/28/25 to 2/28/26, failed to reveal any mention that R4 had been involved in an incident with another resident (R3). During an interview on 4/14/26 at 8:00 AM, Nurse Manager (NM) D stated when there is an incident between two residents, even if it was not witnessed (e.g., a resident is found on another resident's room floor bleeding) she would document it in a progress note. She stated, That's just basic nursing. You document what happened. During an interview on 4/14/26 at 8:15 AM, Licensed Practical Nurse (LPN) E, stated when there is an incident between residents, or a suspected incident, she would make sure the residents are safe. She stated she would do skin assessments on the residents and treat any wounds, if applicable. LPN E further stated she would contact the Nursing Home Administrator (NHA) right away because it would need to be reported [to the State Survey Agency]. She also stated she would also contact the physician. LPN E finally stated she would do vitals (blood pressure, heart rate, respiratory rate) and document the incident in a progress note. During an interview on 4/14/26 at 11:20 AM, the NHA was notified that the surveyor could not locate any progress notes or other notations in R4's medical records that would indicate an incident happened between him and another resident (R3) on 1/28/26. The NHA stated she would get with nursing and see if there was anything noted. During an interview on 4/14/26 at 12:15 PM, the NHA stated she looked into the concern that R4 was missing notes in his medical records about the incident on 1/28/26. She stated they had completed a risk management form, however that was an internal document and not a part of the resident's medical record. The NHA stated there was not anything documented in R4's medical record because R3 was the one with the bloody nose and R4 was not injured. She stated they had only monitored R3's bloody nose and had not monitored R4 post-incident. Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Documentation is sometimes viewed as burdensome and even as a distraction from patient care. High quality documentation, however, is a necessary and integral aspect of the work of registered nurses in all roles and settings. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org, retrieved on 7/27/25). Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care- Assessments; Clinical problems; Communications with other health care professionals regarding the patient. Patient responses and outcomes, including changes in the patient's status; and Plans of care that reflect the social and cultural framework of the patient. Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org, retrieved on 7/27/25).

This citation pertains to intake # 2656241 and #2658212.Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a staff person, for two of three residents (Resident #100 and Resident #101) reviewed for abuse, resulting in the need for emergency medical attention and admission to the hospital for R100. Findings: Resident #100 (R100)Review of an admission Record revealed R100 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnosis of dementia. Review of R100's Plan of Care reflected that R100 was independent with walking, bed mobility, feeding herself with set-up assistance, and transferring between surfaces. During an interview on 11/06/25 at 9:37 AM, R100 stated that in the past, staff shoved her and that it made her mad. Review of an admission Record revealed R101 was a [AGE] year-old male, admitted to the facility on [DATE] with pertinent diagnoses of dementia. Review of video and audio footage, provided by the Administrator, showed the following events that occurred on 10/20/25 at 2:50 AM:-R100 and R101 walked in the hallway, appeared calm, and spoke to no one. -Certified Nurse Aide (CNA) A sat in the hallway and the view of CNA A was partially obstructed by equipment. No other staff were visible on the video footage. -R100 entered a room (room [ROOM NUMBER]) that did not belong to her. CNA A called out for R100, got up from the chair, and entered room [ROOM NUMBER].-CNA A came back into the hallway, alone after a few seconds and yelled God in a frustrated voice. CNA A put on her shoes and went back toward room [ROOM NUMBER].-As CNA A entered room [ROOM NUMBER], R101 walked into the doorway behind CNA A. CNA A turned partially around and faced R101, extended the right arm and shoved R101, on the shoulder, and caused R101 to stumble backwards in the hallway. -CNA A entered room [ROOM NUMBER]. Nothing was heard while CNA A and R100 were in the room together, i.e. no yelling, no instruction by CNA A for R100 to leave the room, no sounds of a physical scuffle, and no calls for help by CNA A.-R100 stepped into the doorway, with her back to the hall, and was propelled across the hallway, hitting the back of her head on the wall across from room [ROOM NUMBER]. A thud was heard on the video/audio recording as R100 hit the wall. CNA A stood in the doorway of room [ROOM NUMBER].-R100 was sent to the emergency room and treated for an open and bleeding cut to the back of her head that required sutures and for a large hematoma (bruise) to her buttock. The 4 cm (centimeter) hematoma to R100's right buttock showed underlying bleeding and R100 was admitted to the hospital for two days to monitoring for bleeding. During an interview on 11/06/25 at 10:07 AM, the Administrator stated that CNA A was fired for her failure to follow the facilities abuse policy and procedure and for the inappropriate physical contact with R100 that caused injury and for shoving R101. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included the re-education of staff regarding recognizing staff burn-out, behavior management, and the abuse policy and procedure. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to complaint #2626994. Based on interview and record review, the facility failed to implement policies and procedures for ensuring reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Social Securities Act regarding reportable incidents for 2 residents (R101 and R102) of 3 residents reviewed for abuse. Findings include:Review of an admission Record revealed R101 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and parkinson's disease. Review of an admission Record revealed R102 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and encephalopathy. Review of MI-FRI #61781 Facility Investigation Report revealed on 9/14/2025 at 3:30 PM R101 struck R102 on the mouth in the activity room. This event was witnessed by facility staff and reported to the Director of Nursing (DON) on 9/14/2025 at 4:00 PM. Further review revealed the Nursing Home Administrator (NHA) submitted the 2-hour notification to the state agency the following morning, 9/15/2025 at 9:18 AM. In a telephone interview on 10/8/2025 at 2:00 PM, the DON reported the incident of abuse that occurred on 9/14/2025 between R101 and R102 was not submitted to the state until the morning of 9/25/2025 as she believed the facility had 24 hours to submit abuse incidents to the state unless the incident caused serious injury. The DON reported the facility's regional staff educated her and the NHA that all abuse incidents and allegations needed to be reported to the state agency within 2 hours. Review of facility policy/procedure Abuse Prohibition, dated 10/14/2022, revealed .reporting abuse. any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation) . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education of the NHA and DON and ongoing surveillance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on interview and record review the facility failed to maintain a complete and accurate medical record for 5 residents (R2, R69, R73, R76 & R88) out of 19 residents reviewed. Findings: Resident #88 (R88) Review of a closed clinical record for a Death investigation during the annual recertification survey revealed R88 originally admitted to the facility on [DATE] with a cognitive communication deficit, aphasia (inability to speak), a history of aspiration (inhalation of particulate into the lungs), and received nutrition through a feeding tube. Review of a Nurses Note dated 1/28/2025 at 2:20 AM reflected (R88) passed away at 1:51 AM 1/28/2025. Daughter (name), PA (physician assistant), DON (Director of Nursing), & Funeral home notified per daughter's request. Progress notes leading up to R88's death were reviewed and revealed the following: Review of a Change in Condition note dated 1/22/2025 at 10:10 AM revealed (R88) moaning on and off all night, per CNA (Certified Nurse Aide). (R88) moaning a few times today with grimacing on her face. A CBC (complete blood count), CMP (comprehensive metabolic panel) and an abdominal x-ray were ordered at this time. Review of a Nurses Note dated 1/23/2025 at 8:55 AM, indicated R88 was sent to the Emergency Department for a CT (computerized tomography) scan to rule out ileus (inability of the intestine to contract normally to remove waste out of the body)/possible obstruction (bowel obstruction). R88 returned to the facility on [DATE] at 5:00 PM with a diagnosed Urinary Tract Infection (UTI) and an order to administer an antibiotic. Review of a Nurses Note dated 1/25/2025 at 10:31 AM reflected R88 was moaning during a transfer. Vital signs indicated R88's respirations (breaths per minute) was 24, heart rate was 150 beats per minute and oxygen saturation (SaO2) was 79% (on room air, normal SaO2 is between 95-100%). The nurse administered supplemental oxygen and after speaking to R88's daughter, obtained an order for oral Roxanol (a highly concentrated solution of the narcotic analgesic morphine sulfate). The note indicated R88's vital signs returned to normal with the supplemental oxygen in place at 2 liters (2L). Review of a Nurses Note dated 1/26/2025 at 12:30 PM, R88's daughter came to visit and provided information regarding funeral home. Review of a Dietary Note dated 1/27/2025 at 12:14 PM reflected R88's daughter was informed .prior formula now available. Order placed this date for 2Cal HN (a high-calorie, high-protein nutritional supplement designed for individuals who require increased caloric and protein intake.) Review of a Nurses Note dated 1/27/2025 at 5:50 PM (8 hours before R88 passed away) reflected R88's daughter was given an update on R88's status which was stable. The note indicated (R88's) son in law came to visit (R88) and stated he thought she looked better then (sic) she did over the weekend. Review of a Nurses Note dated 1/27/2025 at 10:54 PM reflected (R88) currently grimacing/moaning. PRN (as needed) morphine administered, she also has a low grade fever of 99.1. Patient has some pulmonary edema at auscultation of the lungs, PA notified and directed order for a CXR (chest x-ray) stat (right away). Patient was repositioned HOB (head of bed) @ (at) 45 degrees, cool towel applied on forehead for LGF (low grade fever). Supplemental O2 (oxygen) @ 2L, Patient stat (sic) @ 90%. Will continue to monitor for any acute change of condition. The note does not indicate R88's daughter was notified of the change in condition and new order for a chest x-ray. During an interview on 3/26/2025 at 4:26 PM, Licensed Practical Nurse (LPN) L reported she was the nurse on duty at the time R88 passed away and had spoken to R88's daughter during the shift, before R88 passed away. LPN L said that R88's death was not entirely unexpected, but no one expected her to pass away that night, it was a shock on 1/28/2025. LPN L said that she was very concerned about R88's lung sounds which sounded nasty with a lot of fluid. LPN L said she notified the physician and got an order for a chest x-ray and indicated she and CNA's were checking on R88 at least every 30-45 minutes, vital signs were measured with every check. LPN L said she did not ask for R88 to be sent to the hospital because R88's daughter did not want R88 to go back to the hospital after having just been there a few days prior. LPN L said she thought she documented a full physical assessment or change in condition on 1/28/2025. LPN L said she would have written vital signs down on a piece of paper, but did not know where they would be in the electronic health record if she didn't add them. Review of O2 Sats Summary & Blood Pressure Summary reflected the last oxygen saturation & blood pressure was recorded on 1/27/25 at 7:09 AM. A Temperature Summary indicated the last temperature taken was on 1/27/25 at 9:23 PM. Review of the entire Electronic Medical Record (EMR) did not reflect a full physical assessment, or recent vital signs had been recorded after LPN L assumed care for R88 on 1/27/2025 and before she passed away on 1/28/2025. No indication R88 had been placed on comfort care with death anticipated was documented. The progress notes do not indicate R88's daughter did not want R88 sent to the hospital was documented. During an interview on 3/27/2025 at 9:45 AM, the DON reported that the facility had not investigated R88's death because it was not unexpected. The DON said that R88's daughter did not want R88 sent to the hospital again, the morphine was added for comfort, and the tube feeding formula was changed because R88's daughter thought it would be less irritating to R88's digestive system. The DON reviewed R88's clinical record and reported she did not see documentation to support the clinical decision making, physical assessments and vital sign monitoring leading up to R88's death. Resident #69 (R69) Review of an Admission Record reflected R69 admitted to the facility with diagnosis that included acute respiratory failure with hypoxia and a need for assistance with personal care. R69 was their own responsible party. Review of a Notification of Medicare Non-Coverage indicated The Effective Date Coverage of Your Current Skilled Services Will End: 11/15/2024. The form describes R69's right to appeal the decision and includes a space for a signature of the recipient of care to indicate the notice was received and understood. The notice was signed by R69's wife and was not dated. During an interview on 3/27/2025 at 9:50 AM, the DON reported that R69 remained in the facility and shared a room with his wife who would often take control of R69's affairs if R69 was asleep or otherwise busy. The DON reviewed R69's EMR and was not able to locate a progress note or business office/administrative note that would indicate the notice was provided to R69 in a timely manner and there was no explanation for why R69 did not sign the notice himself. 39056 Resident #2 (R2) Review of an Admission Record revealed R2 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Major Depressive Disorder. R2 had a guardian. Review of R2's Order Summary dated 2/1/25-2/16/25 revealed, FLUoxetine (Prozac/antidepressant) HCl Oral Tablet 20 MG (Fluoxetine HCl) Give 1 capsule by mouth one time a day . Review of R2's Order Summary dated 2/17/25 revealed, FLUoxetine HCl Oral Capsule 10 MG (Fluoxetine HCl) Give 1 capsule by mouth one time a day . Review of R2's Nurses Note dated 2/17/25 revealed, New order to decrease Prozac to 10mg PO qd (by mouth every day). Resident and family informed of order update. Review of R2's Electronic Medical Record revealed no documentation that R2's guardian was involved in and consented to the Gradual Dose Reduction (GDR) of R2's Prozac. Review of R2's Nurses Note dated 3/27/2025 written by Director of Nursing (DON) revealed, F/U (follow up) with resident niece on order to decrease Prozac on 2/17. Niece stated she was notified and had been in agreement with plan. DON explained progress note did not reflect agreement and niece confirmed she understood the rationale and agreed with plan at the time of the change . Resident #73 (R73) Review of an Admission Record revealed R73 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: major depressive disorder. R73 had a Durable Power of Attorney (DPOA) activated. Review of R73's Order Summary dated 7/19/25-2/25/25 revealed, SEROquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 25 mg by mouth at bedtime . Review of R73's Order Summary dated 2/25/25 revealed, SEROquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 12.5 mg by mouth at bedtime . Review of R73's Order Summary dated 2/25/25 revealed, Ativan Oral Tablet 0.5 MG (Lorazepam) Give 0.5 tablet by mouth every 24 hours as needed for Anxiety Only to be given on shower days, 30-60 minutes before the resident showers. Review of R73's Nurses Note dated 2/25/2025 revealed, New Order-Decrease Seroquel to 12.5 mg at bedtime. Ativan 0.25 to be given on shower days only. Give 30-60 minutes before shower .Family Notified . Review of R73's Electronic Medical Record revealed no documentation that R73's DPOA was involved in and consented to the Gradual Dose Reduction (GDR) of R73's seroquel or was provided education on the risk versus benefit of Ativan. Resident #76 (R76) Review of an Admission Record revealed R76 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: paranoid personality disorder. R76 had a guardian. Review of R76's Order Summary revealed ZyPREXA Oral Tablet 2.5 MG (Olanzapine) Give 1 tablet by mouth at bedtime for antipsychotic had been discontinued. Review of R76's Resident At Risk note dated 3/13/25 revealed, Reviewed Clinical Indicator: Resident was seen by psych np (nurse practitioner) on 3/11/25 .Do (sic) to successful GDR of Zyprexa per np will d/c (discontinue), Will continue to observe for changes in mood and behavior. Review of R76's Electronic Medical Record revealed no documentation that R76's guardian had consented to the discontinuation of Zyprexa. During an interview on 3/27/25 at 10:40 AM, DON reported she was unable to contact R76's guardian to confirm they were educated on and participated in his Zyprexa GDR/discontinuation. During an interview on 03/27/25 at 08:36 AM, Nursing Home Administrator (NHA) confirmed the documentation for R2, R73, and R76's GDR's was lacking and did not reflect risk versus benefit education documentation or guardian/POA consent. During an interview on 3/27/25 at 10:40 AM, DON reported R2, R73, and R76's documentation did not support that their guardian/POAs had been educated on the risk versus benefits and consented to the GDR's of the psychotropic medications. DON reported that the expectation for staff was to ensure all elements of documentation were in place which included notification of a recommendation of a change in medication, consenting to medication changes, as well as education to guardian/POAs and/or family members.

Based on interview and record review, the facility failed to 1.) accurately document administration of controlled substances and 2.) ensure narcotic medications were administered following the physician order for 4 residents (Residents #23, #74, #84, and #10), reviewed for controlled substances, resulting in medication errors. Findings: Resident #23 (R23) Review of an Admission Record revealed R23 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: generalized anxiety disorder. Review of R23's Order Summary dated 3/5/25 revealed, diazePAM (Valium) Oral Solution 5 MG/5ML .Give 4 ml via PEG-Tube two times a day for ANTIANXIETY AGENTS. To be administered at 8:00 AM and 9:00 PM. Review of R23's Controlled Substance Proof of Use form revealed 1 dose of diazepam was administered on 3/7/25 at 9:45 AM. R23's 9:00 PM dose of diazepam was not documented as dispensed. Review of R23's March Medication Administration Record revealed both doses of R23's diazepam was documented as administered on 3/7/25. Review of R23's Electronic Medical Record revealed no documentation for the withholding of R23's even dose of diazepam on 3/7/25. Resident #74 (R74) Review of an Admission Record revealed R74 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety disorder. Review of R74's Order Summary dated 3/4/25 revealed, Ativan Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 0.5 tablet by mouth every 6 hours as needed for Anxiety for 14 Days. Review of R74's Controlled Substance Proof of Use form revealed: *On 3/5/25 at 8:00 PM a dose of Ativan was dispensed. *On 3/7/25 at 9:00 PM a dose of Ativan was dispensed. *On 3/16/25 at 8:00 PM a dose of Ativan was dispensed. Review of R74's March Medication Administration Record revealed no documentation that R74's Ativan was administered on 3/5/25, 3/7/25, or 3/16/25. Resident #84 (R84) Review of an Admission Record revealed R84 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety disorder. Review of R84's Order Summary dated 3/11/25 revealed, LORazepam (Ativan) Tablet 0.5 MG *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for Anxiety until 03/19/2025 23:59 (11:59 PM). Review of R84's Controlled Substance Proof of Use form revealed: *On 3/16/25 at 9:00 PM a dose of Ativan was dispensed. *On 3/20/25 at 3:00 AM a dose of Ativan was dispensed. *On 3/20/25 at 8:00 PM a dose of Ativan was dispensed. Review of R84's March Medication Administration Record revealed no documentation that R84's Ativan was administered on 3/16/25, or on 3/20/25 at 3:00 AM and 8:00 PM. Review of R84's Electronic Medical Record revealed no documentation of an order for Ativan dated 3/20/25. Resident #10 (R10) Review of an Admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: diabetic neuropathy. Review of R10's Order Summary dated 1/24/24 revealed, Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug* Give 1 tablet by mouth two times a day for pain. To be administered at 8:00 AM and 8:00 PM. Review of R10's Controlled Substance Proof of Use form revealed 1 dose of Norco was dispensed on 3/8/25 at 8:39 AM. Review of R10's March Medication Administration Record revealed both the 8:00 AM and 8:00 PM doses of Norco were administered. During an interview on 3/27/25 at 1:20 PM, Director of Nursing (DON) confirmed the above medication errors/discrepancies and reported medication error reports were generated and 1:1 education as provided. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2021) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 639). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to proved dignified care and services for two facility residents (R10 and R34). Findings: Resident #10 (R10) Review of an Admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: tracheostomy, diabetes mellitus with diabetic neuropathy, kidney disease, and heart disease. Review of a Minimum Data Set (MDS) assessment for R10, with a reference date of 2/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated R10 was moderately cognitively impaired. Review of R10's Care Plan revealed R10 required the use of a mechanical lift and the assistance of 2 staff members to transfer from his bed to his wheelchair. During an observation and interview on 03/26/25 at 08:48 AM, R10 pressed his call light and reported that he was ready to get up and into his wheelchair for the day. R10 reported that it frequently took greater than 30 minutes to have his call light answered and wait times were worse on 3rd shift. The following observations were made while in the hallway outside of R10's room: At 08:52 AM a Certified Nurse Aide (CNA) M entered R10's room, turned off his call light, and reported she had to assist another resident and stated, I'll come back. From 08:53 AM-09:14 AM R10's call light was inactive, and no staff entered his room. At 09:14 AM R10 initiated his call light. At 09:16 AM a housekeeping staff member entered his room to identify his needs. The housekeeping staff member exited his room and notified CNA M that R10 required assistance. The call light remained active. At 09:19 AM CNA M entered R10's room, turned off his call light, and left the room to assist a resident in a different room. At 09:21 AM CNA M entered R10's room, stated she had to go get a sling (for the mechanical lift) and I'll be back. R10's call light remained inactive. At 09:24 AM CNA M brought a mechanical lift sling to R10's room and exited his room. R10's call light remained inactive. At 09:26 AM this surveyor entered R10's room and observed R10 visibly upset (shaking his head and scowling). R10 reported staff would frequently shut his call light off and exit his room which caused feelings of frustration. At 09:31 AM R10 initiated his call light. At 09:32 AM a CNA entered R10's room and assisted R10 (44 minutes from the initial call light activation). During an interview on 03/27/25 at 12:00 PM, Nursing Home Administrator (NHA) reported the expectation is that a staff member will leave the call light on until the residents' needs are met. Review of the facility policy Call Lights last revised 3/12/25 revealed, Policy-Call lights will be placed within the resident's reach and answered in a timely manner .Responding to a Call Light .3. Go to the location of the call light, and turn off the light if you are able to meet the resident request . 31771 R34 Review of the Electronic Medical Record (EMR) Admission Record reflected R34 originally admitted to the facility 2/25/25 and has current pertinent diagnoses of Feeding Difficulties and Need for Assistance with Personal Care. The Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the Resident was mildly cognitively impaired. Section GG (titled Functional Abilities and Goals) of this MDS revealed R34 required Substantial /maximal assistance with eating and that a Helper does more than half the effort. On 3/25/25 at 11:53 AM lunch service was observed to be progress in the North Hall Dining Room. Initially present were three residents at one table, two residents at another, and two residents sitting at tables by themselves. All residents except one resident, (R34) sitting by herself, were eating. R34 reported she has not received her meal yet. At 12:00 PM a female resident was pushed by a staff member to sit at the table with R34. This new resident was immediately provided a meal tray that was set up by the staff. A male resident in a power wheelchair then arrived at a nearby table and was immediately provided a meal. At 12:04 PM a staff member provided coffee and an orange-colored drink to the resident sitting at the table with R34. R34 did not have any beverages. At 12:06 PM a staff member asked R34 if she was done eating and ready to return to her room. R34 reported she had not received her meal yet and the staff member told her she would let someone know. At 12:08 PM a staff member brought a covered tray and set it before R34 telling her she would be back with a clothing protector. While the staff member was away R34 reported she finally got her meal. R34 reported her meal was still covered because she requires assistance with eating. R34 reported the food usually isn't hot enough. R34 reported she has asked staff to reheat her food and stated, they won't do it. When asked if staff have actually told her that before R34 nodded her head yes. At 12:15 PM the staff member returned with a clothing protector and began assisting R34 with her meal. At 12:18 PM the staff member left R34 to assist other residents who had finished their meals and were wanting to leave the Dining Room. At 12:20 PM the staff member returned to the table with R34 and resumed assisting her with her meal. On 3/26/25 at 12:20 PM, R34 was sitting at a table by herself in the North Hall Dining Room. It was observed that R34 had a device attached to her right hand that held a fork allowing her to feed herself. R34 reported that the food was cold again and she had asked for tomato soup. R34 reported that after her lunch the previous day she was not taken back to her room for an hour and that it hurt her bottom on which there was a sore. During an interview conducted 3/27/25 at 8:01 AM the North Unit Manager (UM) K reported that the nurses are responsible for making sure the meal trays are dispensed to the residents. UM K reported the Dining Room is served first then the residents who take their meals in their rooms. UM K was informed of the observation of delayed meal service for R34 on 3/25/25 and that the Resident reported the food was usually cold. UM K was also informed that R34 reported an extended wait to return to her room after the meal and that this prolonged wait caused the Resident discomfort. UM K did not offer any comments or additional information.

Based on observation, interview, and record review, the facility failed to ensure food and beverages were enjoyable for three facility Residents (R34, R59, and R41) out of 19 residents reviewed. Findings: R34 Review of the Electronic Medical Record (EMR) Admission Record reflected R34 originally admitted to the facility 2/25/25 and has current pertinent diagnoses of Feeding Difficulties and Need for Assistance with Personal Care. The Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the Resident was mildly cognitively impair. Section GG (titled Functional Abilities and Goals) of this MDS revealed R34 required Substantial /maximal assistance with eating and that a Helper does more than half the effort. On 3/25/25 at 11:53 AM lunch service was observed to be in progress in the North Hall Dining Room. Initially present were three residents at one table, two residents at another, and two residents sitting at tables by themselves. All residents except one resident, (R34) sitting by herself, were eating. R34 reported she has not received her meal yet. At 12:00 PM a female resident was pushed by a staff member to sit at the table with R34. This new resident was immediately provided a meal tray that was set up by the staff. A male resident in a power wheelchair then arrived at a nearby table and was immediately provided a meal. At 12:04 PM a staff member provided coffee and an orange-colored drink to the resident sitting at the table with R34. R34 did not have any beverages. At 12:06 PM a staff member asked R34 if she was done eating and ready to return to her room. R34 reported she had not received her meal yet and the staff member told her she would let someone know. At 12:08 a staff member brought a covered tray and set it before R34 telling her she would be back with a clothing protector. While the staff member was away R34 reported she finally got her meal. R34 reported her meal was still covered because she requires assistance with eating. R34 reported the food usually isn't hot enough. R34 reported she has asked staff to reheat her food and stated, they won't do it. When asked if staff have actually told her that before R34 nodded her head yes. At 12:15 PM the staff member returned with a clothing protector and began assisting R34 with her meal. At 12:18 PM the staff member left R34 to assist other residents who had finished their meals and were wanting to leave the Dining Room. At 12:20 PM the staff member returned to the table with R34 and resumed assisting her with her meal. On 3/26/25 at 12:20 PM R34 was sitting at a table by herself in the North Hall Dining Room. It was observed that R34 had a device attached to her right hand that held a fork allowing her to feed herself. R34 reported that the food was cold again and she had asked for tomato soup. R59 Review of the medical record reflected R59 admitted to the facility 2/26/25 with pertinent diagnoses that included Protein Calorie Malnutrition and Muscle Wasting Atrophy. The MDS dated [DATE] reflected a BIMS score of 12 out of 15 which indicated the Resident was mildly cognitively impaired. On 3/25/25 at 3:13 PM an interview was conducted with R59 in her room. R59 reported she eats her meals in the North Dining Room about half of the time and the rest in her room. R59 reported the food is always cold. R59 reported the coffee is cool. R59 stated It's not their (staff's) fault R59 indicated the staff are busy and I don't know how you would keep food warm on a tray all the way to the room. On 3/26/25 at 12:17 PM in the room of R59 the R59 reported that the temperature of her lunch was better today but indicated it was still not warm enough. R59 again reported, it's not their fault. During an interview conducted 3/27/25 at 8:01 AM the North Unit Manager (UM) K reported that the nurses are responsible for making sure the meal trays are dispensed to the residents. UM K reported the Dining Room is served first then the residents who take their meals in their rooms. UM K was informed of the observation of delayed meal service for R34 on 3/25/25 and that the Resident reported the food was usually cold. UM K was informed of the two interviews with R59 that the food was cold and that the Resident had stated that it was not the fault of the staff. UM K stated that R59 is very forgiving. UM K did not offer any additional comments or information 29073 Resident #41 (R41) Review of an Admission Record reflected R41 originally admitted to the facility on [DATE] with diagnoses that included paraplegia, depression, anxiety and moderate to severe protein-calorie malnutrition. R41 was their own responsible party. During an interview on 3/25/2025 at 2:05 PM, R41 reported that they were bored with the food, the meals are not very hot and the coffee that is served at the facility is very cold. R41 said they resort to a [delivery service] to bring hot coffee, and despite the delivery distance, the coffee is still hotter than the coffee served at the facility. During an observation of the lunch service on 3/26/2025 at 12:16 PM, an insulated cart containing meal trays was delivered to the unit where R41 lived. R41's tray was the last tray to be delivered and was intercepted at 12:31 PM (15 minutes after the insulated cart was delivered to the unit) by the surveyor to test for palatability and temperature. Staff were instructed to obtain a new meal for R41 at this time. During an observation on 3/26/25 at 12:18 PM, Dietary Manager (DM) C confirmed the temperature of the coffee in the covered mug on R41's meal tray was 109 degrees Fahrenheit. The turkey served with the meal was 126 degrees Fahrenheit, green beans were 133 degrees Fahrenheit, and stuffing was 144 degrees Fahrenheit. DM C said when the food was plated in the kitchen, and the appropriate holding temperatures were maintained. DM C reported that the coffee was poured an hour prior to the temperature observation and the temperature loss is when the food leaves the kitchen and goes onto the unit, Certified Nurse Aides (CNA's) can't deliver the trays right away. DM C said that staff often have to remind to keep the insulated cart doors closed during delivery of meal trays to help maintain palatable temperatures. During a follow-up interview on 3/26/25 at 1:31 PM, R41 reported a notable an improvement in the taste and temperature of the meal and coffee because the staff had to get a fresh tray after the surveyor used the meal originally intended for them to test temperatures. R41 said they enjoyed the meal very much and ate every last bite.

Based on interview and record review, the facility failed to promptly identify a change in condition and act upon those changes for 1 resident (R4) out of 4 residents reviewed for quality of care, resulting in R4 experiencing unnecessary pain, a delay in evaluation and surgical intervention for a femur fracture. Findings: Resident #4 (R4) Review of an Admission Record revealed R4 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: difficulty in walking, muscle wasting and atrophy, need for assistance with personal care, weakness, history of falls prior to admission, and dementia. Review of R4's Brief Interview for Mental Status (BIMS) dated 11/26/24 revealed a score of 11, out of a total possible score of 15, indicating R4 was moderately cognitively impaired. (Last assessment obtained prior to his fall on 1/12/25.). R4's BIMS dated 1/17/25 revealed a score of 15, indicating R4 was cognitively intact. During an interview on 01/23/2025 at 11:15 AM, R4 reported that on 1/12/25 he slipped and fell in the bathroom which resulted in him experiencing pain in his right hip. R4 reported he was assisted back to bed following the fall but experienced significant pain with movement stating he was too painful to move. R4 reported that he couldn't get out of bed and remained in his bed until his transfer to the hospital on 1/14/25. R4 reported that he wanted to go (to the hospital) sooner and was unsure of the cause of the delay in transfer. During an interview on 01/23/2025 at 12:05 PM , Family Member/Emergency Contact (FMEC) C reported that R4 sustained a fall on Sunday 1/12/25 and his wife went to the facility to assess his condition. FMEC C reported that at that time he was in bed and was reporting pain. FMEC C stated that R4 just stayed in bed because he couldn't do anything else and reported as long as he was not moved and remained in bed his pain was manageable. FMEC C reported that it wasn't until Tuesday (1/14/25) that they determined he needed to be evaluated in the emergency department to identify the root cause of his pain/change in condition. FMEC C reported he met R4 at the hospital where he was in shock to find out the extent of R4's injuries and the number of fractures sustained from the fall as well as the need for immediate surgical intervention and was concerned with the delay in his transfer to the hospital with the significant injuries. Review of R4's Incident Report dated 1/12/25 revealed, This was at the beginning of shift he was in bed watching tv. I passed his meds and he took them with no issues. Moments later he put his call light on and before we was able to answer it I heard him at his doorway and when I turned around and noticed him standing with urinal in hand he lost his balance and landed on his right side, no head injuries or any other injuries noted during shift. He was really confused and stated that he was going to bathroom .Notes: 1/13/2025 Resident seems really confused UA (urinalysis) collected to rule out possible UTI (urinary tract infection). 1/13/2025 (no time documented) F/u (follow up) to resident fall on 1/12/25. Therapy attempted to screen this day post fall and resident refused due to new onset of pain .Noted resident is not bearing weight on the right leg. Increased ADL assistance provided. PA (physician assistant) notified and new order obtained for Xray of rt (right) femur/hip for dx (diagnosis): hip pain. Resident has 0/10 pain at rest, non- pharmalogical (sic) pain interventions in place. (Company name omitted) notified of new orders for Xray and will be completed within 24 hours . Confirming the facility was aware that the resident was experiencing pain with movement and had a change of condition of (inability to bear weight on right leg and altered mental status). The resident was not sent to the emergency department despite the change of condition both physically and cognitively and the knowledge that an xray could not be immediately obtained. Review of R4's Post Fall Evaluation dated 1/12/25 revealed, Confused a&o x 1-2 (alert and oriented to person, place, time, situation is x4) .unknown baseline but was told by other staff members that he's normally not that confused (indicating a change in R4's mental status) .he lost his balance and landing sitting up at the right side. He didn't hit his head and denied any pain or discomfort .monitoring throughout shift . Review of R4's Resident At Risk dated 1/13/25 revealed, .Action Taken: Assessed head to toe, rom (range of motion), v/s (vital signs), more confusion ua completed. There was no documentation revealing the outcome of the range of motion assessment despite documentation that R4 was no longer able to bear weight on his right leg and had pain with movement. Review of R4's Order Details dated 1/13/25 at 5:39 PM revealed, X-Ray for right femur/hip DX: Hip Pain. Review of R4's Electronic Medical Record revealed no documentation that the x-ray could not be completed or that the physician was notified of the delay in treatment. Review of R4's Occupational Therapy Missed Visit Details dated 1/13/25 revealed, Pt (patient) unable to be seen today due to having a fall this morning and having right hip pain. Pt unable to stand following fall and 2PA (2 person assist). Nursing addressing . Review of R4's Interdisciplinary Team note dated 1/13/25 revealed, Fall 1/12/25 @ 7:15pm .Resident currently on PT/OT case (physical therapy/occupational therapy) load and when OT approached for treatment that day, he stated he could not participate r/t (related to) too much pain in his right LE (lower extremity/leg), nursing notified of change. Review of R4's Occupational Therapy Treatment Encounter Note dated 1/14/25 revealed, .nursing stated that awaiting xray to come in for stat (immediate) order . Review of R4's Provider Progress Note dated 1/14/25 . Patient had a fall yesterday morning landing on his right hip. He has been unable to weight bear since the fall. Xray was ordered yesterday but has not been done yet. Pain is getting worse as he is requiring being turned q 2 hours for (sic) prevent pressure areas. Discussed with nursing for patient to be sent out for xray and evaluation as if xray is negative, then why can he not weight bear. Nursing will notify Primary care . Extremities .Positive pain noted of the right hip/thigh with any movement . Currently unable to bear weight on right LE . Confirming a delay in obtaining the xray. Review of R4's Pain Summary revealed pain scores of 0/10 indicating no pain. Important to note R4 stated he did not experience pain at rest, only with movement. Review of R4's Electronic Medical Record revealed no comprehensive physical assessments or comprehensive pain assessments following the fall assessment to identify the quality of pain (sharp, dull, achy), aggravating factors (movement), the physical appearance of the injured leg, his cognitive status (had the confusion resolved or continued), or the results of his urinalysis. Review of R4's Tasks for lying to sitting, sitting to standing, and toileting from the time of the fall on 1/12/25-1/14/25 revealed R4 was no longer performing these tasks as he had before and either required a significant change in assistance or did not perform the task. Review of R4's Nurses Note dated 1/14/2025 at 09:02 AM revealed, Resident is c/o pain to left and right hip. Resident has had recent fall and fell on right hip. EMS notified to transfer resident to (name omitted) hospital for evaluation. Son notified of transfer. Review of R4's Nurses Note dated 1/14/2025 at 9:16 AM revealed the ambulance arrived to transport R4 to the emergency department at that time. Approximately 38 hours from the time of the fall. Review of R4's Emergency Department Progress Note dated 1/14/2025 1:26 PM revealed, . presents to the (name omitted) emergency department via EMS (emergency medical services/ambulance) for evaluation following a fall which occurred 2 days prior to arrival . The patient is a resident at [NAME] Manor and reports he had a mechanical fall in the bathroom on the evening of 1/12 .He was helped back to bed and was not ambulatory from that time. He had right hip tenderness which was aggravated by any kind of movement .Imaging studies revealed a right intertrochanteric femur fracture, right inferior pubic ramus fracture, possible sacral insufficiency fracture, and small right retroperitoneal hematoma .Right lower extremity shortened and externally rotated (physical deformity in his right leg) . Review of R4's hospital Tertiary Trauma Survey (trauma provider consultation) dated 1/15/2025 revealed, .Extremities: Neurovascular intact bilaterally, 2+ pulses bilateral radial bilateral DP pulses, external rotation of the right lower extremity that is slightly shortened. Pain over the right hip on palpation. Plan: Right intertrochanteric femur fracture Right inferior pubic ramus fracture Possible acute sacral insufficiency fracture Right retroperitoneal hematoma -Hemoglobin 7.6 from 7.9 from 8.2 Acute blood loss anemia -Likely related to #1 and #2 . Confirming a physical change in R4's right leg from the injury identified by a second provider. During an interview via email on 1/23/2025 at 3:37 PM, Director of Nursing (DON) was asked for documentation of additional monitoring/assessments regarding R4's injury and/or mental status change based on the note monitoring throughout shift on the Post Fall Evaluation dated 1/12/25. DON replied There was a provider who saw him on 1/14 and then he was sent out d/t the pain. There were interventions that she did nonpharmalogically r/t the pain that day- relaxation, positioning and rest- noted on 1/13. Confirming additional monitoring/assessments had not been completed. DON was asked to provide documentation as to why the x-ray was not completed and/or physician notified it could not be completed on 1/13/25. DON stated, The xray was ordered but he went out the hospital and it was done there. There was no documentation provided for the rationale of the delay of the xray or physician notification. During an interview via email on 1/23/2025 at 7:00 PM, DON stated, per our conversation we discussed nurses making a fall progress note every shift for three days, however per our policy there is just to be an assessment done for 72 hrs and doesn't indicate the frequency. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Assessing the characteristics of pain allows you to understand the type of pain, its pattern, and the types of interventions that bring relief .Quality: People use a variety of words to describe the quality of their pain (e.g., pain, ache). Ask patients to describe their discomfort using their own words whenever possible; then use these words consistently to obtain an accurate report. For example, say, Tell me what your discomfort feels like. What do you call it? The patient may describe the pain as aching, crushing, throbbing, sharp, or dull. If the patient reports the pain as dull, ask if it is still dull or if it has changed when you return to assess the patient's pain .Aggravating and precipitating factors: Various factors or conditions bring on or make pain worse. Ask a patient to describe activities that cause or aggravate pain, such as physical movement, positions, drinking coffee or alcohol, urination, swallowing, eating food, or psychological stress. Also ask them to demonstrate actions that cause a painful response, such as coughing or turning a certain way .Behavioral effects: When a patient has pain, assess verbalization, vocal response, facial and body movements, and social interaction. A verbal report of pain is a vital part of assessment. You need to be willing to listen and understand. When a patient is unable to communicate pain, it is especially important for you to be alert for behaviors that indicate it (Box 44.9). [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1141-1143). Elsevier Health Sciences. Kindle Edition.

This citation pertains to intake # MI00149549 Based on observation, interview, and record review, the facility failed to ensure a resident was transferred following care planned interventions and standards of practice for 1 resident (Resident #1) out of 4 residents reviewed for accidents and safety, resulting in R1 sustaining a preventable fall with facial bruising and lacerations requiring hospital treatment. Findings: Resident #1 (R1) Review of an Admission Record revealed R1 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: difficulty in walking, muscle wasting and atrophy, and need for assistance with personal care. Review of R1's Brief Interview for Mental Status (BIMS) dated 12/17/24 revealed a score of 12, out of a total possible score of 15, indicating R1 was moderately cognitively impaired. R1 had a fall at the facility on 11/7/24 and 12/30/24 confirming she was a high risk for falls. During an observation on 01/22/2025 at 11:48 AM, R1 was sitting up in a wheelchair in her room and was noted to have yellow/blue/gray bruising around her right eye spreading down to her cheekbone. Review of R1's Physical Therapy Discharge Summary dated 12/20/24 revealed, .Discharge Recommendations: 1 PA (physical assist) for all functional mobility, RW (rolling walker) use while ambulating with staff . Review of R1's Care Plan last revised 12/19/24 revealed, AMBULATION/WALKING: Resident is limited assist x1 with rolling walker . Review of R1's Care Plan last revised 1/14/25 revealed, AMBULATION/WALKING: Resident is limited assist x1 with rolling walker. Walk to and from the bathroom with gait belt and rolling walker . During an interview on 01/23/2025 at 9:47 AM, Family Member/Guardian (FMG) A reported that R1 had fallen on 1/13/25 in the early morning. FMG A reported that she met with R1 the day of the fall and R1 reported to her that her bed was broken and moved when they were attempting to transfer her back to bed. FMG A reported that a facility nurse called her to notify her of R1's fall and reported that R1 was leaning towards the right during a transfer and the Certified Nursing Assistant (CNA) lost control resulting in R1 falling and smashed her face on the frame of the bed. FMG A reported that R1 was to be transferred with her walker and a gait belt to be safe and the CNA did not follow her care planned interventions for transfer. FMG A reported she discussed her concerns with R1's bed not locking to a facility nurse and the nurse reported to her that when R1's style of bed was in the lowest position the wheels would not lock which was also confirmed by maintenance staff. FMG A reported the CNA lacked the education/understanding of the mechanics of R1's bed and should have ensured the bed was in a locked position prior to transferring R1. The facility nurse reported to FMG A that R1's fall was preventable, and the CNA should have ensured the bed was locked, a gait belt in place, and her walker utilized during R1's transfer back to bed. Review of R1's Interdisciplinary Note dated 1/13/25 revealed, 1/13/25 @ 2am Resident was being assisted back from the bathroom by CNA and was transferring back into bed when she began leaning and CNA lost control of the transfer and resident fell , hitting her head on the bed frame. Laceration to right side of face, sent to ER (emergency room ) for evaluation and returned w/ (with) tests negative .Staff educated to use gait belt and utilize RW (rolling walker) for transfers and ambulation in room. Review of R1's Hospital Record dated 1/13/25 revealed, .The patient is a [AGE] year-old female presents to the ED with fall and skin tear below her right eye .The wound is too close to the eyelid and the skin is too thin for primary closure with sutures or Dermabond. A nonadherent dressing was placed . Review of R1's Post Fall Evaluation dated 1/13/25 revealed, Fall Description Details .Getting back into bed after using the bathroom .w/c (wheelchair) next to bed. CNA assisted resident to standing position-lost balance (and) resident fell .gait belt not in use. Describe initial intervention to prevent future falls: Gait belt to be used during transfers (and) walker-CNA educated . During an interview on 1/23/25 at 9:26 AM, Director of Nursing (DON) confirmed that CNA B did not use a gait belt while transferring R1 which resulted in a fall with a facial laceration. DON reported that due to R1's improper transfer a meeting was scheduled for CNAs for gait belt/transfer education. During an interview via email on 01/23/2025 at 3:37 PM, DON reported that prior to R1's fall, the use of a gait belt was not on R1's care plan because it is a standard of practice. DON stated that due to the statement that the bed moved during the transfer we wanted to cover all bases and just replace the bed. Review of a Disciplinary Action Record for CNA B dated 1/16/25 revealed, Date of Infarction: 1-13-25 .Care plan not being followed. Resident was transferred without a gait belt .(CNA B) stated she helped the resident (R1) off the toilet (and) didn't use gait belt. She stated the bed moved (and) that's why/how the resident moved (and) hit her head. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Several methods are used to help a patient ambulate. For those who can bear weight easily provide support at the waist with a gait belt so that the patient's center of gravity remains midline. The belt helps you to stabilize patients if they lose their balance. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 796). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review the facility failed to record, track, and respond to resident concerns/grievances for two residents (#1, #232) and two residents in confidential resident council meeting resulting in the potential of resident concerns not being addressed and the potential for care needs unmeet. Findings Included: Resident #232 (R232) Review of the medical record revealed R232 was admitted to the facility 03/11/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD), nicotine dependence, hypokalemia (low potassium) hypocalcemia (low calcium), muscle weakness, morbid obesity, gastro-esophageal reflux, ischemic cardiomyopathy (heart damage), hyperlipidemia (high fat content in blood), atherosclerotic heart disease (damage to major blood vessels in the heart), type 2 diabetes, hypertension, and congestive heart failure (CHF). During observation and interview on 04/02/2024 R232 was observed sitting on the side of his bed. R232 explained that he had placed his call light on Thursday or Friday night, because he need assistance. He explained that someone came to his door and refused to come in and assist him. R232 did not know that person's name but explained that he had reported it to Physical Therapy Assistant (PTA) R. When asked if he had been offered to complete a Grievance Form/Concern Form he explained that he had not. R232 also explained that no follow-up had been completed to his knowledge. Review of the facility provided Grievance Log for the last nine months did not demonstrate any concerns that had been completed for R232. In an interview on 04/03/2024 at 01:22 p.m. Nurse Unit Manager (NUM) N was asked if she was aware of any concern regarding R232 about an employee refusing to answer his call light and attend to his request. NUM N explained that she was not aware of any concern that she had been informed of. NUM N explained that if she was aware of this type of concern, she would have completed a facility Resident, Family, Employee, and Visitor Assistance Form and provide it to the Nursing Home Administrator (NHA) A In an interview on 04/03/2024 at 01:37 p.m. Physical Therapy Assistant (PTA) R explained that R232 had explained to her that he had told her that it frequently takes 45 minutes for someone to answer his call light and he had told her that a black girl did not want to answer his call light. PTA R explained that she could not remember what she had done with that information. PTA R could not remember if she had told anyone about R232's concern. When asked if she had completed a facility Resident, Family, Employee, and Visitor Assistance Form she explained that she had not. When asked why she did not complete a Resident, Family, Employee, and Visitor Assistance Form, she explained that resident tell her about delay in response to call lights so frequently that many times she does not complete a Resident, Family, Employee, and Visitor Assistance Form. In an interview on 04/03/2024 at 03:27 p.m. Nursing Home Administrator (NHA) A explained that her expectation was that if residents' concerns could not be addressed immediately that a Resident, Family, Employee, and Visitor Assistance Form was to be completed. Once she received the Resident, Family, Employee, and Visitor Assistance Form she would direct the concern to the appropriate department and then resolution of the concern would occur. NHA A was asked if a resident had reported that an employee would not answer a call light, would that require a Resident, Family, Employee, and Visitor Assistance Form. NHA responded Likely. NHA A was asked if she was aware of a concern regarding R232 with an employee standing in his doorway and refusing to answer his light? NHA A responded that she was not aware of that concern. Review of Facility policy entitle Care Program, origination date of 10/01/2010 and last revised 03/13/2023, stated Purpose: to ensure that the facility actively resolves any concerns/grievances submitted orally or in writing to the Administrator, Director of Nursing, or any other member of the facility's staff. Section entitled Concern, Action, Response, Evaluation (Care) process demonstrated number 2 with stated If the facility receives a concern/grievance orally, staff should document the concern using the Guest/Resident, Family, Employee and Visitor Assistance Form. 27306 Resident #1 (R1) On 04/02/2024 at approximately 11:45 am during the initial dining observation this surveyor was approached by a visitor of Resident 1 (R1) and will be referred to as family member H. Family member H was observed to be upset and who reported she hoped something could be done about the facility being poorly staffed and the lengthy call light response time citing last Friday 3/29/24 the hallway where R1 resides had one Certified Nursing Assistant (CNA) to care for approximately 20 residents. Family member H stated she had complained numerous times to the Nursing Home Administrator (NHA A, Unit managers, Director of Nursing and had even contacted the Regional Director of Operations about her concerns with staffing and nothing gets addressed. Review of the facility grievance log from September 2023 to April 2024 was reviewed, there were no grievance/concern form filed related R1, family member H that pertained to call light response time and the concern with low staffing levels. On 04/03/24 03:28 PM, during an interview with NHA A she reported being aware of family member H's multiple complaints about call light response time and low staffing levels. NHA A agreed family member H visits daily and frequently makes comments and voices concerns. When queried why there were no grievance/concern forms to address the family member H's concern related to staffing, NHA A stated that their was, review of the log reflected family member H's concern pertained to running out of medication , not staffing. NHA A then stated she submits concerns electronically to the corporate system and there had been issues with submission-thus it must have been an oversight on the computers part but she had hard copies. It was requested at that time for all concern/grievance forms related to staffing for the past two months. NHA A reported she had a whole bunch just over the past few weeks. Again citing family member H visits daily and always had complaints about staffing levels. On 04/04/24 at 8:20 am NHA A stated she does not have any concern forms for concerns for call lights from the last two months. 45135 During a resident council meeting on 04/04/24 at 10:45 AM, 7 residents were in attendance. Anonymous residents stated they had voiced concerns with the call light wait time to the nursing staff, then to the administration and it still had not been resolved. Anonymous residents stated they turn their call light on and had to sit and wait. CNA will go into the room to see what they need and then tell them there is someone else in line in front of them. Also stated afternoons and nights are the worst. During an interview on 04/04/24 at 11:44 AM, anonymous resident stated she filed/verbal complaint within the last month. One staff had been removed from her hall. On another concern the CNA still works on the floor and will not provide her care, she goes to get another CNA to do it. Anonymous resident stated she was most upset that the CNA knows she filed a concern regarding her and the administration did not keep it confident. Also stated the first concern, they brought in the grievance form, which she could not read, told her what it said and asked her to sign it. She added that she was not sure what the form said as she cannot read.

Based on interview and record review, the facility failed to provide adequate supervision and assistance for 2 Residents (R2 and R4) to prevent falls, resulting in R2 sustaining multiple falls with injuries and loss of use of her arms and R4 remaining at high risk of falls with injuries. Findings include: Review of R2's face sheet, dated 8/25/23 revealed R2 was an [AGE] year old female admitted to the facility on [DATE] and had diagnoses that included: dementia, wedge compression fracture of sacrum (2/15/23), wedge compression fracture of 5th lumbar vertebra (2/14/23), fracture of the 1st lumbar vertebra (12/28/23, fracture of 4th lumbar vertebra (12/28/23), difficulty walking, muscle wasting, need for assistance with personal care, and fracture of T11-12 vertebra (11/5/21). R2 was not her own responsible party. Review of R2's care plan dated 3/10/23 revealed R2 had a laceration to her right brow r/t (related to) a fall. Review of R2's care plan dated 3/10/23 revealed R2 had a skin tear to her right-hand r/t (related to) a fall. Review of R2's care plan dated 4/4/23 revealed R2 was exhibiting an increase in behaviors of wandering and entering other resident rooms. R2 was swearing/yelling at staff with redirection and delusional thinking that her bedding needs to be changed but when staff look at the bedding the bedding was dry. R2 was prone to urinary tract infections which often increased her behavioral issues. Review of R2's care plan dated 5/15/23 revealed R2 had a red area on her back related to a fall. Review of R2's activity of daily living care plan created on 2/14/23 revealed R2 required assist of 2 people for bed mobility, and a back brace on, as of 5/8/23 R2 was no longer able to walk, required assistance of 2 people for dressing, required staff assistance with toilet use; as of 5/25/23 R2 was not able to use a toilet and required a bed pan with assist of 2 people. On 2/15/23 R2 was independent feeding herself and as of 5/25/23 R2 was totally dependent for feeding. Review of R2's fall care plan initiated on 2/14/23 and last revision on 5/26/23 revealed R2 sustained the following injuries related to falls, compression fractures of L 3 and 5, T11 and T12. R2 was known to self-transfer and did not ask for assistance to get out of her wheelchair or bed. Review of the interventions revealed no information on how the facility planned to supervise R2 when she was awake due to knowing R2 would try to self-transfer and had sustained multiple injuries from self-transferring. Review of R2's, Minimum Date Set (MDS), a nursing assessment, dated 2/20/23, section G revealed R2 required extensive assistance of 1 person for bed mobility, extensive assistance of 2 people for transfers, R2 did not walk in the last 7 days, and required extensive assistance of 1 person to use the toilet. Review of R2's, Minimum Date Set (MDS), a nursing assessment, dated 5/5/23, section G revealed R2 required extensive assistance of 1 person for bed mobility, extensive assistance of 2 people for transfers, did not walk in the last 7 days, and required extensive assistance of 2 people for toilet use. Review of the facility fall timeline for R2, provided by the Director of Nursing (DON) on 8/23/23 at 5:26 PM, revealed R2 had 11 falls from 12/15/23 to 5/21/23. The causes of the falls included unsafe transfers (no indication of being assisted when transfers resulted in falls), weakness, independent toilet use (no indication she was assisted when falls occurred in bathrooms. Interventions did not include any increased supervision except for 2 occasions. During an interview with the Director of Nursing (DON) and Unit Manager F on 8/25/23 at 8:45 AM, R2's fall timeline provided by the DON was reviewed. The DON and UM F confirmed R2 required physical assistance with all of her activities of daily living, R2 was not her own responsible party, R2 did not have any safety awareness and had repeated falls with injuries throughout her stay in the facility. The DON and UM F confirmed they only implemented interventions to attempt to supervise R2 after two of her halls. The DON and UM F denied any process of assessing the safety interventions placed for effectiveness. The DON denied any tracking of unsafe behaviors like self-transferring. The DON denied any assessments being completed for toilet needs, wake or sleep cycles. The DON and UM F confirmed they did not place any interventions that required staff to supervise R2 while awake. Review of R2's incident and accident report dated 5/21/23 at 9:20 AM, revealed Licensed Practical Nurse (LPN) C completed the incident report. The report indicated R2 had an unwitnessed fall in the hall. R2 was found on her stomach with her legs extended, left arm to side of body and right arm under her chest. R2's wheelchair was near her feet, and it was facing the door. R2 reported she hit her head and she had a red area in the center of her forehead. R2 reported she was bending over to pick something up when she fell out of her wheelchair. The following injuries listed, 1) reddened skin right knee, 2. injury right palm unable to determine, 3. Redden skin face. R2's wheelchair brakes were not locked, she was confused, had impaired memory. Review of R2's, Post Fall Evaluation, dated 5/21/23 at 9:20 AM, revealed she had an unwitnessed fall when she tried to pick stuff up and was found lying in the hall on her stomach with her legs extended, left arm to the side of her body and right arm under her chest. Three hours before the fall R2 received her morning care, ate breakfast and was out socializing in the hallway. The intervention to prevent falls listed that R2 was sent to the emergency room for evaluation and treatment. During a telephone interview with LPN C on 8/23/23, LPN C was provided the documentation she placed on R2's incident and accident report on 5/21/23. LPN C recalled R2 had multiple falls while in the facility and they all tried to keep an eye on her. LPN C said she would try to keep R2 with her at the medication cart while she passed medication. LPN C said she could not take R2 into residents' rooms and she had 24 other residents to care for that day. LPN C recalled seeing R2 in the hall moving about in her wheelchair independently. LPN C said she normally works with Certified Nurse Aides (CNA's) D and E on Sundays and could not recall what the CNA's were doing at the time of the fall. LPN C said the facility does not have any program in place to supervise their wandering residents with poor safety awareness. LPN C said we just to our best to monitor their location while we provide care. Review of R2's hospital emergency room report dated 5/21/23 revealed R2 fell in the nursing home and sustained cervical cord compression injury with myelopathy (compression of the nerves in the neck causing loss of movement and pain). R2 was admitted to the hospital for observation and was discharge back to the facility on [DATE]. Review of R2's emergency room report dated 5/25/23 at 12:29 AM revealed R2 was admitted back to the hospital after being discharge back to the facility on [DATE]. R2 was coughing and vomiting. R2 was in a neck collar. R2's fall on 5/21/23 resulted in a C3/4-disc displacement that resulted in loss of movement and weakness in all 4 extremities. R2 was admitted and had neurological work ups. It was determined R2 was not a surgical candidate and due her poor prognosis she was place on palliative care. Review of hospital physician note dated 5/31/23 at 7:46 AM revealed, R2 passed away and was pronounced dead per nursing protocol. All records related to R2's falls was requested on 8/23/23 at 12:16 PM. There was no indication which staff were working at the time of R2's falls other than the incident report generated by LPN C. There were no interviews of staff provided. Telephone calls were made to contact CNA D and E to confirm whether they provided care for R2 on 5/21/23 when she fell , and CNA D and E did not return telephone calls. Timeline of falls indicated: Review of R2's incident and accident report dated 5/13/23 at 21:10 (9:10 PM) revealed R2 was in another resident's room attempting to use the toilet and an unknown CNA witnessed R2 slide off a shower chair. R2 sustained a 3 cm x 4 cm red area to her right upper back. R2 had been observed 10 minutes prior to the fall in a hallway. R2 refused assistance to use the toilet at 19:34 (8:34 PM). R2 had been talking about going home since 18:00 (6:00 PM). Review of the Post Fall Evaluation for R2 dated 5/13/23 at 9:10 PM, revealed, R2 self-transferred in another resident's bathroom and fell back on a shower chair. R2 had been wandering and talking about going home since 6:00 PM. R2 was assisted back to her room several times. The intervention placed post fall was to offer R2 assistance with toilet use after supper. (staff did encourage R2 to use the toilet prior to this on 5/13/23 and it was not successful at stopping this fall). Review of R2's incident and accident report dated 5/10/23 at 17:35 (5:45 PM) revealed R2 had an unwitnessed fall in her bathroom and was found by a social services employee. An unknown CNA assisted R2 back into her wheelchair. The report indicated R2 was walking without assistance and has problems with balance. There was no indication of an assessment or injuries. Review of R2's, Post Fall Evaluation dated 5/10/23 at 17:45 (5:45 PM), revealed R2 had an unwitnessed fall in her bathroom. R2 had last been observed at 17:15 (5:15 PM). R2 was her normal self that day. Review of R2's incident and accident report dated 4/30/23 at 23:40 (11:40 PM) revealed, R2 had an observed fall in her room. R2 was found on the floor on her left side in front of her wheelchair that was about 3 feet from R2's bed. R2 said she was trying to straighten up the blankets on her bed. The immediate action taken was to monitor for signs and symptoms of a urinary tract infection (UTI). The report revealed R2 frequently self-transfers, and they put her back brace in R2's chair to encourage her to use it when she gets up. The report indicated R2 was confused, had impaired memory and had a recent change in cognition. There was not assessment or indication of any injury. Review of R2's, Post Fall Evaluation dated 4/30/23 at 23:40 (11:40 PM) revealed R2 had an unobserved fall in her room. R2 was confused and this was her normal mental status. R2 was assisted to the toilet at 11:00 PM and was observed in bed around 11:20 PM. They were going to continue to monitor for signs and symptoms of a UTI, there was no indication of any injury. No new interventions to increase supervision or assistance were located. Review of R2's Post Fall Evaluation, dated 3/31/23 at 14:40 (2:40 PM) revealed, R2 self-transferred and slipped out of her wheelchair. Root cause of the fall with abnormal vital signs, amount of assistance in effect and medical status/physical condition/Diagnoses, no intervention to increase supervision or assistance were located. Review of R2's Post Fall Evaluation, dated 3/10/23 at 1:40 AM revealed, R2 had an unwitnessed fall in her room. R2 was found on the floor and her wheelchair brakes were not locked. R2 was observed up in her room [ROOM NUMBER] minutes prior to the fall rummaging through her drawer. The root cause of the fall was mood or mental status. No intervention to increase supervision or assistance was located. New interventions were dycem (equipment in seat of wheelchair to prevent sliding) and anti-rollbacks (self-applying wheelchair brakes). Review of R2's Post Fall Evaluation, dated 2/9/23 at 4:30 PM revealed, R2 had an unwitnessed fall in her bathroom when she self-transferred. R2 was sent to the emergency room for evaluation. The root cause was environmental factors/items out of reach. No interventions to increase supervision or assistance were located. The only intervention listed was to remove a shelving unit. Review of R2's Post Fall Evaluation dated 12/28/22 r 9:15 PM, revealed, R2 had an unwitnessed fall in her room attempting to self-transfer, R2 was seen 30 minutes prior to the fall, the root cause was medical status/Physical condition/Diagnoses and mood or mental status. The intervention was to move her room closer to the nurse's station. Review of R2's Post Fall Evaluation dated 12/25/22, at 8:36 AM, revealed R2 had an unobserved fall in her room attempting to self-transfer the root cause was medical status/Physical condition/Diagnoses. No intervention to increase supervision or assistance was located. Interventions listed were sent to the emergency room and continue to treat for a urinary tract infection. Review of R2's Post Fall Evaluation dated 12/15/22 at 7:55 PM, revealed R2 had an unwitnessed fall in her room when she was walking independently. R2 was known to have increased confusion for the last 2 days and her oxygen levels were in the 80's. The root cause was medical status/Physical condition/Diagnoses. No intervention to increase supervision or assistance was located. The interventions listed were applied oxygen, sent to emergency room and assist with transfers. Review of R2's Post Fall Evaluation dated 12/15/22 at 3:45 PM, revealed R2 had an unwitnessed fall in the bathroom when she self-transferred to the toilet. No root cause was provided. No intervention to provide increased supervision or assistance was located. The intervention was to change out the toilet riser. Resident (R4) Review of R4's face sheet dated 8/23/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: difficulty in walking, weakness, need for assistance with personal care, fracture of the 4th cervical vertebra, dementia, and history of falling. R4 was not her own responsible party. Review of R4's fall timeline provided by the Director of Nursing (DON) on 8/24/23 at 3:14 PM, revealed R4 had 3 falls in the last 5 months. The fall on 4/12/23 was caused by a medication, the fall on 4/17/23 was caused by R4 not using her walker and loss of balance and the fall on 8/8/23 was caused by a seizure. Review of R4's fall care plan dated revision on 6/7/23 revealed, R4 was a risk for falls related to a C4 fracture, unsteadiness prior to admission, weakness, decreased mobility, poor safety awareness, anemia, and dementia. Interventions did not include how R4 was to be supervised when she was awake. Review of R4's activities of daily living (ADL) care plan dated revision on 6/7/23 revealed R4 required physical assistance of one person for transfers as of 6/7/23. R4 required physical assistance of one person with a rolling walker for walking as of 6/7/23 and revision on 8/24/23. R4 was listed as being independent with toilet use as of 6/7/23 and revision on 6/12/23. R4 was observed in her room in a lazy boy style chair on 8/23/23 at 3:00 PM, R4's eyes were closed and she did not respond to calling her name. There were no staff visible in the hall and no staff in R4's room. R4 was not supervised at this time. Review of R4's Physical Therapy Evaluation dated 4/19/23 revealed, Patient referred to PT (physical therapy) due to exacerbation of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced functional activity tolerance, reduced static and dynamic balance and increased need for assistance form others indicating the need for PT to assess functional abilities, increase independence with gait, facilitate (l) with all functional mobility, promote safety awareness, enhance rehab potential, improve dynamic balance, increase functional activity tolerance, increase LE (lower extremity) ROM (range of motion), and strength and facilitate discharge planning. Review of R4's Post Fall Evaluation, dated 4/12/23 at 12:00 PM revealed, R4 had an unobserved fall in her room, she was found in front of her recliner. The hall huddle note revealed, R4 grabbed her wheelchair instead of her walker when she got up despite the walker being in reach. The root cause of the fall was vital signs abnormal or significant, blood pressure increased and medication. No intervention to increase supervision was noted. The only intervention was to have the one of R4's medications evaluated. Review of R4's Post Fall Evaluation, dated 4/17/23 at 18:30 (6:30 PM) revealed, R4 had an unwitnessed fall in her room. R4 was care planned to be independent with transfers and was self-transferring. The fall huddle revealed, Resident ambulating with out walker in room, causing her to lose her balance. The root cause was mood or mental status. No intervention to increase supervision or assistance with located the intervention was to have physical therapy evaluate and obtain labs/clinical evaluation. Review of R4's Post Fall Evaluation dated 8/8/23 at 7:37 AM revealed, R4 had a fall in her room that was observed by R4's roommate. The root cause was seizure activity. Intervention was to provided physical assist of one person for transfers. No intervention was located to indicate how the facility was going to supervise R4 to ensure she received assistance with transfers. During an interview with Unit Manager, Registered Nurse G on 8/25/23 at 10:25 AM, UM G confirmed R4 had 3 falls in the last 5 months, and R4 cannot remember to use her call light for assistance. R4 was assessed to need assistance with walking and transfers. R4 spends most of her time in her room and has continued to self-transfer and walk without assistance. UM G said they do not track her unsafe behaviors like walking and self-transferring. UM G denied doing any wake/sleep pattering or assessments for toileting needs. UM G denied implementing any increased supervision and assistance for R4. UM G denied any ongoing assessment of new interventions to prevent falls. UM G said the care plan for falls is addressed post fall and quarterly.

Based on observation, interview and record review, the facility failed to implement appropriate infection control practices to prevent or mitigate the spread of COVID-19 by (1) Not donning and doffing Personal Protective Equipment (PPE) before/after entering COVID isolation rooms, (2) Not utilizing hand hygiene, (3) Failing to contain meal trays from COVID-19 isolations rooms, (4) Not containing lab test vials from a COVID-positive resident while transporting the specimen, (5) Failing to update COVID education and infection control training for staff, and (6) the timely notification of COVID- positive residents to the local health department during a COVID-19 outbreak in the facility that began on 05/03/2022, when the first staff member tested positive for COVID-19 and on 05/09/2022 when the first resident tested positive for COVID-19, resulting in an Immediate Jeopardy when on 05/09/2022 the first resident tested positive for COVID and 26 more residents followed by 05/16/2022. This deficient practice placed all 86 residents at risk for serious harm, injury, and/or death. Findings include: During an interview on 05/16/22 at 10:20 AM, the Administrator (ADM) reported that there were positive cases of Covid 19, among staff and residents, in the facility, and the exact number was unknown at that time. The ADM also indicated that the minimum PPE required throughout the facility was surgical masks and eye protection (unless staff were in an isolation room, then staff followed directions on the signs for what PPE (personal protection equipment) was indicated. During an observation on 05/16/22 at 10:32 AM, staff (OTR/L) V stood in room [ROOM NUMBER] on the A hall, communicating with a resident in the bed closest to the hall. The door to room [ROOM NUMBER] had signage that instructed staff to wear PPE necessary for droplet precautions and a PPE tower stood outside room [ROOM NUMBER]. Staff V had on a surgical mask, no eye protection, gloves or gown. When asked if PPE for an isolation room was required to be in room [ROOM NUMBER], staff V indicated that neither of the residents listed as being in room [ROOM NUMBER] were actually residing in room [ROOM NUMBER], that several room changes were being made and that it's hard to know what's what right now. During an observation on 05/16/22 at 10:40 AM, room [ROOM NUMBER] on the A hall had signage to alert staff that the room was an isolation room, and the door was open. During an observation on 05/16/22 at 10:42 AM, room [ROOM NUMBER] on the A hall had signage to alert staff that the room was an isolation room, and the door was open. During an observation on 05/16/22 at 10:49 AM, staff exited room [ROOM NUMBER] (an isolation room) with a vitals cart, did not wipe the vitals cart down, and entered room [ROOM NUMBER] (not an isolation room) and assessed the vitals for residents in that room. During an observation on 05/16/22 at 10:52 AM, housekeeping exited room [ROOM NUMBER] (an isolation room) with a gown on backwards (opened in the front) and continued down the hall with the gown on. During an observation on 5/16/22 at 3:05 p.m. on the B hall, staff informed this surveyor all the residents in the hall were in COVID isolation except for the residents in rooms [ROOM NUMBERS]. There were two PPE stations in the hallway. The PPE station at the end of the hallway did not have hand sanitizer on it. The hallway consisted of a couple wall mounted hand sanitizer stations. At this time Licensed Practical Nurse (LPN) D exited a COVID positive room (room [ROOM NUMBER]) wearing a disposable gown and doffed (removed) in the hallway disposing it in the trash bin. A minute later Patient Care Assistant (PCA) O exited a COVID positive room at the other end of the hallway with a disposable gown on carrying a meal tray, placed the meal tray on top of the PPE station in the hallway, doffed the gown, cleaned the face shield, then carried the uncovered meal tray through to the other end of the hall, off the unit, to the kitchen. No hand hygiene was observed. A few minutes later, PCA O re-entered the B hall and went directly into room [ROOM NUMBER] (two COVID negative residents) and assisted both residents while in the room. During an observation and interview on 5/16/22 at 3:22 p.m., LPN D exited from room [ROOM NUMBER] (a COVID positive room) wearing the same disposable gown, carrying a COVID PCR (nose swab test) test tube that was just obtained from a resident who tested positive via COVID rapid test earlier that morning, and placed the test tube on top of the PPE station in the hallway next to a box of clean masks and gloves. When queried about a barrier for the test tube, LPN D reported the tube was not touching anything nearby then grabbed a sanitizing wipe, picked up the test tube with the sanitizing wipe, cleaned the area where the test tube was resting and placed the test tube on top of the same sanitizing wipe. When asked if this was their normal practice after obtaining a nasal swab test, LPN D reported earlier they utilized a cart that went down the hallway with them while doing the rapid COVID testing. In an interview on 5/16/22 at 3:25 p.m., PCA O confirmed there was no hand sanitizer on the PPE station at the end of the hall to perform hand hygiene after exiting the COVID positive room with the meal tray and confirmed not performing hand hygiene after exiting the residents room. PCA O reported the kitchen was just around the corner and that the meal tray was placed on an open cart outside of the kitchen. During an interview and record review on 5/17/22 at 9:00 a.m., Infection Control Nurse (RN C) reported that as of this day, the B hall will be a dedicated COVID unit and have dedicated staff. There were COVID positive residents spread out on the A hall, B hall and the North Wing. The first COVID staff member (Staff #1) in the building was on 5/3/22 and was fully vaccinated. On 5/9/22 the first fully vaccinated resident tested positive for COVID. At the time of this interview there were a total of 26 COVID positive residents who were all fully vaccinated and 22 staff who were fully vaccinated. RN C reported being in contact with the Health Department but there were a few days of no contact because of email technical difficulties. Staff #1 provided care for a specific set of residents who tested negative for COVID until later. The facility has been in contact with the health department via email on 5/4/22 informing them that one staff member at that time tested positive for COVID. The first resident (Resident #1) who contracted COVID on 5/9/22 resided on the B hall and was traced back to the dietary staff (tested positive on 5/6/22 and fully vaccinated) and the secretary (tested positive 5/6/22 and fully vaccinated) who he visited every day. He was immediately moved from the B hall to the North Wing in a private room. Two more residents tested positive on 5/10/22 and 5/11/22 and were moved to a shared room together on the B hall. On 5/12/22 (Thursday), nine more residents tested positive. When queried about COVID-19 and infection control education for staff, RN C reported the facility provides education sometimes by putting information in staff paycheck envelopes and utilizes the call out system that sends information directly to their cell phones and emails. RN C reported she will educate staff members on the spot if she sees a concern. RN C could not provide any documentation that covered COVID and infection control education for staff for within the last year except for recently hired staff. RN C reported staff complete infection control education upon hire and utilizes a computer-based education. She reported she does audits for infection control but has no documentation to show it. RN C later provided a list of computer-based education that revealed many staff had not received infection control education since 2/2021.RN C reported she expects staff to take off their gloves and disposable gown before leaving a COVID positive isolation room, hand sanitize, take off their face shield and clean it, then take off the N95 mask and get a fresh one while waiting for their shield to dry before going into another room. The facility is changing the way they transport laundry starting this day as she reported they were in the process of converting the B hall into a COVID unit. RN C expects used meal trays to be placed in an enclosed cart when transporting back to the kitchen. As of this day, the dining services were switching to disposable eatery. RN C reported that after the collection of a lab including a nasal swab specimen, the tube should be place in a biohazard bag immediately and before transporting it out of a resident room. This log was to be emailed to this surveyor and it was not, and the paper copy was not returned. Review of a list of COVID-19 positive residents document dated 5/5/22 to 5/16/22 listed residents who tested positive for COVID-19 on the following dates: 5/9/22 one resident, 5/10/22 one resident, 5/11/22 one resident, 5/12/22 nine residents, 5/13/22 three residents, 5/14/22 three residents, 5/15/22 three residents, and 5/16/22 six residents. All these residents were on the A, B, or C halls with a total of 27 COVID positive residents. Review of a list of COVID -19 positive staff document dated 5/3/22 to 5/16/22 listed staff who tested positive for COVID-19 almost every day until 5/16/22 with a total of 22 staff. Review of email correspondence provided by RN C revealed contact with the Health Department on 5/4/22 to inform them of the first staff member who tested positive for COVID-19. The next email dated 5/11/22 revealed RN C communicated to the Health Department that the email was out of commission for a few days and now had a total of nine staff and three residents positive for COVID-19. On 5/16/22 the next email to the Health Department was to inform them the facility now had a total of twenty-six residents with one death and six more staff who tested positive. During an interview on 5/18/22 at 11:12 p.m., the Health Department Registered Nurse (RN) T reported the facility has not been clearly and timely communicating all the new COVID positive residents with her. On 5/4/22 she was notified by the Nursing Facility of a staff member who tested positive and has not heard from the facility until 5/17/22 when they told her more staff and residents had tested positive for COVID. The facility reported they were going to initiate a COVID unit. RN T reported the Health Department requests notification of any new COVID positive staff and residents in the building so they can ensure appropriate interventions. Review of the Facility Assessment signed 1/12/22 revealed: 82. The facility Infection Prevention and Control Program investigates, controls, identifies, and reports infections in the facility, Preventative ensures include regular staff training on current practices and CDC definitions of infections . Resident and staff infections are monitored for the presence of trends that could possibly relate to infection control practices and to determine if additional training is needed. Clinical observations are performed to assure compliance with policies and standards of practice. Review of a Policy titled Coronavirus (COVID 19) last revised 4/18/22 revealed: Appropriate measures will be utilized for the prevention and control of the Coronavirus (COVID 19). The incubation period is two to fourteen (2-14) days, with the average being four (4) to five (5) days, this virus may be mild, moderate, or severe, and can be potentially life threatening. Mode of Transmission: Person to person spread. Spread from contact with contaminated surfaces or objects. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Core Principals of COVID-19 Prevention: . Hand hygiene (use of alcohol-based hand rub is preferred). Face covering or mask for guest/resident (covering mouth and nose) and physical distancing at least six feet between persons, in accordance with CDC guidelines. Instructional signage throughout the facility . Appropriate staff use of Personal Protective Equipment (PPE). Effective co-horting of guests/residents (e.g., separate areas dedicated COVID-19 care). Managing guests/resident with suspected or confirmed [CONDITION(S)]-CoV-2 infection: .Place a guest/resident with suspected or confirmed COVID 19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, in some circumstances (e.g., memory care units), keeping the door closed may pose guest/resident safety risks and the door might need to remain open. If the guest/resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 unit. HCP (healthcare providers) caring for guests/residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gown, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). COVID-19 Unit: A COVID-19 Unit may be created in the facility to reduce the risk of transmission of the COVID-19 virus. The COVID unit may have a vestibule (if allowed) which will provide an identified transition area to the unit. The unit will have a designated location for entering and exiting. The vestibule kit (if allowed) will provide a measure to decrease potential for transmission to other areas of the facility, along with providing a clearly identified transition area between isolation and non-isolation areas. The unit should have dedicated staff that do not enter other areas of the facility. Meal Service to the unit will have a dedicated, closed cart. Review of the Centers for Disease Control and Prevention (CDC) guidelines (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) last updated 2/2/2022 included but not limited to Recommended routine infection prevention and control (IPC) practices during the COVID -19 pandemic: Establish a Process to Identify and Manage Individuals with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection. Ensure everyone is aware of recommended IPC practices in the facility. Implement Source Control Measures. Optimize the Use of Engineering Controls and Indoor Air Quality. Review of the Centers for Disease Control and Prevention (CDC) guidelines (https://www.cdc.gov/coronavirus/2019-ncov/community/ventilation.html) last updated 6/2/21 revealed: CDC recommends a layered approach to reduce exposures to [CONDITION(S)]-CoV-2, the virus that causes COVID-19. This approach includes using multiple mitigation strategies, including improvements to building ventilation, to reduce the spread of disease and lower the risk of exposure. In addition to ventilation improvements, the layered approach includes physical distancing, wearing face masks, hand hygiene, and vaccination. On 5/17/22, the Administrator was verbally notified and received written notification of the immediate jeopardy that was identified on 5/17/22 and began on 5/9/22, due to the facility's failure to implement appropriate infection control practices. On 5/18/22 the surveyor verified the following interventions were put into place and were effective to remove the immediacy: Event: COVID Outbreak ELEMENT 1 RESIDENTS AT RISK: (27) Residents that are currently Covid + out of a census of 86. ELEMENT 2 IDENTIFYING OTHER RESIDENTS AT RISK: All 86 Residents who reside at the facility. ELEMENT 3 PROCESS IMPLEMENTED TO PREVENT FURTHER OCCURRENCE: Systemic Measures: Doffing PPE in the hallway outside of a Covid + room with Covid - residents living on the hallway. SDC, IC Nurse completed a training in service for all staff on 05/17/22 to be sent out @ 1800 via One-Call. In the one call the staff were re-in serviced on donning and doffing and instructed that doffing cannot take place in the hallway. Failing to perform hand hygiene before and after leaving a Covid + room and removing potentially contaminated PPE in the hallway. SDC, IC Nurse completed a training in service for all staff on 05/17/22 to be sent out @ 1800 via One-Call. Staff were reminded in this call about handwashing before and after entering and exiting a resident room. Failing to clearly identify rooms that required droplet precaution measures. SDC, IC Nurse completed a training in service for all staff on 05/17/22 to be sent out @ 1800 via One-Call. Audit has been started on the AM of 05/18/22 of all resident room doors to ensure appropriate name plate is present and signage is in place. Staff were also in serviced on following the signage that is posted on the door to ensure proper precautions are maintained. Failing to correctly wear masks and face shields. SDC, IC Nurse completed a training in service for all staff on 05/17/22 to be sent out @ 1800 via One-Call. Staff were reminded that masks need to cover mouth and nose, and that shields must be worn in all resident care areas. ELEMENT 4 MONITORING Quality Assurance: An Ad HOC Meeting was held with the Medical Director via CC and the IDT Team to review the Covid-19 policy and procedures on Droplet Precautions, PPE, Handwashing, Door Signage and Donning and Doffing. The administrative nurses will complete weekly audits of handwashing, donning and doffing, appropriate PPE wearing and identification of droplet precaution rooms. Audits will be completed weekly x4, then monthly x3. Results of audits will be reviewed at monthly QAPI meeting. The Director of Nursing and NHA are responsible for sustained compliance Date of compliance is 05/18/22 Although the immediate jeopardy was removed on 5/18/22, the facility remained out of compliance at a pattern that is no actual harm but the potential for harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency

This citation pertains to intakes: MI 371, MI 416, MI 110, MI 319, MI 519, MI 751, MI 448, MI 801, and MI 375 Based on observation, interview, and record review, the facility failed to investigate abuse for 2 Residents (R30 and R 33) of 15 Residents reviewed for abuse, resulting in 2 Residents (R30 and R33) having injuries of unknown origin and not investigated thoroughly to determine the causes of the injuries. This deficient practice resulted in an immediate jeopardy when R30 presented with suspicious deep purple bruising to the upper torso and facility staff failed to investigate and determine cause and again when staff failed to properly identify causes and investigate for R33's suspicious bruises to bottom and inner thigh. This deficient practice places all facility residents at risk for serious harm, injury, and/or death. R 30 Review of R30's face sheet dated 1/29/21 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnose that included: fracture of left pubis (pelvic fracture), anxiety disorder, major depressive disorder, mild cognitive impairment, muscle weakness, difficulty walking, need for assistance with personal care and history of falling. R30 was not her own responsible party according to her face sheet and had a Brief Interview of Mental Status (BIMS) score of 2 (severely mentally impaired) dated 10/8/20. Review of R30's Quality Assurance Interview Summary, dated 10/6/20, at unknown time revealed, under summary of Resident interview, When asked pt (patient) stated, I rolled out of bed. How did you get up? I got myself up. Interview summary for RN FF no date, revealed, Saw pt (patient) between 3-4 pm, 10/6 it was light like smudged make up? Pt (patient) was sitting in recliner by window. Asked pt what happened and pt just smiled at, remarked about (unable to read) on floor. No incidents reported to nurse by cna or during shift report in am or by therapy during the day. Saw pt again @5:30p to answer light Did not notice bruise. There was an interview done at an unknown date and this with only a first name provided. This interview revealed, walked in to remove dinner tray after report observed black eye and notified nurse at that time. Review of R30's Incident and Accident Investigation Form, dated 10/6/20 at 6:00 PM, revealed, R30 had bruising noted surrounding her right eye. This was reported by CNA that was not named at 7:15 PM on 10/6/20. CNA GG and HH were listed as interviewed but no interview for CNA's were found in this report. The conclusion revealed, Patient has hx (history) of frequent falls at home which recently resulted in multiple pelvic fractures. She was noted to have new bruising surrounding her right eye. Was questioned, the pt consistent, states she fell out of bed. Plan to avoid this situation in the future revealed, offer toileting every 2 hours. Noted intervention is typical standard of care. Review of R30's physician assistant note dated 10/6/20 at 5:09 PM revealed, HPI: [AGE] year-old female admitted to this facility for continued medical management and physical rehabilitation following a fall at home with pelvic fracture. Patient is a poor historian due to dementia an unable to articulate any symptoms. Review of R30's progress notes for 10/6/20 reveal no indication of an injury to her face or any information about a fall. Review of R30's progress noted dated 10/7/20 at 12:40 AM revealed, Was notified by CNA at 6:15 PM that pt (patient) had what appeared to be a black eye. No report had been received regarding pt having had a fall or near fall from previous shift. Spoke with off going nurse who reported that pt had had no reported or observed falls since admission. Upon assessment of pt noted pt to have abrasion over R (right) eye and deep purple linear bruise at corner of eye with faint purple above and below eye. When pt questioned as to what happened pt stated I rolled out of bed when asked if pt was helped up pt stated I got myself up. Neuro assessments initiated ADON notified. This review revealed no documentation showing R30's responsible party or physician were notified of this unwitnessed injury to R30's eye. Review of the facility timeline provided by the ADON revealed, CNA HH observed R30's bruise on her right forehead and eye and immediately reported this this to RN II. The facility incident report and the Quality Assurance Interview Summary did not include this information. ADON documented she received report from RN II on 10/6/20 at 7:15 PM about the bruise/abrasion on R30's right forehead and RN II reported she fell and got herself off the floor. According to the timeline 10/7/20 at 8:00 AM, the ADON interviewed R30 and she informed the ADON she had fallen out of bed. The BIMS was completed two days later on 10/8/20. The Nurse Practitioner had documented on 10/6/20 that R30 was alert and oriented but slow to respond. The Nursing Home Administrator (NHA) was asked on 2/9/21 if this was an injury of unknown origin and the NHA responded, No, she fell . Review of R30's, Incident and Accident Report dated 10/13/20 at 3:00 PM, revealed R30 was found on the floor between her recliner and wheelchair. The call light went on just prior to the aide entering the room. R30 sustained a skin tear to her left forearm (no size noted). Interventions implemented revealed, Resident has frequency of urination. New order put in today to PRV (bladder scan). Offer other seating/lay down after toileting. Skin tear Lt forearm/steri strip cover [MEDICATION(S)]. According to CNA AA interview, Resident was toiled and layed (sp) down and PRV (bladder scan) 20 minutes prior to fall. According to CNA X interview, Call light in recliner on. Shoes in place. Resident toileted 20 min prior, wanted back into recliner. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . It was not clear if R30 was left in her wheelchair when she was taken to the bathroom [ROOM NUMBER] minutes prior to the fall or if she was in her recliner. There was no documentation of increased supervision, assistance, or new interventions located in response to this fall. Review of R30's, Incident and Accident Report dated 10/22/20 at 10:15 AM revealed, Family brought to nurse attention bruising on left shoulder radiating down toward left breast. Injury was 23 cm x 24 cm to left neck, shoulder flank area and breast. Injury was reported to the physician at 11:15 am and recommended family take patient to the emergency room for evaluation. Resident discharged at time of report. CNA K's interview revealed, Resident had complained of left shoulder pain and requested ice. Charge nurse notified. Was sleeping in pajamas, was sleeping in pajamas at end of shift. Resident was seen self-transferring two times during the evening. Put to bed after wheel of fortune. Put PJ top before, she had taken off her shirt & touching her breasts. Took to bathroom several times. Calls for help multiple times to go to bathroom. Doesn't always go. Asked for ice said she hurt kept saying sh (sp) neck. On rib cage was pink. Had a lot of bruises form her previous falls. Review of LPN H summary revealed, Patient did not verbalize any complaints, did not observe any bruising or falls for evening. Gave meds about 7:30 -8 pm. Was in w/c - was getting ready to in into bathroom was wearing a long sleaved shirt. Later in evening, adm (administered) TB test to R (right) forearm. Asked how she was doing, pt smiled & did not respond. Name of CNA X approached (name of LPN H) during the night saying pt had asked for ice & that CNA X. (the sentence ended without any addition information.) Review of CNA E interview revealed, Got resident up at 7 am. Bruising to neck and shoulder left noted. Dress resident, no complaints of pain and had full ROM. No indication CNA E reported this new bruise. Review of RN F interview revealed, discharged pt approx (approximately) 10:15 AM. CNA took pt to entrance where son-in-law and dtr (daughter) were waiting. RN F was obtaining dtr signature to release of medications. Went back to station then staff stated dtr had concern of a bruise. Dtr said to nurse, How come I was not notified my mother fell . Then dtr asked pt if she had fallen & pt said yes. Then asked if she fell last night & pt again said yes. Name of RN F told dtr he was not aware of a fall but would go check the chart. There was no documentation in the chart to indicate pt had fallen the previous night. Had 2nd nurse also look at bruise as well. Family asked if they should go to the ER. RN F checked ROM (range of motion) which pt had full ROM to L (left) shoulder. Asked if it hurt, stated no. Did not note any swelling, only bruising. The report conclusion revealed, Patient had an unwitnessed & unreported (to staff) fall resulting in the bruising. Was taking [MEDICATION(S)] 15 mg (medication) daily, which is a NSAID (type of medication category) and can exacerbate bruising. Pt was already discharged to home when nursing was made aware of the bruising. Review of R30's Quality Assurance Interview Summary dated 10/22/20 revealed CNA K's interview, No way she fell because we check her room routinely - every time we pass her room, we lay eyes on her. She likes to get out of bed, so we make it a habit to check her every time we go by. Every time she asks for the toilet even if we just took her, we take her again. Kept switching the ice pack from side to side. Never saw her on the floor stayed in bed except for toileting. Often saw her sitting at edge of bed so they would go into the room and ask her what she was doing. She would always say hi, I love you, I have to go to the bathroom. CNA E interview revealed, Escorted pt in w/c wheelchair from nurses' station to north entrance, then outside to vehicle. Pt then put herself into the front passenger seat by herself. CNA E then buckled up the pts seat belt. Never mentioned pain at all. Did not fall this morning. In AM, saw the old ice pack & towel laying on the bed. She is very confused. Review of the ADON's typed note for R30 dated 10/22/20 revealed, R30's family member came to the facility with photo's the family took of her bruises. I saw a large amount of bruising to the left neck, radiating over her left shoulder, down towards her left breast. The bruising appeared to be a striation pattern on the neck & shoulder area and was a multitude of colors from bluish purple to red to light green. He also showed me a photo of a large bruise on her left flank area. I immediately drew a conclusion she had most likely fallen on something such as an arm of a wheelchair or an assist bar to cause this shape of a bruise. [Name of family member] and I both concluded she had probably fallen, landing on her back, then to her left side, causing the bruising on her left shoulder. He also showed me a photo of a bruise on her leg, which appeared to be near the back of her knee. I was able to clearly see this photo. In the photo, R30's left elbow and forearm were wrapped with [MEDICATION(S)]. According to her records, she had a skin tear in this area from a previous fall. Review of the ADON's typed report, dated 10/28/20, revealed the ADON received a call from the police department about R30. The officer asked about R30's bruise under her eye and the ADON replied no to knowing anything about this bruise. The ADON did say she spoke to the family about a large bruise on R30's neck, shoulder and breast area while she was sitting in their vehicle. The officer informed the ADON he was looking at the facility documentation and she had a fall on 10/14/20 and the family was concerned because they were not informed of that fall. ADON reviewed the notes and informed him the note he saw was a review of the fall that had occurred on 10/13/20. The ADON informed the officer that R30 had two falls prior to finding the bruises on 10/22/20. The officer asked the ADON if she had seen the bruises and found the bruising concerning and she replied, Yes I did. The ADON said she completed a thorough investigation. Staff adamantly denied the patient knowingly fell . The ADON told the officer that the family member that showed the pictures agreed with her that the bruises were a result of her falling. The officer said (TO WHOM - is this your interview or theirs or part of report) R30 had two injuries of unknown origin (facility concluded were falls -did officer say this) and one known fall from 10/2/20 admission to 10/22/20. Review of R30's nursing progress note dated 10/22/20 at 10:15 AM revealed, At 10:15 AM after patient discharged to vehicle, daughter noted bruising to left shoulder. This nurse went to patient in vehicle and assessed the area. Daughter asked why she was not notified that her mother had fallen, and the nurse replied that was not aware of a fall. Daughter questioned resident if she had fallen, resident stated she had. Assessed resident range of motion. Resident had full range of motion to left arm and denied pain. Informed family will investigate and reach out to them when more information is available. Review of R30's Risk note dated 10/22/20 at 10:15 AM revealed, Review Clinical Indicator: At time of discharge, family noted patient had a dark purple, reddish and green discoloration to her left neck/shoulder area radiating down toward her breast, approximately 23 cm x 24 cm. The family immediately notified the Charge Nurse, name of charge nurse. The note goes on to give some information related to the investigation and staff interviews. After Response to previous Actions revealed, Patient is a poor historian r/t (related to) confusion, Dementia and is often non-verbal when spoke to. Patient does transfer herself frequently. It is most likely the patient did transfer herself during the night, fell then got herself off the floor. During an interview with CNA E on 2/4/21 at 10:38 AM., CNA E reviewed the investigation summaries that were provided related to R30's injuries that were found on 10/22/20. CNA E confirmed she saw the massive bruises on R30's left chest, shoulder and back when she got R30 dressed and ready to go home 10/22/20. The Surveyor showed CNA E the photos of R30 that were provided in the police report and CNA E confirmed that R30's bruises looked like that when she got her dressed. The Surveyor asked CNA E why she did not report the massive bruises and CNA E said she had been off for a couple days, every time she saw R30 she had new bruises as she self-transferred and was known to have frequent falls. CNA E said the facility educated her where to document bruises in the medical record and educated her to report all bruises. CNA E was shown the picture of the bruise on R30's back of her right leg/thigh. CNA E said she did not recall if R30 had that bruise because she had so many. During an interview with CNA K on 2/4/21 at 4:40 AM, CNA K reviewed her statements provide about R30's bruises on 10/22/20. CNA K denied seeing R30's skin that night as she said R30 was already in her PJ's when she went to give care. CNA K said R30 complained of shoulder pain that night and she reported it to LPN H. CNA K did not know if LPN H assessed R30's shoulder pain that night. The Surveyor showed CNA K the police photos of R30's bruises. CNA K again denied seeing any bruises because she never saw R30's skin that night. CNA K denied have any knowledge of how R30 obtained her bruises that were found on 10/22/20 at 7:00 AM during morning care. Telephone messages were left for LPN H to see if she assessed R30's complaints of pain on the night of 10/22/20 when CNA E provided R30 with ice and reported this to LPN H. LPN H did not return the phone call. The morning of 2/4/20 the ADON was asked about LPN H's assessment related to R30's compliant of pain the night of 10/22/20. The ADON never provided documentation showing that LPN H did any assessment on 10/22/20 after receiving report of R30 needing ice and reporting pain. Review of R30's physician notes dated 10/22/20 at 12:31 PM revealed, R30's family member reported R30 was bruised and swelling from her shoulder to her breast and the emergency room was too busy. The note at 12:59 PM revealed R30 was complaining of bruising on left shoulder under arm, down in front almost to breast and down the mid back on the same side, also left hip is aching patient had 2 falls during stay this one was not reported. Picture taken. At 1:24 PM orders were given for shoulder x-ray. Review of R30's physician note dated 10/23/20 at 11:40 AM revealed, R30 had bruising in her face (overlying right eye and nasal area). R30 discharged yesterday and noticed she has ecchymosis (bruising) on her left shoulder and back, left hip, multiple bruises on her arms and legs. She also has a laceration on her left lower arm, skin tear on her right thigh - duration unknown. Her fall has not been witnessed. Patient not reliable to give a history on what happened. ? Loss of consciousness, she denies dizziness or headaches. R30's x-ray was negative for fracture. New orders were placed for x-ray of left hip, chest/rib. It was noted R30 is not on blood thinners. Pain medication was also ordered. Review of the local police report #20- 1 dated 10/22/20 at 3:19 PM revealed, the ADON called the police to report R30's bruise that they found when R30 was being discharged . The ADON reported she was investigating the bruise as R30 has dementia and what she says is not always the truth. ADON said R30 may have fallen but she has no proof of it. This police investigation did not have any other interviews. Review of the local police report #20- 7 dated 10/28/20 at 1:51 PM revealed a different police officer was investigation R 30's bruises at were discovered on 10/22/20. This investigation revealed R 30's guardian was interviewed on 10/28/20 at 1:14 PM. R 30's guardian reported, When they picked R 30 up from the facility on 10/22/20 R 30 had a massive bruise on her left body. The emergency room had a long wait, so they took her to their doctor. Several pictures were taken at the doctor's office. The police obtained the pictures that were taken at the doctor's office. The police report contained the pictures they received. The pictures matched the facility report with the exception of a bruise with a laceration that was described as being located behind R 30's right knee and the cut was about 4 inches. R 33 According to the Minimum Data Set (MDS), dated [DATE], R33 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This same assessment indicated R33 required extensive assistance of two staff members to move in bed, transfer, and using the bathroom. Staff assessed R33 as moderately cognitively impaired. On 1/29/21 at 1:45 PM, during the facility tour with the Director of Nursing (DON), R33's door was noted to be shut. The DON opened R33's door and R33 was observed in a wheelchair which had tipped over. R33's left side rested on the floor. Certified Nursing Assistant (CNA) X responded first and stated that she had been checking in on R33 every 10 min. Registered Nurse Z also responded to R33's fall. During an interview on 2/5/21 at 11:30 AM, CNA X recalled R33 was seated in his wheelchair but lying on left side when found on the floor on 1/29/21. Review of Incident and Accident Report and Incident and Accident Investigation Form, both dated 1/29/21, revealed R33 did not have any injuries related to fall. Review of R33's progress notes revealed no post fall assessments for 1/30/21 and 1/31/21. On 2/1/21, RN Z wrote in R33's progress notes, pt. (patient) has noted dark purplish discolorations to buttocks and rear inner-aspect of thigh at groin observed during incontinence care. Pt. has had no increased c/o (complaints of) pain/discomfort reported or observed. Pt. however continues to become combative with care at this time. Attempting to hit, scratch, and kick staff throughout peri care. There was no further description of the bruising, including size or shape, provided. On 2/9/21 at 9:23 AM, when interviewed regarding R33's bruises, RN Z, was unable to recall R33's skin impairments. During an interview on 2/10/21 at 10:00 AM, RN F stated that they had observed the bruising on R33's inner thigh and bottom and that they had determined the injuries were a result of a previous fall. When asked how those types of injuries occurred as R33 was found on their left side seated in the wheelchair with the most recent fall, RN F did not answer. When asked if the bruises had been identified prior to, or following, the most recent fall on 1/29/21, RN F did not reply. The reported nature of R33's bruising did not fit the Surveyor observation of the incident occurring on 1/29/21. This surveyor was unable to locate documentation showing where R33's bruising was reported, investigated, or any other facility follow up was performed. Multiple requests made by surveyor on 2/9/21 for Incident and Accident Reports or facility investigation regarding R33's bruising, and the facility provided no additional documentation by the end of the survey. Facility policy Abuse Prohibition Policy, revised 07/2018, read in part, Investigation 1. Allegations by anyone who becomes aware of verbal, physical, mental, sexual or emotional abuse and mistreatment, neglect, exploitation, involuntary seclusion or misappropriation of property must immediately report it to his/her Administrator. 2. The Director of Nursing or designee will complete an assessment of resident(s) and document the findings in the medical record. 3. An Incident Report will be completed. 4. The licensed nurse will: notify the physician if required b. Notify the family member/responsible party/emergency contact/legal guardian (not necessarily all individuals). 5. A preliminary, on-site investigation will be initiated within twenty-four (24) hours of any report. 6. The Administrator or Director or Nursing/designee shall initiate the Incident and Accident Investigation Form and take the following actions to ensure that the investigation is conducted effectively, and 7. The investigation may consist (as appropriate) of: a. A review of the completed Incident Report. b. An interview with the person(s) reporting the incident. c. Interviews with any witnesses to the incident. d. an interview with the resident, if possible, e. a review of the resident medical record. f. An interview with staff members having contact with the resident during the period/shift of the alleged incident. g. Interviews with the resident's roommate, family members, and visitors. h. a Review of all circumstances surrounding the incident. The facility was notified of Immediate Jeopardy (IJ) at F-610 on 2/9/21 at 4:00 PM, was identified on 2/9/21 and began on 10/22/20, due to the facility's failure to immediately investigate upon discovery and thoroughly investigate a suspicious injury of unknown origin. The deficiency was discovered again on 2/1/21 when the facility failed to thoroughly investigate a suspicious bruising on another resident. This deficient practice placed all facility residents at risk for serious harm, injury, and/or death. Immediacy was removed on 2/10/21 at 10:00 AM when the surveyors were able to verify the facility began to implement their plan: The facility response: IJ Abatement Plan for Failure to Report Allegations of Abuse. (Name of Facility) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy regarding the facility's alleged failure to report multiple instances and allegations of abuse to the administrator (who functions as the facility's abuse coordinator) and / identify, assess and investigate multiple allegations of staff abuse and mistreatment and report to the state agency. Resident identified to be affected by the alleged deficient practice. Resident #33 was readmitted to the facility on [DATE] and a complete skin assessment was performed at that time. Resident #30 no longer resides at the facility. Residents with the potential to be affected by the alleged deficient practice. On 02/09/21 the facility identified 88 residents as having the potential to be affected. Nursing Administration completed a skin sweep of the 88 identified individuals in the building on 02/09/21. Systemic Measures The Nursing Home Administrator and Director of Nursing were in-serviced by the Regional Clinical Coordinator on the Abuse Prohibition Policy 201.00 and General Investigation Guidelines Policy 202.00. The NHA and DON acknowledged understanding of reporting in Accordance State and Federal Guidelines and General Investigation Guidelines. The Abuse Prohibition Policy 201.00 and General Investigation Policy 202.00 were reviewed and deemed appropriate. In-servicing began on 02/09/21 @ 6:00pm on the Abuse Prohibition Policy, and identifying and reporting injuries of unknown origin. NHA sent out a One Call Now to all current staff educating them on the reporting process of injuries of unknown origin. There are 131 facility staff members. Out of 131 employee's, 85 were in-serviced on the Abuse Prohibition Policy and reporting injuries of unknown origin as of 02/10/21 at 937 am. The remaining facility staff will be in-serviced on the Abuse Prohibition Policy and reporting of injuries of unknown origin prior to the start of their next shift beginning 02/10/21. All newly hired staff will be in-serviced on the Abuse Prohibition Policy and on the reporting of injuries of unknown origin upon hire by Staff Development Director or designee. Quality Assurance The administrative nurses will complete random skin assessments of 10% of residents weekly for 4 weeks, than monthly for 2 months. Any injuries of unknown origin will be reported and investigated per Abuse Prohibition Policy 201.00 and General Investigation Policy 202.00. RCC or designee will audit 10% of Incident Accident reports to ensure Abuse Prohibition Policy 201.00 and General Investigation Policy 202.00 were followed. The NHA is responsible for sustained compliance Date of compliance is 02/10/21. Although the Immediate Jeopardy (IJ) was removed on 2/10/21, the facility remained out of compliance at a scope of isolated and a severity of Actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency.

This citation refers to Intakes MI 375, MI 644, MI 625, MI 799 and MI 179 Based on observation, interview, and record review, the facility failed to provide appropriate interventions and sufficient supervision to prevent falls for Residents (R33, R1, and R17), failed to provide supervision for one resident (R12), and failed to identify sources for injuries of unknown origin for one resident (R30) out of five residents reviewed. This deficient practice resulted in falls with fractures, repeated resident to resident altercations potentially affecting the whole memory care unit, and suspicious bruising. Findings include, During interviews on 2/9/21 at 8:47 AM and 10:17 AM, RN Y and LPN S respectively, reported that general and high risk fall precautions for all residents included residents always having grippy socks or shoes on, use of ancillary staff (activity aides) for diversional activities, and frequent checks by staff, at least every two hours and more frequent as needed. R33 According to the Minimum Data Set (MDS), dated [DATE], R33 had multiple diagnosis including abnormal heart rhythm, diabetes, stroke, and seizures. This same assessment indicated R33 required extensive assistance of two staff members to move in bed, transfer, and using the bathroom. Staff assessed R33 as moderately cognitively impaired. R33 was not a reliable source of information and therefore was not interviewable. Review of document Nursing Comprehensive Evaluationv1.1-V11, dated 11/27/20 (same day as R33's initial admission to facility), Staff identified R33 as a fall risk related to R33 having a history of falls with injury. On 1/29/21 at 1:45 PM, during the facility tour with the Director of Nursing (DON), R33's door was noted to be shut. The DON stated it was the Observation Unit guidelines to prevent COVID-19 infections. Then, the DON opened R33's door and R33 was observed in a wheelchair which had tipped over. R33's left side rested on the floor. Certified Nursing Assistant (CNA) X responded first and stated that she had been checking in on R33 every 10 min. Review of Resident falls revealed R33 had six falls within seven weeks, beginning 12/14/20 to 1/29/21. The fourth fall, on 1/19/21, resulted in a cervical fracture (broken neck). Fall 1 Review of Incident and Accident report dated 12/14/21, that day at 2:50 PM, staff found R33 on the floor in their room, there were no witnesses to the event, and it was determined R33 was attempting to self-transfer when his feet tangled in the foot pedals of the wheelchair. Staff care planned interventions for R33's foot pedals be removed from wheelchair when R33 was not being propelled and to keep frequently used personal items on R33's left side (see R33's care plan for Impaired visual function, initiated 11/27/20, and not a new intervention). During an interview on 2/9/21 at 11:36 AM, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Nursing Home Administrator (NHA) were interviewed regarding R33's falls. The DON did not agree that removal of foot pedals were standards of practice and that foot pedal removal is determined based upon a resident assessment. Review of R33's progress notes between 12/14/20 through 1/4/21 revealed at least 8 episodes when R33 was found by staff to be up independently and performing unsafe self-transfers. There were no new interventions developed from these observations to prevent R33 from additional falls and or injuries. Fall 2 Review of Incident and Accident report dated 1/4/21 at 1:30 PM, staff found R33 on the floor, there were no witnesses to the event, no injuries and it was determined R33 was attempting to self-transfer and had poor safety awareness. Staff care planned interventions for R33 to have shoes on while out of bed and activity staff was to play cards with R33 prior to meals as staff were able. A Sleep monitoring study was also performed and involved staff documenting on the January 2021, Medication Administration Record (MAR) the total number of hours, out of the 12-hour shift, that R33 spent sleeping and awake. This occurred for 3 days. There were no specific times indicating when resident was awake during each of those days. During an interview on 2/9/21 at 11:36 AM, the Director of Nursing (DON) reviewed the sleep study document with the surveyor and agreed staff found nothing significant from the sleep study to prevent R33 from falling again. The DON reported the staff determined from the spouse that R33 used to work nights (this was not found in R33's Activity care plan per DON guidance). Review of R33's progress notes dated 1/5/21 read, resident has been wandering in his room ambulating by himself but is easily redirected. Another progress note dated 1/7/21, read, Resident was standing in room by sink with brief and sweatpants down to his ankles, the note indicated the resident was confused, that it was the third time R33 had self-transferred to the bathroom and that staff are offering R33 assistance to the bathroom every hour and a half. R33 declined to participate in interventions from activity aides. Additional progress notes indicated staff continued to find R33 wandering or self-transferring, staff described R33 as having frequent impulsive behaviors. Fall 3 Review of Incident and Accident report dated 1/12/21 at 2:00 PM, staff found R33 on the floor in his room, there were no witnesses to the event, staff identified a small red bump on R33's left forehead. Staff determined R33 was attempting to self-transfer without assistance and bumped his forehead on the wheelchair. Staff identified a potential cause for self-transferring could be related to [MEDICATION(S)] pain and staff implemented interventions for R33 including a new chair cushion, medications, and a referral to a general surgeon. Review of Post Fall Evaluation, dated 1/12/21 for fall occurring at 2:00 PM, revealed R33 was wearing only gripper socks at time of the alleged fall despite staff care planning, on 11/27/20 and again with the last fall on 1/4/21 (a week prior), that R33 was to wear shoes during the day. The facility investigation did not indicate why R33 did not have shoes on at time of fall. Review of January 2021 MAR, R33 began receiving a medication for [MEDICATION(S)] pain on 1/9/21, three days prior to the fall. During an interview on 2/9/21 at 11:36 AM, this Surveyor began to review progress notes that described R33's continued unsafe transfers, the Director of Nursing (DON) stopped this Surveyor and stated, I see what you are saying, he (R33) was self-transferring. Progress notes following R33's third fall, dated 1/13/21, indicated the pain interventions were not effective. And on 1/15/21 progress notes indicated R33 had multiple attempts at self-transferring throughout am (morning) shift. On 1/16/21staff documented that R33 had poor safety awareness and was attempting to self-transfer after using the bathroom. Staff documented that R33 was in the hallway attempting to hit other residents. Similar progress notes written daily indicated R33 was self-transferring and staff would find R33 walking in his room or in the hallway. Fall 4 Review of Incident and Accident report dated 1/19/21 at 3:15 AM, staff found R33 on the floor in the bathroom, there were no witnesses to the event, staff identified a lump on the right side of R33's forehead. R33 complained of neck pain and an ambulance was called. Staff determined R33 was attempting to self-transfer without assistance and bumped his head on the door frame. Staff identified a potential cause for fall could be related to impaired cognition and impaired vision. Staff implemented interventions for R33 including offering the bathroom every two hours around the clock and the right side of R33's bed was to be placed against the wall to allow for better vision from R33's left eye (see also Impaired Vision care plan initiated 11/27/20). Progress notes, dated 1/25/21, revealed R33 was readmitted to the facility following a hospital stay for a C5 fracture (broken neck) and secondary findings of diverticulitis (infected pouches of the large intestine). R33 returned to the facility wearing a cervical stabilization collar. R33 was treated by the facility for pain with medication four times daily for seven days and an antibiotic for the infection. Fall 5 Review of Incident and Accident report dated 1/26/21 at 11:45 AM, staff found R33 laying in the middle of the room on the floor, there were no witnesses to the event, staff documented R33 had no injuries. Staff determined R33 self-transferred from the recliner and may have been going to bed. Staff implemented interventions for R33 including offering the toilet every two hours while awake and staff were to offer a nap between meals. Nursing staff was to evaluate the effectiveness of the new interventions. Review of the Post Fall Evaluation, dated 1/26/21 at 11:45 AM, revealed R33 had gripper socks on at the time of this fall despite being care planned on 11/27/20 and again on 1/4/21, to have shoes on during the day. The facility investigation did not indicate why R33 did not have shoes on at time of fall. Post fall follow up Progress note dated 1/27/21, indicated staff had implemented the fall precaution interventions, however, R33's response to the interventions were not documented. On 1/28/21 staff did not document R33's response to care planned interventions. On 1/29/21 staff documented R33 was attempting to lift his wheelchair and turn it upside down and was agitated. R33 was anxious and trying to stand often. R33 refused a nap after lunch. Fall 6 Review of Incident and Accident report dated 1/29/21 at 1:45 PM, staff (and this Surveyor) found R33 laying in the middle of the room on the floor, there were no witnesses to the event, staff documented R33 had no injuries. Staff determined R33 had put himself on to the floor to fix the wheelchair. Staff implemented interventions for R33 including one on one supervision and referral to physician for pain evaluation. Staff did not document Post fall follow up progress notes on 1/30/21 or 1/31/21. There was no staff follow up to interventions to determine their effectiveness to prevent R33 from falling again. Staff did not document any signs of injuries. During an interview on 2/9/21 at 11:36 AM, the DON, ADON, and NHA agreed that they had reviewed all of R33's falls and stated that the interventions implemented after each fall matched the root cause of each fall. During an interview on 2/5/21 at 12:05 PM, CNA E, when asked what interventions the facility implemented to prevent R33 from falling, replied, frequent checks and to offer toilet every hour. That was pointless, (R33) needed to be cathed (tube inserted into bladder to drain urine). During an interview on 2/5/21 at 2:47 PM, Activity AA reported R33 had been evaluated and some interventions included having a male activity aide attempt to engage R3 in an ipad activity and at another time R33 was given a bolt board. Activity Supervisor AA reported R33 did not enjoy either activity. During an interview on 2/9/21 at 8:47 AM, RN Y stated that there was never enough help on the COVID observation unit because of the resident acuity and high fall risk. RN Y also conveyed that some fall interventions prior to COVID were no longer viable and that they could use some help identifying appropriate interventions now with COVID restrictions in place. It was reported that it was hard to take care of everyone and safety was the number one priority. R1 According to the MDS, dated [DATE], R1 was admitted to the facility with multiple diagnoses including fall related fractures and [CONDITION(S)] (abnormal heart rhythm). R1 to required extensive assistance of one person for moving in bed, transferring, and other hygiene needs including using the bathroom. Staff assessed R1 as moderately cognitively impaired with disorganized thinking patterns. This same assessment indicated R1 had a history of falls and recently had a fall outside the facility that resulted in a cervical (C5) fracture (broken neck). According to the Nursing Comprehensive Evaluation, 12/30/20, R1 was admitted to the facility for rehabilitation therapy and had a cervical stabilization collar on. Therapy notes, dated 1/9/21, revealed R1 does continue to self-transfer. C-collar (cervical collar) in place. Another note dated 1/12/21 indicated R1 would self-transfer and walk every day. Review of Skilled Daily Visit Note dated 1/12/21, staff documented R1 wanders in hallway at times easily directed. Review of Incident Accident Report dated 1/13/21 at 10:15 PM, staff found R1 on the floor in his room. There were no witnesses to the event and staff documented R1 had bumped the left side of his head on the wall. Staff documented R1 was wearing regular socks at the time of the fall. Staff determined R1 was confused and frequently transferred without asking for assistance. It was also determined the cervical stabilization collar may have affected R1's ability to safely transfer. Staff implemented interventions on 1/13/21 for R1 including Resident to wear gripper socks at all times and then beginning on 1/18/21 staff were to offer R1 the bathroom every two hours while awake. Review of facility 72 Hour Admission Conference note, dated 1/15/21, R1 was admitted to the hospital following the fall on 1/13/21 and had a newly fractured C7 (fracture of another bone in the neck). R1 returned to the facility in less than 24 hours. During an interview on 2/9/21 11:36 AM, the DON stated that R1 should have had non skid socks on when the fall occurred causing the fracture. R 12 Review of R 12's face sheet dated 2/3/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] she had diagnoses that included: [CONDITION(S)], major depressive disorder, generalized anxiety disorder, dementia in other diseases classified elsewhere with behavioral disturbance, psychotic disorder with hallucinations due to known psychological condition, [CONDITION(S)] and restlessness and agitation. R 12 was not her own responsible party. Review of R 12's Minimum Data Set (MDS) dated [DATE] revealed she was assessed in section C and was coded as severely impaired (never/rarely made decisions). She was assessed to need supervision and physical assistance of 1 person for bed mobility, transfers, walking in her room and hall, moving about the nursing unit, and eating. She was assessed to need limited assistance of 1 person for dressing, and extensive assistance of 2 people for toilet use and hygiene. (see observation on 2/10/21 at 9:45 AM, as she needed more assistance at times than was coded on this MDS). During an observation made on 1/29/21 at 1:15 PM, R12 was observed approaching another resident in the dining area. R12 then reached out as if to take food off the resident's plate, a CNA that was helping another resident eat lunch intervened and redirected R12. Two other staff members were in the same room. During an observation made on 1/29/21 at 1:15 PM, R12 was observed to have a bruise and skin tear on the back of the left wrist. R12 was observed on 2/10/21 at 9:17 AM sleeping in a recliner by the nurse's station on the dementia unit. R12 had both feet on the seat of the recliner. R12 had gripper socks on both feet. R12 had a dime size scab on her left wrist on the lateral side. Four other residents were sitting in the same area. They were all just a bit further than arm's length away from each other. Licensed Practical Nurse (LPN) T was in the nurse's station with the door open. LPN T said R12 was sleeping in the chair when she started her shift at 6:00 AM. LPN T said she needed to keep any eye on R12 because she has difficulty standing up and tends to scoot forward in the chair and fall. When asked how she prevents R12 from having unwanted physical contact with other residents she said we need to redirect her. LPN T said R12 has a frontal brain injury and can be up wondering more than 24 hours and at times will sleep for 2 days. When R12 wonders she does not realize that the person in her path may not move and due to dementia, the other residents do not move out of her path. LPN T said if we see she is walking toward another resident we just calmy redirect her around them. The Surveyor asked LPN T to show her where in R12's care plan she had a history of Resident-to-Resident physical altercations and what interventions were care planned. LPN T was not able to locate any information in R12's care plan that indicated she had resident to resident altercations or any interventions to supervise her and redirect her when coming near other residents. LPN T said current staffing levels did not allow staff to keep R12 in eyesight when she is up and wondering. They just do their best to frequently check on her location. R12 is still known to go into other residents' rooms and be out of eyesight of staff. On 2/10/21 at 9:45 AM, R12 started to wake up in the recliner she was in at the nurse's station. R12 took the gripper sock off her right foot and put it over the gripper sock on her left foot. R12 started scooting toward the edge of the seat of the chair. LPN T came over to R12 and calmly asked her if she could help her with her socks and took the gripper sock off her left foot and put it back on the right foot. LPN T started to help R12 stand by holding her under her right arm. R12 was not able to stand. Certified Nurse Aide (CNA) V came onto R12's left side and gave her support under her left arm. R12 was able to stand with physical assistance of 2 staff. R12 started walking down the hall but was leaning backwards and to her sides at times. Both staff had a good hold on both of R12's arms and provided physical assistance to keep her up right. The staff walked R12 into her bathroom, assisted her with her clothing and R12 sat on the toilet. R12 allowed staff to change her brief, change her clothing and wash her. R 12 did get slightly agitated at times. Staff spoke calmly with her and backed off when she started pushing away or moving away from them. R12 did attempt to swat staff at times, but they were able to move back so no contact was made. Both staff had to assist R12 the first time she stood up from the toilet, but after that R 12 independently sat down on the toilet and stood up again. R12 was able to walk independently in her room after care and independently sit and stand from her bed. R12 was left to walk independently around the dementia unit after care. During an interview on 2/10/21 at 9:45 AM, CNA V was asked if R12 had any physical altercations with other residents and CNA V said, yes. CNA V was asked how staff know what to do to prevent R12 from having physical altercations with other residents. CNA V said she knows she is not to leave R12 in the dining room after lunch and that would be on the Kardex. CNA V went over to the computer screen on the wall and opened R12's Kardex. CNA V was not able to locate any information about R12 having physical altercations with other residents or any intervention about keeping R12 out of the dining room after lunch. R12 said they just do their best to check on her frequently and redirect her when she is going into other resident rooms and near another resident. CNA V said they do not have enough staff to provide all residents care and keep an eye on R12 when she is wandering. Review of R 12's Incident and Accident Report, dated 3/8/20 at 2:10 PM, revealed R 12 struck R 19 with a pillow in the head. R 19 grabbed R 12 by the arm and shook her. R 12 physician was contacted and ordered [MEDICATION(S)] 2 mg IM for 7 days (antipsychotic medication given by injection). The conclusion revealed R12 was restless prior to this incident and was putting on other residents' shoes. R 12 had abrasions on her 4th and 5th toes. It was possible that the increased restlessness was due to sores on her toes. R 12's family was contacted to bring in shoes. No increased supervision was noted. Care plan reviewed and no mention of Resident-to-Resident altercation found or increased supervision during this time noted. Review of R12's Incident and Accident Report, dated 3/17/20 at 10:55 AM revealed, R12 was walking by R21. R21 was sitting in a recliner and R12 tapped R21's head. R21 in return tapped R 12's right arm. No injuries were noted. R12 was noted to have a urinary tract infection (UTI) and was started on an antibiotic on 3/18/20. CNA JJ's interview revealed, R12 slapped R 21 on the head. CNA JJ was standing by the soiled linin room when this incident occurred. CNA KK's interview revealed R12 slapped R21 on the head and R21 touched R12's arm. CNA KK was standing by the soiled linen room when this event occurred. The conclusion revealed, R12 was ambulating as normal and tapped the back R21's head in a non-aggressive manner to which R21 tapped R12's right arm with the back of her hand. The root cause was R12 had a UTI. The eyewitness to the event described the contact as slapped this is an aggressive term that did not match the conclusion. No intervention to increase supervision was noted or care planned. Review of R12's Incident and Accident Report dated 4/5/20 at 2:00 PM, revealed, R12 struck R14 in the cheek. R14 was exiting the dining room when R12 walked pasted her and hit her. This incident was witnessed by the housekeeper. Nursing staff working at the time did not witness this incident. The conclusion revealed, R12 has dementia and psychotic disorder with hallucinations. R14 was struck by R12 as she walked by. R12's [MEDICATION(S)] was increased to attempt to stabilize mood. No increased supervision was noted or care planned. Review of R12's Incident and Accident Report dated 8/26/20 at 12:50 PM revealed, R12 was attempting to take R25's lunch tray and staff tried to move the tray. R12 then struck R25 in the left shoulder. CNA V interview revealed she was standing by R25 when R12 reached for R25's lunch tray. CNA V was attempting to keep R25's lunch tray away for R12 and reached out and hit R 25 in the left upper arm. CNA LL's interview revealed she was in the far end of the dining room and heard someone state, no name of R12, hitting s (sp) not nice. CNA LL did not witness what happened. The conclusion revealed R 12 came into the day room while R25 was finishing her lunch. Staff attempted to move R25's tray out of R12's reach. R12 responded by making a closed hand and made contact to R25's upper arm. The plan was to assist R12 to bed if she is tired after meals and close the door to the day room. Provide finger foods as needed. Do a medical review and increase pain medication. There was no documentation of increased supervision, assistance, or added interventions provided, or care planned. Review of R12's Incident and Accident Report dated 10/24/20 at 1:00 AM revealed, R12 was sitting on R31's floor in his room. R31 had R 12's hair in his hand. R12 had a scratch on her left wrist, left hand, front of her neck, back and her left shoulder. CNA MM's interview revealed she heard a scream and found R12 on the floor and R31 holding her by the hair. R12 had been repeatedly wandering into other rooms, had used the toilet, was changed and fed. CNA J's interview revealed she observed R12 on the floor. R31 (male resident) stated, she pulled his pants down. CNA J had attempted to redirect R12 out of other rooms, but her attempts were short lived. R31's Incident and Accident Report dated 10/24/20 at 1:00 AM revealed R 31 stated, female came into room and sat on bed, jestered (sp) chest made motion of pushing female off his bed, stated pulled and jestured (sp) to pants. CNA MM's interview revealed she heard yelling went into observe female resident sitting on the floor, male resident sitting on bed with pants/outer pulled down to mid-calf. Male resident had hand (Left clinched in female residents' hair, male resident was yelling, and female resident was attempting to stand up from crouched position. CNA J's interview revealed Took care dirty linen, heard yelling went down to room 45 and observed resident sitting up in bed, and female resident crouched next to this bed. Assisted female resident up and out of his room. Noted scratches to female resident attempted to keep both residents apart. Not allowing female resident to wander. Plan for R31 was to move him to another floor. Resident R12 was provided 1:1 supervision. There was no specified time documented of how long she would receive increased supervision. Review of facility reported incident dated 1/20/21 at 7:55 AM revealed, R12 was observed hitting R6 with her left-hand making contact with R6's right shoulder. R6 was noted be yelling out prior to the physical contact. There was a CNA in the room sitting next to R6 when this incident occurred. The summary concluded that R12 had gas but refused gas-x. The facility concluded that the incident occurred because R12 had stomach discomfort. There was no documentation of increased supervision, assistance, or added interventions provided, or care planned. Review of R12's Incident and Accident Report, dated 1/29/21 at 12:15 AM, revealed she was wandering and noted to have a skin tear to her left wrist. Staff were not able to measure it. The wound was cleaned and treated with triple antibiotic ointment and a band-aid. CNA J's interview revealed, R12 had been sleeping in a chair @ the Nurses station. Woke and got up and ambulating in hallway and into some resident's rooms. All were sleeping. Noted as she came up to the nurse's station skin tear to left wrist. No bleeding noted. No change with mood of behavior noted. The conclusion revealed, bumped wrist coming out of room 47 or while in room 47. Resident in room 47 remained sleeping entire time. There was no documentation showing R12 was care planned to have an increase in supervision or assistance after this unwitnessed injury was investigated. The documentation did not indicate how long R12 was wandering in and out of rooms prior to the noted injury or how many rooms R12 entered while up wandering. R12's care plan did not show that she had a history of resident-to-resident altercations resulting in injury or that staff should supervise R12 to prevent resident-to-resident altercations. During a telephone interview 2/11/21 at 10:00 AM with R12's Social Service worker SS B reviewed all R12's incident reports from 3/8/20 to 1/29/21. The only incident report that indicated R12 was provided increased supervision was on 10/24/20. SS B was asked how long R12 was on 1:1 care and SS B said until R31 was moved off the unit. The surveyor asked SS B what interventions were placed so that R12 would not continue to wander into other residents' rooms and stop her from having unwanted physical contact. SS B said, R12 lives on a Dementia Unit and wandering is what they do. The surveyor reviewed R12's behavior care plan with SS B. SS B could not find any indication in R12's care plan that she had a history of Resident-to-Resident physical altercations. SS B was not able to locate any interventions of increased supervision that prevented R12 from having Resident to Resident physical altercations and injuries as shown happened on review of 5 incident and accident reports over the last 10 months. During a confidential interview with staff NN, staff NN wanted to remain anonymous and expressed concern about staffing. Staff NN said on the dementia unit they only have 2 staff at night and R12 constantly wonders. They are not able to keep her in eyesight at all times due to needing to provide care for other residents. Staff NN said R12's incidents could have been prevented with more supervision. During a confidential interview with staff OO, staff OO wanted to remain anonymous. Staff OO was asked about preventing falls and injuries. OO said they cannot get the help they need. When they ask for more help, they are told they cannot increase staffing and that residents have to stay in their rooms due to COVID, which means staff can no longer provide constant supervision for residents that are known to self-transfer. During a confidential interview with staff PP,staff PP wanted to remain anonymous. Staff PP said they work frequently on the dementia unit with R12. PP said R12 can go for days without sleeping and walks constantly. Now that they only have one CNA on that unit and 11 Residents to care for, they cannot always keep her in eyesight. R12's husband visited frequently before COVID now he is not able to visit. This puts more supervision on the staff. During a confidential interview with staff QQ staff QQ wanted to remain anonymous. Staff QQ said they frequently work on the dementia unit with R12. Staff QQ said normally they prevent resident to resident altercations with R12 by redirecting her. Some residents need assist of 2 people for care so they cannot always supervise R12 as no one can stay in the hall to make sure she does not have contact with other residents. QQ said R12 wanders on all shifts and with current staff they are not able to supervise her when she is wandering. Review of a complaint filed with the State of Michigan on 7/28/20 revealed the complainant wanted to remain anonymous. The complainant reported, Our building is not being staffed correctly. We are understaffed most days. Recently reflections a dementia unit is being ran with one nursing assistant with 12 behavioral residents the week of the 22nd of July we had 5 falls in a 48-hour period. Reflections has 1 nurse but is now pulled to nurse another hall (Walsh). Most of our residents are wanderers, mobile. A few years ago, it was written in stone that reflections does not go without 2 aides per state regulations. Please help us. R17 Review of R17's admission reentry Minimum Data Set (MDS), nursing assessment dated [DATE] revealed, she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. She had a Brief Interview of Mental Status (BIMS) score of 12/15 (normal cognition). She required extensive assistance of one person for bed mobility, transfers, movement in her room and on the unit, dressing, toilet use and hygiene. R17 was not able to walk. Review of R17's Designation of Patient Advocate Form dated 11/18/17 revealed she had two family members named as her advocates. Review of R17's hospital emergency room note dated 1/17/20 revealed R17 was found at home on the floor by her housekeeper and R17 said she hit her head on something. R17 had a fasting blood sugar of 444 at that time, abnormally high, normal is 70 to 110. When R17 was evaluated at home the emergency medical service reported her blood sugar was 442. R17 reported she did not recall when she took her insulin last, but it was normal 35 or 40. (35 to 40 is considered extremely low and can require medical intervention). R17's granddaughter was present and said the blood sugar information was not true. The granddaughter said she takes her insulin daily but has had a history of recurrent UTI's (urinary tract infections). R17's neurological assessment revealed she was confused, only oriented to person and place. She believed it was 1969. R17 was able to follow commands. R17 was admitted to the hospital with the following diagnoses: altered mental status, UTI (urinary tract infection), Fall, and [CONDITION(S)] (high blood sugar). Review of R17's hospital discharge summary dated 1/23/20 revealed her Primary Discharge Diagnosis: [CONDITION(S)] (a life-threatening infection), pneumonia, [MEDICATION(S)] (inflammation of the bladder, normally caused by a urinary tract infection), [CONDITION(S)] (abnormal heartbeat), [CONDITION(S)] (high blood sugar), acute kidney injury and mechanical fall at home. In the review of Hospital Course revealed, Per PT notes she was still quite a high fall risk. Review of R17's facility progress note dated 1/23/20 at 15:57 (3:57 PM) reve [TRUNCATED]

This citation pertains to MI 359 Based on observation, interviews, and record review, the facility failed to prevent a fall with injury for one resident (Resident #2) out of three residents reviewed for falls, from a total sample of three residents. This deficient practice resulted in a fall with a fractured arm. Findings include: According to the Minimum Data Set assessment, dated 5/3/18, Resident #2 was admitted to the facility with multiple [DIAGNOSES REDACTED]. This same assessment indicated Resident #2 was extensive assist of two people for transfers, bathing, toileting, and bed mobility. Review of Resident #2's Incident and Accident Report, dated 5/7/18, revealed Resident #2 was walking from bathroom to bedroom with assistance by one CENA (Certified evaluated nursing assistant) and her walker with her arm strapped on. the walker moved too far in front of her and her left leg dragged behind her causing her to lose her balance and both CNA and resident fell to floor with resident's left arm still attached to hemi-walker. Review of Resident #2's Kardex, printed 5/8/18, and provided by the facility revealed Resident #2 was an extensive two person assist with use of platform walker for transfers, non-ambulatory-only with therapy, and toilet use with extensive two person assist with platform walker. During an observation on 5/22/18 at 8:15 am, Resident #2 was transferred from a wheelchair to the toilet with the use of a hemi-walker and assistance of CNA (Certified Nursing Assistant) J and CNA K. During an interview on 5/22/18 at 8:25 am, Resident #2 stated, There was probably more times when one person transferred me, but only that one time (referring to the fall) there was a problem. CNA G was identified as the CNA working with Resident #2 at time of the fall. CNA G no longer worked at the facility and was unavailable for interview by phone. During an interview on 5/21/18 at 3:20 pm the Director of Nursing (DON) B stated, CNA G was terminated .she (Resident #2) was a two (person) assist with transfers. I checked resident (Resident #2's) documents, care plan, and Kardex, (facility) had her as two assist. I looked at his employee file and he (CNA G) was educated. He told me he knew she (Resident #2) was a two assist . Review of Resident #2's X-ray of left shoulder, dated 5/8/18, read, There is a [MEDICAL CONDITION] neck of the humerus (upper arm). The fracture is displaced (bones not aligned) and angulated and there appears to be impacted (multiple bone fragments wedged together) .

Based on observation, interview and record review, the facility failed to prevent facility-acquired heel pressure ulcers and/or deep tissue injury and friction wounds for 2 (#8, #16) of 4 sampled Residents from a total sample of 24 residents reviewed, resulting in Resident #8 who was admitted with no pressure ulcers or friction wounds sustaining upper right superior and upper medial (side) calf/below knee Stage II and lower superior ankle friction wounds Stage II from Ted hose and right black eschar heel. Resident #16 who was admitted with no pressure ulcers sustained bilateral heel pressure ulcers-Stage II. Findings include: Record review of facility Skin Management policy, revision date 6/2016, revealed the it is the policy of the facility that a resident does not develop pressure injury unless clinically unavoidable. Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Record review of Nurses.com article preventing Heel Breakdown' (M. Graff, J.(NAME) N. Beinlich) November 6, 2000 revealed the prevalence of heel pressure ulcers is a major health care problem. Heel ulcers develop as a result of pressure, shear or friction concentrated on a small area over a bony prominence that lacks subcutaneous tissue. Significant risk factors for development of heel breakdown include immobility, age, mental status, nutrition, chronic illness and orthopedic surgical procedures, especially hip pinning and hip replacement surgeries. It is important for nurses to identify patients at risk for heel pressure ulcers and to initiate appropriate preventative interventions .Heel pressure ulcers are painful, can take up to several months to heal, and my contribute to other serious complications such as [MEDICAL CONDITION], osteo[DIAGNOSES REDACTED], loss of the affected limb, or even death The majority of pressure ulcers are preventable. Facility-Acquired Pressure Ulcers: Resident #8: Record review of Resident #8's Admission assessment, dated 4/12/17, for skin assessment revealed a surgical wound to the right thigh with right lower leg discolorations. There were no friction or pressure wounds noted to the lower right leg at the time of admission. Record review of Resident #8's Minimum Data Set (MDS), dated [DATE], revealed a [AGE] year-old female with Brief Interview of Mental Status (BIMS) score of 6 out of 15-severely impaired cognitive abilities. Medical [DIAGNOSES REDACTED]. Skin assessment noted no pressure or friction wounds. Record review of Resident #8's progress note, dated 5/2/17 at 1:24 PM and written by Registered Nurse E, revealed resident presents with unstageable pressure injury to right heel, and 100% black soft eschar, no drainage, no signs symptoms of infection noted. Treatment will be to paint with iodine and cover with gauze and wrap with kerlix two times daily. Traumatic friction injury to front of right ankle with 75% thin slough and 25% pale pink granulation tissue, no drainage, no signs symptoms of infection. Right lower leg below knee wound with non-granular tissue, no slough noted, no drainage, and no signs symptoms of infection noted. Wound treatment to both wounds will be to place impregnated hydrogel gauze (packing dressing for wounds with depth) on wound bed only and cover with dry gauze, wrap with kerlix, change daily. Right lower extremity venous duplex ultrasound showed good compressibility and blood flow. Impression: No sign of [MEDICAL CONDITION] in the lower extremity. [DIAGNOSES REDACTED]. Record review of Resident #8's 'Wound/Skin Healing Record', dated 5/2/17, revealed wound measurements of Right Heel: pressure 5.5. cm length X 6.1 cm width unstageable black/brown eschar. Right ankle front traumatic friction 5.1 cm length X 1.8 cm width X 0.1 cm depth pink/beefy red with slough. Right lower leg front (below knee) traumatic friction 1.5 cm length X 10.6 cm width X 0.1 cm depth. Record review of Resident #8's therapy progress note, dated 8/10/17 at 2:59 PM, revealed that the resident felt warm to the touch and increased pain noted in right foot as evidence by resident crying out. Record review of Resident #8's progress note, dated 8/16/17 at 12:15 PM and written by RN/Wound nurse/Infection Control E, revealed right heel pressure 5.1 cm length X 6.0 cm width unstagable .experiencing pain. Pressure injury to right heel with eschar and sloughing wound edges, small amount of SS (serosanguineous-blood) drainage with slight odor, odor has improved since ABX (antibiotic) started, wound clinic appointment made for next week . In an interview on 8/22/17 at 12:25 PM while seated in the main dining room in a wheelchair, Resident #8 was asked about her leg sores/wounds and stated that the sores just happened and that her socks were too tight. Record review of Resident #8's report of consultation form from the wound clinic on her first visit, dated 8/22/17, revealed that the wounds were to be cleansed with normal saline, patted dry, apply santyl and cover with damp dressing covered by dry dressing. Observation made on 8/23/17 at 11:30 AM of Resident #8's friction and pressure wounds of the left leg with Licensed practical Nurse (LPN) Y, who stated that the upper calf friction wounds matched up to where the residents Ted hose tops would be. In an observation of the right leg superior tibia wound (front leg below knee) LPN Y estimated the wound at 2 cm in length across the leg and a black fly was crawling on the leg near the wound, LPN Y waved her gloved hand to move the fly from the leg, cleansed the wound and placed santyl ointment into the wound with a wooden tongue depressor and applied a wet 2 x 2 gauze with a dry 22 gauze over the wound. Observation of the right leg wounds revealed that the fly was crawling in the foot/ankle wound. In an observation of the medial tibia (side of leg below knee), LPN Y estimated at 2.5 cm in length across leg. The wound was cleansed with saline solution and patted dry. Santyl ointment was applied to the wound with wooden tongue depressor and dressing applied. LPN Y waved her hand over the foot/ankle superior wound when the fly landed in the wound then left the bedside to go to the bathroom sink and wash her hands after de-gloving. While LPN Y was in the bathroom, the fly returned to the right ankle/foot superior (top of the foot) wound and walked about the wound. LPN Y came back to the bedside and put on new gloves and waved the fly off the wound and applied santyl ointment to the wound with a wooden tongue depressor stick. LPN Y did not re-cleanse the wound. Record review of Resident #8's wound culture lab results, dated 8/11/17, revealed right heel: Heavy growth of Proteus mirabilis. An interview on 8/24/17 at 12:15 PM with Registered Nurse/Infection Control/Wound Care E revealed, when asked what would a nurse do if a fly landed in the wound during a dressing change, that the nurse should start over with cleansing the wound and then proceed with the treatment and dressing. Resident #16: Record review of Resident #16's Minimum Data Set (MDS), dated [DATE], revealed an [AGE] year-old female with a Brief Interview of Mental Status (BIMS) score of 9 out of 15-moderately impaired cognitive ability. Medical [DIAGNOSES REDACTED]. Skin assessments included deep tissue injury to heels. Record review of Resident #16's progress note, dated 1/30/17 at 2:53 PM, noted resident experiencing pain related to the wound. Resident presents with deep tissue injury to bilateral heels: left heel with pressure 4.0 cm length x 7.0 cm width, boggy dark purple discolored intact blood filled blister, surrounding skin is normal skin tone and blanchable. Resident expresses pain when touched, unable to rate but states hurts when touched, floating helps relieve pain. Right heel measuring 2.0 cm X 2.9 cm with boggy purple discolored intact skin, no blood filled blister noted Resident has stayed in bed more due to her recent upper respiratory infection, she is receiving antibiotic. Record review of Resident #16's skin care plan, revised date 4/13/17, revealed that interventions included to float heels in bed and up in chair. Record review of Resident #16's actual impairment to skin care plan, revised date 8/1/17, revealed that interventions included no shoes on until pressure injury to heels are healed, gripper socks only. In an observation on 8/22/17 at 2:08 PM, the state surveyor was in the main dining room entrance and observed Certified Nurse Assistant (CNA) FF pushing Resident #16 while seated in her wheelchair from the back of the wheelchair with no foot pedals in place and heard a scuffing sound. Observed Resident #16 to have on black ballerina style slippers with a white gauze bandage to the left foot with the slipper over it, scuffing on the floor while being pushed from the beauty shop on B-hall through the main dining room and out into the C-hall with her feet scuffing the floor. In an interview on 8/24/17 at 11:00 AM, Registered Nurse/Wound Care Nurse E was asked when the pressure ulcers were avoidable. She revealed that Resident #16 hand left sided weakness in both left side extremities and the left and right heel wounds started as deep tissue injury's from the bed. RN E revealed that Resident #16 was sick for 3-4 days and did not get out of bed, but that interventions were in place on the care plan. RN E would not respond when asked if the interventions were in place, was the care plan followed. In an interview on 8/24/17 at 11:15 AM, Resident #16 revealed that she had gotten really sick and didn't get out of bed for 3-4 days and then she got the black stuff on her heels.

Based on observation, interview and record review, the facility failed to ensure proper pain management for 1 resident (sampled Resident #2) who had a history of [REDACTED]. Findings Include: Review of the Face Sheet, care plans dated 8/21/17, nurse and physician notes dated 8/21/17 through 8/22/17, physician orders [REDACTED].#2 was a [AGE] year-old alert female, admitted to the facility on [DATE], able to make her own healthcare decisions and dependent on staff for assistance with her Activities of Daily Living (ADL). The resident's [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The resident was admitted to the facility for rehabilitation; her hospice services were terminated while at the facility. Review of the facility admission nurses' notes, dated 8/21/17 at 5:46 p.m., stated res (Resident #2) admitted to (the facility) from (hospital) via EMS (Emergency Medical Services) on stretcher, res here for PT/OT/ST post hospital admission (for a fall at home with pelvic fractures), res was recently at home on hospice d/t (related to ) [MEDICAL CONDITION] with metastasis (cancer spread) to the bone, res goal to increase strength and decrease pain and return to community, res verb (verbalized) adequate pain relief with current regimen at hospital, res able to make needs known. Review of Resident #2's physician orders, dated 8/21/17, and the Electronic Medication Administration Record [REDACTED]. [MEDICATION NAME] (narcotic pain medication) tablet 4 mg, give 1 tablet by mouth every 4 hours as needed for pain 5 (pain level 5 or less), [MEDICATION NAME] tablet 4 mg, give 2 tablet by mouth every 4 hours as needed for pain 6 (pain level 6 or above). Review of the resident's Pain care plan, dated 8/21/17, stated anticipate residents need for pain relief PRN (as needed) and respond immediately to any complaint of pain. Review of the hospital records, dated 8/21/17, revealed the resident was admitted to the hospital on [DATE], after a fall at home with multiple [MEDICAL CONDITION] for which she was not a surgical candidate. Review of the hospital records. dated 8/21/17, stated anterior hip pain worse when she moves her left leg, pain will be controlled with patients home medication (MS 100 mg ER every 12 hours and [MEDICATION NAME] 4 mg every 4 hours as needed, 1 to 2 tablets). Review of the facility records (admission records dated 8/21/17), revealed the resident was admitted to the facility on [DATE] at approximately 5:30 p.m. Review of the hospital records, dated 8/21/17, revealed Resident #2 had received her MS at the hospital at 8:00 a.m. She would have been due for her next scheduled dose at the facility at 8:00 p.m. and she had received her [MEDICATION NAME] 4 mg at 10:55 a.m At the facility, the resident was due for her MS at approximately 8:00 p.m. and she could have received her [MEDICATION NAME] when she requested it at approximately 8:00 p.m., due to her last documented dose of [MEDICATION NAME] being at 10:55 a.m., at the hospital. During an interview on 8/24/17 at 7:10 a.m., staff member M (Charge Nurse, RN) was asked by this surveyor if he had been the admitting nurse for Resident #2 and if he had taken the resident's hospital phone report and he answered yes. When this surveyor asked staff member M when Resident #2 had last received her breakthrough medication ([MEDICATION NAME] 4 mg) at the hospital prior to being transferred to the facility he stated, I thought she got it at the hospital, I don't know the time. Review of the hand written hospital nurse's report regarding Resident #2's admission on 8/21/17 (staff member M's handwritten note), revealed no documentation of the time the resident had received her pain medications (MS and [MEDICATION NAME]) prior to being transferred to the facility. During an interview on 8/23/17 at 12:25 p.m., staff member B (DON) stated she (Resident #2) wasn't due, she just received [MEDICATION NAME] before the transfer. Upon request by this surveyor, staff member B was not able to produce any documentation that Resident #2 had received [MEDICATION NAME] at the hospital on [DATE], other than at 10:55 a.m. Review of the facility EMAR, dated 8/17, and nurse's notes, dated 8/21/17, revealed on 8/21/17, Resident #2 received MS 100 mg for pain at 9:00 p.m. No documentation was found that she received [MEDICATION NAME] ([MEDICATION NAME] 4 mg) at the facility on 8/21/17 per her request. Observation and interview was done during the initial facility tour on 8/22/17 at 9:33 a.m. Resident #2 was laying in her bed, hardly moving, with facial grimaces indicating discomfort and pain. The resident verbalized she was in a lot of pain, and when this surveyor asked her when she had last received pain medication, she said she had gotten her MS 100 mg at around 8:00 p.m., but not her [MEDICATION NAME] (for break through pain) after she was admitted to the facility on [DATE], at approximately 5:30 p.m. The resident stated my hip, O God I don't know, it was all night I did not have pain medication. Per review of the physician's orders [REDACTED]. Observation and interview was done on 8/22/17 at 12:50 p.m. Resident #2 was in her room sitting in her chair, holding her left hip area. The resident stated, It's (her pain level) a little better, but still is not ok because they (the facility) messed it up. I rely on that pain pill ([MEDICATION NAME] 4 mg every 4 hours for breakthrough pain) to keep things regular, I feel it when it gets messed up. It's (pain level) about a 8 to 9, my whole body hurts. Resident #2 said she had requested her [MEDICATION NAME] 4 mg pain medication on 8/21/17 at approximately 8:00 p.m. from the nurse (staff member G, Charge Nurse, RN). However she never received it. Review of the EMAR, dated 8/17, revealed on 8/22/17 at 8:06 a.m., the first day of the survey, the resident received [MEDICATION NAME] 4 mg (for pain) and klonopin 0.5 mg (for anxiety) for a pain level of 10 and at 12:00 p.m. (on 8/22/17), her pain level was at still high being a 9. Observation and interview was done on 8/23/17 at 7:20 a.m. Resident #2 was in her room, in her bed. The resident said she did not want to get out of bed because she hurt and stated, it's a high 7 (her pain level), when it's (pain) high, it takes a long time to get back down. The resident said she was depressed and in pain so she just wanted to stay in her room in bed. During a phone interview done on 8/23/17 at 5:28 p.m., staff member G (Charge Nurse, RN) was asked by this surveyor if she had looked in the facility medication back-up box for [MEDICATION NAME] 4 mg to give Resident #2 when it was requested on 8/21/17, at approximately 8:00 p.m. Staff member G stated, what's this about, we don't have [MEDICATION NAME] in the back-up box, well that's what I was told; no I did not check in (the back-box for [MEDICATION NAME]). Staff member G said she did not look in the facility back-up box for [MEDICATION NAME] when Resident #2 requested it for breakthrough pain due to [MEDICAL CONDITION] and multiple [MEDICAL CONDITION]. Review of the pharmacy documentation given to this surveyor by staff member B (DON) on 8/23/17, revealed the only medication that was taken out of the facility back-up box on the rehab unit was [MEDICATION NAME] 5 mg for a resident other than Resident #2 for the week of 8/21/17. Observation of the medication back-up box was conducted on 8/23/17 at 7:15 a.m. accompanied by staff member B (DON) and staff member F (Charge Nurse, RN). The back-up box seal had to be broken and a total of 5 [MEDICATION NAME] 4 mg tablets were found inside which would be a total of 10 mg. Resident #2's order was for 4 mg (1 or 2 tablets) of [MEDICATION NAME] for pain on an as needed basis. During an interview on 8/23/17 at 7:00 a.m., staff members B (DON) and F (Charge Nurse, RN) both verbalized the [MEDICATION NAME] 4 mg tablets were normally in the back-up box and the back-up box was kept in the medication room on the rehab unit. It was available on 8/21/17. During an interview on 8/23/17 at 10:00 a.m., staff member I (Physical Therapist/PT) revealed she had evaluated and treated Resident #2 on 8/22/17, and stated, she verbalizes pain when she moves. During an interview on 8/23/17 at 10:10 a.m., staff member J (Occupational Therapist/OT) revealed she had evaluated and treated Resident #2 on 8/22/17, and stated she does have pain with movement. During an interview on 8/23/17 at 10:45 a.m., staff member K (Speech Therapist) revealed she had treated the resident on 8/23/17 in the morning and stated she had neck pain while in bed, I want her out of bed for feeding. The resident stays in her room, in her bed due to pain and depression per an interview done with her on 8/23/17 at 7:20 a.m. Review of the facility Pain Management policy, dated 5/2010 and revised 8/20/16, stated The facility will evaluate and identify residents for pain, determine the type, location and severity and development a care plan for pain management. Residents will be monitored for the presence of pain and be evaluated Pain is subjective, when the resident says they are in pain, they are in pain and all interventions should be implemented to elevate their pain, including giving the requested ordered pain medication. It is important for the resident to receive the appropriate medication and to stick to a scheduled dose, or to give the medication upon request to treat his or her medical condition and relieved the pain. The physician should be contacted if the medication does not relieve the resident's pain. In addition, in the terminally ill resident, there is no basis to fear them becoming addicted to a narcotic given for pain. The federal guidelines regulating hospice require the hospice to make every reasonable effort to assure that the patient's pain is controlled. Findings suggest that [MEDICATION NAME] management for daily pain is better for nursing home residents enrolled in hospice services at the time they are in the nursing home. Hospice Patients Alliance, Pain Control: Methods and Standards of Care http://www.hospicepatients.org/hospice29.html, PPM Practical Pain Management, Pain Management in Nursing Homes and Hospice Care https://www.practicalpainmanagement.com

Based on observation, interview and record review the facility failed to prevent the recurrence of a resident-to-resident physical incident for 1 resident (Resident #2) of 2 residents, resulting in Resident #2 being hit with a closed hand (punched), which caused Resident #2 to fall and sustain a fracture. Findings: Record review of the Michigan State Operations Manual (SOM) revealed each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. According to 'Encyclopedia & Dictionary of Medicine, Nursing & Allied Health' Miller-Keane 6th edition, page 8, abuse is any act resulting in a non-accidental physical injury, including not only intentional assault but also the results of unreasonable punishment. In 'National Institute of Health' [DATE] issue manuscript 'Resident-to-Resident aggression in Long-Term Care Facilities: An Understudied Problem' by Rosen, Pillmer & Lachs, defined resident -to- resident aggression (RRA) in long-term care facilities as negative and aggressive physical, sexual, or verbal interactions between long term care residents, that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress to the recipient .' In the article 'Elder Abuse and Neglect: In search of Solutions' by the American Psychological Association, 2012 noted 'Older adults who show signs of dementia may become abusive as part of the disease process, The object of the abuse may be another adult for example, a family caregiver, professional caregivers or other individuals with whom the person interacts. The abuse may take the form of hitting or gripping another person to the extent of causing bruises or creating hazards .Although abusive behavior by older adults may be explained by changes in his or her cognitive abilities or triggered by an abusive response by a care giver, it is still unacceptable'. In 'The New England Journal of Medicine' [DATE] issue, the article 'Elder Abuse', by Lachs and Pillmer, page 1952, table2. Identified that elder abuse can occur in long-term care facilities; resident-to-resident abuse is increasingly recognized as the most common form of abuse in such settings. On page 1954, the Omnibus Budget Reconciliation Act of 1987, which created a federal framework for the standardized assessment and care of nursing home residents, heighten both awareness and reporting of elder abuse in nursing homes .Studies have pointed to the very high prevalence of mistreatment of [REDACTED]. Physicians should be alert to this possibility when examining and treating nursing home residents, because clinically significant injuries have been found to result from resident-to-resident aggression'. Observation on [DATE] at approximately 10:30 AM during the entrance tour at the beginning of the on-site investigation of the Reflections secured dementia unit revealed there to be one hallway with secured doors at each end of the hall, with an all-purpose room used for dining/activities, and at the other end of the hallway there was a nosing desk located in the middle of the hallway with a small sitting room to the side with 3 chairs and a smaller room with a fireplace beyond that with no chairs. Review of the facility resident list noted that there were currently 19 cognitively impaired residents living within the unit. A review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed that Resident #2 is an [AGE] year-old female with severely impaired cognitive skills. Medical [DIAGNOSES REDACTED]. Resident #2 was noted to reside on the secured dementia unit at the time of the incident. Record review of Resident #2's care plans revealed care plans for short-term memory loss and long-term memory loss with confusion, difficulty with word finding, requiring cueing and redirection and staff anticipation of needs at times due to [DIAGNOSES REDACTED]. Care plan for exhibition behaviors of wandering and care plan for falls related to [DIAGNOSES REDACTED]. Record review of Resident #1's Minimum Data Set (MDS), dated [DATE], revealed that Resident #1 was an [AGE] year-old male with severely impaired cognitive skills. Medical [DIAGNOSES REDACTED].#1 was noted to reside on the secured dementia unit at the time of the incident. Record review of Resident #1's 'Incident and Accident Report' form, dated [DATE] at 7:00 AM, revealed that Resident #1 was observed in the hallway hitting another male resident with a closed fist. Record review of Resident #1's 'Incident and Accident Report' form, dated [DATE] at 6:15 PM, revealed that Resident #1 was observed to exit his room into the hallway and hit another male resident with a hair brush in the arm and head, after which both residents began hitting and kicking at each other. Resident #1 and Resident #2 Incidents: Record review of an 'Incident and Accident Report' form, dated [DATE] at 1:45 AM, for Resident #2 revealed that Resident #2 was eating a sandwich and tried to give Resident #1 a part of the sandwich. Resident #1 was noted to grab Resident #2's finger and push her away. Record review of an 'Incident and Accident Report' form, dated [DATE] at 4:00 PM, for Resident #2 described an incident during which Resident #2 was found sitting on floor as a result of a hit by Resident #1. A brief description of the incident revealed that Resident #1 was in Resident #2's room. Resident #1 got upset when Resident #2 put her hand on his arm. Resident #1 pulled his arm back. Resident #2 moved closer to him. Resident #1 hit Resident #2 in the upper abdominal region with 2 punches, causing Resident #2 to lose her balance. Record review of 'Incident and Accident Report' form, dated [DATE] at 11:30 PM, for Resident #2 described an incident, which revealed that 'Resident #2 was observed in front of her doorway falling to the floor. Resident #1 was observed standing in front of Resident #2 with arms/hands raised upward. Complained of right hip pain'. Review of noted staff interviews on [DATE] revealed that Certified Nurse assistant (CNA) M observed Resident #1 strike at Resident #2. Resident #2 then fell to the floor. CNA M was noted to state that Resident #1 had been walking up and down the halls and states he was going to wake everybody up. A noted interview at the top of page 2, of the staff interview form revealed that CNA on [DATE] at 2:35 PM stated Resident #1 had been agitated, wanting staff to call his family, when they explained it was (late), he became upset, walked down the hallway to Walsh doors (other end of hallway). At that time Resident #2 walked out of room turned to her left and Resident #1 approached her with his right hand strike Resident #2 with a fist, then push her backwards, causing Resident #2 to fall backwards. Record review of Licensed Practical Nurse (LPN) O staff interview revealed that the nurse was at the nursing station and observed Resident #2 walk out of her room, Resident #1 was standing in front of Resident #2 with arms/hands raised up as Resident #2 fell against the wall then to the floor. Resident #1 was removed from the area and LPN O noted that she assisted Resident #2 to standing position and questioned Resident #2 about pain and resident stated Yes and touched her right leg. Passive range of motion with no grimacing or guarding. Observed ambulating with merriwalker. In a telephone interview on [DATE] at 11:30 AM, Certified Nurse Assistant (CNA) M revealed that she saw the incident from a distance from the nursing station. Resident #2 came out of her room, took ,[DATE] steps toward the Walsh doors, Resident #1 was already there, he took one look at Resident #2 and he swung at her with a closed fist, he threw a punch at Resident #2's face causing the resident to fall to the floor on her right side. Interview a telephone interview on [DATE] at 12:12 PM, Certified Nurse Assistant (CNA) N revealed that she was working the 2nd shift on [DATE] when Resident #1 became angry/upset wanting the staff to call his family while at the nursing station (end of the hall). Resident #1 then walked down the hallway to the Walsh doors (other end of hall). He was looking out the door window when Resident #2 started walking down the hall (without her merriwalker device) toward the Walsh doors. Resident #1 had a look on his face of anger. Resident #1 saw Resident #2 and hit her with a closed fist across the face very hard pushing her back into the wall and then hit Resident #2 again in the stomach, that's when Resident #2 fell to the floor and Resident #1 was going to hit Resident #2 again while on the floor and CNA N stopped/redirected him away. On [DATE] at 6:40 AM, Resident #2 was sent to the local emergency room as a result of the physical assault, with noted pain and discomfort to her right leg and entire body. Resident fell on to the floor as a result of multiple punches. Resident #2 was admitted to the hospital for 3 days due to pelvic fractures. #

This citation pertains to MI# 161 Based on interview and record review, the facility failed to include timely interventions to address the resident's risk factors to prevent falls in 1 (#101) out of 4 total sampled residents reviewed resulting in unwitnessed falls and hospitalization for an injury of a left hip fracture Findings Include: Record review of facility "Fall Management" policy dated 7/2014 noted, " The facility will identify hazards and resident risk factors and implement interventions to minimize falls. Each resident is assisted to attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk of falls........If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk assessment, treatment, evaluation, and monitoring of resident falls". Record review of facility "Comprehensive Plan of Care" policy dated 5/2013 noted, "Each resident will have a plan of care based on the comprehensive assessment. Additional resources will also be utilized to ensure that any additional needs or risk areas are identified......The care plan must be specific, resident centered, individualized and unique to each resident and may include.......involve and communicate the needs of the resident with the direct care staff....." In typed letter by the Director of Nursing services dated 11/12/14, " The facility does not utilize devices as a standard of practice for residents identified at risk for falls........" A tour on 11/12/14 at 8:50 AM during the entrance tour at the beginning of the investigation revealed that Resident #101 was not living at the facility, but was still hospitalized for [REDACTED]. Closed record review of Resident #101's admission nursing note dated 10/15/14 at 4:27 PM noted Resident #101 as high risk for falls related to his medications, [DIAGNOSES REDACTED]. Family member requested a trunk restraint as he frequently gets up from his wheelchair and falls. Record review of Resident #101's Incident and Accident Report dated 10/15/14 revealed that the resident's family member removed the wheelchair lap buddy from the wheelchair, transferred resident to the bathroom and left him to stand by the door. A facility staff who came to assist observed Resident #101 on the floor. Record review of Resident #101's Incident and Accident Report dated 10/28/14 revealed the description of the second fall which was unwitnessed as:, "'Resident was trying to attempt to self-transfer, fell out of bed and hit head on bottom drawer of dresser that was partially open... The Resident #101 was interviewed and it was noted that Resident confused, couldn't say why he was getting up and what he was trying to get'". The incident/accident form noted facility's plan or intervention to avoid the another fall situation in the future was, "History of low sodium levels and noted blood pressure fluctuations, hydralazine....Assess orthostatic blood pressures, recheck labs BNP and TSH". The history of low sodium levels and noted blood pressure fluctuations may be considered risk factors that added to Resident #101's risk for falling. Aside from checking the orthostatic blood pressure and laboratory work, it was unclear if there was anything more specific to add to the falls intervention. A record review of Resident #101's 'Risk for Falls' care plan created on 10/15/14 noted Resident #101 was at risk for falls related to his diagnosis, unaware of safety needs, gait/balance problems, psychoactive drug use, confusion, incontinence, poor communication/comprehension, [DIAGNOSES REDACTED]. Interventions dated 10/15/14 included gripper socks or shoes at all times. Lap buddy in wheelchair; remove at mealtime, for repositioning every one hour as needed. Offer to lie down after meals. Put the resident call light in reach and encourage him/her to use it for assistance as needed. Ensure resident is wearing appropriate footwear. PT/OT evaluation and treat as ordered or PRN (whenever necessary). It is unclear whether resident #101 use of a call light is appropriate given his assessment of confusion, poor communication/comprehension and unaware of safety needs. It is unclear whether his incontinence was addressed given this risk assessment. Interventions that were added on 10/28/14 after the second unwitnessed fall wherein resident #101 was found on the floor included: 'Check BNP, NA+, TSH and orthostatic vital signs as ordered. Transfer one person assist". Resident #101 was described to self-transfers despite his fall risks. Record review of Resident #101's progress notes by nurse practioner dated 10/28/14 at 1:46 PM revealed that the resident fell out of bed this morning.....laceration of head s/p fall- continue with orthostatic BP checks, apply triple antibiotic ointment to cut on head and cover with dry gauze BID (twice a day). Dementia- at baseline, continue with supportive care and redirection, monitor for impulsive actions and attempts to transfer per self. It was unclear whether the nurse practitioner's assessment and directives were incorporated to the care plan after the 10/28/14 incident. It was unclear how the directive, " Monitor for impulsive action and attempts to transfer per self" were addressed in a quantifiable objective. Record review of Resident #101's Incident and Accident Report dated 11/05/14 revealed that there was a fracture left hip per x-ray with no known event. Conclusion on the accident/incident form revealed, "At 4:00 PM nurse saw the resident standing awkwardly at the bedside, it is presumed , although unable to prove, that resident had gotten to that position after falling to the floor... In a witness statement on 11/6/14 from Licensed Practical Nurse (LPN) "G" attached to the incident/accident form revealed that two hours after on duty around 4:00 PM while passing meds, noted him (resident #101) standing and leaning over her saying 'Help, help", incontinent of bowel. Resident #101 complained of left leg pain and assessed and gave Tylenol. After dinner helped with toileting and resident didn't want to bear weight at all....." Record review of Resident #101's nurse note dated 11/6/14 at 0:42 AM noted left leg externally rotated and appears 1 inch shorter than the right...... Record review of Resident #101's nurse note dated 11/6/14 at 1:50 AM noted Resident #101 sent to emergency room at that time. An interview on 11/13/14 at 11:25 AM with the Assistant Director of Nursing (ADON) "C" revealed the review of Resident #101's 'Risk for Falls' care plan which she created on 10/15/14 noted the safety interventions put in place were gripper socks or shoes. The Resident was found on the floor on 10/28/14 and interventions included orthostatic B/P and labs were placed or added. The ADON "C" was asked if any interventions were placed related to the resident's self-transferring and the ADON "C" stated, "None, we wouldn't have changed anything, he was confused". The care plans that were modified did not adequately address the risk factors and reassessments for resident #101 that may have prevented the fall on 10/28/14 and an inference to a probable fall on 11/05/14. ( # }

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO TIMELY IDENTIFY PRESSURE ULCERS AND IMPLEMENT PRESSURE RELIEF AND/OR OTHER APPROPRIATE TREATMENT INTERVENTIONS IN ORDER TO PREVENT THE DEVELOPMENT OF PRESSURE WOUNDS IN TWO (#5 AND 8) OF TWO RESIDENTS REVIEWED FOR PRESSURE WOUNDS IN A TOTAL SAMPLE OF 19 RESIDENTS, RESULTING IN THE DEVELOPMENT OF A STAGE 3 (FULL THICKNESS SKIN LOSS INVOLVING DAMAGE AND/OR NECROSIS OF SUBCUTANEOUS TISSUE) PRESSURE WOUND ON THE COCCYX (TAILBONE) AND SUSPECTED DEEP TISSUE INJURY (SDTI) WOUNDS ON BOTH HEELS FOR RESIDENT #5 AND THE DEVELOPMENT OF A STAGE 2 (PARTIAL THICKNESS SKIN LOSS) LEFT LATERAL HEEL WOUND FOR RESIDENT #8. FINDINGS INCLUDE: BASED ON THE ACCUMULATED [DIAGNOSES REDACTED].M. AND THE INITIAL MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE], RESIDENT #5 WAS A [AGE] year OLD WITH MODERATE COGNITIVE IMPAIRMENT WHOSE [DIAGNOSES REDACTED]. THE MDS REFLECTED RESIDENT #5 USED THE WHEELCHAIR AND REQUIRED EXTENSIVE ASSIST OF ONE STAFF FOR TRANSFERS AND LOCOMOTION IN THE HALLS. RESIDENT #5 STOOD/WALKED ONLY IN THERAPY. ACCORDING TO THE "BRADEN SCALE-FOR PREDICTING PRESSURE ULCER RISK" RESIDENT #5 WAS SCORED "18" ON 10/10/12 AND 10/17/12 AND "17" ON 10/24/12 AND 10/30/12. (A SCORE OF LESS THAN 18 REPRESENTED HIGH RISK FOR PRESSURE ULCER DEVELOPMENT.) BASED ON RESIDENT #5'S "NURSING COMPREHENSIVE EVALUATION" COMPLETED ON ADMISSION ON 10/3/12, AND THE UNIT NURSING NOTES, DATED 10/4/12 AT 12:00 MN (MIDNIGHT), THERE WERE NO DOCUMENTED OPEN AREAS ON RESIDENT #5'S COCCYX OR HEELS. THE "SKIN NOTES", DATED 10/4/12, WRITTEN BY WOUND CARE REGISTERED NURSE (RN) "C" REFLECTED "SKIN INTACT." THE FIRST DOCUMENTATION RELATED TO A COCCYX PRESSURE ULCER WOUND WAS FOUND ON THE NARRATIVE PORTION OF THE "MEDICARE DAILY NURSES NOTES", DATED 10/21/12, WHICH REFLECTED: "...CONTINUES WITH OPEN AREA TO COCCYX WITH TREATMENT CREAM APPLIED." THERE WAS NO DOCUMENTATION TO STATE WHEN THE COCCYX WOUND DEVELOPED AND, WITHOUT A DESCRIPTION OF THE WOUND, THERE WAS NO EVIDENCE THAT THE "CREAM" APPLIED WAS THE APPROPRIATE TREATMENT. A TREATMENT ORDER WRITTEN ON THE "INTERIM ORDERS", DATED 10/22/12, REFLECTED "...STAGE 2 DECUBITUS ULCER COCCYX CLEANSE WITH NS (NORMAL SALINE) COVER WITH ALLEVYN (TYPE OF OCCLUSIVE DRESSING) CHANGE Q (EVERY) 3-5 DAYS AND PRN (AS NEEDED)." A STAGE 2 PRESSURE ULCER IS A SUPERFICIAL WOUND. THERE WAS NO DOCUMENTATION OF THE COCCYX WOUND FOUND ON THE "NURSING WEEKLY (HEAD-TO-TOE) SKIN ASSESSMENT" FORM FOR ENTRIES DATED 10/18/12, 10/25/12 AND 11/1/12. HOWEVER, ON 10/25/12, THE WOUND CARE NURSE RN "C" DOCUMENTED THE COCCYX WOUND ON A DIFFERENT FORM, THE "WOUND/SKIN HEALING RECORD" AND, THIS TIME, THE WOUND WAS DESCRIBED AS A "STAGE 3" MEASURING 5 CM BY 1.8 CM WITH 80% OF THE WOUND BED COVERED BY SLOUGH (DEAD TISSUE). THERE WAS NO INFORMATION PROVIDED TO EXPLAIN HOW THE WOUND HAD DETERIORATED FROM A STAGE 2 ON 10/22/12 TO A STAGE 3 ON 10/25/12. BASED ON THE "INTERIM ORDERS" WRITTEN FOR RESIDENT #5 ON 10/25/12, THE TREATMENT WAS CHANGED TO ADD A DAILY [MEDICATION NAME] AGENT TO THE SLOUGH. ON 11/21/12, THE TREATMENT WAS INCREASED TO TWICE DAILY, AND THE WOUND MEASURED 3 CM BY 1 CM WITH SLIGHTLY DECREASED SLOUGH, ACCORDING TO THE "SKIN NOTES" AND THE "WOUND/SKIN HEALING RECORD" WRITTEN BY RN "C". ON 11/27/12 THE "SKIN NOTES" AND "WOUND/SKIN HEALING RECORD" REFLECTED THE WOUND WAS THE SAME SIZE WITH 75% WHITE SLOUGH AND THE TREATMENT WAS CHANGED TO [MEDICATION NAME] TWICE DAILY WITH AN OCCLUSIVE DRESSING. ON 12/5/12 AT 11:20 A.M., RESIDENT #5 WAS OBSERVED IN HER ROOM DURING WOUND CARE PERFORMED BY RN "D". THE RESIDENT HAD AN OPEN AREA OVER THE COCCYX, MEASURING APPROXIMATELY 2 CM BY 1 CM AND ONE ON THE RIGHT BUTTOCK (3-4 INCHES FROM THE COCCYX WOUND) MEASURING APPROXIMATELY 1 CM BY 0.25 CM. BOTH WOUND BEDS WERE RED AND SHINY WITHOUT SLOUGH (DEAD TISSUE) AND THE EDGES OF THE WOUNDS HAD A THIN RIM OF WHITE TISSUE. THE RESIDENT'S BUTTOCKS WERE PURPLISH RED IN AN 8-10 CIRCLE AROUND THE WOUNDS. DURING AN INTERVIEW, ON 12/6/12 AT 11:45 A.M., RN "C" STATED THE PRESENCE OF THE TWO SMALLER WOUNDS OBSERVED ON 12/5/12 INDICATED HEALING OF THE LARGER WOUND INTO TWO SMALLER AREAS, NOT THE DEVELOPMENT OF A NEW WOUND. DURING THE SAME OBSERVATION, ON 12/5/12 AT 11:20 A.M., RESIDENT #5'S HEELS WERE OBSERVED. THE LATERAL EDGE OF THE RIGHT HEEL HAD AN APPROXIMATELY 1.5 CM BY 1.0 CM AREA COVERED WITH A LIGHT BROWN ESCHAR (DEAD LEATHERY TISSUE) WITH 2 ROWS OF SMALL BLACK DOTS GOING ACROSS THE WOUND. THE LATERAL EDGE OF THE LEFT HEEL HAD AN APPROXIMATELY 1.0 CM ROUND WOUND COVERED WITH BLACK HARD ESCHAR. BOTH OF RESIDENT #5'S LEGS WERE SWOLLEN WITH 2-3 + [MEDICAL CONDITION] (FLUID RETENTION AS MEASURED FROM 1-4 +, WITH "4" BEING THE LARGEST AMOUNT OF RETAINED FLUID). DURING INTERVIEW AT THE TIME OF OBSERVATION, RN "D" SAID THAT THE [MEDICAL CONDITION] WAS NORMAL FOR RESIDENT #5. RESIDENT #5'S "INITIAL CARE PLAN" SECTION 8, DATED 10/3/12, HAD BOXES CHECKED TO INDICATE ALTERATION IN SKIN INTEGRITY AND THE POTENTIAL FOR ALTERATION IN SKIN INTEGRITY. THE INTERVENTIONS INCLUDED REPOSITIONING EVERY 2 HOURS, AND AS NEEDED, AND KEEPING THE RESIDENT CLEAN AND DRY AND OFF THE AFFECTED AREA(S), IF POSSIBLE. RESIDENT #5'S COMPREHENSIVE CARE PLAN, DATED 10/10/12 AND LAST REVISED 11/8/12, REFLECTED INTERVENTIONS OF TURN/REPOSITION EVERY 2 HOURS, OR MORE OFTEN AS NEEDED OR REQUESTED, A SPECIALTY MATTRESS ON THE BED AND A PRESSURE RELIEVING CUSHION IN THE WHEELCHAIR. HOWEVER, THE NURSE AIDE CARE GUIDE (STORED IN THE RESIDENT'S CLOSET AND USED BY THE NURSING AIDES WHEN GIVING CARE), UPDATED 11/16/12, DID NOT REFLECT THE RESIDENT'S NEED TO BE REPOSITIONED EVERY 2 HOURS IN BED OR EVERY HOUR IN THE CHAIR. AND, THE "ADL FLOW RECORD", USED BY THE NURSING AIDES TO DOCUMENT THE CARE THEY PROVIDED, DATED 10/2012 AND 11/2012, DID NOT REFLECT REPOSITIONING FOR THE RESIDENT. DURING AN INTERVIEW ON 12/6/12 AT 11:45 AM, RN "C" AGREED THERE WAS NO DOCUMENTATION RELATED TO THE COCCYX WOUND UNTIL 10/21/12 AND NO DESCRIPTION OF THE WOUND UNTIL 10/25/12. THE "MEDICARE DAILY NURSES NOTES" FOR RESIDENT #5, DATED 11/4/12 AT 9:00 PM, REFLECTED "...RIGHT HEEL HAS SMALL BLACK AREA MSG (MESSAGE) LEFT FOR TREATMENT NURSE TO OBSERVE..." THE DESCRIPTION OF THE BLACKENED SKIN THAT WAS DOCUMENTED IN THE NOTES WAS AN INDICATION THAT THE WOUND WAS NOT IDENTIFIED UNTIL IT HAD ALREADY DETERIORATED TO A LATER STAGE OF DEVELOPMENT. THERE WAS NO EVIDENCE THAT ROUTINE MONITORING OF THE RESIDENT'S HEELS HAD IDENTIFIED EARLIER STAGES OF HEEL WOUND DEVELOPMENT (SUCH AS REDNESS, MUSHY AREAS AND NON-BLANCHABLE AREAS). THERE WAS NO FULL DESCRIPTION OR MEASUREMENT OF THE WOUNDS UNTIL 11/5/12 WHEN THE WOUND CARE NURSE RN "C" DOCUMENTED ON THE "WOUND/SKIN HEALING RECORD" THAT THE RIGHT HEEL WOUND WAS 1 CM BY 1 CM WITH BLACK/BROWN ESCHAR AND THE LEFT HEEL WOUND WAS 3 CM BY 1.4 CM WITH BLACK/BROWN ESCHAR. BOTH WERE IDENTIFIED AS SUSPECTED DEEP TISSUE INJURY. "INTERIM ORDERS", DATED 11/5/12, REFLECTED "...PRAFO (PADDED BOOTS WITH OPEN HEELS TO RELIEVE PRESSURE ON THE HEEL AREA) BOOTS AT ALL TIMES X (EXCEPT) WHEN WALKING WITH THERAPY MONITOR BLISTERS ON HEELS Q (EVERY) SHIFT..." ELEVATING HEELS OFF THE BED WAS NOT IDENTIFIED AS AN INTERVENTION ON RESIDENT #5'S "INITIAL CARE PLAN" SECTION 8, DATED 10/3/12. BECAUSE OF RESIDENT #5'S [MEDICAL CONDITION], DIABETES, [MEDICAL CONDITION], COGNITIVE IMPAIRMENTS AND MOBILITY LIMITATIONS, THE RESIDENT WAS AT INCREASED RISK FOR BREAKDOWN ON HER HEELS. THE COMPREHENSIVE CARE PLAN, DATED 10/10/12 AND LAST REVISED 11/8/12, REFLECTED INTERVENTIONS OF TURN/REPOSITION EVERY 2 HOURS OR MORE OFTEN AS NEEDED OR REQUESTED, AND A SPECIALTY MATTRESS ON BED, BUT THE INTERVENTION FOR ELEVATING THE RESIDENT'S HEELS OFF THE BED WAS NOT ADDED UNTIL 11/7/12, AFTER THE HEEL PRESSURE WOUNDS HAD ALREADY BEEN IDENTIFIED. FURTHERMORE, THE NURSE AIDE CARE GUIDE STORED IN THE RESIDENT'S CLOSET AND USED BY THE NURSING AIDES WHEN GIVING CARE, UPDATED 11/16/12, DID NOT REFLECT THE REQUIRED USE OF THE PRESSURE RELIEVING BOOTS (AS ORDERED BY THE PHYSICIAN ON 11/5/12), OR ELEVATION OF THE HEELS OFF THE BED. THE "ADL FLOW RECORD", USED BY THE NURSING AIDES TO DOCUMENT CARE, DATED 10/2012 AND 11/2012, DID NOT REFLECT ELEVATION OF THE RESIDENT'S HEELS WHILE IN BED. DURING AN INTERVIEW, ON 12/6/12 AT 11:45 A.M., RN "C" STATED, SINCE RESIDENT #5 HAD BEEN PROVIDED WITH A LOW AIR LOSS MATTRESS FOR HER BED AT ADMISSION, ELEVATION OF THE HEELS WOULD NOT HAVE BEEN REQUIRED. ACCORDING TO THE CLINICAL PROCESS GUIDELINE FOR THE PREVENTION AND MANAGEMENT OF PRESSURE ULCERS, EFFECTIVE 3/31/03, POSITIONING SHOULD ALLEVIATE PRESSURE OVER BONY PROMINENCES AND SHEARING FORCES OVER THE HEELS, REGARDLESS OF THE TYPE OF MATTRESS USED. IN OTHER WORDS, THE USE OF A PRESSURE RELIEVING MATTRESS DOES NOT TAKE THE PLACE OF ELEVATING THE HEELS TO OFF-LOAD PRESSURE AND PREVENT THE DEVELOPMENT OF PRESSURE WOUNDS. ( ) RESIDENT #8 WAS A [AGE] year OLD FEMALE RE-admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ON 12/4/12 DURING THE INITIAL TOUR OF THE FACILITY, UNIT MANAGER, REGISTERED NURSE (RN) STAFF "C" IDENTIFIED RESIDENT #8 AS HAVING A LEFT LOWER EXTREMITY ULCERATION ON HER LEFT HEEL. ON 12/4/12 AT 11:13 A. M., RN "C" WAS ASKED TO PROVIDE A COPY OF RESIDENT #8'S CARE PLAN WITH THE INTERVENTIONS THAT WERE IN PLACE TO PREVENT PRESSURE AREAS PRIOR TO THE DEVELOPMENT OF RESIDENT #8'S LEFT HEEL ULCER. RN "C" INDICATED RESIDENT #8'S PREVIOUS CARE PLANS INCLUDED INTERVENTIONS TO PREVENT LOWER EXTREMITY SKIN BREAKDOWN. THE CARE PLANS THAT WERE REQUESTED WERE NOT PROVIDED. ON 12/4/12 AT APPROXIMATELY 11:30 A.M., RESIDENT #8 WAS OBSERVED LYING IN BED IN HER ROOM WITH HER RIGHT FOOT ELEVATED WITH A PILLOW AND HER LEFT FOOT WITH A PRESSURE RELIEVING BOOT ON, BUT NOT ELEVATED, AND RESIDENT #8 INDICATED TO THIS SURVEYOR, AT THE TIME OF OBSERVATION, THAT HER LEFT LEG HURT A LOT. RESIDENT #8'S ADMISSION NURSING COMPREHENSIVE EVALUATION WAS COMPLETED AT THE TIME OF HER ADMISSION ON 9/13/12. THE EVALUATION REFLECTED A BRADEN SCALE (TOOL FOR PREDICTING PRESSURE SORE RISK) WITH A SCORE OF "18". A CARE PLAN WAS TO BE INITIATED, PER THE TOOL'S DIRECTIONAL COMMENT: "IF RISK IS 18 OR LESS, INITIATE CARE PLAN". RESIDENT #8'S CARE PLAN FOR ACTIVITY OF DAILY LIVING (ADL) SELF PERFORMANCE DEFICIT RELATED TO DEMENTIA, CONFUSION, IMPAIRED BALANCE AND DECREASED MOBILITY, DATED AS INITIATED ON 9/29/12, IDENTIFIED THE INTERVENTION FOR BED MOBILITY AS: "RESIDENT REQUIRES EXTENSIVE 1 PERSON STAFF PARTICIPATION TO REPOSITION AND TURN IN BED". RESIDENT #8'S MINIMUM DATA SET assessment dated [DATE] ALSO INDICATED RESIDENT #8 NEEDED ASSISTANCE FOR BED MOBILITY ("HOW THE RESIDENT MOVES TO AND FROM A LYING POSITION, TURNS SIDE TO SIDE AND POSITIONS BODY WHILE IN BED"). HOWEVER, NO INTERVENTION TO FLOAT RESIDENT #8'S HEELS WAS FOUND LISTED AS AN INTERVENTION ON HER CARE PLAN. RESIDENT #8'S BRADEN SCALES' DATED 9/19/12, 9/26/12, INDICATED SCORES OF 15; AND, ON 10/3/12 AND 10/8/12, THE BRADEN SCALES INDICATED SCORES OF 14. (BOTH 14 AND 15 SCORES FALL INTO THE RANGE REQUIRING THAT PRESSURE ULCER PROTOCOLS BE IMPLEMENTED.) THE CERTIFIED NURSING ASSISTANT (CNA) CARE GUIDE INITIATED PER THE UNIT MANAGER RN "C" UPON ADMISSION 9/13/12 REFLECTED ON THE GUIDE THAT: "THIS MUST BE POSTED IN THE RESIDENT'S CLOSET OR OTHER DESIGNATED AREA". THE CARE GUIDE HAD A CHECK BOX LIST WHERE THE INTERVENTIONS FOR PREVENTION OF PRESSURE AREAS WERE TO BE CHECKED, INSTRUCTING THE CNA TO IMPLEMENT THE INTERVENTIONS. THE AREAS LISTED ON THE GUIDE FOR RESIDENT #8 WERE AIR MATTRESS, PRESSURE RELIEVING BOOT, CHAIR CUSHION, ELEVATING HEELS OFF THE MATTRESS AND "OTHER", BUT ONLY THE CHAIR CUSHION BOX WAS CHECKED AS APPLICABLE. THE INTERVENTION TO ELEVATE HEELS OFF THE MATTRESS WAS NOT CHECKED AS APPLICABLE. A REVIEW OF THE CNA ADL FLOW RECORD FOR SEPTEMBER, 2012, INDICATED THAT RESIDENT #8'S HEELS WERE FLOATED FOR THE MONTH OF SEPTEMBER, AS INDICATED BY THE "ITEM" (TO) "ELEVATE HEELS ON MAROON PILLOW WHEN IN BED." BUT, IN OCTOBER, 2012, THIS "ITEM" TO ELEVATE THE HEELS WAS NOT FOUND ON THE CNA ADL FLOW RECORD, AND ONLY ON 10/7/12 AND 10/8/12 DID NURSE'S NOTE DOCUMENTATION INDICATE THAT RESIDENT # 8'S FEET WERE ELEVATED ON A PILLOW. DURING AN INTERVIEW ON 12/5/12 AT 10:15 A.M., RN "C" WAS ASKED TO REVIEW THE CNA CARE GUIDE THAT WAS FOUND POSTED INSIDE RESIDENT #8'S CLOSET. RN "C" INDICATED THAT THE CARE GUIDE HAD BEEN INITIATED UPON ADMISSION. WHEN ASKED WHERE IT WAS INDICATED THAT RESIDENT #8'S HEELS WERE TO BE ELEVATED, RN "C" REPLIED, "IT'S NOT CHECKED." DURING AN INTERVIEW ON 12/5/12 AT 10:25 A.M., RN "C" WAS ASKED WHY THE INTERVENTION TO ELEVATE RESIDENT #8'S HEELS IN BED WAS NOT DOCUMENTED IN THE OCTOBER CNA ADL FLOW SHEET AND RN "C" REPLIED, "I DON'T KNOW WHY THE INTERVENTION DIDN'T GET FROM SEPTEMBER TO OCTOBER". RN "C" WAS ASKED TO PROVIDE DOCUMENTATION TO SHOW HOW THE PRESSURE ULCER WAS UNAVOIDABLE. NO FURTHER DOCUMENTATION WAS PROVIDED BY RN "C". ON 10/8/12 A NURSING WEEKLY (HEAD TO TOE) SKIN ASSESSMENT WAS DOCUMENTED FOR 6 PM BY RN "R" AND HAD THREE AREAS CIRCLED ON A DIAGRAM OF RESIDENT #8'S BODY: THE LEFT POSTERIOR HEEL AND BOTH ELBOWS. NO COMMENTS WHERE DOCUMENTED REGARDING THE CIRCLED AREAS, BUT "THE SKIN INTACT, NO PROBLEM" CHECK BOX WAS CHECKED. NO EXPLANATION WAS DOCUMENTED AS TO WHAT THE CIRCLED AREAS INDICATED. THERE WERE NO NURSING NOTES OR SKIN NOTES FOR THE DATE 10/8/12 THAT IDENTIFIED ANY CONCERN RELATED TO THE "CIRCLED" LEFT HEEL OR ELBOWS. RESIDENT #8'S PHYSICIAN ORDERS [REDACTED]. RESIDENT #8'S NURSE NOTE DOCUMENTATION DATED 10/23/12 INDICATED "LEFT LATERAL HEEL WITH STAGE II 1 CENTIMETER (CM) BY 1 CM AND LESS THAN 0.2 CM DEEP, CLEANSED WITH NORMAL SALINE, ALLEVYN APPLIED. TREATMENT CHOICE TO ACCOMMODATE DAILY USE OF TED HOSE. WOUND BED PALE, MOIST. FLOAT HEELS IN BED. LEFT BOOT, PRAFO, IN BED. DIABETIC SHOE DURING DAY. NURSE PRACTITIONER AWARE. CONTINUE PLAN OF CARE." DURING AN INTERVIEW ON 12/6/12 AT APPROXIMATELY 10:35 A.M., THE DIRECTOR OF NURSING (DON) WAS ASKED ABOUT NURSE "R"'S DOCUMENTATION ON 10/8/12 AND THE CIRCLED AREAS ON THE "NURSING WEEKLY (HEAD TO TOE) SKIN ASSESSMENT" DIAGRAM WITHOUT ANY FURTHER ASSESSMENT FINDINGS. THE DON WAS ALSO ASKED TO PROVIDE ANY FACILITY POLICY OR PROCEDURE THAT EXPLAINED THE NURSE'S RESPONSIBILITY WHEN POTENTIAL NEW SKIN PROBLEM AREAS WERE IDENTIFIED. DURING THE SAME INTERVIEW, THE DON WAS ASKED WHY THE INTERVENTION TO ELEVATE RESIDENT #8'S HEELS WAS OMITTED FROM THE OCTOBER'S 2012 ADL FLOW RECORD. THE DON STATED THAT THE ITEMS WERE HAND ENTERED, AND MUST HAVE BEEN DROPPED OFF THE OCTOBER FORM IN ERROR. THE SKIN MANAGEMENT CLINICAL GUIDELINE PROVIDED BY THE DON, DATED 5/2010, INDICATED UNDER PRACTICE GUIDELINES, NUMBER # 3: "APPROPRIATE PREVENTATIVE MEASURES WILL BE IMPLEMENTED ON RESIDENTS IDENTIFIED AT RISK (SCORE 18 OR LESS ON THE BRADEN SCALE) AND THE INTERVENTIONS DOCUMENTED ON THE CARE PLAN; UNDER #8: "THE LICENSED NURSE WILL DOCUMENT PREVENTATIVE MEASURES ON THE RESIDENT CARE GUIDE"; UNDER #12: "IF A NEW AREA OF SKIN IMPAIRMENT IS IDENTIFIED, NOTIFY THE RESIDENT, RESPONSIBLE PARTY, ATTENDING PHYSICIAN, DON AND TREATMENT TEAM, IF APPLICABLE, AND PLACE THE RESIDENT ON THE 24-HR (HOUR) REPORT." ( )

Applies to MI 494 Based on observation, interview, and record review, the facility failed to ensure the safety in 1 of 7 sampled residents (Resident #104) (have adequately secured a television set (TV) and stand in a common area) from a total sample of 7 residents resulting in Resident #104 sustaining a skin tear, brusing, pain of her arm, and subsequent hospitalization after the TV fell on to her arm. Findings include: Review of closed medical record file MDS (Minimum Data Set) dated 7/13/11 revealed Resident #104 had [DIAGNOSES REDACTED]. Review of Physical Therapy "Discharge Summary" dated 8/1/11 revealed Resident #104 was independent for wheelchair propulsion. Review of I/A (Incident/Accident report) dated 7/30/11 at 6:10 am revealed the following: "...(Resident #104)sic was in front of the television when it fell forward off the stand and hit her. (Resident #104)sic received a skin tear to her right forearm and a deep skin tear exposing fatty tissue." CNA (Certified Nursing Assistant) #3 was interviewed on 8/26/11 at 12:15 pm in a conference room. She said she just came on duty and was standing at the Walsh Hall nurse station. Said, "...I heard a BANG, then an OUCH. I went to the gazebo room and saw the TV on the floor face down still playing. (Resident # 104)sic was sitting in the wheelchair slightly next to the TV...(Resident #104)sic was not complaining of pain at first. We took her to the nurse's station and she started complaining of pain to her nurse...we found the TV controller in her wheelchair..I never noticed if the TV stand had wheels or legs...it wasn't very high off the floor..." RN (Registered Nurse) #4 was interviewed on 8/24/11 at 3:15 pm in a conference room. RN #4 said, "...Came in gazebo room about 6:00 am...TV was face down on the floor...(Resident #104)sic was sitting up in her wheelchair like nothing happened...she was facing the hall (the bird hall) like wheeling out...the TV stand was standing up straight. The TV stand was in the same exact spot; it never moved...Later the remote control was found tucked in (Resident #104's)sic wheelchair..there was (Resident #104's) sic fat and fluids (from the arm) on the top of TV set..." Review of nurse's notes dated 7/30/11 at 6:15 am revealed "...2 deep skin tears to right upper arm and right forearm..." Review of "Progress Notes" dated 8/1/11 "...right upper arm deep tissue laceration...(resident #104)sic was sent to emergency room for treatment of [REDACTED]. Administrator #1 was interviewed on 8/24/11 at 2:12 pm in gazebo room. Staff #1 said TV remote was attached to TV stand with a wire. She said the TV stand had wheels but the front wheels were offset back from the two front corners of the stand. She said pulling (the remote) caused the cabinet to move (tip forward), "due to the wheels further back in the front" allowing the TV to slide off the stand. Maintenance Supervisor Staff #5 was interviewed on 8/28/11 at 1:45 pm in a conference room. Staff #5 said the wheels on the TV stand elevated the stand "about 1/4 inch" above floor surface. Observation on 8/24/11 at 2:12 pm revealed a television remote control attached to upper area, inside right hand door partition with about 2.5 feet of stranded picture frame wire. The top of TV set was observed to have about 2 inches of scraping followed by about a 1/4 inch wide gouge about 1/8 inch deep. The TV set was a flat screen picture tube (cathode ray tube) type measuring about 32 inches diagonally with an estimated weight of 100 pounds or more.

This citation pertains to MI# 692 Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall in 1 (#101) of 5 sampled resident, resulting in resident #101 being found by staff lying on bathroom floor bleeding from his nose and laceration to the left eye brow with bruising, and a skin tear to left forearm. Findings include: Record review of facility reported accident/incident report dated 1/4/11 at 7:00 PM revealed that resident #101 was found lying on the bathroom floor "....was bleeding from his nose, moderate amount...." Injuries were noted of laceration to left eye brow, below left eyelid, left side of nose. Bruise under right eye. Small skin tear to left posterior forearm. The back side of the incident report had hand written notes of: no alarms sounding pull tab alarm on d/c (discontinue) - intact and working; bathroom door alarm on door, not alarming, but working when tested . Resident had laceration to the left side of face, bruise to right under eye, skin tear to left posterior forearm... Review of the second page of the resident #101's incident/accident report dated 1/4/11 revealed that the resident had a history of [REDACTED]. Resident was witnessed in the past by the charge nurse to reach up to door alarm and manipulate the trigger mechanism for the alarm. Staff confirm that alarm was in place and in the on position prior to incident. The alarm was disengaged by resident. Record review of resident #101's other incident/accident reports revealed that on 1/4/11 at 10:30 AM the resident had a fall while in the bathroom by himself. Record review of resident #101's activity for daily living (ADL) care plan dated 2/23/10 revealed that the resident requires limited to extensive assist with all aspects of ADL care r/t (related to ) right rib fractures and dementia. Listed under approach was: Ambulate to bathroom with one SBA (stand by assist). Observation on 1/20/11 at 3:00 PM of resident #101's room while with the corporate nurse consultant, revealed a woman visitor sitting on the bed with an empty wheelchair next to the bed. There was no sign of the resident or staff in the room. While observing resident #101's room, the bathroom door opened and the resident #101 self ambulated from the bathroom. There were no alarms sounding nor any staff present with the resident. An interview on 1/20/11 at 3:05 PM with the resident #101 and his wife (female visitor) revealed that neither of them shut the sensor alarm off that was located on the bathroom door frame. An interview on 1/20/11 at 4:00 PM with staff #10 revealed that the resident was already in the bathroom when she got to the room. The alarm sounded and she shut off the alarm because the resident was already in the bathroom. Staff #10 stated that she left the room because the resident was in the bathroom and stated that no one else was in the room when she left the room. Staff #10 stated that she left the room to answer call lights. An interview on 1/20/11 at 4:25 PM with staff member #6 in charge of resident safety, revealed that on 1/4/11 at 10:30 AM resident #101 had a fall in the bathroom and that his alarms were off. The resident had a history of [REDACTED].#101 was found by staff on the bathroom floor with injuries and alarms were off. Staff #6 stated that medical staff looked at resident #101 because of dizziness, orthostatic blood pressures non-conclusive, urinalysis was negative. During the interview, staff #6 was notified of the state surveyor observation of resident #101 being in the bathroom by himself with the alarm shut off and the residents ADL care plan for stand by assistance. Staff #6 stated; "No, he's not safe now, because of alarm being off, the aide didn't stay in the room with him. Aide should have stayed in the room, not in the bathroom, but outside the bathroom door because he falls in the bathroom". The staff #6 revealed that there was to be an interdepartmental team (IDT) meeting that day and she would discuss how to keep the resident safe. #

This citation pertains to MI# 606 Based on, interview and record review the facility failed to provide antipsychotic medication to 1 (#105) of 6 sampled residents, resulting in resident #105 not receiving his antipsychotic medication Geoden for 8 days prior to resident #105 have a sexual behavior issues toward a female resident. Findings: According to the Lexi-comp's drug reference handbook Geriatric Dosage Handbook, 12th edition, 2007, page 1666 for Ziprasidone (Geoden) antipsychotic agent. Patient information: Use this medication exactly as directed; do not alter dosage or discontinue without consulting prescriber- may take 2-3 weeks to achieve desired results. Record review of resident #105's transfer papers/progress notes from a geriatric psych hospital dated range from 10/4/10 through 10/22/10 revealed that the resident was discharged on antipsychotic medication (Geoden) for behaviors of hitting, grabbing, kicking and making choking actions. Progress notes also noted that the resident was on every 15 minute safety checks. Record review of resident #105's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On the back side of the MAR form there were 4 dated entry's (12/22, 12/24, 12/28, 12/29/10) stating that the Geoden was not available and that the pharmacy was called. Record review of resident #105's MAR for 12/10 revealed that there was no antipsychotic medication added to replace the missing doses of Geoden. An interview on 1/6/11 at 11:15 AM with the nurse practioner (NP) #3 revealed that resident #105 was admitted from a geriatric psych unit and that the resident was admitted on Geoden, [MEDICATION NAME] and Amenda. The NP #3 stated that the resident was child like and clam when admitted , but on 11/1/10 the NP #3 revealed that the resident was confused and punched a wall and was sobbing (crying). The NP #3 revealed that between 11/9/10 and 12/29/10 the insurance stopped paying for the Geoden and it ran out on 12/22/10. Then the resident was off the Geoden for 9 days, and that [MEDICATION NAME] 0.25 mg was ordered on [DATE]. The NP #3 stated that the facility was waiting for the drug to come from the pharmacy, pharmacy said that they gave facility a 5 day notice (of stoppage), but the NP#3 was not aware of the drug stopping for 9 days. On 12/29/10 the NP #3 started Respirdal, and then the son came in to facility and told them the story of the psych hospital and that Geoden was the only drug that worked. The Geoden was restarted and tapered up in dose. The NP #3 did reveal that the resident #5 had a sexual incident against another female resident that could have been from stopping the Geoden. During the interview on 1/6/11 at 11:15 AM with NP #3, revealed that a different nurse practioner #10 was following resident #105 for psychiatric issues and psychiatric medication recommendations. Record review of psychiatric evaluation and management notes (2 page document noting psych visits) dated 11/23/10 revealed that resident #105 had a day of delusion of another couple being very intimate. Psychiatric assessment/formulation recommendations were to continue redirection and 1:1 (supervision). Record review of psychiatric evaluation and management notes dated 12/7/10 revealed that staff documents increased sexual advances toward other residents, increased angriness, [MEDICAL CONDITION] of having a date...... Psychiatric assessment/formulation: Increased behaviors and recommended urinalysis (U/A), if negative, recommend increased Geoden 40 mg daily-lower..... Record review of psychiatric evaluation and management notes dated 12/14/10 revealed [MEDICAL CONDITION] and getting up set with redirection...Psychiatric assessment/formulation: continues behaviors, awaiting last recommendation- U/A, increased Geoden. Continue redirection and 1:1 (supervision). Monitor and document behaviors, mood. Further note revealed that gradual dose reduction was determined to be contraindicated at this time for the following reason: Mood, behaviors currently unstable. Record review of psychiatric evaluation and management notes dated 12/21/10 revealed: Asked to see resident (#105) regarding continuing behaviors of sexual attempts with other resident of pushing her into his room and shutting door.....Psychiatric assessment/formulation: Continues with behaviors, recommended U/A, rule out urinary tract infection [MEDICAL CONDITION]-change in behaviors. Continue redirection and 1:1 (supervision). Monitor and document behaviors, mood. Further note revealed that gradual dose reduction was determined to be contraindicated at this time for the following reason: Mood, behaviors currently unstable. A phone interview on 1/7/10 at 3:55PM with the nurse practioner for psychiatric #10 revealed that she was not aware that the resident #105's Geoden (antipsychotic medication had been stopped and doses missed for 9 days until 1/4/1, by phone call from the facility. NP #10 stated that she was aware of resident #10 was having change of behaviors on 12/7/10 of sexual behaviors and recommended a urinalysis. If the urinalysis (UA) was negative she recommended increasing the Geoden (antipsychotic). The facility did not do the UA, did not increase the Geoden. The NP #10 did not know if the facility increased supervision, stating "....that they should have, they were aware of his increased sexual behaviors. And he has a history of high sexual/inappropriate behaviors". Record review of the facility incident/accident report dated 12/31/10 at 4:45 AM revealed that located on C-west lobby, an incident of sexual type occurred. Noted: Resident #105 was wandering the facility, at approximately 4:45 AM, he was in C-west lobby by Christmas tree, and another (female resident #104) was sitting in wheelchair in lobby. Resident #105 walked up to resident #104 and kissed her on the arms and face. Then he proceeded to unzip his pants. According to witness (Certified nurse assistant #4) resident #104 had her hand on resident #105's bare erect penis. Resident #104 was touching his penis and he was starting to thrust (hips)..... (# )

THIS CITATION PERTAINS TO INTAKES NUMBER MI 235, MI 244, AND MI 283. BASED ON OBSERVATIONS, INTERVIEWS, AND RECORDS REVIEW, THE FACILITY FAILED TO PREVENT FALLS IN 1 OF 11 SAMPLED RESIDENTS (#101), RESULTING IN IMMEDIATE JEOPARDY, WHEN RESIDENT #101 fell TO THE FLOOR, SUSTAINING A SKULL FRACTURE, SUBARACHNOID BLEED, PNEUMOCEPHALUS, AND SUBSEQUENT DEATH, AND THE POTENTIAL FOR FALLS WITH SERIOUS HARM AND WORSENED MEDICAL CONDITION FOR RESIDENT #109 WHO RECEIVED CARE WHILE STANDING UPRIGHT IN A SIT-TO-STAND LIFT WHOSE BRAKES WERE UNLOCKED. FINDINGS INCLUDE: RESIDENT #101 THE FACESHEET REVEALED RESIDENT #101 WAS AN [AGE] year OLD MAN WHO WAS admitted to the facility on [DATE], AND RE-admitted on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO HOSPICE CARE RECORDS, RESIDENT #101 ENTERED HOSPICE CARE ON [DATE] FOR END OF LIFE/COMFORT CARE RESULTING FROM [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS ((MDS) dated [DATE] AND [DATE], REVEALED RESIDENT #101 WAS SEVERELY COGNITIVELY IMPAIRED, EXPERIENCED BOTH LONG AND SHORT TERM MEMORY LOSS, WAS UNABLE TO MAKE HIS NEEDS KNOWN, RARELY UNDERSTOOD OTHERS, AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS (MOVEMENT FROM SURFACE TO SURFACE) THROUGH USE OF A MECHANICAL LIFT, WITH ASSISTANCE FROM TWO FACILITY STAFF MEMBERS. ACCORDING TO THE PHYSICAL THERAPY PROGRESS NOTES DATED [DATE] AND [DATE] (UNTIMED), AND THE INTERDISCIPLINARY REHAB SCREEN DATED [DATE], RESIDENT #101 EXPERIENCED A CHANGE IN STATUS AND WAS "UNDERGOING A STEADY DECLINE FROM LAST SCREEN." RESIDENT #101 WAS RECOMMENDED USE OF A HOYER LIFT AND TWO PERSON ASSISTANCE WITH TRANSFERS. THE PHYSICIAN ORDERS [REDACTED].#101 BE TRANSFERRED WITH USE OF A HOYER LIFT. THE FACILITY POLICY ("HOYER LIFT," DATED [DATE]) SPECIFIED "ALL HOYER-LIFT TRANSFERS WILL BE PERFORMED WITH 2 STAFF MEMBERS." THE POLICY SAID RESIDENTS REQUIRING USE OF A HOYER LIFT WILL HAVE THAT NEED INDICATED ON THE ADL (ACTIVITIES OF DAILY LIVING) SHEET, THE RESIDENT'S CARE PLAN, AND ON THE RESIDENT DOORWAY NAME-CARD. THE RESIDENT TRANSFER PROTOCOL, DATED [DATE], INCLUDED " A HOYER LIFT ALWAYS REQUIRES 2 STAFF MEMBERS . . . RESIDENT'S TRANSFER INTERVENTION WILL BE ENTERED ON THEIR CARE PLAN, ADL SHEET, DOOR NAME TAG, AND THE CLOSET CARE PLAN." THE RESIDENT CARE GUIDE (UNDATED) SPECIFIED RESIDENT #101 WAS TO UTILIZE A HOYER LIFT WITH ALL TRANSFERS, AND ALL TRANSFERS WERE TO BE DONE WITH TWO PERSONS ASSISTING. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED [DATE], RESIDENT #101 EXPERIENCED A FALL DURING A TRANSFER FROM HIS WHEELCHAIR TO A SHOWER CHAIR AT 10:25 A.M. ON [DATE]. THE RESIDENT WAS REPORTED AS SENT TO A LOCAL HOSPITAL FOR EVALUATION OF A HEMATOMA (SWELLING CONTAINING BLOOD) OF HIS LEFT FOREHEAD, RIGHT CHEEK, AND A NOSEBLEED. ACCORDING TO THE HOSPITAL DISCHARGE SUMMARY DATED [DATE] (UNTIMED), RESIDENT #101 WAS diagnosed with [REDACTED]. THE REPORT INCLUDED RESIDENT #101 WAS discharged BACK to the facility on [DATE] TO RESUME COMFORT CARE MEASURES WITH HOSPICE AT HIS FAMILY'S REQUEST. THE CERTIFICATE OF DEATH DATED [DATE] REVEALED RESIDENT #101 died on [DATE] AT 11:15 A.M. THE CERTIFICATE OF DEATH INCLUDED CAUSE OF DEATH AS INTRACRANIAL BLEED (BLEEDING WITHIN THE SKULL). DURING AN INTERVIEW ON [DATE] AT 9:40 A.M., A CERTIFIED NURSE AIDE (CNA, STAFF MEMBER #3) SAID, "I WAS ASSIGNED TO THE RESIDENT (#101) FIRST SHIFT ON [DATE]. I'VE TAKEN CARE OF HIM A LOT FOR THE PAST TWO YEARS. HE WAS A TWO PERSON, HOYER LIFT, DEFINITELY. HE COULDN'T STAND OR HOLD ONTO A GRAB BAR. HE COULDN'T USE A SIT-TO-STAND LIFT. SHE (STAFF MEMBER #4) HELPED ME CARE FOR HIM IN THE PAST. WE ALWAYS USED A HOYER LIFT, NOT THE SIT-TO-STAND LIFT. SHE (STAFF MEMBER #4) HAS CARED FOR HIM BEFORE. HE HAD A CNA CARE GUIDE IN HIS CLOSET, AND ALSO ON HIS ADL'S CARE SHEET THAT HE WAS A TWO PERSON ASSIST WITH A HOYER LIFT, NOT THE SIT-TO-STAND. HE ALSO HAD "H2" (FACILITY DESIGNATION FOR 2 PERSON HOYER LIFT TRANSFER) ON HIS NAME PLATE, I'M CERTAIN." DURING AN INTERVIEW ON [DATE] AT 10:15 A.M., A CNA (STAFF MEMBER #4) SAID, "I KNEW THE RESIDENT (#101); I CARED FOR HIM LOTS OF TIMES BEFORE. HE WAS A HOYER LIFT TRANSFER. THE POLICY SAYS A HOYER LIFT IS SUPPOSED TO BE DONE BY 2 PEOPLE. I WAS NOT ASSIGNED TO THE RESIDENT ON [DATE], ANOTHER CNA (STAFF MEMBER #3) WAS. THE OTHER CNA (STAFF MEMBER #3) TOLD ME SHE NEEDED TO DO HIS SHOWER AND SHE WAS GOING TO DO IT AFTER HER BREAK. I THOUGHT I'D DO HER A FAVOR, HELP HER OUT. I WAS GOING TO SURPRISE HER. I GOT THE SIT-TO-STAND LIFT, INSTEAD OF THE HOYER LIFT. I WANTED TO SHOWER HIM, AND THE HOYER LIFT PAD WOULD'VE GOTTEN WET AND IT WOULDN'T HAVE BEEN AS EASY TO DRESS HIM AFTERWARD WITH THE HOYER PAD. SO, I GOT THE SIT-TO-STAND LIFT INSTEAD. IT WAS A BAD IDEA. I DIDN'T ASK FOR HELP TO DO THE TRANSFER. I USED THE SIT-TO-STAND BY MYSELF. HE WAS IN HIS WHEELCHAIR. I PUT THE PAD BEHIND HIM. I PUT HIS FEET ON THE LIFT. I THEN PUT HIS HANDS ON THE GRAB BAR; HE DIDN'T GRASP IT. HE JUST LET ME LAY HIS HANDS ON THE BAR. I USED THE LIFT TO PULL HIM UP FROM HIS WHEELCHAIR. I MOVED THE SIT-TO-STAND TO THE SHOWER CHAIR. THE SHOWER CHAIR WAS HIGHER THAN NORMAL; IT SEEMED TO BE MADE FOR A TALLER MAN. I DIDN'T SEE THAT THERE WAS A MISMATCH BETWEEN THE SHOWER CHAIR AND THE SIT-TO-STAND LIFT. HIS BUTT ONLY CAME TO THE FRONT OF SHOWER CHAIR. I PUSHED HIM BACK, THEN STEAdied HIM WITH MY HAND, BUT DETACHED THE PAD FROM THE LIFT, THEN MOVED THE LIFT OUT OF THE WAY. I THEN REMOVED THE PAD FROM AROUND HIS BACK, AND PLACED IT ON THE LIFT. AT THAT POINT I'D LET GO OF THE RESIDENT TO USE BOTH MY HANDS TO PUT THE PAD ONTO THE LIFT; IT WAS HEAVY. MY HEAD AND BODY WERE TURNED AWAY FROM THE RESIDENT, TO THE LIFT IN BACK OF ME. I HEARD A THUD AND HE WAS ON THE FLOOR. I DIDN'T ACTUALLY SEE HIM HIT THE FLOOR. I BENT DOWN OVER HIM. HE HAD BLOOD ON THE LEFT SIDE OF HIS FACE AND ON THE FLOOR. HIS NOSE WAS BLEEDING. I RAN TO GET HELP. I KNEW THE POLICY AND HAVE FOR A LONG TIME. I WAS TRYING TO BE EFFICIENT AND QUICK." DURING AN INTERVIEW ON [DATE] AT 11:15 A.M., A NURSE (STAFF MEMBER #5) SAID, " I KNEW THE RESIDENT (#101) WELL. HE WASN'T ABLE TO GRASP ONTO ANYTHING, OR STAND. ANYONE USING A SIT-TO-STAND LIFT ON HIM WASN'T SAFE. HE'S BEEN A HOYER LIFT TRANSFER THE WHOLE TIME I'VE BEEN HERE, SO AT LEAST FOR 6 MONTHS. TWO PEOPLE MUST DO TRANSFERS WITH THE HOYER LIFT AND THE SIT-TO-STAND. ONLY THE SIT-TO-STAND CAN BE DONE WITH ONE PERSON ASSIST, AND ONLY IF THERAPY SAYS IT'S O.K., AND IT HAS BEEN CARE PLANNED. THE DAY OF HIS FALL I WAS AT LUNCH. I CAME BACK TO THE FLOOR WHEN I HEARD HE' D FALLEN. THE CNA USED A SIT-TO-STAND LIFT BY HERSELF; THAT'S NOT WHAT WAS ORDERED. " DURING AN INTERVIEW ON [DATE] AT 11:35 A.M., A PHYSICAL THERAPIST (STAFF MEMBER #6) SAID, "HE (RESIDENT #101) WAS A TOTAL ASSIST WITH TRANSFERS. I RECOMMENDED A HOYER LIFT BE USED FOR ALL TRANSFERS OF THIS RESIDENT; A SIT-TO-STAND LIFT WAS NOT SAFE FOR THIS RESIDENT BECAUSE OF HIS SLOW REACTION TIME. HE COULDN'T EVEN BEAR WEIGHT ON HIS LEGS. A TWO PERSON HOYER LIFT TRANSFER WAS THE ONLY SAFE WAY TO TRANSFER THIS RESIDENT. " DURING AN INTERVIEW ON [DATE] AT 12:20 P.M., A PHYSICIAN'S ASSISTANT (WITNESS #8) SAID, "HE (RESIDENT#101) WAS SUPPOSED TO USE A HOYER LIFT. HE had a history of [REDACTED]. IT WAS NOT SAFE FOR HIM TO USE A SIT-TO-STAND LIFT. " DURING A PHONE INTERVIEW ON [DATE] AT 2:55 P.M., RESIDENT #101'S ATTENDING PHYSICIAN (WITNESS #9) SAID, "I ORDERED A HOYER LIFT TRANSFER FOR THIS RESIDENT; IT WAS SAFEST FOR THIS RESIDENT. USE OF A SIT-TO-STAND FOR THIS RESIDENT WOULD HAVE BEEN A POOR CHOICE, SAFETY WISE, FOR THIS RESIDENT. " DURING AN INTERVIEW ON [DATE] AT 12:05 P.M., THE DIRECTOR OF NURSING SAID, "THE RESIDENT (RESIDENT #101) WAS SUPPOSED TO BE A TWO PERSON ASSIST WITH A HOYER LIFT AT ALL TIMES; THIS WAS SPECIFIED BY HIS PHYSICIAN AND THERAPY. HIS MDS ASSESSMENT WAS THAT HE WAS DEPENDENT, AND WAS A TWO PERSON ASSIST. THE CNA CARE CARD, HIS ADL FLOW SHEET, AND HIS NAME PLATE BY THE DOOR ALL INDICATED HE WAS A TWO PERSON ASSIST WITH TRANSFERS, AND USED A HOYER LIFT. WE DID FIND IN OUR INVESTIGATION THAT THERE WAS AN ERROR IN THE RESIDENT' S CARE PLAN; IT SAID HE WAS SUPPOSED TO USE A SIT-TO-STAND LIFT. THAT WAS AN ERROR ON THE PART OF A NURSE, WHO RECEIVED ONE TO ONE EDUCATION FROM ME. THE CNA (STAFF MEMBER #4) WHO WAS INVOLVED IN THE RESIDENT'S FALL (RESIDENT #101) WAS INTERVIEWED AND SAID SHE WAS AWARE HE WAS A TWO PERSON ASSIST WITH A HOYER LIFT; SHE DIDN'T FOLLOW POLICY AND WAS TERMINATED. REGARDING THE WHEELS OF THE SIT-TO-STAND LIFT, WHEN A RESIDENT IS STANDING UPRIGHT, RECEIVING CARE, THE WHEELS SHOULD DEFINITELY BE LOCKED; IT'S A SAFETY MEASURE TO PREVENT MOVEMENT." DURING AN INTERVIEW ON [DATE] AT 12:20 P.M., THE NURSING HOME ADMINISTRATOR SAID, "THE RESIDENT (#101) SHOULD HAVE BEEN A TWO PERSON ASSIST WITH A HOYER LIFT. I EXPECT MY STAFF TO FOLLOW DOCTOR'S ORDERS AS WRITTEN, AND FOLLOW FACILITY POLICIES AT ALL TIMES. IF A RESIDENT IS STANDING UPRIGHT IN A SIT-TO-STAND DURING CARE, THE WHEELS ON THE SIT-TO-STAND LIFT SHOULD BE LOCKED. COMMON SENSE TELLS ME THEY SHOULD BE LOCKED. " RESIDENT #109 THE FACESHEET REVEALED RESIDENT #109 WAS A [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MDS dated [DATE], RESIDENT #109 WAS MILDLY COGNITIVELY IMPAIRED, EXPERIENCED BOTH LONG AND SHORT TERM MEMORY LOSS, WAS USUALLY ABLE TO UNDERSTAND OTHERS AND TO MAKE HER NEEDS KNOWN, AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS, WITH USE OF A MECHANICAL LIFT, ASSISTED BY ONE PERSON. ACCORDING TO THE PHYSICAL THERAPY EVALUATION DONE [DATE], RESIDENT #109 WAS RECOMMENDED TO USE A SIT-TO-STAND LIFT FOR TRANSFERS, WITH ASSIST OF ONE FACILITY STAFF MEMBER. THE CARE PLAN INITIATED [DATE], IDENTIFIED RESIDENT #109 AT RISK FOR FALLS, AND SPECIFIED USE OF A SIT-TO- STAND LIFT FOR TRANSFERS DONE WITH ONE PERSON PHYSICAL ASSIST. DURING AN UNANNOUNCED, ON SITE INVESTIGATION, RESIDENT #109 WAS OBSERVED ON [DATE] AT 11:15 A.M., IN THE CARE OF A CNA (STAFF MEMBER #10), STANDING UPRIGHT IN A SIT-STAND-LIFT WHOSE WHEEL BRAKES WERE NOT LOCKED. THE CNA WAS PROVIDING CARE TO THE RESIDENT INCLUDING PULLING DOWN OF PANTS, REMOVAL OF BRIEF (ADULT DIAPER), CLEANSING OF BUTTOCKS, REPLACEMENT OF BRIEF, AND PULLING UP OF PANTS. THE LIFT WAS NOTED TO MOVE BACK AND FORTH DURING THE CARE PROVIDED. ON [DATE] AT 10:30 A.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE], WHEN STAFF DISREGARDED A physician's orders [REDACTED].#101 FALLING FORWARD ONTO THE FLOOR, SUSTAINING A SKULL FRACTURE, SUBARACHNOID BLEED, PNEUMOCEPHALUS, AND SUBSEQUENT DEATH. ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. ALL RESIDENTS' RECORDS (121 RESIDENTS) WERE REVIEWED FOR TRANSFER STATUS AND EQUIPMENT USE. THIS REVIEW WAS COMPLETED [DATE]. 31 OF 31 RESIDENTS UTILIZING MECHANICAL LIFTS (25 RESIDENTS USING HOYER LIFTS AND 6 RESIDENTS USING SIT-TO-STAND- LIFTS) MEDICAL RECORDS HAVE BEEN REVIEWED AND ARE UP TO DATE WHICH INCLUDE THE ADL'S & SAFETY CARE PLAN, ADL SHEET, CLOSET CARD, AND NAME CARD AS OF [DATE]. 2. THE FACILITY POLICY ON TRANSFER PROTOCOL WAS REVIEWED BY THE INTERDISCIPLINARY TEAM AND DEEMED APPROPRIATE. 3. THE CNA WAS TERMINATED FROM EMPLOYMENT AT THE FACILITY ON [DATE] AT 10:30 A.M. SHE DID NOT WORK ON [DATE]. SHE FULFILLED HER SCHEDULE ON [DATE] FOR THE REMAINING 2 HOURS, AND DID NOT DO ANY RESIDENT TRANSFERS DURING THAT PERIOD OF TIME. 4. ON [DATE] A MEMO WAS POSTED ON EACH UNIT REGARDING RESIDENT TRANSFER STATUS INFORMATION, LOCATION OF THE INFORMATION AND EXPECTATION THAT STAFF FOLLOW THE PLAN OF CARE FOR EACH RESIDENT. STAFF WERE REQUIRED TO SIGN ACKNOWLEDGEMENT OF THE NOTICE. 5. 81 STAFF MEMBERS WERE INSERVICED AT THAT TIME (2 CNA STAFF OFF ON FMLA) 6. ON [DATE] A MANDATORY INSERVICE FOR NURSING STAFF WAS COMPLETED. RESIDENT TRANSFER STATUS INFORMATION, LOCATION OF THE INFORMATION AND EXPECTATION THAT STAFF FOLLOW THE PLAN OF CARE FOR EACH RESIDENT WAS REVIEWED. ON [DATE], 52 NURSING STAFF WERE INSERVICED (8 RN'S, 12 LPN'S, 32 CNA'S). ON [DATE], 12 NURSING STAFF WERE INSERVICED (2 RN'S, 2 LPN'S, 8 CNA'S). ON [DATE], 3 NURSING STAFF WERE INSERVICED (NO RN'S, NO LPN'S, 3 CNA'S). ON [DATE], 25 NURSING STAFF WERE INSERVICED (2 RN'S, NO LPN'S, 23 CNA'S). AS OF [DATE], 92 OF 96 NURSING STAFF HAVE BEEN INSERVICED. 12 OF 12 RN'S, 14 OF 14 LPN'S, 66 OF 70 CNA'S HAVE BEEN INSERVICED. THE REMAINING FACLITY STAFF WILL RECEIVE EDUCATION ON THE ABOVE POLICY/PROCEDURE UPON REPORTING FOR DUTY ON THEIR NEXT SCHEDULED DAY AND WILL NOT BE ALLOWED TO WORK UNTIL THE EDUCATION IS COMPLETED. 7. NEW ADMISSION CHARTS WILL BE REVIEWED IN THE MORNING STAND-UP MEETING TO ENSURE THAT RESIDENTS TRANSFER STATUS AND FALL INTERVENTIONS HAVE BEEN IMPLEMENTED. THERE HAVE BEEN 12 NEW ADMISSIONS AND 4 RE-ADMITS SINCE [DATE] EACH OF THESE HAVE BEEN REVIEWED FOR TRANSFER STATUS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE AND SEVERITY OF PATTERN WITH NO ACTUAL HARM, BUT POTENTIAL FOR MORE THAN MINIMAL HARM BUT NO IMMEDIATE JEOPARDY DUE TO ALL STAFF WERE NOT IN SERVICED AND SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY.

THIS CITATION PERTAINS TO INTAKES NUMBER MI 235, MI 244, AND MI 283. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO FOLLOW A PHYSICIAN ORDER [REDACTED]. (#101) RESULTING IN IMMEDIATE JEOPARDY, WHEN RESIDENT #101 fell TO THE FLOOR, SUSTAINING A SKULL FRACTURE, SUBARACHNOID BLEED, PNEUMOCEPHALUS, AND SUBSEQUENT DEATH DURING TRANSFER WITH USE OF A SIT-TO-STAND LIFT. FINDINGS INCLUDE: THE PROFESSIONAL STANDARD OF QUALITY FOR DOCTOR'S ORDERS STATED, "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). THE FACESHEET REVEALED RESIDENT #101 WAS AN [AGE] year OLD MAN WHO WAS admitted to the facility on [DATE], AND RE-admitted on [DATE], WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS ((MDS) dated [DATE] AND [DATE], REVEALED RESIDENT #101 WAS SEVERELY COGNITIVELY IMPAIRED, EXPERIENCED BOTH LONG AND SHORT TERM MEMORY LOSS, WAS UNABLE TO MAKE HIS NEEDS KNOWN, RARELY UNDERSTOOD OTHERS, AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS (MOVEMENT FROM SURFACE TO SURFACE) THROUGH USE OF A MECHANICAL LIFT AND ASSISTANCE FROM TWO FACILITY STAFF MEMBERS. ACCORDING TO THE PHYSICAL THERAPY PROGRESS NOTES DATED [DATE] AND [DATE] (UNTIMED), AND THE INTERDISCIPLINARY REHAB SCREEN DATED [DATE], RESIDENT #101 EXPERIENCED A CHANGE IN STATUS AND WAS "UNDERGOING A STEADY DECLINE FROM LAST SCREEN." RESIDENT #101 WAS RECOMMENDED USE OF A HOYER LIFT AND TWO PERSON ASSISTANCE WITH TRANSFERS. THE PHYSICIAN ORDERS [REDACTED].#101 BE TRANSFERRED WITH USE OF A HOYER LIFT. THE FACILITY POLICY FOR HOYER LIFT TRANSFERS, DATED [DATE], SPECIFIED "ALL HOYER LIFT TRANSFERS WILL BE PERFORMED WITH TWO STAFF MEMBERS." THE RESIDENT CARE GUIDE (UNDATED; GUIDE DIRECTING PROVISION OF CARE BY NURSE AIDES) SPECIFIED RESIDENT #101 WAS TO UTILIZE A HOYER LIFT WITH ALL TRANSFERS, AND ALL TRANSFERS WERE TO BE DONE WITH TWO PERSONS ASSISTING. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED [DATE], RESIDENT #101 EXPERIENCED A FALL DURING A TRANSFER FROM HIS WHEELCHAIR TO A SHOWER CHAIR AT 10:25 A.M. ON [DATE]. THE RESIDENT WAS REPORTED AS SENT TO A LOCAL HOSPITAL FOR EVALUATION OF A HEMATOMA (SWELLING CONTAINING BLOOD) OF HIS LEFT FOREHEAD, RIGHT CHEEK, AND A NOSEBLEED. ACCORDING TO THE HOSPITAL DISCHARGE SUMMARY DATED [DATE] (UNTIMED), RESIDENT #101 WAS diagnosed with [REDACTED]. THE REPORT INCLUDED RESIDENT #101 WAS discharged BACK to the facility on [DATE] TO RESUME COMFORT CARE MEASURES WITH HOSPICE AT HIS FAMILY'S REQUEST. THE CERTIFICATE OF DEATH DATED [DATE] REVEALED RESIDENT #101 died on [DATE] AT 11:15 A.M. THE CERTIFICATE OF DEATH INCLUDED CAUSE OF DEATH AS INTRACRANIAL BLEED (BLEEDING WITHIN THE SKULL). DURING AN INTERVIEW ON [DATE] AT 10:15 A.M., A CNA (STAFF MEMBER #4) SAID, "I KNEW THE RESIDENT (#101); I CARED FOR HIM LOTS OF TIMES BEFORE. THE RESIDENT CARE GUIDE (SHEET INSTRUCTING AIDES ON ASPECTS OF CARE) SAID HE WAS A HOYER LIFT TRANSFER. THE POLICY SAYS A HOYER LIFT TRANSFER IS SUPPOSED TO BE DONE BY 2 PEOPLE. ANOTHER CNA (STAFF MEMBER #3) TOLD ME SHE NEEDED TO DO HIS SHOWER AND SHE WAS GOING TO DO IT AFTER HER BREAK. I THOUGHT I'D DO HER A FAVOR, HELP HER OUT. I GOT THE SIT-TO-STAND LIFT, INSTEAD OF THE HOYER LIFT. I DIDN'T ASK FOR HELP TO DO THE TRANSFER. I USED THE SIT-TO-STAND BY MYSELF. HE WAS IN HIS WHEELCHAIR. I USED THE LIFT TO PULL HIM UP FROM HIS WHEELCHAIR. I MOVED THE SIT-TO-STAND TO THE SHOWER CHAIR. HIS BUTT ONLY CAME TO THE FRONT OF THE SHOWER CHAIR. I PUSHED HIM BACK, THEN STEAdied HIM WITH MY HAND, BUT DETACHED THE PAD FROM THE LIFT, THEN MOVED THE LIFT OUT OF THE WAY. I THEN REMOVED THE PAD FROM AROUND HIS BACK, AND PLACED IT ON THE LIFT. AT THAT POINT I'D LET GO OF THE RESIDENT TO USE BOTH MY HANDS TO PUT THE PAD ONTO THE LIFT; IT WAS HEAVY. MY HEAD AND BODY WERE TURNED AWAY FROM THE RESIDENT, TO THE LIFT IN BACK OF ME. I HEARD A THUD AND HE WAS ON THE FLOOR. I DIDN'T ACTUALLY SEE HIM HIT THE FLOOR. I BENT DOWN OVER HIM. HE HAD BLOOD ON THE LEFT SIDE OF HIS FACE AND ON THE FLOOR. HIS NOSE WAS BLEEDING. I RAN TO GET HELP. I KNEW THE POLICY AND HAVE FOR A LONG TIME. I WAS TRYING TO BE EFFICIENT AND QUICK." DURING AN INTERVIEW ON [DATE] AT 11:15 A.M., A NURSE (STAFF MEMBER #5) SAID, " I KNEW THE RESIDENT (#101) WELL. HE WASN'T ABLE TO GRASP ONTO ANYTHING, OR STAND. ANYONE USING A SIT-TO-STAND LIFT ON HIM WASN'T SAFE. HE'S BEEN A HOYER LIFT TRANSFER THE WHOLE TIME I'VE BEEN HERE, SO AT LEAST FOR 6 MONTHS. TWO PEOPLE MUST DO TRANSFERS WITH THE HOYER LIFT AND THE SIT-TO-STAND. ONLY THE SIT-TO-STAND CAN BE DONE WITH ONE PERSON ASSIST, AND ONLY IF THERAPY SAYS IT'S O.K., AND IT HAS BEEN CARE PLANNED. THE DAY OF HIS FALL I WAS AT LUNCH. I CAME BACK TO THE FLOOR WHEN I HEARD HE' D FALLEN. THE CNA USED A SIT-TO-STAND LIFT BY HERSELF; THAT'S NOT WHAT WAS ORDERED." DURING AN INTERVIEW ON [DATE] AT 12:05 P.M., THE DIRECTOR OF NURSING SAID, "THE RESIDENT (#101) WAS ORDERED, BY HIS ATTENDING PHYSICIAN, TO HAVE A TWO PERSON ASSIST WITH TRANSFERS USING A HOYER LIFT AT ALL TIMES." DURING AN INTERVIEW ON [DATE] AT 12:20 P.M., THE NURSING HOME ADMINISTRATOR SAID, "THE RESIDENT (#101) SHOULD HAVE BEEN A TWO PERSON ASSIST WITH A HOYER LIFT. I EXPECT MY STAFF TO FOLLOW DOCTOR'S ORDERS AS WRITTEN, AND FOLLOW FACILITY POLICIES AT ALL TIMES." ON [DATE] AT 10:30 A.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE], WHEN STAFF DISREGARDED A physician's orders [REDACTED].#101 FALLING FORWARD ONTO THE FLOOR, SUSTAINING A SKULL FRACTURE, SUBARACHNOID BLEED, PNEUMOCEPHALUS, AND SUBSEQUENT DEATH. ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. ALL RESIDENTS' RECORDS (121 RESIDENTS) WERE REVIEWED FOR TRANSFER STATUS AND EQUIPMENT USE. THIS REVIEW WAS COMPLETED [DATE]. 31 OF 31 RESIDENTS UTILIZING MECHANICAL LIFTS (25 RESIDENTS USING HOYER LIFTS AND 6 RESIDENTS USING SIT-TO-STAND- LIFTS) MEDICAL RECORDS HAVE BEEN REVIEWED AND ARE UP TO DATE WHICH INCLUDE THE ADL'S & SAFETY CARE PLAN, ADL SHEET, CLOSET CARD, AND NAME CARD AS OF [DATE]. 2. THE FACILITY POLICY ON TRANSFER PROTOCOL WAS REVIEWED BY THE INTERDISCIPLINARY TEAM AND DEEMED APPROPRIATE. 3. THE CNA WAS TERMINATED FROM EMPLOYMENT AT THE FACILITY ON [DATE] AT 10:30 A.M. SHE DID NOT WORK ON [DATE]. SHE FULFILLED HER SCHEDULE ON [DATE] FOR THE REMAINING 2 HOURS, AND DID NOT DO ANY RESIDENT TRANSFERS DURING THAT PERIOD OF TIME. 4. ON [DATE] A MEMO WAS POSTED ON EACH UNIT REGARDING RESIDENT TRANSFER STATUS INFORMATION, LOCATION OF THE INFORMATION AND EXPECTATION THAT STAFF FOLLOW THE PLAN OF CARE FOR EACH RESIDENT. STAFF WERE REQUIRED TO SIGN ACKNOWLEDGEMENT OF THE NOTICE. 5. 81 STAFF MEMBERS WERE INSERVICED AT THAT TIME (2 CNA STAFF OFF ON FMLA) 6. ON [DATE] A MANDATORY INSERVICE FOR NURSING STAFF WAS COMPLETED. RESIDENT TRANSFER STATUS INFORMATION, LOCATION OF THE INFORMATION AND EXPECTATION THAT STAFF FOLLOW THE PLAN OF CARE FOR EACH RESIDENT WAS REVIEWED. ON [DATE], 52 NURSING STAFF WERE INSERVICED (8 RN'S, 12 LPN'S, 32 CNA'S). ON [DATE], 12 NURSING STAFF WERE INSERVICED (2 RN'S, 2 LPN'S, 8 CNA'S). ON [DATE], 3 NURSING STAFF WERE INSERVICED (NO RN'S, NO LPN'S, 3 CNA'S). ON [DATE], 25 NURSING STAFF WERE INSERVICED (2 RN'S, NO LPN'S, 23 CNA'S). AS OF [DATE], 92 OF 96 NURSING STAFF HAVE BEEN INSERVICED. 12 OF 12 RN'S, 14 OF 14 LPN'S, 66 OF 70 CNA'S HAVE BEEN INSERVICED. THE REMAINING FACLITY STAFF WILL RECEIVE EDUCATION ON THE ABOVE POLICY/PROCEDURE UPON REPORTING FOR DUTY ON THEIR NEXT SCHEDULED DAY AND WILL NOT BE ALLOWED TO WORK UNTIL THE EDUCATION IS COMPLETED. 7. NEW ADMISSION CHARTS WILL BE REVIEWED IN THE MORNING STAND-UP MEETING TO ENSURE THAT RESIDENTS TRANSFER STATUS AND FALL INTERVENTIONS HAVE BEEN IMPLEMENTED. THERE HAVE BEEN 12 NEW ADMISSIONS AND 4 RE-ADMITS SINCE [DATE] EACH OF THESE HAVE BEEN REVIEWED FOR TRANSFER STATUS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE AND SEVERITY OF PATTERN WITH NO ACTUAL HARM, BUT POTENTIAL FOR MORE THAN MINIMAL HARM BUT NO IMMEDIATE JEOPARDY DUE TO ALL STAFF WERE NOT IN SERVICED AND SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY.