Every finding on record at Bronson Commons

Based on observation, interview, and record review the facility failed to ensure 1) outdated food items were discarded, 2) the kitchen's ice machine was maintained in a clean and sanitary manner, and 3) appropriate air-drying and cleanliness of an air-drying area with the potential to affect any resident out of the census of 84 who consumed food/beverages from the kitchen resulting in the potential for foodborne illness and/or physical food contamination.Findings include:Outdated Food/Discarding:During an observation on 07/22/2026 at 9:54 AM, in the kitchen's walk-in cooler there were 10 individual strawberry yogurts that had a use by date of 6/29/2026.During an interview on 07/22/2026 at 11:29 AM, Food Services Manager (FSM) I confirmed staff should have checked the dates of product when their food delivery was received from the distributor to avoid storing outdated items. During an observation on 07/23/2026 at 11:27 AM, in the pantry's refrigerator on the 300 unit there were 2 cartons of whole milk dated July 22.During an observation on 07/23/2026 at 11:52 AM, in the pantry's refrigerator on the 400 unit there was 1 whole milk carton dated July 22.Ice Machine:During an observation on 07/22/2026 at 10:02 AM, the ice machine in the kitchen was observed to have black material accumulated on the top of the inside and pink material accumulated on the lowest part of the ice guard inside the machine that was directly touching ice. Review of the ice machine's Service Order Form, dated 2/11/26, indicated the ice machine in the kitchen was last cleaned on 1/27/26.Review of an email communication, dated 7/23/26, noted Nursing Home Administrator A indicated the ice machine was scheduled to be cleaned twice a year.Review of the facility's Ice Machine Preventative Maintenance policy, dated 7/2023, stated, The ice machine will have preventative maintenance completed to ensure infection prevention .Review of the 2022 Food and Drug Administration's Food Code, stated, Frequency . 4-602.11 Equipment Food-Contact Surfaces and Utensils .Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms (tiny living things such as bacteria). Air-drying:During an observation on 07/22/2026 at 11:17 AM, the green shelving in the storage area just outside the main kitchen had 10 black drink lids stacked directly on top of each other that were still wet. The lids were stacked on a black tray that had debris on it. The bottom shelf was covered with a clear plastic shelf liner that was visibly soiled with heavy white material buildup and other debris. There were 5 red mugs that were resting directly on the soiled shelf liner and when the mugs were lifted white material was observed stuck to the mug's opening that had transferred from the liner. During an interview on 07/22/2026 at 11:30 AM, FSM I reported lids should not be stacked until they are fully dried. Review of the facility's Dishwashing Operation policy, dated 5/2025, stated, .Remove dishes from machine and let air dry.During an observation on 07/23/2026 at 10:04 AM, the green shelving area presented as it had on the previous observation, 7/22/26 at 11:17 AM. During an interview on 07/23/2026 at 12:10 PM, FSM I reported the shelving and liner should be cleaned daily.Review of the 2022 Food and Drug Administration's Food Code, stated, 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored .Review of the 2022 Food and Drug Administration's Food Code, stated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. The objective of cleaning focuses on the need.to remove soil from nonfood contact surfaces so that pathogenic microorganisms (commonly called germs, such as bacteria) will not be allowed to accumulate and insects and rodents will not be attracted.

Based on interview and record review, the facility failed to develop person centered, comprehensive care plans for 4 (Resident #2, #8, #50 and #81) of 24 residents reviewed for care planning, resulting in the potential for unmet care needs related to the use of a anticoagulant medication. Findings include: Resident #2 (R#2):Review of R#2's medication list, dated 7/23/26, indicated she received the medication apixaban (an anticoagulant (blood thinner) used to prevent harmful blood clots (a blockage in a blood vessel which obstructs blood flow) from forming) 5 mg (milligrams) twice a day.Review of the manufacturer's insert for apixaban, dated 4/2025, noted the medication was indicated to be used to reduce the risk of stroke (when the blood supply to the brain is interrupted or reduced) and systemic embolism (blood clot) in individuals with atrial fibrillation (an irregular heart rhythm). The insert indicated a warning and precaution that the medication could cause serious, potentially fatal, bleeding and to promptly evaluate signs and symptoms of blood loss.Review of R#2's minimum data set (assessment tool used to evaluate health needs), dated 6/11/26, indicated she had a diagnosis of atrial fibrillation and received an anticoagulant medication. Review of R#2's care plan, dated 7/23/26, indicated there was no care plan addressing anticoagulation medication use. Review of an email communication, dated 07/23/2026, noted Director of Nursing (DON) B confirmed R#2's care plan did not address anticoagulation medication use. Resident #8 Review of an admission Record revealed Resident #8 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic atrial fibrillation (is a type of heart arrhythmia (irregular heartbeat) that causes the top chambers of your heart, to quiver and beat irregularly). Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 5/20/26, Section N: Medications revealed Resident #8 was taking an anticoagulant. In an interview on 7/21/26 at 10:24 AM, Resident #8 reported she was taking a medication to thin her blood. Review of Resident #8's Care Plan revealed no care plan related to chronic atrial fibrillation and/or anticoagulant medications. Review of Resident #8's Physician Ordered Medication list revealed, orders for Warfarin 5 mg (milligram) tablets and Warfarin 6 mg tablets. Warfarin is the generic drug name for Coumadin. In an interview on 7/23/26 at 10:48 AM, Unit Coordinator (UC) V reported Resident #8 had been taking Coumadin (anticoagulant medication) to manage atrial fibrillation for a long time. UC V reported that Resident #8 did not have a care plan related to the medication use and/or risks associated with the medication. UC V reported that when Resident #8 re-admitted from the hospital on 4/24/26 the anticoagulant part of the care plan did not pull over when they reinstated her previous care plan. UC V reported that she had not been aware of the issue until this surveyor inquired about it. Resident #50 Review of an admission Record revealed Resident #50 was originally admitted to the facility on [DATE] with pertinent diagnoses which Atrial fibrillation (irregular heartbeat.) Review of Resident #50's Orders revealed, Eliquis (anticoagulant medication that prevents or reduces blood clotting) 5 mg (milligrams) two times daily. Start date: 10/6/25. Review of Resident #50's Care Plan did not reveal a focus area related to (r/t) Resident #50's use of Eliquis. During an interview on 7/23/2026 at 10:41 AM, Director of Nursing (DON) B reported that the facility's Unit Coordinators were responsible for the development of resident care plans. DON B confirmed that residents at the facility that were taking anticoagulants should have a care plan in place r/t anticoagulant use. During an interview on 7/23/2026 at 11:58 AM, Unit Coordinator (UC) X reviewed Resident #50's care plan with this writer and confirmed that Resident #50 did not have a plan r/t the use of anticoagulants. Resident #81 Review of an admission Record revealed Resident #81 was originally admitted to the facility on [DATE] with pertinent diagnoses which included history of thromboembolism (the formation of blood clots (thrombi) that can lead to deep vein thrombosis (DVT) and pulmonary embolism (PE), both of which can have serious health implications.) Review of Resident #81's Orders revealed, Eliquis 5 mg by mouth in the morning and before bedtime. Start date: 6/29/26. Review of Resident #81's Care Plan did not reveal a focus area related to (r/t) Resident #81's use of Eliquis. During an interview on 7/23/2026 at 11:58 AM, Unit Coordinator (UC) X reviewed Resident #81' s care plan with this writer and confirmed that Resident #81 did not have a plan r/t the use of anticoagulants. Review of the facility's Care Planning Policy revealed, Policy: It is the policy of the facility to develop and implement a comprehensive person centered-care plan for each patient, consistent with patient rights, that includes measurable objectives and timeframes to meet a patient's medical, nursing, and mental and psychosocial needs that are identified in the patient's comprehensive assessment

Based on observation, interview, and record review the facility failed to maintain proper cleaning of resident shared equipment. This deficient practice resulted in increased potential for the spread of infection, cross-contamination, and disease transmission.Findings include: During an observation on 7/22/26 at 8:54am, a mechanical lift used to transfer dependent (helper does more than half the effort) residents, sat outside room [ROOM NUMBER]. The vertical support bar in the middle of the device was soiled with a thick, dried brown substance that measured approximately 3 (inches) in length. During an observation on 7/22/26 at 12:21pm, mechanical lift #3 sat in the hallway across from room [ROOM NUMBER], in a storage cubby. The lift remained soiled with dried brown drop of an unknown substance. The substance was thick and left a raised surface on the support bar of the device.During an observation on 7/22/26 at 2:44pm, mechanical lift #3 sat outside room [ROOM NUMBER], the dried brown substance remained on the support bar of the device.During an observation on 7/23/26 at 9:10am, mechanical lift #3 sat in the hallway, plugged in across from room [ROOM NUMBER], the dried brown substance remained on the support bar of the device. The shape and size of the brown debris remained unchanged.In an interview on 7/23/26 at 9:23am Certified Nursing Assistant (CNA) O reported CNA's were responsible for cleaning mechanical lifts after each use. CNA O reported wipes for cleaning shared equipment were kept in the clean utility room.In an interview on 7/23/26 at 9:41am CNA S reported mechanical lifts should be cleaned with disinfecting wipes after every use.In an interview on 7/23/26 at 10:06am, Infection Preventionist (IP) W reported it was the expectation that CNA's clean mechanical lifts after each use. IP W reported staff were expected to retrieve disinfecting wipes from the clean utility room, nurse's station or off the vital tower when they needed to clean a piece of resident shared equipment. IP W confirmed this was done to reduce the likelihood of the spread of infection, cross-contamination, and disease. When further queried, IP W reported the staff should wipe down every surface of the device. IP W confirmed a soiled lift device left in circulation for use for more than 24 hours created an increased risk for spread of infection. IP W reported the facility did not currently audit/monitor the cleanliness of shared resident equipment as are part of the Infection Control plan.Review of a Cleaning and Disinfecting of Patient Equipment policy with a reference date of 3/26 revealed It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to.prevent the development and transmission of infections to the extent possible.3. Cleaning considerations include, but not limited to, the following.g. Direct care staff are responsible for cleaning multiple-patient use equipment (such as.lifts) shall be cleaned and disinfected after each use.

This citation pertains to intakes: #2790330, #2794131, #2798407Based on observation, interview and record review the facility failed to 1.) accurately assess and prevent an elopement of 1 (Resident #100) of 3 residents reviewed for elopement risk, resulting in an immediate jeopardy when Resident #100 left the premises on 2/14/26 at 5:04 AM, alone, unbeknownst to staff and was later located by staff at 5:55 AM approximately 100 yards from the facility; 2). Ensure safety during a mechanical lift transfer to 1(Resident #104) of 2 residents reviewed for safe transfers resulting in a fall with a head laceration.Findings include:The immediate jeopardy began on 2/13/26 and was identified on 3/11/26 when the facility failed to ensure the safety of and prevent an elopement for Resident #100 who was admitted to the facility on [DATE] and inaccurately assessed as not being an elopement risk. Resident #100 subsequently eloped from the building on 2/14/26 at 5:04 AM and was found by staff at 5:55 AM, the same day, approximately 100 yards from the facility near a neighboring house. Resident #100 was inappropriately dressed at the time of elopement with the recorded temperatures between 24 and 26 degrees Fahrenheit. On 3/11/26 at 10:47 AM, the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy. The surveyor confirmed by observation, interview, and record review the immediate jeopardy was removed on 3/11/26, but noncompliance remains at the scope of isolated and severity of actual harm due to not all staff receiving the education and sustained compliance has not been verified by the State Agency. According to [NAME] and [NAME], (2017) Patients with actual or potential risks to safety require a nursing care plan with interventions that prevent and minimize threats to their safety. Design your interventions to help a patient feel safe to move about and interact freely within the environment. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing – Ninth Edition - E-Book (Kindle Locations 25441-90239). Elsevier Health Sciences. Kindle Edition. Resident #100 Review of an Facesheet revealed Resident #100 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: history of falls, multiple rib fractures, and right frontal and vertex scalp hematoma with acute intercranial abnormality (a collection of blood beneath the scalp, often resulting from a head injury on the right side of the head). Review of an Elopement assessment for Resident #100 completed on 2/13/26 during admission, by Registered Nurse (RN) ZZ revealed Resident is NOT at Risk. In an interview on 3/10/26 at 11:30 AM, Registered Nurse (RN) L reported when a resident was identified as an elopement risk, a wander guard (a bracelet with an electronic transmitter that works with a mounted box at exit doors that alarms when a transmitter gets within range to alert staff of a person possibly leaving unattended from the building) was applied. RN L reported if the resident was assessed as not an elopement risk, no wander guard was applied. In an interview on 3/10/26 at 11:33 AM, Certified Nurse Assistant (CNA) YY reported when a resident was an elopement risk they wore a wander guard. CNA YY reported he looked for a wander guard on newly admitted residents. CNA YY reported when a resident was an elopement risk, that information was communicated in shift-to-shift report. CNA YY did not know of additional resources to use to determine if a resident was at risk for an elopement. In an interview on 3/10/26 at 11:35 AM, CNA F reported she would identify a resident at risk for elopement when she would look to see if a wander guard was present. CNA F denied being aware of additional resources to use to determine if a resident was at risk for an elopement. In an interview on 3/10/26 at 1:45 PM, RN L reported elopement assessments were to be completed on admission, day 3 and day 10 of stay. RN L reported an elopement assessment should be completed with a change in condition and after an elopement occurred. When queried if an elopement assessment could be completed at any time, RN L stated he was unsure, but thought there was a way to access the assessment to update the resident assessment. In an interview on 3/10/26 at 2:00 PM, RN R reported when a resident was assessed to be an elopement risk, they received a wander guard that was applied by a nursing manager, and they would need to be reevaluated during their stay. RN R reported when a resident was assessed to not be at risk for an elopement, no reevaluation was done. RN R reported she was unable to see resident assessments, and if a reassessment was needed the assessment would trigger when it was due. In an interview on 3/10/26 at 2:50 PM, RN ZZ reported she was the nurse who admitted Resident #100. RN ZZ reported when she received report from the transferring hospital about Resident #100, she was told Resident #100 was alert and oriented with some delirium related to recent narcotic use for pain management. RN ZZ reported when Resident #100 arrived at the facility she was terrified and had absolutely no clue what was going on. RN ZZ reported Resident #100 was not alert and oriented, voiced she thought someone was going to murder her, that she had been made a part of a sex trafficking ring, and her focus was to get out. RN ZZ reported Resident #100 verbalized (Name Omitted) transferring hospital was out to get her, had stolen her belongings including her coat, and were keeping her from her friends and family. RN ZZ reported Resident #100 also verbalized wanting to speak to her husband and son, and she repeatedly stated she wanted to leave. RN ZZ reported Resident #100 was frequently up walking around her room, to the bathroom, and to the sink and there was always a concern for elopement when a resident was wandering. RN ZZ reported Resident #100 had several broken ribs, was in significant pain, had an unsteady gait (walking pattern), walked hunched over, was retaining urine, and she was concerned Resident #100 was going to fall. RN ZZ reported she repeatedly had to inform Resident #100 that she was not going to hurt her, she was trying to help her. RN ZZ reported she informed Unit Coordinator (UC) V and LL that she needed additional help with Resident #100 and CNA MM was assigned to make additional rounds on Resident #100 throughout the shift. When queried about Resident #100's elopement assessment and risk status, RN ZZ stated She (Resident #100) was definitely an elopement risk; I would say, yes, that I documented her as an elopement risk. In a subsequent interview on 3/11/26 at 2:57 PM, RN ZZ stated she did not assess and document Resident #100 as an elopement risk because I did not think she was physically capable of making it all the way to the door and I was hopeful and optimistic she would adjust to being in the facility. In an interview on 3/10/26 at 3:57 PM, UC V reported RN ZZ had told her she had concerns for Resident #100's status and behaviors after RN ZZ had received verbal report from the hospital and before Resident #100 had arrived at the facility. In an interview on 3/10/26 at 3:58 PM UC LL reported RN ZZ had requested help from her when Resident #100 was admitted to the facility. UN LL reported RN ZZ was in and out of Resident #100's room and had delegated tasks to her for another resident. UC LL reported she completed the delegated tasks and RN ZZ continued to complete the admission of Resident #100. In a telephone interview on 3/10/26 at 4:39 PM, CNA H reported she was assigned to Resident #100 during the third shift (11:00 PM to 07:00 AM) on the night she eloped and Resident #100 was wandering during the shift. CNA H reported the information she received in report about Resident #100 was that she was new to the facility, she had had a fall at home, had a knot on her head, and that she was fine. CNA H reported her first encounter with Resident #100 she noted she was very confused. CNA H reported Resident #100 wanted to call her son, was heard saying she didn't know how she got there (to the facility), asking for her husband and son, and that she wanted to leave. CNA H reported she had Resident #100 sitting in a chair at the nurse's station with her and was reassuring her she was safe prior to taking her lunchbreak at 3:00 AM. CNA H reported she returned to the unit after her break at 3:30 AM and Licensed Practical Nurse (LPN) I told her she had assisted Resident #100 to bed. CNA H reported she began her rounds and did not see Resident #100 again during her shift. In a telephone interview on 3/11/26 at 8:07 AM LPN I reported she was the nurse assigned to Resident #100 on the night she eloped from the building. LPN I reported she was told in report that Resident #100 had some confusion and she wasn't happy; didn't want to be here. LPN I reported at one point she had Resident #100 out at the nurse's station with CNA H. LPN I reported she had assisted Resident #100 into bed at about 3:30 AM and continued with her work on the unit. LPN I reported she had walked past Resident #100's room a couple of times after she helped her to bed and had observed her feet in the bed. LPN I reported she was outside of Resident #100's room at about 5:30 AM and was preparing to administer medications to Resident #100 when she discovered she was not in bed. LPN I reported she started looking for her in the building, to all the other courts (halls), other areas of the building, and notified other staff that she could not find her. LPN I reported she exited the building, searched the parking lot, and did eventually locate Resident #100 on the entryway steps to a neighboring house, sitting on the ground, wearing a hospital gown and grippy socks with a blanket wrapped around her shoulders. LPN I reported when she approached Resident #100, she asked her why was she out here and LPN I reported Resident #100 told her she was out here to get away from you guys and that she wants to go home. LPN I reported when Resident #100 said she wanted to go home she pointed to the house. LPN I reported she asked Resident #100 if she had fallen or if she was hurt and that Resident #100 replied I'm fine. LPN I reported she completed an assessment checking for injuries, called the staff in the building. LPN I reported she asked for extra blankets to be brought to her, because one blanket was not enough. When queried why one blanket was not enough, LPN I stated I was cold, so I knew she (Resident #100) was cold. LPN I reported she waited with Resident #100 for the paramedics to arrive and she was transferred to the local emergency department for evaluation. LPN I reported the cameras were reviewed and it was noted that Resident #100 exited the building on 2/14/26 at 5:04 AM and that she (LPN I) was to her just before 6 AM the same day. LPN I reported as far as she knew, Resident #100 was not a wander risk, and she was not wearing a wander guard. In an interview on 3/11/26 at 9:45 AM CNA RR reported she was assigned to Resident #100 when she admitted to the facility. CNA RR reported when Resident #100 admitted to the facility she was very confused, made accusations that the transporting paramedics had stolen things from her, and that she wanted to get back to her husband, to the hospital. Review of Care Plan for Resident #100 revealed .Problem: I have a potential for sudden changes in my mental status related to my medical diagnosis- Interventions: please provide a supportive environment for me by maintaining safety.Problem: Mood: I have changes in mood due to medical diagnosis- Interventions: monitor for increased signs or symptoms of depression or anxiety. with initiation dates of 2/13/26. Review of Progress Notes for Resident #100 dated 2/13/26 at 2:00 PM revealed .Resident #100 is very confused asking to call her husband.Resident #100 is confused and cannot answer questions appropriately. She reports she is in severe pain. and no one will help her.Resident #100 states (Name Omitted) hospital is trying to [NAME] her and planning to keep her from her friends and family.Confusion reported to provider. Review of Progress Notes for Resident #100 dated 2/13/26 at 3:37 PM revealed .Resident #100 asked CNA staff if they would be willing to help her commit a mass murder to get the (Name Omitted) hospital people; after being found ambulating (walking) in room without walker. Review of Progress Notes for Resident #100 dated 2/13/26 at 4:37 PM revealed .Resident #100 is normally fully alert and oriented and can be anxious at times.Resident #100 having increased fear and confusion. Review of Progress Notes for Resident #100 dated 2/13/26 at 8:44 PM revealed .Resident #100 has calmed after talking with her son.son reports that Resident #100 is often anxious, but it (is) confused and unlike herself. Review of Progress Notes for Resident #100 dated 2/14/26 at 5:05 AM revealed .Patient.Seems anxious and overwhelmed at this moment. Review of admission History and Physical dated 2/13/26 revealed . Resident #100 was transferred to (Name Omitted) facility quite confused, agitated, and impulsive with abnormal behaviors on 2/13/26.Physical Exam.Resident #100 is ill-appearing.Neurological: Quite confused.Psychiatric: agitated, confused.Encephalopathy overnight during hospitalization that continues here with agitation, abnormal behaviors and impulsiveness.Patient quite confused, express that While I was in the hospital she was taken to basement filled with water and people bicycling and abnormal behaviors going on down there. Review of Significant Event for Resident #100 dated 2/14/26 at 6:45 AM revealed .Patient was discovered to be missing from room around 05:30 (5:30 AM). Previous to this time around 03:30 (3:30 AM) I assisted her back to bed after she had been up with us for a short period of time due to being slightly disoriented and confused about why she is here.At this time I searched around the building to each court, notified staff she was missing while looking, at the time that I had not found her within the building I exited the building and proceeded to look for her. I located her up the driveway at the neighbors house sitting on the walkway. She went up 6 stairs and about 20 feet up further from stairs towards their house. When I found her I asked her if she was in pain, or if she fell. She stated she did not fall and had no pain. She stated she was trying to get home. At this time I stayed with her, ensured the blanket she had with her stayed around her shoulders. I contacted staff within (Name Omitted) facility to assist with getting more blankets, contacting emergency services to help safely get her up off the walkway and contact our (Name Omitted) Management/Administration. Assessing (Name Omitted) Resident #100 I did not see signs of fracture or harm. Waited for EMS (emergency medical services) before attempting to get her up off ground. Called building starting at 05:55 (5:55 AM), stayed on phone with LPN GG until EMS arrived at 06:10-06:20 (6:10 – 6:20 AM) During this time CNA brought extra blankets out for Resident #100 to help keep her a bit warmer until EMS could arrive. EMS assessed her also felt comfortable assisting her up to wheelchair. At his time per Nursing Home Administrator (NHA) A (Name Omitted) EMS service were instructed to take her (Resident #100) to (Name Omitted) hospital. [NAME] of Incident Review dated 2/16/26 revealed 2/14/26. 3:19 AM Per her report and recorded footage LPN I assists (Name Omitted) Resident #100 back to her room: LPN I reported she helped Resident #100 into bed .4:58 AM Recorded camera footage reveals that (Name Omitted) Resident #100 self-propelled out of her room towards the café, seated in her wheelchair with a hospital gown, non-skid socks, and blankets on her lap. She travels directly to the main entrance of the facility.5:03 AM (Name Omitted) Resident #100 is observed via recorded footage to push the handi-cap button on the wall to open the door. She self-propels through the door and stops in the vestibule. She is observed standing up from her wheelchair, arranging a blanket over her shoulders, rearranging an additional blanket on the seat of the wheelchair, then using the wheelchair as one would use a walker to push it through the front door. She can be seen on recorded footage walking along the west side of the parking lot, headed south through the lot.5:09 AM (Name Omitted) Resident #100 exits camera view on the south side of the driveway round-about.5:34 AM Per her report and recorded footage review, LPN I enters (Name Omitted) Resident #100's room to administer scheduled morning medications and notes (Name Omitted) Resident #100 is not in her room. LPN I reports she immediately began a room-to-room search and notified other staff to assist.5:45 AM while other staff continued to search inside the facility, LPN I exited the facility to search the exterior. She located (Name Omitted) Resident #100 approximately ten minutes later, approximately 100 yards away from the facility, near the neighboring homes front porch, sitting on the ground. LPN I remained with (Name Omitted) Resident #100 while she phoned emergency services for assistance. She also called the facility to advise that (Name Omitted) Resident #100 had been located. She asked staff to bring more blankets as they waited for EMS to arrive.6:03 AM LPN GG phoned. NHA A to advise of incident. While waiting for EMS, LPN I reports she asked of (Name Omitted) Resident #100 if she fell and she said no. LPN I asked (Name Omitted) Resident #100 if she was injured or had any pain and she said no. LPN I performed a brief physical assessment noting no obvious signs of injury. LPN I reports she asked (Name Omitted) Resident #100 what happened and she said she was trying to get home.6:10 AM approximately EMS arrived. EMS noted no signs of injury. NHA A requested that (Name Omitted) Resident #100 be taken to the emergency department for evaluation.6:20 AM EMS departs with (Name Omitted) Resident #100 enroute to (Name Omitted) hospital.Patient review.throughout her hospital stay (Name Omitted) Resident #100 began to experience confusion short-term memory loss and poor insight. upon arrival to (Name Omitted) facility (Name Omitted) Resident #100 exhibited non-sensical conversation, agitation.Following this event (Name Omitted) Resident #100 was evaluated in the emergency department and found to have E. Coli in her urine and encephalopathy with paranoia. Review of Discharge Summary for Resident #100 dated 2/19/26 revealed .admission date 2/14/26.Primary Diagnosis: encephalopathy with paranoia- suspected drug induced, possibly related to tramadol and oxycodone- resolved.HPI at time of presentation.Presented to the ED (emergency department) brought in by ambulance from (Name Omitted) facility for evaluation of AMS (altered mental status). Upon arrival to (Name Omitted) facility patient confused and agitated with reported paranoia and hallucinations.This morning patient eloped from (Name Omitted) facility and was found 100 m (meters) away at surrounding house. In an observation and interview on 3/12/26 at 7:25 AM, upon entrance to the facility, a staff member CNA E was observed sitting at a desk placed next to the entrance door. CNA E reported she was assigned to sit at the desk and observe the door for the duration of her shift that started at 11:00 PM and ended at 7:30 AM. CNA E reported that the front doors to the building did not lock from the inside; anyone could push on the door, open them and exit the building. CNA E reported the outer doors to the vestibule were open, but the doors to the building from the vestibule were locked after hours and someone had to let a visitor into the building. The immediate jeopardy began on 2/13/26 and was removed on 3/11/26 when the facility took the following actions to remove the immediacy: On 2/17/26 Elopement and missing person policies and procedures were reviewed. On 3/11/26 the elopement assessment tool scoring was modified to enhance identification of safety risks. On 3/11/26 all 90 residents in the building were reassessed for elopement risk. Two residents were identified as elopement risks related to the changes in the elopement assessment tool and wander guards were initiated for both residents. On 3/11/26 all wander guards and alarms were checked for functionality. On 3/11/26 comprehensive education on elopement prevention including ongoing assessments, definitions, exit seeking behaviors, and role expectations to all licensed nursing staff and certified nursing assistants began with 88 of 172 total employees being educated. Staff development instructor, leaders, or designee will provide education to the remaining employees prior to the start of their next working shift. Education material and completion to be reviewed quarterly at the QAPI meeting. Effective immediately, 3/11/26 nursing leaders will perform weekly audits of new admissions for the next 4 weeks to ensure elopement assessments are done on admission, and up to date and that there is a care plan to address the risk if any. On 3/11/26 a workstation was created at the main entrance to the building and scheduled staff to monitor the flow of traffic in and out of the building (Monday- Friday 1700-0730 (5:00 pm to 7:30 AM) and weekends/holidays staffed 24/7. On 3/11/26 a Red Box Audible Alarm was installed at the main entrance. Alarm will be active 2300-0600 (11:00 PM to 6:00 AM) and maintained by entrance attendant. Alarm is activated any time the door is opened. Resident #104 Review of a Facesheet revealed Resident #104 was a female. Review of a Diagnosis List revealed Resident #104 had pertinent diagnoses which included: moderate cognitive impairment and generalized weakness. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 1/15/26 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #104 was moderately cognitively impaired. Further review of said MDS revealed Resident #104 was dependent on staff to roll left and right (the ability to roll from lying on back to left and right side.), sit to lying (the ability to move from sitting on side of bed to lying flat on the bed), lying to sitting on side of bed (the ability to move from lying on the back to sitting on the side of the bed with no back support), sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair [or wheelchair]), toilet transfer (the ability to get on and off a toilet or commode) and tub/shower transfer (the ability to get in and out of a tub/shower). Review of an Incident/Accident Report report for Resident #104 revealed, Incident On 2/20/26, (Resident #104) was transferred to (hospital name omitted) following an incident during which she fell from the Hoyer (a specialized type of equipment with a sling used to safely transfer patients between surfaces) sling (a specialized harness used with a hoyer lift for safe patient transfers).Incident Review Staff was assisting (Resident #104) to transfer from her bed using a Hoyer lift. As the lift was pulled away from the bed, (Resident #104) was unable to maintain arm support necessary for the sling that was used. She immediately slid out of the sling and landed on the legs of the machine.The nurse completed an assessment and pressure was applied to her head wound.(Resident #104) was transported to the hospital via stretcher at 0830 (8:30 AM).Head laceration was repaired with four staples. Review of Resident #104's Emergency Department Notes dated 2/20/26 revealed, Patient was brought in by ems (emergency medical services) from (facility name omitted) due to a fall out of the hoyer. Patient landed on her head at bed height.Patient has a history of dementia and Alzheimers (a type of dementia). Shoulder pain and back pain. LAC (laceration) to the back of head.Procedure.The laceration was closed with staples.Other Items: Staple count: 4.The patient tolerated the procedure well. In an interview on 3/10/26 at 12:59 PM, Certified Nurse Aide (CNA) O reported that she and CNA YY got the sling on Resident #104 and CNA YY was lifting Resident #104 up and she went around the other side to guide Resident #104 and before she could get to Resident #104, she fell. CNA O reported they had used the sling they use to put her on the toilet (referred to as a hygiene sling – a specialized sling designed with a large opening under the buttocks and lower back typically used for toileting) because that was the sling in the room at the time of the transfer and they had been using that sling on Resident #104 for months. CNA O reported after the fall, management removed the sling from Resident #104's room. In an interview on 3/10/26 at 1:08 PM, CNA YY reported he and CNA O were transferring Resident #104 from her bed to her recliner chair by placing the sling underneath her, properly placing the back part where it was supposed to be, crossing the leg portion, and looping the bands through each other. CNA YY reported they raised the hoyer and lowered the bed at the same time. CNA YY reported by the time he pulled the hoyer away from the bed, he looked up and Resident #104 had fallen backwards landing on her upper left shoulder and hitting her head. CNA YY reported they had used the sling they always used with Resident #104 which was the hygiene sling. In a follow-up interview on 3/11/26 at 8:50 AM, CNA YY reported the CNAs will use the slings that are in the resident rooms. CNA YY reported they used the hygiene sling for Resident #104 because that was the one in her room at the time of the transfer on 2/20/26. CNA YY reported the care plan does not indicate what type of sling to use. In an interview on 3/10/26 at 1:21 PM, Supervisor of Rehabilitation (SR) QQ reported CNA O and CNA YY had been using the hygiene sling to transfer Resident #104 at the time of her fall on 2/20/26. SR QQ reported staff should have used the standard hoyer sling (a type of sling that provides full body support). In a follow-up interview on 3/10/26 at 2:26 PM, SR QQ reported prior to Resident #104's fall on 2/20/26, therapy had not assessed Resident #104 for the appropriateness of using the hygiene sling for transfers. In an interview on 3/10/26 at 1:44 PM, Registered Nurse Unit Coordinator (RNUC) V reported at the time of Resident #104's fall on 2/20/26, Resident #104 was in the hygiene sling. RNUC V reported that sling was her preference. RNUC reported Resident #104 was normally able to use her upper body to support herself and she just couldn't that day and she dropped. RNUC V reported on re-evaluation it was determined that the hygiene sling was not an appropriate sling to use for Resident #104 but at the time it was the appropriate sling until it wasn't. In a follow-up interview on 3/10/26 at 2:51 PM, RNUC V was requested to provide this surveyor with evidence that the hygiene sling was Resident #104's preference. RNUC V reported there was no such documentation. In an interview on 3/10/26 at 3:02 PM, Nursing Home Administrator (NHA) A was requested to provide this surveyor with Resident #104's assessment indicating that she was appropriate to use the hygiene sling for transfers. In an interview on 3/10/26 at 3:32 PM, NHA A reported the facility did not have an assessment for Resident #104 indicating that she was appropriate to use the hygiene sling for transfers. In an interview on 3/10/26 at 3:42 PM, Physical Therapist (PT) BB reported in order to use the hygiene sling, a resident would need to keep their shoulders engaged and have enough core strength to counterbalance. PT BB reported the hygiene sling was a very specific type of sling and it would not be appropriate for everybody. PT BB reported she would not prescribe a resident to use a hygiene sling unless they were assessed to be appropriate to do so. In an interview on 3/11/26 at 10:50 AM, Occupational Therapist (OT) TT reported a hygiene sling was supposed to be used for toileting purposes. OT TT reported it would not be an appropriate sling to be used if a resident was being transferred from a bed to a chair. OT TT reported it would be a good idea for a resident to be assessed before using a hygiene sling because it is a very specialized type of sling. OT TT reported without assessing Resident #104, she would not know if Resident #104 was appropriate for the hygiene sling. OT TT reported when therapy recommended a hoyer lift to be used, normally it would be a standard hoyer sling that was used for the transfer, not a hygiene sling. OT TT reviewed Resident #104's therapy notes and reported therapy had not assessed Resident #104 for use of the hygiene sling. OT TT reported OT and PT expected Resident #104 to be using the standard hoyer sling for transfers. OT TT reported if it was a resident preference to use the hygiene sling, it would be documented that they were educated that it was not safe to use the hygiene sling for transfers and that therapy did not recommend that. OT TT reported for a normal transfer, a hygiene sling should absolutely not be used because it is less safe than a standard hoyer sling and does not provide enough support. OT TT reported when therapy reco

Based on interview and record review the facility failed to ensure a Registered Nurse (RN) served full time in the role of Director of Nursing potentially affecting all 89 residents that reside in the facility.Findings include:On 3/10/26 at 9:50 AM, surveyors entered the facility and were met by Staff Development/Registered Nurse (SD/RN) III. Surveyors requested to meet with either the Nursing Home Administrator and/or the Director of Nursing and SD/RN III reported the NHA and DON were the same person.On 3/10/26 at 9:55 AM, Director of Nursing (DON) B while meeting with survey team in the conference room, reported she was also the Executive Director/Nursing Home Administrator (NHA) A at this time.In an interview on 3/11/26 at 7:42 AM, DON B reported she had held the position of DON for about 5 years, and in August of 2025, the previous NHA vacated the position and she assumed the role. DON B reported she has been the only person in both roles since the previous NHA left until present. DON B reported here role as DON included auditing and education, new processes, policy updates, employee issues, a bit of payroll and budget, staff meetings, skills fairs, infection prevention meetings, clinical oversight, and IDT (interdisciplinary) meetings. DON B reported she was responsible for managing skills fairs, running IDT meetings and the daily check meetings. DON B reported her role as DON has several parts, many of which she was delegating to the unit coordinators. DON B reported in addition to her DON duties, as the interim NHA she was now responsible for rehabilitation department, activities department, dietary, social work, and that the social work supervisor was on a medical leave.In an interview on 3/11/26 at 10:41 AM, Unit Coordinator (UC) X reported she had been given multiple delegations by DON B.In an interview on 3/11/26 at 10:42 AM, DON B reported she was one person doing 40 hours' worth of work in two roles and was not always performing quality work. DON B reported things could have been managed better with better oversite if there were two people to fulfill the roles of NHA and DON. DON B stated there are meetings I can't attend, and things I cannot do because of the things related to the executive director position. My responsibilities as the DON were delegated to and shifted to the unit coordinators and their responsibilities were shifted accordingly.In an interview on 3/11/26 at 10:46 AM UC LL reported access to DON B had been limited when trying to work through something. UC LL reported DON B was just not as available as she used to be when she wasn't doing dual roles.In an interview on 3/11/26 at 10:52 AM DON B reported she had not been able to welcome staff to discuss things, she had to direct them to their direct leaders. DON B reported she could not be as hands on as she had been before with the clinical staff. DON B reported she felt as though she had been less available for the staff.In an interview on 3/11/26 at 10:58 AM, UC M reported one week after she started, she was placed into the safety committee spot that DON B had previously occupied, due to the DON B's additional role as NHA. UC M reported she had been learning on the fly since she started. In an interview on 3/11/26 at 11:01 AM, DON B stated UC M took my place on the safety committee, I had been on that committee for years, but I could no longer fulfill that role. I was already doing two jobs; I couldn't do three! DON B reported UC LL does more interviews now. DON B also stated I used to do the nurse aide training program, and I am no longer involved due to the responsibilities of the NHA role, Staff Development (SD) III now leads the nurse aide training program. DON B reported in the role of interim NHA she was now responsible for the whole building.In an interview on 3/11/26 at 11:07 AM, UC X reported DON B was no longer as available to touch base or discuss things throughout the day as she had once been.Review of Facility Assessment dated August 8, 2025, revealed .Interim Executive Director and Director of Nursing were the same name, the same person.Review of Employee Report revealed no noted named employee listed as Executive Director.

This citation pertains to Intake MI00151630 Based on observation, interview, and record review, the facility failed to ensure appropriate transfer techniques were implemented for 2 (Resident #172 and #65) of 4 residents reviewed for falls resulting in a fall with a hand laceration and a fracture for Resident #172 and an improper transfer with a slide board resulting in bruising on the bilateral (both) upper arms for Resident #65. Findings include: Resident #172 Review of an admission Record revealed Resident #172 was a female, originally admitted to the facility on [DATE]. Review of Resident #172's a Level of Assistance flowsheet revealed Resident #172 was limited assistance for transfer assistance with Therapy Recommendations including Front wheeled walker; Wheelchair-manual; Gait Belt; Verbal cues. Review of Resident #172's Radiology Report dated 3/16/25 revealed, .IMPRESSION: Suspected acute periprosthetic fracture (a break in the bone near an orthopedic implant) is along the distal femoral shaft (lower portion of the thigh bone) associated with the distal intramedullary rod (a surgical implant used to stabilize broken bones) . Review of a Facility Reported Incident (FRI) Incident Summary revealed, Patient had a witnessed and assisted ground-level fall. She was admitted to (facility name omitted) for physical and occupational therapy following a previous ground-level fall resulting in a left femur (the bone running from the hip to the knee) fracture requiring surgical repair .Initial statements reveal that patient was being assisted from the bathroom to the bed by a CNA (certified nurse aide). While standing near the bed, the CNA turned to situate the bedding. The patient let go of the walker and began to fall backwards. The aide immediately reached out and attempted to assist the patient to the floor. Nurse was notified and assessment revealed a laceration to her hand. Neuro (neurological) assessment revealed no concerns. Patient was sent to the hospital for further assessment and repair of the laceration. At that time a left distal femur (lower part of the thigh bone just above the knee) fracture was discovered. CNA was removed from patient care pending investigation . Review of Resident #172's Incident/Accident Report/Investigation document provided by the facility revealed, Patient Interview with (Resident #172) Interview conducted by (Unit Coordinator (UC) R) on 3/19/25 over the phone. (Resident #172) indicated that she was assisted from the bathroom to her bed by an aide. She stated that the girl had hands on her at all times, though a gait belt was not used. When the aide was pulling down the covers, (Resident #172) states she lost her balance and fell . Review of Resident #172's Incident/Accident Report/Investigation document provided by the facility revealed, Interview with (CNA UU) Interview conducted by (Director of Nursing (DON) B) on 3/17/25. (CNA UU) answered the bathroom call light and found (Resident #172) on the toilet with her walker in front of her. (Resident #172) stood up independently and proceeded to pull up her undergarments and pants without assistance. (CNA UU) provided limited assistance to (Resident #172) as she ambulated back to the bed. As (CNA UU) pulled the bedding back, (Resident #172) let go of the walker to point at the bed control and began to fall backwards. (CNA UU) attempted to assist her but was unable to stop her from falling. (DON B) asked (CNA UU) if she knew a gait belt was part of (Resident #172)'s care plan and (CNA UU) admitted she did not. (CNA UU) shared because (Resident #172) got up from the toilet on her own and managed her undergarments independently, she didn't think to check the care plan to see if a gait belt was needed . In an interview on 6/11/25 at 10:11 AM, DON B, who conducted the interview with CNA UU on 3/17/25 reported CNA UU had responded to Resident #172's bathroom call light. DON B reported CNA UU had reported that Resident #172 stood up and was pulling up her own pants and brief and started to walk to the bedroom area. DON B reported CNA UU had reported she didn't think to put a gait belt on Resident #172. DON B reported CNA UU had reported she helped Resident #172 to the bed and then went to pull the sheets down and Resident #172 was trying to point to the bed controller and took her hand off the walker and fell. DON B reported after the fall, Resident #172 was sent to the hospital and that is when it was found that there was a new acute fracture to her distal femur. DON B reported during the interview with CNA UU, CNA UU reported she did not look at the care plan for Resident #172 before the transfer to identify that Resident #172 needed a gait belt. DON B reported when CNA UU saw Resident #172 stand, CNA UU should have asked the resident to sit back down and then look at the care plan and apply the gait belt. DON B also reported that in addition to that, CNA UU should have, after she put the gait belt on Resident #172, pulled the linens down before Resident #172 was transferred so she didn't have to take that extra step while Resident #172 had been standing. Attempts were made to contact Resident #172 during the survey but were unsuccessful. Attempts were made to contact CNA UU during the survey but were unsuccessful. Resident #65 Review of a Facesheet revealed Resident #65 was a female who was admitted to the facility on [DATE] with pertinent diagnoses which included: Gastroparesis (slow or stopped gastro motility) and dependence for cares. Review of a Minimum Data Set (MDS) assessment for Resident #65, with a reference date of 5/20/2025 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #65 was cognitively intact. In an observation and interview on 6/10/25 at 11:43 am, Resident #65 reported that over the weekend, a CNA (certified nurse assistant) did not know how to do a proper slide board transfer for her to use the bathroom and while they transferred her, she received bruises on her inner upper arms. Resident #65 opened her arms and pointed to the upper inside of her left arm where a scattering of bruises was noted. Bruising was noted on the upper inner right arm as well. In an interview on 6/11/25 CNA Y reported that Resident #65 was to be transferred with a hoyer lift to the toilet. CNA Y reported that Resident #65 was working with therapy using a slide board but had not been upgraded to a slide board transfer to the bathroom yet. CNA Y reported that Resident #65 was a slide board transfer from her bed to wheelchair and wheelchair to bed only. CNA Y reported Resident #65 had been a hoyer transfer to the toilet since she admitted to the facility, CNA Y stated her transfer status had never changed. Review of Level of Assistance for Resident #65 revealed transfer assistance limited assistance; 2 or more person physical assist slide board transfer to/from w/c (wheelchair)>bed. Please continue to use hoyer for toileting .started on 5/27/2025 12:55 pm .Toileting Assistance Total dependence; 2 or more person physical assist please use Hoyer for toilet transfers .started on 5/27/2025 at 12:55 pm .Therapy Recommendations wheelchair-manual; gait belt; slide board . stated 5/27/2025 12:55 pm. In an interview on 6/11/25 at 12:43 pm CNA I and CNA PP reported that Resident #65 was slide board transfer between bed and wheelchair, and a hoyer transfer to the toilet. CNA PP reported that Resident #65's care plan; level of assistance was how the CNAs knew how she transferred. In an interview on 6/11/25 at 2:23 pm, CNA Y reported that Resident #65 had reported to her on Monday 6/9/25 that staff was transferring her some time over the weekend with a slid board to the toilet, staff had gotten impatient with using the slide board and then did a stand and pivot transfer to the toilet. CNA Y reported that Resident #65 reported to her the transfers were what had caused the bruising on her inner arms. CNA Y reported she saw the bruising on Resident #65's inner arms. CNA Y reported she reported the bruising and the Resident #65's account of what happened to Registered Nurse (RN) MM. In an observation and interview on 6/11/25 at 2:27 pm, Resident #65 reported she was a slide board transfer from bed to wheelchair or back and that she was a hoyer transfer to the toilet. Resident #65 reported that two girls were transferring her over the weekend and were using the slide board, when they got impatient with how long it was taking her to get her onto the toilet, and that the girls then decided to pick her up and transfer her to the toilet. Resident #65 reported her thought that was when her arms were bruised. Resident #65 lifted her left arm to show this surveyor the bruising that was still present on her inner upper left arm. There was a scattering of bruising noted. In an interview on 6/12/25 at 9:20 am Physical Therapy Assistant (PTA) BBB reported that Resident #65 reported to her on Monday 6/6/25 in the morning, that the aides instead of using the hoyer lift to transfer her onto the toilet, one aide said I don't have time to use the hoyer or the slide board, and Resident #65 reported the aides just picked her up and put her in the chair and then again picked her up to put her onto the toilet. PTA BBB reported she observed bruising noted on the inner upper arms of Resident #65. PTA BBB reported that Resident #65 was a hoyer lift transfer to the toilet. In an interview on 6/12/25 at 10:37am, Unit Coordinator (UC) R reported that she had spoken to Resident #65 and that she had noted the bruising on her inner upper arms with the bruising being greater on the left. UM R reported that Resident #65 should be a hoyer lift transfer to the toilet, and she believed the bruising was from a slide board transfer. UM R reported she had not yet interviewed any staff that worked over the weekend to determine any details of the situation during the transfer with Resident #65. In an interview on 6/12/25 at 10:45 am, Nursing Home Administrator (NHA) A reported she was aware of the bruising with Resident #65 and her expectations were that her leadership team would conduct an investigation to try to understand the event fully. NHA A reported that there was concern that Resident #65's care plan was not followed, and she was transferred incorrectly, and that staff would need further education. In a telephone interview on 6/12/25 at 11:16 am, CNA P reported that she did complete a slide board transfer with Resident #65 from the wheelchair to the toilet on Friday. CNA P reported that she believed that Resident #65's transfer status had changed from a hoyer lift to slide board. CNA P stated that she did assist Resident #65 with a gait belt into a standing position with another CNA present to assist pulling up Resident #65's pants. CNA P reported she did not complete a stand a pivot transfer with Resident #65. CNA P reported that she had since been reeducated by the leadership nurses on how Resident #65 transferred. CNA P reported that she had been contacted by the facility and asked about the bruising to Resident #65's arms, and CNA P reported she did not see any bruising until Resident #65 showed her on Monday. In a telephone interview on 6/12/25 at 1:31 pm, CNA ZZ reported she was assigned to work with Resident #65 on a night over the weekend. CNA ZZ reported that she did not perform a transfer with Resident #65, she was working alone, and when Resident #65 asked to use the bathroom during her shift, she reported that she told Resident #65 that she did not have time to use the slide board or the hoyer to transfer her and CNA ZZ reported she offered her the use of a bed pan. CNA ZZ reported that she was told by the CNAs that worked the shift her over the weekend that Resident #65 was now a slide board transfer. CNA ZZ reported she was reeducated last night on Resident #65's transfer status.

Based on interview and record review the facility failed to inform residents and/or educate residents and effectively implement the grievance process for six of six residents from a confidential group meeting and all 85 residents that reside in the facility, resulting in the potential for residents to not meet their highest practicable level of wellbeing due to grievances not being documented, tracked, and the results of conclusions and/or resolutions not being recorded. Findings include: During a confidential group meeting on 06/11/25 at 10:34 AM, six of six residents reported that they talked about the same concerns month after month in resident council meetings. These residents also reported that they were not aware that they could have their private concerns documented on a form, that staff could assist them to complete the form, and/or that they could complete a concern form anonymously. The residents did not know that there were forms available and reported that they would utilize the concern forms if they had access to them. During an observation on 06/11/25 at 11:25 AM in the sitting area next to the main lobby there was a shelf hanging approximately 4-5 feet up on the wall containing a binder that housed blank concern forms. In an interview on 06/11/25 at 12:02 PM, Licensed Practical Nurse (LPN) JJ reported that she did not know where to find concern forms for residents to submit their concerns; she did not assist residents with concern forms. LPN JJ reported that management handled resident concerns. In an interview on 06/11/25 at 01:59 PM, Activity Associate (AA) AA reported that she was not familiar with concern forms that residents could complete. In an interview on 06/12/25 at 11:19 AM, Nursing Home Administrator (NHA) A reported that the concern forms were located in an area that residents do not frequent and were not easily accessible. In an interview on 06/12/25 at 02:53 PM, Activity Associate (AA) U reported that she conducted resident council meetings monthly and emailed the group's concerns to the related departments but did not follow up to ensure the concerns were all addressed. AA U reported that during resident council meetings she discussed any responses from the previous month concerns. In an interview on 06/12/25 at 01:28 PM, Director of Nursing (DON ) B reported that concern forms are available for residents in the lobby but they are out of the way and posted high on the wall. DON B reported that typically staff are the ones to initiate the concern form.

Resident #13 Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cancer, heart failure (chronic condition in which the heart does not pump blood as well as it should), anxiety and depression (persistent depressed mood or loss of interest in activities causing significant impairment in daily life). Review of a Minimum Data Set (MDS) assessment for Resident #13 with a reference date of 4/26/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #13 was cognitively intact. Section N of the MDS revealed Resident #13 received antianxiety, antidepressant, a diuretic (drug that causes the kidneys to make more urine) and opioid (class of drug used to reduce moderate to severe pain) medications. Review of a Care Plan for Resident #13 with a reference date of 5/14/24, revealed a problem/goal/interventions of: Problem: I use my medication to help me manage my diagnosis. I want to avoid any potential drug related complications. Goal: I would like to remain free of drug related complications. Interventions: .monitor me for side effects of my medication . In an interview on 6/10/25, at 12:48pm, Resident #13 reported the nurses sometimes left her medications for her to take on her own. Resident #13 reported earlier on 6/10/25, when she dropped one pill on the floor and no staff were present, she almost attempted to pick up on her own but then remembered she had previously fallen out of her chair when she tried to pick something up from the floor. Review of Physician Orders for Resident #13 with a reference date of 5/1/24-present, revealed no orders for nurses to allow the resident to self-administer any medications. In an interview on 6/10/25 at 10:26am, Registered Nurse (RN) K reported no residents on Resident#13's unit had been assessed as able to self-administer medications. In an interview on 6/11/25 at 11:53am, Resident #13 reported she thought the nurse's usually just left her supplements and vitamins for her to take on her own. Resident #13 reported in addition to other prescribed medications, she was prescribed a supplement for arthritis (swelling and tenderness in the joints) and a vitamin C tablet. In an interview on 6/11/25 at 3:46pm, Licensed Practical Nurse (LPN) HHH reported no residents on Resident #13's unit had been assessed as able to self-administer medications. Review of an emailed response from Nursing Home Administrator (NHA) A with a reference date of 6/12/25 at 9:18am, revealed: We do not have self-administration screens(assessments) for these patients (Resident #65, Resident #272, and Resident #13). Review of a Self-Administration and Completion of Medication Administration policy with no reference date, revealed POLICY: Applies to any resident who wishes to self-administer medication or complete medication administration without direct visual supervision .Procedure: .2) If the resident wishes to pursue this offer (self-administration), an assessment must be completed .5) If deemed safe, a provider order will be placed in the electronic medical record indicating the resident may self-administer or that medications prepared by the nurse may be left with the resident to complete administration without direct visual supervision .7) a MAR (Medication Administration Record) Note will be added to the resident's MAR that highlights the resident has an order to self-administer or that medications prepared by the nurse may be left with the resident . Based on observation, interview, and record review the facility failed to ensure residents were assessed to be appropriate for self-administration of medications for 3 (Resident #65, Resident #272, and Resident #13) of 3 residents reviewed for self-administration of medications resulting in medications being left unsecured at resident's bedside, residents self-administering medications without staff assessment, and the potential for negative outcomes from taking/applying/instilling too much or too little medications. Findings include: Resident #65 Review of a Facesheet revealed Resident #65 was a female who was admitted to the facility on [DATE] with pertinent diagnoses which included: Gastroparesis (slow or stopped gastro motility) and dependence for cares. Review of a Minimum Data Set (MDS) assessment for Resident #65, with a reference date of 5/20/2025 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #65 was cognitively intact. During an observation and interview on 6/11/25 at 2:30 pm, Resident #65 retrieved a green in color bottle of eye drops from her bedside table and instilled drops into each eye independently. When queried, Resident #65 stated the drops were hers, for her dry eyes, she did them herself when she needed them. Review of Order Summary for Resident #65 revealed no order noted for any eye drops. In an interview on 6/12/25 at 10:03 am, Unit Coordinator (UC) R reported all eye drops required a physician order, including any over the counter drops. UC R reported that no resident's had orders to self-administer medications. UC R reviewed Resident #65's medical record and confirmed that Resident #65 did not have a physician order for any eye drops, did not have a completed assessment for self-administration of medications, and did not have an order to self-administer medications. In an interview and observation on 6/12/25 at 2:10 pm, Licensed Practical Nurse (LPN) JJ reported that a physician order was required for a resident to receive eye drops, even if they were over the counter and not prescription. LPN JJ reported that the facility had over the counter artificial tears available for residents and demonstrated a bottle white/clear in color. In an interview on 6/12/25 at 2:10 pm, Registered Nurse (RN) II reported Resident #65 did not have an order for eye drops and that she was aware Resident #65 had eye drops in her room. RN II reported that Resident #65 did not have an assessment to self-administer medications, and that Resident #65 would not be a good candidate to self-administer medications due to her history of having to have unauthorized items removed from her bedside. RN II reported that today was the first time she had ever seen Resident #65 with a bottle of eye drops, but it was not the first times she had to remove medications from Resident #65's bedside. Resident #272 Review of a Facesheet revealed Resident #272 was a female who was admitted to the facility on [DATE] with pertinent diagnoses which included: end stage kidney disease (kidneys no longer function) and dependence on dialysis (a blood filtration process due to the lack of kidney function). Review of a Minimum Data Set (MDS) assessment for Resident #272, with a reference date of 5/29/2025 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #272 was cognitively intact. In an interview on 6/10/25 at 2:52 pm, Resident #272 reported it was easier when the nurse left her chewable tablet (Fosrenal 1000mg) with her so she could take it when she was done eating. Resident #272 reported that some nurses left it, and some nurses did not leave it. Resident #272 reported that she should eat her chewable tablet immediately after she was done eating a meal. Review of Order Summary for Resident #272 revealed . Lanthanum (Fosrenal) chewable tablet 1000 mg (milligrams) one po (by mouth) with meals . (Fosrenal- a chewable tablet that binds with phosphate in the body to allow for the body to absorb calcium, a lack of calcium absorption can lead to a very serious medical complication. Fosrenal should be taken with food or immediately after a meal). In an interview on 6/11/25 at 11am, Resident #272 reported she wanted the facility to be consistent with her medications. Resident #272 reported she would like the nurses to leave her chewable tablet with her meals so she could take it when she was done eating, but some nurses left it, and others returned after her meal was finished to give it to her. Resident #272 reported she would like consistency with her medications. In an interview on 6/11/25 at 11:15 am, RN II reported that the nurses do leave Resident #272's Fosrenal chewable tablet at the bedside when she had her meal. RN II reported that Resident #272 was not assessed for self-administration of medications and that the facility does not allow for self-administration of medications. RN II reported that she does leave Resident #272's Fosrenal at her bedside when she has her meal because she knows she will take it. RN II reported that Resident #272 would be appropriate to self-administer medications.

Based on observation, interview, and record review the facility failed to ensure that enhanced barrier precautions (EBP) were maintained during tube feeding administration for 1 (Resident #21) of 1 resident reviewed for tube feeding administration resulting in the potential for introduction of infection, cross-contamination, and disease transmission. Findings include: Review of a Facesheet revealed Resident #21 was a female who had admitted to the facility on [DATE] with pertinent diagnoses which included: cardiovascular accident (CVA/Stroke) and PEG (percutaneous gastrostomy tube/feeding tube). During an observation on 6/10/25 at 11:55 am, outside of Resident #21's room was a sign posted on the door frame indicating that the resident was in enhanced barrier precautions. Review of Physician Orders for Resident #21 revealed .diet order NPO (nothing by mouth) ordered 8/16/2024 .Isosource 1.5 bolus (single administration, all at one time) feed oral liquid 250mL (milliliters) via feeding tube four times a day started 12/20/2024 .Free water 250 mL via tube feeding five times a day with a start date of 12/20/2024 . Review of Care Plan for Resident #21 revealed .Problem .ADLs (activities of daily living) interventions included enhanced barrier precautions .with a start date of 7/25/2024 .Problem .I require enteral feeding and I'm at risk for complications .with a start dated of 9/5/2024 . During an observation and interview on 6/11/25 at 12:14 pm, Licensed Practical Nurse (LPN) JJ entered Resident #21's room and administered a bolus feeding through Resident #21's feeding tube. LPN JJ did not wear a gown during the administration of Resident #21's bolus feeding. LPN JJ reported that the signage on the door indicating Resident #21 was in enhanced barrier precautions was for the CNAs (certified nursing assistants) to wear a gown and gloves when they were coming in contact with the resident's feeding tube. LPN JJ stated I get lucky since I don't actually come in contact with her feeding tube, I don't have to do anything with it (EBP sic) at all. In an interview on 6/12/25 at 12:10 pm, Registered Nurse (RN) RR reported that EBP were not used for administration of feeding through a feeding tube. In an interview on 6/12/25 at 12:20 pm, LPN C reported that when administering a bolus feeding through a feeding tube the nurse would need to wear a gown, and gloves as indicated for EBP. In an interview on 6/12/25 at 12:25 pm, Certified Nurse Assistant (CNA) UU reported she did not administer any tube feedings to resident, and that EBP did no apply to her. In a telephone interview on 6/12/25 at 1:03 pm Unit Coordinator (UC) S reported that EBP (wearing a gown and gloves) should be used when administering a feeding through a feeding tube for a resident. Review of a facility policy Enhanced Barrier Precautions Standard Work undated and provided by the facility revealed .purpose: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed it reduce transmission of multidrug-resistant organism (MDRO) that includes gown and gloves use during high contact resident care .1. All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions . EBP will be implemented for resident with any of the following: b. indwelling medical devices .feeding tube .implementation of EBP: PPE (personal protective equipment) for EBP is only necessary when performing high-contact care .device care or use .feeding tube .

Based on observation, interview, and record review the facility failed to ensure one out of five residents (Resident #26) had water available at the bedside, resulting in the potential for dehydration. Findings include: Review of an admission Record revealed Resident #26 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (a progressive disease that primarily affects memory, thinking and behavior) and renal insufficiency (disease in which the kidneys lost the ability to remove waster and balance fluids). Review of a Minimum Data Set (MDS) assessment for Resident #26 with a reference date of 6/4/25, revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #26 was severely cognitively impaired. Review of a Care Plan for Resident #26 with a reference date of 9/25/19, revealed a problem/goal/interventions of: 1. Problem: Nutritional Status. Goal: My nutritional needs will be met through the next review. Interventions: Please give me my diet as ordered .monitor my food acceptance. 2. Problem: ADLs (Activities of Daily Living). Goal: I will accept assistance with care needs .Interventions: I have a self-care deficit related to weakness . Review of a Fluid Intake Report for Resident #26 with a reference date of 5/13-6/11/25, revealed the resident drank less than 720 milliliters(ml) per day during that period. During an observation on 6/10/25 at 11:04am, Resident #26 was assisted from her restroom to her bed by Certified Nursing Assistant (CNA) UU. During an observation and interview on 6/10/25 at 11:05am, Resident #26 laid in her bed on her back. A large covered maroon cup was stored on the sink counter, approximately 8' from the resident. No other beverage was present in Resident #26's room. The resident's lips appeared dry and stuck to her dentures when she spoke. Resident #26 reported she was thirsty. During an observation on 6/11/25 at 11:14am, Resident #26 laid on her back in bed in her room. The resident's maroon water cup was stored on the sink counter, across the room. The bedside table was the foot of her bed. No other beverage was present. An unidentified CNA, entered the room, looked at Resident #26 and left the room. During an observation on 6/11/25 at 11:25am, Resident #26 was asleep in bed. The bedside table was next to her bed with nothing on it. The maroon water cup remained on the sink counter, across the room. During an observation on 6/11/25 at 11:58am, Resident #26 laid on her back in bed. The resident's maroon water cup was stored on the sink counter, across the room. During observations on 6/11/25 at 2:32pm and 3:44pm, Resident #26 laid on her back in bed. The resident's maroon water cup was stored on the sink counter, across the room. The bedside table was at the foot of her bed and no beverages were present in the room. In an interview on 6/11/25 at 3:46pm, Licensed Practical Nurse (LPN) HHH reported the expectation was for CNA's to ensure the resident has their call light and water within reach before leaving the room. In an interview on 6/12/25, at 9:16am, CNA J reported Resident #26 should have her water within reach when she is in her room. CNA J reported the facility provided maroon drinking cups for every resident and the nursing staff filled the cups at the beginning of each shift at a minimum. CNA J reported some residents who were weak had difficulty holding the maroon cup, including Resident #26, and should be provided a smaller, clear cup with a lid. In an interview on 6/12/25, at 9:22am, LPN C reported potential complications that could result from a resident being dehydrated included: urinary tract infections, confusion and falls. LPN C reported fresh water should be kept at the resident's bedside and replenished every shift at a minimum. LPN C reported the facility provided large maroon, covered water cups for every resident. LPN C reported any staff member that enters a resident's room was expected to ensure the resident's water, call light and belongings were in reach before exiting the room. LPN C reported Resident #26 was not on a fluid restriction. Review of a Water Pass policy with no reference date revealed POLICY: Due to the risk of dehydration (and other health concerns) and for patient comfort (weather related), fresh water must be available 24 hours per day .PROCEDURE: .CNA provides fresh ice water mug to each patient .

Based on observation, interview, and record review the facility failed to provide meaningful activities to promote psychosocial well-being for 1 (Resident #42) of 1 resident reviewed for activities. This deficient practice resulted in decreased feelings of connectedness to the community, a lack of meaningful leisure involvement and increased boredom. Findings include: Review of an admission Record revealed Resident #42 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression (persistent depressed mood or loss of interest in activities causing significant impairment in daily life). Review of a Minimum Data Set (MDS) assessment for Resident #42 with a reference date of 10/8/24, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #42 was cognitively intact. Section F revealed it was very important for Resident #42 to choose her bedtime, be around pets, and to participate in her favorite activities. Review of a Care Plan for Resident #42 with a reference date of 2/13/23, revealed a problem/goal/interventions of: Problem: Activities Goal: I will participate in activities I enjoy daily through the next review date. Interventions .I enjoy participating in group activities that are meaningful to me .I like dogs, and I might like to visit with pets .ask me which of my favorite activities are important to keep doing while I am here . During an observation on 6/10/25 at 9:29am, Resident #42 was in bed with the curtains pulled and lights off, dressed in sleepwear. In an interview on 6/10/25 at 11:34am, an unknown Certified Nursing Assistant (CNA) emerged from Resident #42's room and reported the resident had just gotten up because she preferred to sleep in/stay up late. In an interview on 6/10/25 at 11:35am, Resident #42 reported the facility was not supporting her involvement in the activities that were of interest to her. Resident #42 stated I feel like I'm in jail. In an interview on 6/10/25 at 2:51pm, Resident #42 reported she felt the activities program did not meet her needs. Resident #42 reported no group activities were offered in the evening even though she was a night owl. Resident #42 reported she often felt bored in the evenings. Resident #42 reported it had been difficult to adjust to living at the facility because it's not my routine/not the things I like. Resident #42 reported she missed her dogs very much and wanted to participate in pet therapy on a regular basis, but it was not offered. Resident #42 described the group activities that were offered as rinky dink. When further queried, Resident #42 reported the group activities did not support her need to feel like she was making a difference for others and thereby give her a sense of purpose. Resident #42 also reported a lot of the activities seemed too childish for her. Review of Activity Calendars for the last 6 months revealed group activities began at 9:30am and ended at 3:30pm each day. Pet Therapy visits were not listed. No community outings were offered. No activities that offered residents to serve others were routinely offered. Review of an Activity Participation Record for Resident #42 with a reference date of 5/16-6/05/25, revealed the resident did not participate in pet therapy, community outings or service activities during that period. In an interview on 6/12/25 at 10:01am Activity Director/Nursing Home Administrator (AD/NHA) A reported the facility had not provided community outings in many years. AD/NHA A reported residents had voiced an interest in pursuing community-based leisure opportunities but unless they had family or friends that could take them, the facility had not provided opportunities for community-based leisure involvement. AD/NHA A reported the facility had not provided evening activities in the last 5 years and the need to do so had not been assessed in a few years. AD/NHA A reported she was responsible to ensure activities were provided to meet the needs of residents and she was not aware of a need to provide activities in the evenings. AD/NHA A reported the activity assistants assessed residents activity needs using only the MDS assessments and she did not routinely review the findings. AD/NHA A reported most of the residents who stayed up in the evenings were loners. When queried about the provision of activities that allow residents to gain a sense of purpose and to serve others, AD/NHA A reported the last activity the facility provided in this programming domain was a one-time activity that took place in December 2024. During an observation on 6/12/25 at 10:22am, Resident #42 was in her bed with the curtains closed, lights off. In an interview on 6/12/25 at 11:39am, Resident #42 reported she had not been in the community for any leisure involvement in the last several years. Resident #42 reported she had mentioned her desire to pursue community-based leisure activities, and her need to have purpose in her leisure involvements, but the facility did not provide any support for her to do so. When further queried, Resident #42 stated The idea of spending the rest of my life in this building is scary. I'd like to contribute to society. You shouldn't have to stop living (when you become a resident) and you should be able to look forward for what else you can do. In an interview on 6/12/25 at 1:43pm, AD/NHA A reported the resident population of the facility was diverse in needs, abilities and leisure interests. AD/NHA A reported it was the responsibility of the facility to ensure the leisure needs of all residents were met. Review of Participating in Activities You Enjoy as You Age, published by the National Institute on Aging, 3/28/22, revealed: Research has shown that older adults with an active lifestyle: Are less likely to develop certain diseases. Participating in hobbies and other social activities may lower risk for developing some health problems, including dementia, heart disease, stroke, and some types of cancer . Studies looking at people's outlooks and how long they live show that happiness, life satisfaction, and a sense of purpose are all linked to living longer. Doing things that you enjoy may help cultivate those positive feelings . Studies suggest that older adults who participate in activities they find meaningful, .say they feel happier and healthier . When people feel happier and healthier, they are more likely to be resilient, which is our ability to bounce back and recover from difficult situations. Positive emotions, optimism, physical and mental health, and a sense of purpose are all associated with resilience .research suggests that participating in certain activities, such as those that are mentally stimulating or involve physical activity, may have a positive effect on memory - and the more variety the better .

Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 1 residents (Resident #3) of 18 reviewed for the provision of nursing services, resulting in medication not administered following physician ordered parameters, the lack of assessment, and the potential for medication adverse effects and complications Findings include: In an interview on 06/10/25 at 09:27 AM, Resident #3 reported that Registered Nurse (RN) E did not listen to her and/or follow the physician orders for her blood pressure medication. Resident #3 reported that the night before she had tried to tell RN E that her blood pressure was too low, and that she should not take her Apresoline (medication used to treat high blood pressure). Resident #3 reported that RN E still gave her the medication along with her other medications; Resident #3 felt dizzy and kept her eyes closed for a long time afterwards. In an interview on 06/10/25 at 09:17 AM, Unit Coordinator (UC) DD reported that when blood pressure readings are required during medication administration, the nurse would document it in the flowsheet tab of the resident's chart. Review of Resident #3's flowsheets Blood Pressure record revealed a result of 112/56 at 5:35 AM on 6/9/25, and there was no record of the resident's blood pressure results in the evening that day. Review of Resident #3's current Physician Orders revealed, Apresoline tablet 25 mg (milligram) .Frequency: 2 times daily .Administration instructions: Hold for SBP (systolic blood pressure: the top number in a reading and represents the pressure in your arteries when your heart beats) less than 130 . Review of Resident #3's Medication Administration Record (MAR) indicated that the first dose of Apresoline was not given on 6/9/25 at 8:23 AM, the second dose was given by RN E at 7:21 PM. In an interview on 06/12/25 at 09:49 AM, Licensed Practical Nurse (LPN) JJ reported that Resident #3 knows her medications and remembers her blood pressure results. LPN JJ reported that the resident will remind the nurse that her blood pressure was too low, and that she cannot have her blood pressure medication. LPN JJ reported that 9 times out of 10, they hold the resident's Apresoline due to the top number of her blood pressure being lower than the physician ordered parameters. LPN JJ reported that dizziness was a side effect that Resident #3 exhibited when her blood pressure was low. LPN JJ reported that there was no documentation of blood pressure being taken prior to the residents's evening dose of Apresoline on 6/9/25, and there was no nursing note indicating that the resident was experiencing dizziness. LPN JJ reported that if the Certified Nursing Assistant (CNA) does not report a blood pressure result near the time of medication administration, then the nurse would have to obtain the blood pressure and document verification of a result being within the limits of the physician ordered parameter. In an interview on 06/12/25 at 11:05 AM, RN E reported that she normally documented blood pressure results when she administered medication; if there was a blood pressure medication due, the computer would prompt the nurse for the blood pressure and pulse results. RN E reported that she administered Resident #3's Apresoline in the evening on 6/9/25. RN E reported that a blood pressure of 112/56 would be within the parameters for blood pressure medication to be given, but that she did not remember exactly what Resident #3's blood pressure result was on 6/9/25. In an interview on 06/12/25 at 01:36 PM, Director of Nursing (DON) B reported that nurses were expected to verify blood pressure medication parameters with the physician order prior to the administration of the medication and document it. DON B reported that the nurse should ensure that the blood pressure is obtained and recorded it in the resident record prior to each dose of medication. DON B reported that the computer does not prompt the nurse to obtain or enter a blood pressure result during medication administration, but that it was expected for a nurse to follow the physician order which would require that a blood pressure was obtained prior to the administration of Apresoline. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, (Nurses) are responsible for documenting any preassessment data required of certain medications such as a blood pressure measurement for antihypertensive (used to treat high blood pressure) medications . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 609). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review the facility failed to accurately assess 1 (Resident #70) of 1 resident reviewed for minimum data set (MDS) discharge encoding resulting in inaccurate discharge location data being submitted. Findings include: Review of a Facesheet revealed Resident #70 was a female who admitted to the facility on [DATE] with pertinent diagnoses which included: weakness and the need for personal assistance. Review of MDS for Resident #70 dated 3/19/25 revealed .A2000 discharge date [DATE], A2150 Discharge status, Code entered 04 indicating resident discharged to Short-Term General Hospital. Review of Resident #70's medical record revealed no noted documentation of a transfer from the facility to any hospital. In a telephone interview on 6/11/25 at 2:51 pm MDS Coordinator (MDSC) WW reported she was the nurse who had completed Resident #70's discharge MDS assessment. MDSC WW reviewed the MDS while on the phone and confirmed that she has coded Resident #70 as a short stay hospital discharge (transfer from the facility to the hospital). MDSC WW reported that Resident #70 had discharge to home, she had not gone to the hospital. MDSC WW reported she had inaccurately coded Resident #70's discharge. In an interview on 6/12/25 Nursing Home Administrator (NHA) A reviewed Resident #70's discharge MDS with this surveyor and confirmed that Resident #70's discharge MDS was inaccurate. NHA A reported MDS Registered Nurse (MDS/RN) Q was ultimately responsible for the submission of MDS data. NHA A stated MDS/RN Q owns the submission information when she signs and submits the information. In an interview on 6/12/25 at 11:02 AM- MDS/RN Q reported she was the nurse that signed a resident's completed MDS assessments, and her responsibility was to ensure that all areas were completed. MDS/RN Q reported she did not review all areas of the MDS assessment for accuracy but did spot checks before she submitted it. MDS/RN Q reported she did submit Resident #70's discharge MDS assessment a the time of Resident #70's discharge. MDS/RN Q did confirm that Resident #70's MDS discharge assessment was inaccurate when it was submitted. MDS/RN Q reported the correction report had been created and was waiting to be submitted.

Resident #17 Review of Resident #17's Physician Orders revealed, Lorazepam (Ativan) tablet 0.5 mg .Frequency: Daily as needed for anxiety .Duration: 30 days Start Date/Time (after last modification): 5/19/25 .End Date/Time: 6/18/25 . The most recent dose was given on 6/6/25 at 7:36 AM. An attempt to interview Medical Director (MD) III on 06/12/25 at 12:18 PM was made, with no return phone call prior to survey exit. This surveyor requested physician rationale for Resident #17's order for PRN (as needed) Lorazepam written for greater than 14 days at a time. Review of Resident #17's Psychiatry Progress Note dated 5/14/25 revealed, .states that she has had some increased anxiety due to some issues she is working through with staff, but the extra Xanax (sic) during the day helped .Staff report no new or clinically significant changes or concerns with mood or behaviors at this time .Generalized anxiety disorder: moderately stable .Continue Lorazepam 0.5 mg 1 tablet at 4:35 PM PRN anxiety x 30 days. GDR (gradual dose reduction) CI (contraindicated) 4/9/25 as dose continues to be beneficial in controlling ongoing symptoms of anxiety . No rationale for the medication being written for greater than 14 days. Review of Resident #17's Pharmacy Monthly Medication Regimen Review from June 2025 indicated no irregularities and no new recommendations. Based on interview and record review, the facility failed to limit the duration of a PRN (as needed) psychotropic medication to 14 days and/or ensure the physician documented rationale to extend the duration of use for two (Resident #26 and Resident #17) out of five reviewed for unnecessary medications. Findings include: Resident #26 Review of an admission Record revealed Resident #26 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (a progressive disease that primarily affects memory, thinking and behavior) and major depressive disorder (persistent sad mood that interferes with daily life). Review of a Minimum Data Set (MDS) assessment for Resident #26 with a reference date of 6/4/25, revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #26 was severely cognitively impaired. Section E revealed Resident #26 had no behaviors during the 14-day assessment period. Review of a Care Plan for Resident #26 with a reference date of 9/25/19, revealed a problem/goal/interventions of: Problem: Mood. Goal: I have changes in mood due to my medical diagnosis. I want negative symptoms to be manageable daily and through the next review. Interventions .assess my mood on all review dates and as needed .provide medications as ordered .Monitor for increased signs or symptoms of depression and anxiety. Review of Physician's Orders for Resident #26 revealed a current order: LORazepam tablet .25mg (milligrams) Every 8 hours PRN (as needed), Start: 5/30/25 1251 End: 6/29/25 1250. Review of a Long Term Rounding-Progress Note for Resident #26 written by a provider on 4/21/25, revealed Assessment/Plan: .17. Generalized anxiety disorder. Continue (Brand name omitted) LORazepam PRN-utilizes minimally .Psychiatric/Behavioral: Positive for confusion. Negative for agitation. The patient is not nervous/anxious. Review of Medication Administration Records for Resident #26 revealed the resident did not receive any doses of LORazepam .25mg PRN from 4/13-6/12/25. In an interview on 6/11/25, at 11:06am, Social Services Coordinator (SSC) L reported Resident #26 received the order for LORazepam .25mg on 2/18/24 and it had been renewed several times. SSC L confirmed Resident #26 currently had an order for a PRN psychotropic medication that extended greater than 14 days. SSC L reported the use of psychotropic medications was monitored during a monthly Behavioral Health meeting and Resident #26's order for LORazepam could be added to the agenda. In an interview on 6/11/25 at 2:28pm, Unit Coordinator (UC) DD confirmed Resident #26 had a PRN order for a psychotropic medication that was greater than 14 days and this was not within compliance perimeters for this type of medication unless the provider documented a rationale for doing so. UC DD reported she would provide documentation of a provider's rationale if it was made available. No additional documentation identifying the provider's rationale for extending a PRN psychotropic medication beyond 14 days for Resident #26 was provided by the conclusion of the survey.

Based on interview, and record review, the facility failed to ensure activities of daily living (ADL) cares and assistance were provided per resident preference for 1 (Residents #17) of 2 residents reviewed for resident preferences, resulting in dissatisfaction with care and the potential for decline in sense of physical, mental, and psychosocial well-being. Findings include: Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 4/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #17 was cognitively intact. Review of the Functional Abilities revealed that Resident #17 was dependent for toileting and transfers. In an interview on 06/10/25 at 10:57 AM, Resident #17 reported that she had moved rooms so that she could had access to a ceiling mechanical lift that would allow her to transfer easier. Resident #17 reported that staff tell her that she cannot use the commode every time she has to use the bathroom, because it takes too much of their time. Resident #17 reported that especially at night and during mealtimes, staff offer the bedpan instead of the bedside commode; the bedpan is uncomfortable and the resident prefers to use the commode. Resident #17 reported that she had tried to request the commode when she knew there were enough staff working. In an interview on 06/11/25 at 11:52 AM, Certified Nursing Assistant (CNA) J reported when there are enough staff, Resident #17 used the commode, but otherwise she used the bedpan. CNA J reported that Resident #17 did get upset about using the bedpan. In an interview on 06/11/25 at 12:07 PM, Licensed Practical Nurse (LPN) JJ reported that Resident #17 was not always happy with the care that she received, and that related to hoyer (mechanical) transfers staff had told her we can't do this all day in the past because of the amount of time it takes. In an interview on 06/11/25 at 02:16 PM, CNA F reported that Resident #17 used the commode for toileting, except for during meal times. CNA F reported that staff cannot stop passing trays and answering call lights to transfer the resident, unless they have extra staff. Review of Resident #17's Care Plan revealed, Problem: I am incontinent of urine. Date Start: 04/24/25, Goal: I will be clean, dry and odor free .INTERVENTIONS: I need to be checked and changed routinely and as needed. Encourage me to verbalize the need to use the toilet. Please keep my call light in reach . There was no preference noted for toileting. Review of Resident #17's Kardex (CNA care guide) revealed, .Level of Assistance - 06/12/25 at 08:53 (AM) Toileting, Toilet type: Bedside commode; Brief Change; Incontinence pad . Review of Resident #17's Progress Note dated 6/2/25 revealed, Cognition/behaviors/mood: A &O (alert and oriented) x 4 but has herself c/o (complained of) memory deficits recently. At times has numerous requests for transfer to and from commode, but frequently is incontinent while being transferred (via overhead lift) while in transit to commode. During mealtimes a bedpan is offered as it requires too many staff off the floor to use mechanical lift .Bowel/bladder: Incontinent of bladder, bowel continence varies. Review of Resident #17's Occupational Therapy (OT) note dated 3/13/23 revealed, .Toileting Comments: reports incontinent of urine at baseline; encouraged up to BSC (bed side commode) with nursing staff, as pt (patient) not appropriate for use of bedpan .

Based on observations and interviews, the facility failed to ensure the results of the most recent federal surveys and corresponding plans of correction were readily accessible to all residents in the facility, with a census of 85 residents, resulting in the residents not being informed of identified deficiencies and solutions as written in the plan of correction. Findings include: During a confidential group meeting on 06/11/25 at 10:34 AM, six of six residents reported that they were not aware they could read the survey reports; they did not know who to ask or where to find them. During an observation on 06/11/25 at 11:25 AM in the sitting area next to the main lobby there was a shelf hanging approximately 4-5 feet up on the wall containing a binder that housed survey reports. In an interview on 06/11/25 at 12:02 PM, Licensed Practical Nurse (LPN) JJ reported that she did not know where to find the survey reports; and was not sure how residents were expected to get access to those. In an interview on 06/12/25 at 11:19 AM, Nursing Home Administrator (NHA) A reported that the survey reports were located in an area that residents do not frequent and were not easily accessible. In an interview on 06/12/25 at 02:53 PM, Activity Associate (AA) U reported that she conducts resident council meetings monthly but was not aware of how residents would obtain access to the survey reports.

Based on interview and record review, the facility failed to provide a written notice of transfer for 1 of 3 residents (Resident #65) reviewed for hospitalization s, resulting in the potential of residents and/or resident representatives being uninformed of the reason for transfer and their rights. Findings include: Resident #65(R65) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R65's admitted was 1/17/2024. Brief Interview for Mental Status (BIMS) score was a 12 which indicated her cognition was moderately impaired (8-12 moderately impaired). Resident had several discharges to the emergency roiagnom on [DATE] and 2/18/2024 and a hospital admission from 1/28 to 2/6/2024. During an interview on 5/14/2024 at 10:30 AM, R65 said that she couldn't remember if she received a written transfer notice each time she went to the hospital. Review of R65's chart revealed no evidence that R65 received a written notice of transfer each time she went to the hospital and which included the following information: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. During an interview on 5/16/2024 at 10:32 AM, Registered Nurse (RN) S presented paperwork that is sent with a resident whenever they leave the facility. It was observed that a transfer/discharge notice was not included in the paperwork. RN S wasn't sure what the transfer/discharge notice was. During an interview on 5/16/2024 at 10:51 AM, Executive Director (ED) A was asked about the transfer/discharge notice and she stated that they haven't been sending a transfer/discharge notice out with residents.

Based on interview and record review the facility failed to ensure that (1) pre and post dialysis treatment assessment and monitoring communication between themselves (the facility) and the dialysis provider (Name Omitted) was maintained and (2) that an agreement between themselves (the facility) and the dialysis provider (Name Omitted) was established and maintained in 1 (Resident #54) of 1 resident reviewed for dialysis services resulting in the potential for unrecognized adverse reactions, and/or resident decline related to dialysis treatments and the potential for a disruption in the continuity of care. Findings include: Review of a Face sheet revealed Resident #54 had pertinent diagnoses which included: renal failure (failure of the kidneys) and dependence on renal dialysis (treatment to remove waste and excess water from the body when the kidneys are no longer able to do it). Review of a Minimum Data Set (MDS) assessment for Resident #54, with a reference date of 2/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #54 was cognitively intact. On 5/14/24 Executive Director (ED) A reported during entrance conference that the facility has no contract/agreement for dialysis treatments with any dialysis provider. In an interview on 5/14/24 at 11:17 AM., Resident #54 reported that he has dialysis three times a week on Monday, Wednesday, and Friday. Review of Resident #54's medical record revealed no noted communications from the facility to the dialysis center prior to dialysis, nor communications from the dialysis center to the facility post dialysis treatment. Review of Resident #54's care plan revealed .Goal .I want to safely receive dialysis as ordered .interventions .patient often quits dialysis before completion/or refuses to go- .I have experienced significant weight gain due to increased snacking .I order many snacks and different foods from grocery stores for delivery .I require dialysis. Please communicate routinely with dialysis RD (registered dietitian) regarding nutritionally pertinent labs, weight goals, and plan of care . In an interview on 5/16/24 at 8:29 AM., Licensed Practical Nurse (LPN) KK reported that the facility provided information sent with Resident #54 to the dialysis treatment center (Name Omitted) did not include Resident #54's pre dialysis treatment assessment information. LPN KK reported that she did not recall communicated information from the dialysis center (Name Omitted) after Resident #54 received dialysis treatment. LPN KK reported that the dialysis center (Name Omitted) would call the facility or fax information regarding Resident #54's condition only if there was something abnormal. In an interview on 5/16/24 at 8:49 AM., Unit Coordinator (UC) L reported that there was no communication with the dialysis center (Name Omitted) on a regular basis, communication occurred only when something was abnormal for Resident #54. In an interview on 5/16/24 at 8:52 AM., Unit Clerk (UC) HH reported that the dialysis center (Name Omitted) faxed abnormal laboratory results last week. UC HH reported that she did not receive regular communications from the dialysis center (Name Omitted). In an interview on 5/16/24 at 9:00 AM., Director of Nursing (DON) B reported that there is no actual communication sent with Resident #54 for dialysis treatment. DON B reported that the facility has no contract/agreement with any dialysis center for treatment, including the dialysis center (Name Omitted) that provided Resident #54's treatment. In an interview on 5/16/24 at 9:04 AM., ED A reported that she was not aware of any contract/agreement for dialysis services with any outside provider. In an interview on 5/16/24 at 12:44 PM., ED A reported that the dialysis center (Name Omitted) uploaded post dialysis treatment information for Resident #54 to an electronic record program that was accessible by both the facility staff and the dialysis center. ED A reported that she could not guarantee that the facility staff caring for Resident #54 read the post dialysis treatment information provide to the electronic record progam by the dialysis center (Name Omitted) after every treatment Resident #54 completed. ED A reported that she could not verify that the communication from the facility to the dialysis center (Name Omitted) occurred every time Resident #54 received dialysis treatment. The facility did not provide an agreement for dialysis treatment between themselves and any dialysis treatment center by the time of exit.

Based on observation, interview, and record review the facility failed to provide oxygen services per the professional standards of practice when storing CPAP (continuous positive airway pressure) masks in 3 (Resident #8, Resident #13, Resident #59) of 3 residents reviewed for infection control practices when storing CPAP masks resulting in the potential for the development of a respiratory infection. Findings include: Resident #8 Review of a Facesheet revealed Resident #8 had pertinent diagnosis which included: obstructive sleep apnea (starting and stopping breathing while sleeping due to partial blockage of the airway). Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 3/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #8 was cognitively intact. During an observation on 5/14/24 at 11:08 PM., Resident #8's CPAP mask was laying uncovered, without a barrier, on top of the CPAP machine, on the nightstand beside the bed in Resident #8's room. Review of Resident #8 Physician Orders revealed .CPAP/BiPAP home unit to be used at night to keep oxygen levels above 92% . During an observation and interview on 5/14/24 at 3:24 PM., Resident #8's CPAP mask was laying uncovered on top of the CPAP machine on the nightstand beside the bed in Resident #8's room. Resident #8 reported that he has used a CPAP machine while sleeping for years, he can remove the mask himself, and the staff assists with storage of the mask when not in use. During an observation on 5/15/24 at 9:01 AM., Resident #8's CPAP mask was laying uncovered, without a barrier, on top of the CPAP machine, on the nightstand beside the bed in Resident #8's room. During an observation on 5/16/24 at 8:45 AM., Resident #8's CPAP mask was laying uncovered, without a barrier, on top of the CPAP machine, on the nightstand beside the bed in Resident #8's room. Resident #13 Review of a Facesheet revealed Resident #13 had pertinent diagnoses which included: dysphagia (difficulty swallowing) and hypoxemia (low oxygen levels in the blood). Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 3/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #13 was cognitively intact. During an observation on 5/14/24 at 9:00 AM., Resident #13's CPAP mask was laying uncovered, without a barrier, on top of the CPAP machine, on the nightstand beside the bed in Resident #13's room. Review of Resident #13 Physician Orders revealed .CPAP/BiPAP home unit to be used at night to keep oxygen levels above 92% . During an observation on 5/14/24 at 3:27 PM., Resident #13's CPAP mask was laying uncovered, without a barrier, on top of the CPAP machine, on the nightstand beside the bed in Resident #13's room. During an observation on 5/15/24 at 7:59 AM., Resident #13's CPAP mask was laying on top of a plastic bag inside of the top drawer of the nightstand beside the bed in Resident #13's room. During an observation and interview on 5/16/24 at 8:00 AM., Resident #13's CPAP mask was laying uncovered, without a barrier, on top of the CPAP machine, on the nightstand beside the bed in Resident #13's room. Resident #13 reported that she can take her CPAP mask off herself, but staff will store it for her. Resident #13 reported that staff had been in, and her CPAP mask was already taken care of today. Resident #59 Review of a Face sheet revealed Resident #59 had pertinent diagnoses which included: parkinson's disease and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #59, with a reference date of 3/18/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #59 was cognitively intact. During an observation on 5/14/24 at 9:14 PM., Resident #59 was in bed, sleeping, with his CPAP mask in place on his face. Review of Resident #59 Physician Orders revealed .CPAP/BiPAP home unit to be used at night to keep oxygen levels above 92% . During an observation on 5/14/24 at 3:26 PM., Resident #59's CPAP mask was laying in the drawer of the bedside nightstand, uncovered and without a barrier, in Resident #59's room. In an observation and interview on 5/15/24 at 2:22 PM., Resident #59's CPAP mask was laying on top of the CPAP machine on the bedside table, exposed and without a barrier, in Resident #59's room. Resident #59 reported that he can take off his mask, but he cannot put it on. Resident #59 reported that staff help him with his CPAP mask. Family Member (FM) X reported that respiratory therapy comes in to clean the machine. FM X reported that she does not maintain the machine, she only ordered supplies when needed. In an interview on 5/15/24 at 2:34 PM., Licensed Practical Nurse (LPN) KK reported that CPAP masks should be stored in a plastic bag in the bedside table when not in use. In an interview on 5/16/24 at 8:06 AM., Certified Nursing Assistant (CNA) NN reported that CPAP masks should be placed into a bag and kept in the top bedside drawer when not in use. In an interview on 5/16/24 at 8:09 AM., Unit Coordinator (UC) L reported that CPAP masks should be stored in their own pouch or bag when not in use. In an interview on 5/16/24 at 1:20 PM., Respiratory Therapist (RT) EE reported that she cleans CPAP machines and masks weekly. RT EE reported that her process was to clean the mask, coil the tubing and place it on top of a plastic bag on top of the machine to dry. When the mask was dry, the floor staff should place the mask into the bag provided for storage when not in use. In an interview on 5/16/24 at 1:26 PM., Director of Nursing (DON) B reported that CPAP masks should be stored in bags when not in use. DON B acknowledged that CPAP masks were not stored in bags when not in use during this survey. Review of Standard work for CPAP/BiPAP facility education provided by DON B revealed .How to store when not in use (bags)

Based on observation, interview, and record review, the facility failed to: 1. Ensure cleanliness of food and non-food contact surfaces; 2. Securely store food product after opened; 3. Properly label/date opened food products; and 4. Discard expired food items. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected all residents who consume food/supplement from the kitchen and all residents who consume food from the pantry refrigerators/freezers. Findings include: During an observation/interview with Culinary Associate (CA) L during the initial kitchen tour on [DATE] beginning at 8:50 AM in the Dry Storage area, noted an opened case of granulated sugar wherein the inner product bag was fully opened and unsealed such that the product was exposed. There were two bags of blueberry muffin mix with a use by date of [DATE] on the back shelving rack. One of the bags was opened, but not labeled or dated. On a separate shelving rack, there was a piece of plastic on top of the bottom shelf where cases of artificial sweetener were located. There was a build-up of what appeared to be dried, stuck on artificial sweetener product on the plastic. In the corner on the floor to the right of the entry into the dry storage area, there was a moderate amount of dust and debris buildup. At 8:55 AM Nutrition Supervisor (NS) X arrived in the Dry Storage Area. NS X reported the case of sugar should have been better secured, the blueberry muffin mix was expired and needed to be discarded, and the soiled areas needed to be cleaned. During an observation/interview with Dietary Manager (DM) AA during the initial kitchen tour on [DATE] at 9:20 AM in the 400 Hall Pantry refrigerator, noted a storage bag that contained 3 pieces of pizza. The bag was not labeled or dated. There was an opened nutritional shake that was not labeled or dated. There was a dried puddle of green and brown spillage under the drawer in the freezer. DM AA reported the opened/leftover food products/beverages should have been labeled with the opened and discard date. DM AA acknowledged the spillage and reported it should have been cleaned. During an observation/interview with Dietary Manager (DM) AA during the initial kitchen tour on [DATE] at 9:27 AM in the 300 Hall Pantry refrigerator, noted an opened container of cranberry juice that was 75% empty. The juice was not labeled with the opened or discard date. There was dried brown spillage and debris in the interior bottom of the refrigerator. In the freezer, there was a yellow beverage that was opened but not labeled or dated. DM AA reported the opened beverages should have been labeled with the opened and discard date. DM AA acknowledged the spillage/debris and reported it should have been cleaned. During an observation/interview with Dietary Manager (DM) AA during the initial kitchen tour on [DATE] at 9:34 AM in the 200 Hall Pantry refrigerator, noted opened containers of nutritional shake and thickened water. Neither of the items were labeled or dated. There was a container of vanilla yogurt with a use by date of [DATE]. Noted debris that appeared to be coffee grounds in the bottom of the drawer that contained condiment packets. The interior of the freezer contained varied dried spillage and debris. DM AA reported the opened products should have been labeled with the opened and discard date and the expired product should have been discarded. DM AA acknowledged the spillage/debris and reported it should have been cleaned. During an observation/interview with Dietary Manager (DM) AA during the initial kitchen tour on [DATE] at 9:50 AM in the 600 Hall Pantry refrigerator, noted an opened container of thickened water that was not labeled or dated. The use by date on the container was [DATE]. Noted two containers of yogurt with a use by date of [DATE]. There was dried brownish spillage under the drawers of the refrigerator. The interior of the freezer contained red/purple colored spillage that appeared to be melted popsicles that had since frozen. DM AA reported the opened products should have been labeled with the opened and discard date and the expired products should have been discarded. DM AA acknowledged the spillage/debris and reported it should have been cleaned.

This citation pertains to intake MI 849. Based on observation, interview and record review, the facility failed to adequately assess, monitor, and prevent a coccyx pressure ulcer consistent with professional standards of practice to prevent an avoidable pressure ulcers for one (1) resident (R101) of four (4) residents reviewed for the risk for the development of pressure injuries, resulting in an immediate jeopardy when, beginning on 12/4/2020, facility staff did not follow facility policy and procedure for pressure ulcer prevention and/or treatment. This deficient practice resulted in the likelihood for serious harm, injury, and/or death due to the development of an avoidable pressure ulcer, the likelihood for infection and the overall deterioration in health status for a resident identified with a pressure ulcer and a resident who had been identified as at risk for skin breakdown. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R101 scored 15/15 (cognitively intact) on his BIMS (Brief Interview Mental Status), had clear speech, understood others and was understood by others, required extensive assistance by two-plus persons physical support for bed mobility (repositioning and turning), transfers between surfaces, and dressing, had an enteral feeding tube with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R101's Admission History and Physical Date of Service: 11/17/2020 11:45 AM revealed, .Date of Admission 11/16/2020 .REASON FOR ADMISSION: Rehab following MVA (motor vehicle accident) and fall with lumbar and cervical spine fractures with spinal cord injury and [CONDITION(S)] (paralysis) .He went to the OR (Operating Room) for cervical spine stabilization on 11/6 (2020). Further imaging showed a L1 fracture as well and so lumbar stabilization was performed on 11/9(2020) .Posterior Cervical Fusion C2-T2, Posterior Cervical Laminectomy C5-C7 .Posterior Spinal Fusion T10-L3 with Instrumentation, Cervical Fusion Extension T2-T4 .Review of Systems .Skin-negative . It is noted that upon assessment of R101 no mention of skin concerns/issues were documented in the facility's physician's Admission History and Physical. According to https://my.clevelandclinic.org/, The spine has three normal curves: cervical, [MEDICATION(S)], and lumbar. There are seven cervical vertebrae in the neck (C1-C7), 12 [MEDICATION(S)] vertebrae in the torso (T1-T12), and five lumbar vertebrae in the lower back (L1-L5). The sacrum consists of a triangular-shaped bone and consists of five segments (S1-S5) that are fused together at the bottom of the spine. The coccyx is a triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum Review of R101's Orders dated 11/16/2020 revealed, .Admission . initiate pressure injury protocol for any areas that appears to be developing a pressure injury . Review of R101's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R101's Flowsheet Admission assessment dated [DATE] at 2:00 PM indicated the resident had a pressure injury to his left heel but did not have documentation indicating a coccyx wound was assessed. Review of an email dated November 16, 2020, 10:51 PM by Registered Nurse (RN) Y to facility Wound Referral Team revealed, Admission .Incision to entire length of spine C-L (not assessed under dressing) . It was noted there was no referral to the facility's Wound Team to assess a coccyx wound. Review of R101's Care Plan start date 11/25/2020 revealed, Problem . I have a Pressure Injury .Goal .My skin will heal .Interventions . Check my skin with care It was noted the pressure injury location and stage were not identified in the resident's care plan. During an interview on 11/1/2021 at 3:42 PM with Family Member (FM) E stated, My father (referring to R101) had a pressure ulcer on his heel when he was admitted to the facility on [DATE]. He did not to my knowledge have a pressure ulcer to his bottom when admitted to the facility. My question is don't they do a skin assessment upon admission? When my father was transferred to (name of specialty rehabilitation hospital (rehab hospital)) on 12/18/2021, I was present during the admission assessment. The admitting nurse told me they (the facility) did not tell them (name of specialty rehabilitation hospital) the pressure ulcer on his coccyx was as bad as it was. The rehab hospital saw during their admission assessment he (R101) had a stage 4 but then called it unstageable pressure ulcer on his tailbone. He was at the facility for 32 days. There had been little communication regarding my father's pressure ulcers from the facility. I was questioning the facility about the pressure ulcer my dad was complaining about at a care conference on 12/14/2020. The Unit Manager (UM N) was in the meeting, saying something about my dad had to go to the wound clinic and it will be on our dime (referring to the facility covering the cost). When my dad went to (name of rehab hospital), they had to get the infectious disease team involved and had to do testing to find out what type of infection he had. (R101) was not able to receive the therapy he needed at the rehab hospital right away because of the pressure ulcer on his coccyx. He needed to learn to transfer on a slide board and could not because of the pressure ulcer on his coccyx. During an interview and record review on 11/3/2021 at 12:47 PM with Unit Manager (UM) N stated, (R101) was admitted on [DATE] with a spinal cord injury and discharged on [DATE] to a specialty rehabilitation hospital. His admission skin assessment dated [DATE] indicated a Braden score of 14. He had a pressure injury of a blister on his left heel but nothing else was documented. Review of R101's Flowsheets dated 11/16/2020 to 12/18/2020 indicated on 12/6/2021 the wound nurse documented the first assessment of R101's coccyx wound. UM N stated, (R101) was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He developed the pressure injury to his coccyx while he was at this facility. An unavoidable pressure injury is a pressure wound that the facility has done everything in their power to prevent it. During an interview and record review with on 11/3/2021 at 1:10 PM UM N stated, The wound nurse first documented on (R101) on 12/6/2021 that the wound on his coccyx was unstageable. (RN M) sent an email dated 12/4/2020 to the wound nurse reporting the wound on his coccyx is not good with lots of yellow slough. Can you please look at it.? During review of R101's medical records regarding R101's coccyx wound UM N stated, There has to be more to it than that; it has to be documented earlier than that. There must be a note documented on his wound earlier than 12/4/2020. (R101) was dependent on care. During an interview on 11/3/2021 at 2:47 PM Director of Nursing (DON) B stated, It is hard to find documents relating to (R101's) pressure injury to his coccyx. From what the facility has right now, the pressure injury to (R101's) coccyx was first identified on 12/6/2020. DON B was unable to provide documentation to Surveyor regarding R101's coccyx pressure ulcer. During an interview on 11/3/2021 at 3:48 PM Nursing Home Administrator (NHA) A stated, (R101) first documentation regarding his coccyx pressure ulcer was on 12/6/2021 by the wound nurse (RN O). There is no documentation regarding (R101's) coccyx wound prior to 12/6/2020. During an interview on 11/3/2021 at 3:48 PM DON B stated, CNAs (Certified Nursing Assistant) are to tell the nurse if they see a skin issue when caring for a resident. It is up to the nurse to document about skin issues. (RN M) sent an email to the wound referral team on 12/4/2020 stating something to the effect the wound (R101's coccyx wound) was getting worse and she changed the dressing that day (12/4/2020). Review of a facility email dated 12/4/2020 6:46 PM RN M stated, .(R101) wound on his coccyx is really bad. I have changed the [MEDICATION(S)] (wound dressing) twice in 3-hours due to stooling (bowel movements). It (the wound) smells bad and has a lot of yellow sloughing. I'm not sure what to do if we (nurses) have to keep changing the [MEDICATION(S)] (wound dressing). Could you please look at it again? During an interview on 11/4/2021 at 9:24 AM Certified Nursing Assistant (CNA) F stated, I remember (R101) as being a very tall man. I could not reposition him by myself he was so tall. It took at least two staff to reposition him. I don't remember if he had a wound. CNAs try to look at a resident's skin every day. There is nothing for CNAs in the electronic charting system to chart our findings regarding skin. CNAs are to tell the nurse what skin issues they find. Requested on 11/4/2021 at 11:08 AM in an email of NHA A and DON B the wound assessment of R101's wound assessment dated [DATE]. In an email dated 11/4/2021 at 11:20 AM from DON B stated, Unfortunately, there is not a documented assessment of the specific findings other than her (RN M) email referral to the wound referral group. This nurse did document that the dressing was clean, dry, and intact during her shift; I can only presume that since she sent the email with the findings that it was an oversight on her part to not document such in the record as well. During an interview on 11/4/2021 at 12:34 PM FM E stated, My father first told me about the pressure sore on his bottom the weekend before 12/7/2020. On 12/7/2020 I sent an email to the Social Worker (SW L) stating I was informed by my dad he had some pressure sores that started the week prior. I asked her to forward my email to (UMN). SW L replied UM N would be looking into the nursing questions. On 12/10/2020 I emailed SW L stating I had not heard anything back from unit coordinator N. During a telephone meeting on 12/14/2021 meeting with my mother, and all my siblings, UM N was in the meeting with other staff. UM N asked if anything else needed to be discussed. I said yes, the wound needed to be discussed. UM N said my father needed to be seen by a wound clinic and would be on their dime. But he did not go to a wound clinic until he got to the rehab hospital. On 12/15/2020 a (name of rehab hospital) nurse came to the facility to assess my father for placement at the rehab hospital with a video call to the doctor there. On 12/18/2020 my father was discharged to (name of rehab hospital) and I met him there. The nurse told me during his admission assessment that the wound on his coccyx was noted to be worse than what the facility told them for the referral. The nurse told me the wound smelled and she thought it was infected. The hospital started him on IV antibiotics which lasted six weeks. I think he had a bone biopsy to diagnose a bone infection ([CONDITION(S)]). My father had surgical debridement at another hospital who did the infectious disease for (name of rehab hospital) the coccyx wound on 1/27/2021. During an interview on 11/4/2021 at 1:17 PM DON B stated, It is a standard order that surgical dressings are not removed when a resident is first admitted to our facility. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . For (R101) there were orders not to remove his surgical dressing when he first came to us (11/16/2020). On 11/25/2020 he had a follow-up appointment with the NP (Nurse Practitioner JJ) from the surgeon's office. (LPN H) that spoke with the surgeon's office on 11/26/2020, got a verbal order, from the same NP, to remove the dressing. The nurse did not write out the order for whatever reason. When (LPN H) removed the dressing, she found two openings on his coccyx. The facility does not know when the openings developed. It is a standard order not to remove dressings so that part of (R101's) skin was not assessed upon admission and the facility does not know when the opening developed. The facility's IT department is still looking for the standard orders. The standard orders were not received by the Surveyor by survey exit on 11/10/2021. During an interview on 11/4/2021 at 2:21 PM Social Worker (SW) L stated, I had a telephone call on 11/19/2020 with (R101's) family regarding an air mattress that was ordered to relieve the resident's pressure areas. I don't know when or if it was placed on the resident's bed. During an interview and record review on 11/4/2021 at 2:43 PM with Practice Manager X, stated, It depends on the surgery if the surgical dressing stays in place until the follow-up appointment. I'm reviewing right now with you on the telephone (R101's) Physician Discharge Summary .Orthopedic Spine Discharge Instructions . dated 11/16/2020 1631 (4:31 PM) the Trauma Unit's PA (Physician Assistant) documented, regarding wound and dressing care .wound care okay to change dressing if no drainage leave the wound open to air, if there is drainage may change dressing daily, if Dermabond (liquid stitches) is present okay to shower, if staples present wait til seen in office to shower . official date 11/19/2020 note creation time, encounter date 11/5/2020. This is what the discharge instructions say .I don't know if the facility nurse looked at these orders or not. During an interview on 11/4/2021 at 3:24 PM LPN H stated, (R101) was paralyzed from the neck down and incontinent of stool. He was getting stool in his surgical dressing on his lower back. I used text-paging to contact the NP (Nurse Practitioner HH) of the surgeon. (NP HH) called me back and said go ahead and take off the dressing if it is getting soiled. It was a verbal order to just take off the dressing and not per another one on. I did not write an order. I did write a multi-disciplinary note indicating what the NP told me. I noticed two small areas in the incision line. It wasn't on his coccyx. It three fingers up above the gluteal cleft (the top of the groove between the buttocks). I think the areas were open next to the incisional line, more like the incision had dehiscence (surgery complication where the incision reopens) It was not like a pressure wound. I didn't document it like it was a pressure wound because I didn't think it was. It is standard for us not to remove a surgical dressing until we have permission to remove it. The dressing was soiled with bowel movement that day. He had loose stools that day and I had to remove the dressing. I should've put the order from the NP in the computer I probably overlooked it. I guess I thought by me documenting it in the note was enough. Nurses are not supposed to remove a dressing post-surgical unless we have an order. Upon admission, it is at the discretion of the facility's provider to peek under the dressing to assess the surgical site. There was no one from the surgeon's office to come in for a follow-up visit on 11/25/2020 nor did the resident go out to the surgeon's office for a follow up visit. The dressing would have been left on if I had not called the NP to tell him the dressing was soiled and asked him what he wanted. During an interview on 11/8/2021 at 9:25 AM Practice Manager X stated, The NP had a video-visit with (R101) on that day (11/25/2020). The NP did not do a room visit. The NP did not note if he saw the wound on (R101's) coccyx. The NP did not document that he gave orders for the coccyx wound. During an interview on 11/8/2021 at 12:04 PM RN Z stated, The admission process includes a head-to-toe assessment within the first few hours by the admitting nurse. The surgical wound dressing can be taken off unless the surgeon puts in an order not to remove the dressing. It may be a dressing from knee surgery that is required to help the healing process. I always check under the skin unless there is an order not to. The resident's accompanying hospital discharge records should be available for the facility's admitting nurse to review. Those records would tell the nurse what was under the dressings and if there were any skin issues. They would be available in the flowsheet section of the resident's medical records. RN Z was unable to pull up R101's medical records due to technical difficulties and look at the resident's admitting documentation. Review of R101's Nurse Practitioner Encounter Date: 11/25/2020 revealed, . following up 2 weeks after his Posterior Spinal Fusion T10-L3 with Instrumentation, Cervical Fusion Extension T2-T4 via telephone visit . It was noted there was no documentation a wound was discussed, and no orders for dressing removal nor dressing application. Review of R101's Encounter Date of Service: 11/26/2020 11:14 AM revealed, Surgical dressing was removed today per order. Two small areas were still open along incision line. [MEDICATION(S)] was placed on both . It was noted the dressing was along the surgical incision where the two open areas were discovered 10 days post-surgery. The coccyx was not covered by a surgical dressing. Review of R101's Wound History added 12/6/2020 2226 (10:26 PM) revealed, Wound Pressure Injury Coccyx Midline; Posterior Stage 4 as documented by (name of hospital that performed surgical debridement) [DATE] .Primary Wound Type: Pressure Injury .Orientation: Midline; Posterior .Location: Coccyx .Date/Time: 12/14/20 1330 (1:30 PM) Wound Length .7.3 cm Wound Width .4 cm Wound Surface Area 29.2 . 12/09/20 1449 (2:49 PM) Wound Length .6.5 cm Wound Width .3 cm Wound Depth .1 cm Wound Surface Area 19.5 . 12/06/20 2232 (10:32 PM) Wound Length .6.5 cm Wound Width .3 cm Wound Surface Area 19.5 . Review of R101's Wound History 12/9/2020 revealed, Wound Pressure Injury Coccyx Midline; Posterior Stage 4 as documented by (name of hospital that performed surgical debridement January 2021) .6.5cm x 3cm x 1 cm . Review of R101's Braden Scale revealed, 11/16/2020 at 2000 (8:00 PM) indicated the location of skin during assessment was Generalized .warm, dry .abrasion, bruising . 11/16/2020 at 2010 (9:10 PM) score of 14 11/16/2020 at 2102 (10:02 PM) score of 14 11/23/2020 at 1814 (6:14 PM) score of 14 11/20/2020 at 2214 (10:14 PM) score of 14 12/7/2020 at 1813 (6:13 PM) score of 14 12/14/2020 at 1847 (6:47 PM) score of 14 Review of R101's Encounter Note 12/14/2020 1:30 PM revealed, Summary: US (unstageable) on coccyx . Unstageable pressure injury to coccyx. Old dressing intact, with moderate amount of serosanguineous drainage noted. Area cleansed with wound wash. 75% yellow slough covering wound bed. Tunneling noted at the 5 o'clock position. Edges attached. Wound measures 7.3cm by 4cm. Tunneling is 1.2cm x 1cm x 2cm . Review of R101's Nurse Practitioner Acute Problem Progress Note dated 12/14/2020 3:30 PM revealed, .originally admitted to (name of facility) on 11/16/2020 .with lumbar and cervical spine fractures with spinal cord injury and [CONDITION(S)] .On 11/6 he underwent cervical spine stabilization. On 11/9 he underwent lumbar stabilization for an L1 fracture .States he has knowledge of several wounds to his body secondary to surgery and immobility. Discussed likely referral to outpatient wound clinic for assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Assessment: coccyx wound .nonselective debridement (nonsurgical brushing, irrigation, scrubbing, or washing of devitalized tissue, necrosis, or slough with wound dressing) . Referral to BMH Burn and Wound Clinic for evaluation and treatment .Unable to reposition self in bed .1. Wound-small open area on distal end of former surgical incision (diagram indicated this area was located in the middle of R101's back) .2. Coccyx wound - wound be covered in tightly affixed white/yellow slough Odor present. Tunneling noted a 5 o'clock. Wound measures 7.3 x 4 (cm) with tunnel 1.2x1.x2 (cm). Peri wound edges (area around wound) soft, flat, and moist. Moderate amount of serious drainage noted (diagram indicated this area was located at the gluteal cleft (groove between the buttocks) . Review of R101's Ambulatory Referral to Burn and Wound Clinic date12/14/2020 revealed, .Decubitus ulcer of coccyx, unspecified pressure ulcer stage .type of wound: pressure ulcer, location of wound: coccyx . Review of R101's Registered Dietician Note dated 12/14/2020 4:30 PM revealed, .Assessment . Also note US PI (unstageable pressure injury) to coccyx . Spoke with NP regarding increased protein and calorie needs related to healing of PI . Integumentary: US PI to coccyx . Review of R101's Discharge Summary dated 12/18/2020 9:08 AM revealed, .The wound team has been following him for a coccyx (wound) .he was referred outpatient wound clinic for further care post discharge. Social work discussed this with (name of rehab hospital) and states that they can manage the wound and will utilize this referral if needed . Skin . Comments: Wound on .coccyx not assessed due to clean/dry/intact recent bandages applied . Review of R101's NP Progress Note 12/14/2020 3:30 PM revealed, .being seen today for evaluation of multiple wounds and recommendations for necessary dressings . States he has knowledge of several wounds to his body secondary to surgery and immobility. Discussed likely referral to outpatient wound clinic for assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .PLAN .-Change coccyx wound dressing to triad cream on dry gauze for nonselective debridement, cover with [MEDICATION(S)] border. Perform dressing change twice weekly. -Turn every 2 hours to offload pressure to wounds-Referral to (name of hospital) Burn and Wound Clinic for evaluation and treatment-Continue PEG tube feedings as ordered Referral to dietician for recommendations regarding increased protein intake . Review of (name of specialty rehabilitation hospital) Admission Records dated 12/18/2020 1745 (5:45 PM) revealed, .admitted with a stage 4 sacral wound .History .Hx (History) Present Illness .for management of wounds .Skin Wound .Coccyx unstageable 6.5cm x3cm x 1cm .Sensation and Skin Integrity .Pressure Injury History: Stage 4 .with [CONDITION(S)] .will be at risk for septic shock ( life-threatening condition caused by a severe localized or system-wide infection) due to a poorly managed pressure ulcer .1/27/2021 debride wound ( thoroughly cleaning the wound and removing all thickened skin, infected, and nonviable (necrotic or dead) tissue, foreign debris, and residual material from dressing) .Wound Care Note dated 12/22/2020 indicated an unstageable pressure ulcer was present on admission (12/18/2020) located on the resident's sacrum for the past month and started on an IV ( Intravenous (within a vein) ) antibiotic and a wound vac (Negative-pressure wound therapy, also known as a vacuum assisted closure, is a therapeutic technique using a suction pump, tubing and a dressing to remove excess exudate and promote healing) as part of wound management .bone exposed, coccyx palpable, L (length) 6 cm W (width) 4 cm D (depth) 3.5 cm, moderate odor, wound bed necrotic, moderate sersang (serosanguineous drainage containing both blood and serous fluid) .Stage 4 .increased odor and necrotic tissue .recommend tx (treatment) for [CONDITION(S)] due to exposed bone in wound bed and wound deterioration . Review of facility policy PRESSURE INJURY and WOUND CARE: PREVENTION, ASSESSEMENT, AND TREATMENT reviewed/revised 11/20, revealed, .PURPOSE: To provide a consistent multi-disciplinary plan for the assessment and care of the patient with potential or actual skin integrity loss . SKIN INTEGRITY ASSESSMENT: All patients must have a head-to-toe assessment of skin integrity, by a licensed nurse upon admission. This will be documented in the Electronic Health Record (EHR) . WOUND/PRESSURE INJURY ASSESSMENTS: All wounds, incisions, pressure injuries, vascular injuries, diabetic injuries, skin tears, and other wounds are to be assessed and charted in the EHR upon admission and as needed thereafter. 1. Remove dressing(s) unless provider orders contradict this or the patient refuses. Document wound description on Active LDA's and Wounds Avatar and/or enter relevant corresponding documentation in integumentary flowsheets in the EHR .Document pressure injuries accordingly on the Active LDA's and Wounds Avatar in the EHR. Description, measurements, drainage, and injury stage must be documented in the integumentary flowsheets in the EHR . Stage 1: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)] (discoloration of the skin that does not turn white when pressed) .Presence of blanchable [CONDITION(S)] (red when it blanches, turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed .may precede visual changes . Stage 2: Partial thickness skin loss with exposed dermis thickest layer of skin that lies beneath the epidermis and above the subcutaneous layer), the wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), slough (purulent (pus-like) stringy wound drainage) and eschar (dry dead tissue) are not present. These injuries commonly result from adverse microclimate (is created from due to excessive heat and moisture from sweat, incontinence (urine and/or bowel), drainage from wounds, or sitting on a seat surface that is not breathable, preventing ventilation due to a lack of appropriate airflow) and shear in the skin over the pelvis (force generated when the skin is moved against a fixed surface such as a bony skeleton moving in an opposite direction to the surface skin). This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions) . Stage 3: Full thickness skin loss Full thickness loss of skin, in which adipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury . Stage 4: Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the injury. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury . Unstageable: obscured full thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed INITIATING A WOUND CARE/SKIN INTEGRITY CONSULT: 1. The Wound Care Nurse and/or designee(s) have been delegated to serve as a resource in the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound care/skin integrity consults and dietary consults related to wound treatment may be initiated by the nurse without a provider order. Initiate a wound care/skin integrity consult by emailing the group (name of facility) Wound Referrals. NOTE: When placing a wound care/skin integrity consult, do not cover the wound/injury with duoderm (thin dressing) before the wound nurse/designee has evaluated it. Cover stage 3 & 4 pressure injuries with moist saline dressing loosely packed into the wound space. 3. These nurses are available to assist with: a. Implementing plan of care for stage 3 & 4 pressure injuries, non-improving stage 2 pressure injuries, unstageable pressure injuries, deep tissue injury, vascular injuries, and diabetic injuries. b. Ongoing evaluation of wounds. c. Solving wound care problems (i.e., difficult to dress areas, incontinence, heavy drainage, odors, etc.). d. Use of unfamiliar dressing devices, topicals or appliances. e. Discharge planning related to skin/wound management. f. Patient handouts are available through the patient education link on the Center for Learning web page. g. Assist in determining need and ordering specialized products for skin care and wound management . SKIN INTEGRITY CARE PLANS The care plan is a template and must be individualized to each patient. It incorporates a multidisciplinary plan to direct patient care for all stages of pressure injuries. For Braden Scale assessment results, initiate the following care plans: . Braden Score >18: General Medical care plan individualized to patient needs Braden Score <18 and no skin breakdown: Pressure Injury > At Risk for Skin Problems Pressure Injury Stage 1 or greater: Pressure Injury > I Have a Pressure Injury . PRESSURE INJURY PREVENTION: Please see Attachment B - Pressure Injury Risk Reductions Interventions for a guide to pressure injury prevention interventions . On 11/8/2021 the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy that was identified on 11/8/2021 as a result of the facility's failure to prevent pressure ulcer development resulting in an immediate jeopardy. A written plan for the removal of the immediate jeopardy was received on 11/9/2021 and was verified on 11/10/2021: 1. On 12/18/2020, Resident 101 was discharged to (proper name of) Inpatient Rehabilitation Center. Resident 101 has not readmitted to (name of facility). 2. On 11/8/21, Skin Assessments and audits were started on all residents and completed on 11/9/2021. -Audits included: -Ensure all treatments, supplies, and equipment were readily available for ordered wound treatments. -Ensure routine skin assessments were completed and treatment recommendations/orders were in place. -Ensure that treatment recommendations/orders were on the care plan and the care plan was being followed. 3. Beginning 11/9/21, all new admissions with surgical incisions and/or dressings will have all dressings removed for skin assessment completion with subsequent documentation in EMR within 24-hours of arrival, unless specifically ordered otherwise by physician. For all patients with a surgical dressing with a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. On 11/9/2021 Policy PRESSURE INJURY AND WOUND CARE: PREVENTION, ASSESSMENT, AND TREATMENT was reviewed and edited to address frequency of skin assessments and appropriate interventions. 5. Beginning on 11/9/2021, before second shift, Director of Nursing (DON B) or nursing leader(s), started education to all licensed nurses on edited facility policy PRESSURE INJURY AND WOUND CARE: PREVENTION, ASSESSMENT, AND TREATMENT. This includes ensuring nurses are educated that all new admissions with surgical incisions and/or dressings will have all dressings removed for skin assessment completion with subsequent documentation in EMR within 24-hours of arrival, unless specifically ordered otherwise by physician. All patients with a surgical dressing with a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Sixteen (16) nurses out of forty (40) received education as of first shift on 11/10/2021. Beginning before second shift on 11/9/2021, DON B or nursing lea [TRUNCATED]

Complaint Intake Numbers: MI 488 & MI 360 Based on observation, interview, and record review, the Facility failed to provide adequate supervision with use of assistive devices (mechanical lifts) in 3 of 4 residents reviewed for mechanical lift use (#101, #106 & #107), in the sample of 6, resulting in actual harm (fractured toe and laceration to the foot which required sutures and a bruise to the ear) for Resident #101, painful bruise with secondary infection for Resident #106, the potential for injury to Resident #107. Findings include: Resident #101 Per the Minimum (MDS) data set [DATE], Resident #101's [DIAGNOSES REDACTED]. Per the Incident Report dated 9/03/12, dried blood was noted on Resident #101's left foot. Inspection revealed a laceration between the 4th and 5th toes. Resident #101 was sent to the hospital where an x-ray identified the 5th toe on his left foot was fractured. Per the Nurses' Notes dated 9/03/12, Resident #101 returned from the hospital with "3 sutures to top of foot" and his toes "buddy taped." In an interview on 1/30/13 at 10:20 a.m., Nurse Aide #20 said she found "dried blood" on Resident #101's bed linens when she started morning care on 9/03/12. Nurse Aide #20 said Resident #101 wore a "boot" while in bed due to past history of sores and a habit of rubbing his feet together. Nurse Aide #20 said she contacted Licensed Practical Nurse (LPN) #39 and between them they removed the boot. Nurse Aide #20 said, "It kinda looked like there was a cut between his 4th and 5th toes. The blood on the boot and on his foot was dry. There was quite a bit of blood on the top of his foot and blood on the cut. It was not dripping out." Nurse Aide #20 said prior to this incident, Resident #101 was transferred via a mechanical lift by two aides. In an interview on 1/30/13 at 3:25 p.m., LPN #39 said on 9/03/12 she observed dried blood on Resident #101's foot after the boot was removed. LPN #39 said staff had no direction to keep the boot on Resident #101's foot during transfers. LPN #39 said "some staff did and some didn't." In an interview on 1/04/13 at 2:02 p.m., Registered Nurse (RN) #48 said on 9/03/12 she observed a "bloody cut between (Resident #101)'s 4th and 5th toes. I cleaned it up and sent him to the emergency room . I don't know how it happened." In an interview on 1/30/13 at 3:42 p.m., Nurse Aide #42 said on 9/02/12 Resident #101 had been wearing the boot in bed and at 3:30 p.m. she took the boot off before transferring Resident #101 out of the bed. Nurse Aide #42 said Resident #101 had socks on and she did not see his foot unclothed thus she did not know if the cut was present before the transfer. Nurse Aide #42 said she transferred Resident #101 from bed to chair via the mechanical lift with Nurse Aide #41 "at the controls." Nurse Aide #42 said no one held or protected Resident #101's feet during the transfer as she was standing behind him and "pulled him back" into the chair while Nurse Aide #41 stood behind the machine and operated the controls. Nurse Aide #42 said, "after supper" she and Nurse Aide #41 transferred Resident #101 from the wheelchair into his bed. Nurse Aide #42 said she removed his socks and put the boot on and the boot remained on for the rest of her shift (she never saw the foot unclothed again). Nurse Aide #42 said Resident #101 "could have hit his foot on a chair or table leg in the dining room. Or maybe when we were rolling him his foot was just right in the boot. Possibly it didn't bleed right away." Nurse Aide #42 said when she took the socks off at bedtime, "I didn't spread his toes apart. I wouldn't have seen the cut. He wasn't able to tell us his toe was hurting." In an interview on 1/30/13 at 3:32 p.m., Nurse Aide #41 said on 9/02/12 she helped Nurse Aide #42 transfer Resident #101 out of bed at 3:30 p.m. "We got him up for supper. We layed him down after supper." Nurse Aide #42 said Resident #101's boot was removed prior to the transfer out of bed. "He had socks on. We put his shoes on after the transfer. When we put him back to bed he just had his socks on. I helped to undress him." Initially Nurse Aide #41 said she and Nurse Aide #42 removed Resident #101's socks but then said Resident #101, "still had his socks on. I didn't see his foot naked. (Nurse Aide #42) gave his care later." Per the investigation file notes dated 9/06/12 the night shift staff never transferred Resident #101 out of bed and he wore the boot all shift. None of the night shift admitted to seeing Resident #101's foot uncovered and none noted blood on his sheets. In an interview on 1/30/13 at 11:58 a.m., RN #36 said she conducted the investigation into the injuries sustained by Resident #101 on 9/02 or 9/03/12 and did not determine a cause of the injury. Review of the "Mechanical Lift" Policy and Procedure dated July 2011 revealed there were no instructions for staff to hold the residents' feet to prevent them from injury during a transfer. Per the Nurses' Notes dated 1/24/13 a "purple bruise" was found on the "outside" of Resident #101's right ear. In an interview on 2/05/13 at 10:43 a.m., RN #17 said Resident #101's Nurse Aide care plan was amended on 1/26/13 to have 3 persons while transferring him with the mechanical lift. RN #17 said, "Something happened. That's why I changed it to 3 instead of 2 (nurse aides). He had a bruise on his right ear. That happened during a transfer. The Hoyer sling bar lined up with the bruise." In an observation on 1/30/13 at 10:50 a.m. Nurse Aide #32 and Nurse Aide #3 transferred Resident #101 from the bed via the mechanical lift. This Surveyor questioned why the cloth sling was wet which resulted in his return to the bed and incontinence care was given. At 10:55 a.m. Resident #101 was again lifted from the bed via the mechanical lift and positioned in his chair. He was wearing a boot which was removed. Inspection revealed no cut or obvious deformity of the 5th toe on his left foot. Resident #101 did not make any sounds or facial expression of pain when the staff opened his toes for inspection. Slippers were put on after he was in his wheelchair. ( ) Resident #106 Per the Nurses' Notes dated 1/22/13, a 2.0 cm yellow "bump" was noted on Resident #106's mid right shin. Per the Incident Report dated 1/22/13, the bath aide reported a bruise and bump on Resident #106's right shin. Per an interview documented on 1/22/13, found in the investigation file, Resident #106 said the injury happened "during a transfer using the sit-to-stand. She said it hurt when she stood up and it pressed against her legs. She thought it happened a few nights ago with the 'blue' lift." In an observation on 1/31/13 at 3:46 p.m. with Registered Nurse (RN) #47, Resident #106 had a large raised red area on her mid right shin. Resident #106 flinched and drew back when RN #47 initially touched the injured area. Resident #106 said the injury happened "with the lift-the blue one. When she let me down on the bed it pushed down real tight." When RN #47 pulled Resident #106's support hose back up, Resident #106 moaned with pain. In a telephone interview on 2/16/13 at 12:03 p.m., Nurse Aide #58 said the injury to Resident #106's right leg occurred "when we were transferring her back to bed. The alarm cord was under the bed. The cord got caught on the sit-to-stand wheel. That jarred the bed and pushed the back of her legs against the bed and pushed her shin into the sit-to-stand. She didn't say anything out of normal. She doesn't like the sit-to-stand. I didn't see any marks at that point. I looked. I didn't tell anybody." In a statement dated "1/05/13" (sic) Nurse Aide #58 said she remembered the sit-to-stand lift got "caught" on the alarm cord "which jarred the machine. The back of her legs bumped the bed, which very well could have and probably did put pressure on the shin resting against the sit-to-stand." Per the Nurses' Notes dated 1/31/13, Resident #106's "right lower leg lesion has redness around it and extends down the anterior of the shin, there is swelling at the lesion site. Resident denied pain but when area was touched she winced." According to the note, the physician was notified and x-rays ordered. Per the Physician's Progress Note dated 2/01/13, Resident #106 was a "[AGE] year-old female who had an injury on 1/22/2013. (Resident #106) struck the sit-to-stand machine on her left (sic) shin and developed a contusion, hematoma. There was a concern yesterday in that there is some distal redness and the area is quite tender. We did do an x-ray of the area of the right tibia and fibula, and there was no evidence of acute fracture or dislocation...The right distal third of the shin has a contusion hematoma with bruising and swelling. There is a small amount of fluctuation, and the area is tender. There is some increased warmth and redness distally...Assessment: 1. contusion hematoma right shin secondary to an accident on 01/22/2013. 2. Possible cellulitis developing..." The antibiotic Zithromax was prescribed to be given for 5 days. Per the Minimum (MDS) data set [DATE], Resident #106's [DIAGNOSES REDACTED]. ( ) Resident #107 In an observation on 1/30/13 at 10:40 a.m. Nurse Aides #24 and #32 transferred Resident #107 via the mechanical lift. As they turned the machine while Resident #107 was suspended in the air in a sling, Resident #107's feet struck the door jamb of the open bedroom door three times. This Surveyor intervened, told the aides to "stop", and placed her body between the door jamb and Resident #107's feet. Both aides and Resident #107 were behind the privacy curtain-with just his feet sticking out and striking the door jamb. Upon entering the room this Surveyor noted there was little space between the bed and the open door for staff and the mechanical lift. This Surveyor asked why the staff had not pushed the bed out of the way to enlarge the space and thus prevent Resident #107's feet from striking the door jamb. Nurse Aide #32 said, "We don't have permission to move the furniture." Per the Minimum (MDS) data set [DATE], Resident #107's [DIAGNOSES REDACTED]. Per the Pressure Sore Log entry dated 1/28/13, Resident #107 had a full thickness pressure sore on the bottom of his left foot. ( )

Based on observation, interview, and record review, the facility failed to use an assistive device in 1 of 3 sampled residents who required a UNO Lift (mechanical lift), from a total sample of 4 residents identified as being at risk for falls, resulting in Resident #101 sustaining a fractured right ankle. Findings include: Review of the 24 Hour Facility Investigation Report dated 6/16/11 revealed Resident #101 had an acute non-displaced fracture of distal tibial diaphysis (ankle fracture) noted on x-ray and no known injury preceded discovery of the fracture. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had severe cognitive impairments, was totally dependent on facility staff with activities of daily living (ADL's), was extensive assistance of 2 staff members for transfers, and was diagnosed with [REDACTED]. Review of the Fall Care Plan dated 3/15/11 revealed Resident #101 was at risk for falls due to blindness. The Fall Care Plan updated on 1/17/11 revealed Resident #101 required a UNO Lift and two facility staff for all transfers. Review of the "Door" Care Plan (used by certified nursing aides to guide resident care) dated 2/8/11, 4/29/11, and 6/21/11 revealed Resident #101 required the assistance of two staff and a UNO Lift for all transfers due to general weakness. Review of Nurses' Notes dated 6/13/11 at 6:30 PM revealed Resident #101 complained of right ankle pain. Review of Nurses' Notes dated 6/14/11 at 10:00 AM revealed no new orders were received after Physician #3 examined Resident #101's right lower leg. The nurse documented they (facility staff) would continue to monitor. Review of Nurses' Notes dated 6/14/11 at 10:00 PM revealed Resident #101 was yelling out in pain when her right shin and lower leg were gently touched. The nurse documented Resident #101's right foot at ankle was slightly edematous (swollen), which was unchanged from the morning assessment and at the "right mid to medial shin (middle front of lower leg)" there was redness and bruising noted. Review of the physician's orders [REDACTED].#101 had an order for [REDACTED]. In an interview, on 7/6/11 at 11:17 AM, Physician #3 stated he ordered an X-Ray on 6/15/11 due to Resident #101 having "vague pain in lower extremities for a couple of days". Physician #3 stated he was not aware of any history of an accident related injury per staff or Nurses Notes. When Physician #3 was asked if he was aware of Resident #101's "knees buckling" during a transfer, he stated, "Yes, I did know the aides stood her (Resident #101) up and her knees buckled " . Review of the imaging (x-ray) report, dated 6/15/11 revealed Resident #101 had an acute non-displaced fracture of the distal tibial diaphysis (fractured right ankle). Review of Nurses' Notes, dated 6/15/11 at 10:15 PM revealed Resident #101's x-ray results were faxed to the facility, the Director of Nursing (DON) was made aware, and the results were placed in the "Doctor's Book" (communication book for the physician). In an interview on 7/6/11 at 2:15 PM, Certified Nurse Aide (CNA) #16 stated that on 6/13/11 between 10:00-10:30 AM she assisted CNA #15 perform a two person transfer from a shower chair to the wheelchair while in the bathing room for Resident #101 and did not use a Hoyer (UNO) Lift or a gait belt. CNA #16 stated she and CNA #15 both pulled on the back of Resident #101's pants with one hand and placed one arm underneath Resident #101's armpits. CNA #16 demonstrated the transfer techniques used on Resident #101. CNA #16 stated when they (CNA #15 and CNA #16) went to lift Resident #101 the resident "did not assist at all," stood for only a "couple of seconds", and then her "knees gave out". CNA #16 stated they (CNA #15 and CNA #16) slowly lowered Resident #101 to the floor and then lifted her (Resident #101) from the floor to the wheelchair using the same method previously demonstrated. CNA #16 reported she and CNA #15 did not have their gait belts with them during the transfer of Resident #101. CNA #16 stated, "On her (Resident #101) care plan she is a Hoyer (UNO lift)". CNA #2 then stated, " It was probably a bad decision on our part (performed the transfer the way they did), we should not have done it. " Review of the Facility Gait Belt Policy dated 11/09, revealed "all CNA's are provided a gait belt and are expected to carry the gait belt on their person at all times while on duty and assist the resident at the waist rather than pulling on the resident 's arms or shoulders". Review of the Facility "Lifting Residents" Policy dated 11/09 revealed facility staff are to use a gait belt for all transfers. On 7/7/11 at 10:45 AM CNA #15 was asked to demonstrate the transfer of Resident #101 that was done on 6/13/11 while in bathing room. CNA #15 described the wheelchair as being on an right angle and approximately three feet away from the shower chair. CNA #15 stated when they (CNA #15 and CNA #16) attempted to place Resident #101 back in the wheelchair they had to hold her (Resident #101) up underneath her armpits. CNA #15 then demonstrated how she quickly pulled the wheelchair with one arm towards Resident #101, while holding onto Resident #101 with the other arm. CNA #15 reported the wheelchair hit Resident #101's right leg. CNA#15 stated, "I don't remember (Resident #101) going all the way to the floor, but she could have". In an interview on 7/6/11 at 2:50 PM, the Physical Therapist (PT) #9 stated," if a Hoyer (UNO lift) is ordered for transferring, we (therapists) would not recommend the resident to be stood up or bear weight; (if a Hoyer is ordered) a Hoyer should be used for all transfers." In an interview on 7/6/11 at 12:18 PM, CNA #15 pointed to Resident #101's "Door" Care Plan and stated she did not realize that Resident #101 was a Hoyer Lift at the time of the incident. CNA #15 stated, "I did not use the Hoyer, I never used the Hoyer on her (Resident #101); she normally stood for you". When CNA #15 was asked about the use of a gait belt during the transfer on 6/13/11, she stated, "I didn't have my gait belt on me that day. I normally have it in my car". On 7/6/11 at 12:39 PM, 4 out of the 8 CNA's were observed by surveyor # on the unit where Resident #101 resided to not have gaits belts on their person. On 7/6/11 at 12:39 PM, Surveyor # observed CNA #11 without a gait belt in the hallway where Resident #101 had resided. In an interview on 7/6/11 at 12:39 PM, CNA #11 stated her gait belt was "in the bathing room". Surveyor # accompanied CNA #11 to the bathing room where CNA#11 was unable to locate her gait belt. On 7/6/11 at 12:40 PM, Surveyor # observed CNA #14 without a gait belt in the hallway where Resident #101 had resided. In an interview on 7/6/11 at 12:40 PM, CNA #14 stated her gait belt was, "in her locker". On 7/6/11 at 12:42 PM, Surveyor # observed CNA #12 without a gait belt on the unit where Resident #101 had resided. In an interview on 7/6/11 at 12:42 PM, CNA #12 stated she was a bath aide that day and that her gait belt was in the trunk of her car. On 7/6/11 at 12:44 PM, Surveyor # observed CNA #20 without a gait belt on the unit where Resident #101 had resided. In an interview on 7/6/11 at 12:44 PM, CNA #20 stated she did not have her gait belt, but she knew where to find one in the linen closet, if she needed one. During the entrance conference on 7/6/11 at 10:00 AM, Surveyor # requested documentation regarding when the last in-service for transfers was completed from DON #2. An in-service report titled, "Back Safety In-Service" dated 9/22/10, was subsequently provided by DON #2 as evidence the of most recent in-servicing on safe transfers. In an interview on 7/6/11 at 1:59 PM, DON #2 stated that after the facility completed its investigation, CNA #15 was not disciplined or re-educated on safe patient transfer techniques or the importance of following a residents care plan. ( and )