Every finding on record at Burcham Hills Retirement Center

This citation pertains to Intake 2987836. Based on interview and record review, the facility failed to monitor and address a significant weight gain and increased edema in one (R1) of three reviewed resulting in unrecognized worsening of edema, significant weight gain, loss of consciousness, and hospitalization. Findings include:In a telephone interview on 4/23/26 at 12:13 PM, R1's Significant Other (SO) I reported earlier in the week, prior to R1 transferring to the hospital, they noticed R1 had increased edema in his legs and reported R1 mentioned an increased difficulty in breathing. SO I reported they believed the increased edema was not being addressed. SO I reported R1 remained in the hospital as of 4/23/26. Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included atrioventricular block, bradycardia, acute respiratory failure with hypoxia, congestive heart failure (CHF), and atrial flutter. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed R1 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R1 had an activated Durable Power of Attorney for health care. Review of Hospital notes dated 3/23/26 revealed R1 had acute congestive heart failure. Review of the Clinical admission dated 3/24/26 revealed R1 had non-pitting edema to his right and left palms. There was no mention of lower extremity edema. Review of the Physician's Order dated 3/24/26 revealed R1 was prescribed Furosemide (diuretic medication) 20 milligrams (mg) two times a day for hypertension (high blood pressure). The order was re-written on 4/3/26 to change the timing of the Furosemide, but the dosage remained the same. Review of the Physician's Order dated 3/24/26 revealed an order for weekly weights every Wednesday evening shift. Review of R1's diuretic care plan included an intervention dated 3/24/26 that revealed weigh resident weekly and as needed. Review of the Physician H&P (History and Physical) dated 3/25/26 revealed Problem List .CHF. Review of the Dietary/Nutrition Evaluation dated 3/31/26 revealed R1 had impaired nutrient utilization related to altered sodium and fluid balance secondary to congestive heart failure.Continue to monitor weight trends. Review of the Treatment Administration Record (TAR) revealed on 3/25/26 R1 had two weights obtained which were 221 pounds and 223 pounds. Review of the Weekly Weight Task revealed one weight documented on 3/28/25 which was 215.6 pounds. The next weights were scheduled for 4/1/26, 4/8/26, and 4/15/26 but were not documented as completed on the TAR. The weight box on 4/15/26 was coded as 09-Other/See Nurse Note. Review of the Nurse Notes revealed no documentation as to why the weights were not obtained. Review of R1's Vitals Summary revealed the following weights documented:3/24/26= 223 pounds3/26/26= 221 pounds3/28/26= 215.6 pounds4/10/26= 249 pounds (13 days since previous weight; gain of 33.4 pounds) Review of the Physician Visit Note dated 4/6/26 and documented by Nurse Practitioner (NP) J revealed Weight loss: Weight decreased from 223 lbs at admission to 215.6 lb.Request repeat weight to confirm trend and accuracy. (Of note, the weight of 215.6 pounds was obtained on 3/28/26). A reweight was not documented in the medical record. The next weight was documented on 4/10/26 at 249 pounds, which was a gain of 33.4 pounds. Review of the Physician Visit Note dated 4/13/26 and documented by NP J revealed no mention of R1's most recent weight or the significant weight gain. Review of the N Adv Skilled Evaluation note dated 4/6/26 revealed no edema present. Review of the Physician Progress note dated 4/6/26 and documented by NP J revealed Physical Exam.Extremities: no edema. Review of the N Adv Skilled Evaluation note dated 4/8/26 did not mention edema. Review of the N Adv Skilled Evaluation dated 4/9/26 revealed no edema present. Review of the N Adv Skilled Evaluation note dated 4/10/26 revealed R1 had +1 pitting edema to the left lower extremity and the right lower extremity. The edema was documented as unknown if this was a new onset. The N Adv Skilled Evaluation dated 4/11/26 revealed R1 had 1+ pitting edema to the right and left lower extremities. The edema was documented as unknown if this was a new onset. The N Adv Skilled Evaluation note dated 4/12/26 revealed R1 had 2+ pitting edema to the right and left lower extremities. The edema was documented as unknown if this was a new onset. The N Adv Skilled Evaluation dated 4/13/26 revealed R1 had 2+ pitting edema to the left lower extremity and 1+ pitting edema to the right lower extremity. The edema was documented as unknown if this was new onset. According to the Cleveland Clinic, Pitting edema is a type of swelling where pressing on a swollen body part leaves behind a dent or pit that takes time to refill. The deeper the dent and the longer it takes to refill, the more severe this swelling is .Edema grading uses a scale to check how severe pitting edema is. The grading also lets providers estimate how much fluid has built up in your tissues. To find the grade, they'll use a pitting test. To do this test, they'll gently press their finger on a swollen area of your skin for five to 15 seconds. If you have edema, a pit or dimple will remain on your skin when they pull their finger away. They grade edema based on how deep the pit goes and how long it takes for the pit to fill in (rebound) and return to being flat skin.The grades are:Grade 1 [1+]: Immediate rebound with a 2 millimeter (mm) pitGrade 2 [2+]: Rebound in under 15 seconds with a 3 to 4 mm pitGrade 3 [3+]: Rebound in between 15 and 60 seconds with a 5 to 6 mm pitGrade 4 [4+]: Rebound within two to three minutes with an 8 mm pitThe pitting test only works if you have pitting edema. It's also possible to have nonpitting edema. (https://my.clevelandclinic.org/health/symptoms/pitting-edema) Review of the Progress Note dated 4/17/26 at 2:09 AM revealed Res [Resident] stated this evening he is in congestive hear [heart] failure. Dtr [daughter] stated he has a dx [diagnosis] of CHF.Res also expressed concern about tibia edema not resolving or getting worse. Review of the Progress Note dated 4/17/26 at 9:32 AM revealed R1 was sent to the Emergency Department related to loss of consciousness and hypoxia. Review of the Physician Visit Note dated 4/17/26 at 9:46 AM and documented by NP J revealed Chief Complaint: Loss of consciousness.history of congestive heart failure.concern that heart failure is worse due to persistent and worsening lower-leg swelling.reports tibial edema progressing.Assessment & Plan: 1. Acute respiratory distress: Patient developed respiratory distress in bed; EMS called, placed on non-rebreather with edema present.Congestive heart failure with worsening lower-extremity edema : Patient reports progressive tibial edema despite furosemide 20 mg twice daily.edema noted on exam. Concern for fluid overload contributing to symptoms. Most likely form recent abdominal CT with contrast causing fluid overload. In a telephone interview on 4/23/26 at 2:48 PM, Registered Nurse (RN) H reported they were a dayshift nurse and were not responsible for conducting assessments on odd number rooms. RN H reported night shift assessed odd number rooms and dayshift assessed even number rooms. RN H reported they never assessed R1's edema but received in report that R1 had edema without any changes. When asked if they were aware that R1 had a significant weight gain, RN H reported they didn't look at his weight. RN H reported if there is a weight increase of 3 pounds in one day or 5 pounds in one week, the physician should be notified. In a telephone interview on 4/24/26 at 7:43 AM, Licensed Practical Nurse (LPN) G reported they thought R1 was admitted with 2+ pitting edema to both legs, but could not recall. LPN G reported the night before R1 was sent to the hospital, he was anxious and R1's family mentioned the edema in his legs might be bigger. LPN G reported they believed R1 was weighed weekly but did not know if R1 had any weight changes. LPN G reported they did not know R1 had CHF because they did not see the diagnosis in the medical record. LPN G reported residents with a diagnosis of CHF were supposed to be weighed daily and the physician should be notified if there is a weight gain of 3 pounds in one day or 5 pounds in one week. In an interview on 4/24/26 at 10:48 AM, NP J reported R1 had CHF. When asked about monitoring a resident with CHF, NP J reported it depended on how stable the resident was; often weights were daily, sometimes weekly. NP J reported the weights were the major thing and edema would be another thing to monitor. NP J reported they assessed R1 on 4/6/26 and no edema was present. When asked about her note on 4/6/26 that indicated a reweight was requested, NP J reported they would expect that reweight to be done the next day or the day after. NP J reported they were not notified of R1's 33.4# weight gain but would be expected to be notified. NP J reported she was not aware of R1's weight gain when she assessed R1 on 4/13/26 but wished she would have been aware so that she could have obtained a reweight. In an interview on 4/24/26 at 11:09 AM, Director of Nursing (DON) B reported if a resident admitted with a CHF diagnosis, the facility started with daily weights on admission. DON B reported nursing was responsible for monitoring weights and reporting to the physician if there was a 3-pound gain in one day or a 5-pound gain in one week. DON B reported R1 did not have an order for daily weights but instead had an order for weekly weights. When asked if the weekly weights were completed, DON B reported it appeared the weights were obtained every two days to start and then there was a two-week gap with a big jump in R1's weight. DON B reported they received an email on 4/14/26 from the dietitian requesting a reweight of R1 but did not see the reweight in R1's medical record. DON B reported reweights should be obtained within 24 hours of being requested. DON B reported they would have expected staff to notify the provider of R1's weight gain of 33.4 pounds and also the change in edema. DON B reported they reviewed R1's progress notes from the night before hospitalization and had requested the team to have the provider (physician/NP) follow up because R1 seemed to have a change in condition with his anxiety.

This citation pertains to intake #2787869.Based on observation, interview, and record review the facility failed to ensure activities of daily living were provided for one (Resident #1) out of three reviewed for activities of daily living. Findings include: Review of the medical record reflected Resident #1 (R1) was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/6/26, reflected R1 scored 9 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).On 3/3/26 at 9:13 am, R1 was observed in his room on his cellphone. R1 carried on a conversation and answered questions appropriately. R1 reported concerns with not receiving showers, stating that he went days without a shower and he disliked smelling himself. R1 stated that his preference was to receive two showers a week however if he asked for additional showers at times he was told by staff that they did not have time to give him a shower. Additionally, R1 expressed concerns with timeliness with incontinence care, stating on a few occasions, he had been left wet in urine for extended periods of time. Review of the Task list reflected R1 preferred shower 2x (two times) weekly and PRN (as needed).Review of the shower task list revealed R1 received a bed bath on 2/7/26 and 2/14/26. R1 received his first shower since his 1/30/26 admission on [DATE] and did not receive another shower until 3/2/26. No shower refusals documented in the electronic medical record. Review of a Progress Note dated 2/20/26 stated patient (Resident #1) in bed requesting to get OOB (out of bed). patient and bed soiled with urine.In an interview on 3/4/26 at 10:37 am, Therapy Staff I and J stated that they had gone into R1's room the morning and discovered that R1 was pretty saturated in urine. R1 had soaked through his clothing, bed linens and down to the mattress. They notified nursing and assisted R1 with incontinence care. In an interview on 3/4/26 at 2:22 pm, Licensed Practical Nurse (LPN) N reported that she had entered R1's room on 2/20/26 to assist therapy staff with incontinence care. LPN N reported that it was in the morning time and confirmed that R1 was saturated in urine through his clothing and bed linens.According to the Policy titled, Activities of Daily Living (ADLs), reviewed on 10/19/23, appropriate care and services will be provided for residents who are unable to care out ADLs independently .including appropriate support and assistance with hygiene (bathing) and elimination (toileting).

This citation pertains to intake #2787869.Based on observation, interview, and record review the facility failed to prevent a fall in one (Resident #1) out of three residents reviewed for falls. Findings include: Review of the medical record reflected Resident #1 (R1) was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/6/26, reflected R1 scored 9 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).On 3/3/26 at 9:13 am, R1 was observed in his room on his cellphone. R1 carried on a conversation and answered questions appropriately.In an interview on 3/4/26 11:06 AM R1 reported that he sustained a fall out of his bed. R1 explained that he has to use the bathroom to have a bowel movement but could not find his call light. R1 stated that his left side of his body has weakness and he has issues with immobility however, at times, staff will attach the call light to his left side. R1 was feeling around in his bed for his call light with his right arm but could not find it in time before having a bowel movement. R1 attempted to get out of bed to attempt to make it to the bathroom but slid out of bed and onto the ground. R1 stated that he yelled out until staff discovered him. Review of a Progress Note dated 2/6/26 reflected Resident (R1) found on the floor bedside bed after calling out for assistance. Resident stated he had a bowel movement and was getting out of the bed when he fell and hit his head. The resident was observed entangled in his bedding and peg tube. Resident is A&O to baseline .The resident was assisted back to bed safely by two staff members. Incontinence care provided and linens changed.Review of an Incident Report dated 2/6/26 revealed R1 reported that he had a bowel movement on himself and was trying to get out of the bed. Intervention included offering the bedpan every two hours if awake, resident is continent of bowel. Review of the Post Fall evaluation dated 2/6/26 confirmed that R6 did not have his call light activated.Review of R6's Fall Care plan reflected an intervention to ensure R1's call light was in reach at all times.In an interview on 3/4/26 at 1:54 pm, Licensed Practical Nurse (LPN) O confirmed that they were working the night that R1 sustained a fall. LPN O recalled walking down the hall and heard someone yelling. LPN O arrived to R1's room and observed him on the floor. LPN O looked in the hall for other staff that could assist however, did not see anyone so LPN O pulled the call light cord out of the wall. LPN O stated that R1 reported that he had to use the bathroom and had a bowel movement in bed. LPN O said that R1 was able to use the call light appropriately when he had care requests.

This citation pertains to Intake 2675469.Based on observation, interview, and record review, the facility failed to properly manage and document feeding tube administrations for one (R4) of three reviewed.Finding include:R4Review of the medical record revealed R4 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with hyperglycemia (high blood sugar), dysphagia, functional quadriplegia, and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date of 9/1/25 revealed R4 had severely impaired cognitive skills for daily decision making. R4 had a PEG tube (percutaneous endoscopic gastrostomy-tube inserted into the stomach through the abdominal wall to provide feeding). An observation on 12/1/25 at 8:03 AM revealed R4 was in bed with the head of the bed elevated. Glucerna 1.5 cal was being administered via the feeding tube at 40 milliliters (mL) per hour. The bottle of Glucerna was not dated or timed. Review of the Physician's Order with a start date of 10/23/25 revealed infuse Glucerna 1.5 via PEG 40 mL/hour x 22 hours daily START @ 1600 [4:00 PM]. New tubing @1600. A second Physician's Order with a start date of 10/23/25 revealed enteral feed order one time a day STOP @ 1400 [2:00 PM] or when infusion is complete for a total of 880 mL/1320 kcals. Review of the November Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following documented amounts, above or below the ordered 880 mL, when the feeding was stopped at 2:00 PM:11/1/25: 938 mL11/2/25: 970 mL11/4/25: 925 mL11/8/25: 583 mL11/9/25: 583 mL11/10/25: 623 mL Review of the Nurse Practitioner Progress Note dated 11/10/25 revealed Resident was seen today for an evaluation of her blood sugars. Last week, the resident's blood sugars were in the 60s-70s. Her lantus [long-acting insulin] was reduced and it was held of Thursday. The reason for the low blood sugars is that the tube for the tube feeds was [sic] clogged and the resident was not receiving her tube feeds. Reviewed blood sugars from today and yesterday and it has been running in the high, mid to low 200s .Nurse manager did some education for nursing to properly place the tube feeds and to only set the rate per hour and not the total volume to be infused so that nursing is setting eyes on the pump to make sure that it is running .Spoke with nurse manager to place order for nursing to monitor tube feeds hourly. Plans discussed with nurse. Review of the Progress Note dated 11/12/25 at 8:22 AM revealed blood glucose 57, kangaroo pump switched. Glucose [sic] given orally. Glucagon given SQ [subcutaneous] 1 mg [milligram]. Recheck now 71 .A second Progress Note dated 11/12/25 at 8:16 PM revealed This morning glucagon 1mg IM [intramuscular] was administered a second time at 0915 [9:15 AM] . Review of the Physician Visit Note dated 11/14/25 revealed Low blood sugar: contacted on 11/12/25 regarding BS [blood sugar] 57. She received no tube feedings thru the night. Lantus 40 units given on the evening of 11/11/25. Lantus held the morning of 11/12/25. Glytose given and Glucagon 1 [mg] SQ x 2 doses. Review of the Physician's Order dated 11/13/25 revealed Total infused enteral feed to be documented every two hours. Review of the Progress Note dated 11/13/25 revealed Added documentation for accuracy of infusion. Total infused enteral feed to be documented every two hours. with a start date of 11/13/25. Review of the November and December MAR/TAR revealed the tube feeding amount infused was not consistently documented. There was documentation where the amount remained the same and where the amount decreased over time, for instance (not an all-inclusive list):On 11/17/25 at 12:01 AM, 2:00 AM, and 4:00 AM, and 6:00 AM, the amount was documented at 40 mL each time.On 11/20/25 at 6:00 AM, the amount was documented as 373 mL, at 8:00 AM the amount was documented as 805 mL, and at 10:00 AM the amount was documented as 533 mL. On 11/22/25 at 6:00 AM, the amount was documented as 521 mL, at 8:00 AM the amount was documented as 10 mL, and at 10:00 AM the amount was documented as 199 mLOn 11/29/25 at 2:00 AM, the amount is documented as 407 mL, but at 4:00 AM the amount is documented as 356 mL. On 12/1/25 at 12:01 AM, the amount was documented as 2025 mL, at 2:00 AM the amount was documented as NA (not applicable), and at 4:00 AM the amount was documented as 465 mL. Further review of the November MAR/TAR revealed 24 missing documentations for the total infused every two hours and continued documented tube feeding administrations above and below the ordered 880 mL which included the following:11/13/25: 1061 mL11/14/25: 802 mL11/15/25: 784 mL11/16/25: 798 mL11/17/25: 814 mL11/18/25: 791 mL11/19/25: 840 mL11/20/25: 781 mL11/21/25: 814 mL11/22/25 840 mL11/23/25: 781 mL11/24/25: 820 mL11/25/25: 820 mL11/26/25: 762 mL11/27/25: 798 mL11/28/25: 781 mL11/29/25: 789 mL11/30/25: 825 mL Review of R4's weights revealed the following:11/2/25 135.3 #11/12/25 130 #11/14/25 130 #11/16/25 130.8 # In a telephone interview on 12/1/25 at 2:14 PM, Licensed Practical Nurse (LPN) I reported they recently worked with a feeding tube pump that was not functioning correctly but could not recall the details. LPN I reported they have not received any education since this related to feeding tube pumps. In a telephone interview on 12/1/25 at 2:28 PM, LPN J reported one morning, R4's feeding tube pump was not functioning properly the night before and when she entered R4's room, R4's blood sugar level was 57. LPN J reported she had to give R4 glucose on her lips, tongue and cheek. LPN J stated somehow it [the pump] was still showing an amount had been infused but the infusion hadn't moved. LPN J reported she was unsure how long R4's tube feed had not been running properly. LPN J reported now they check R4's tube feeding every two hours and document how much has been administered. In an interview on 12/2/25 at 11:41 AM, Nurse Manager (NM) N reported R4's family had reported they did not think R4 was getting the correct amount of feeding. NM N reported she started checking the total administered every morning she worked. NM N reported around 7:30 AM, she expected approximately a little more than half the tube feeding bottle to be administered. NM N reported one morning she came in and found the feeding had not been infused. NM N reported the pump revealed 0mL had been infused and the pump was not alarming. NM N reported they notified R4's nurse, checked R4's blood sugar which was pretty concerning because R4's blood sugar was low, and replaced the feeding tube pump, feed bottle, and tubing. NM N reported since that incident, the nurses now check every two hours and document the total infused. NM N reported she audits the nurses' every two-hour documentation. When asked about the missing documentation of the two-hour infusion total, the same amounts documented back-to-back, and decreasing totals, NM N reported she was unaware of the reason. NM N reported R4 is ordered to receive a total of 880 mL over a 22-hour period. When asked why some of the documentations were less than 880 mL at 2:00 PM when R4's tube feeding was stopped for two hours, NM N reported staff should continue to run the tube feed until 880 mL was administered and document that the feeding was continued past the scheduled 2:00 PM shut off time. For the days with less than 880 mL documented, NM N was unable to provide any documentation that the feeding was continued until 880 mL was administered. Upon review of the MAR and TAR with NM N, NM N agreed there were days that 880 mL was not administered based on the numbers documented. In an interview on 12/2/25 at 2:42 PM, Director of Nursing (DON) B reported there was a recent issue with R4's feeding tube pump not functioning correctly. DON B reported she was unsure how long R4's feeding had not been running properly, but that it appeared to not run most of the night. DON B reported R4's tube feeding starts on day shift and ends the next day on day shift, so they implemented every two-hour check to ensure all shifts were checking that the feeding was running. DON B was unaware there was missing documentation on the two-hour checks.

This citation pertains to intake MI00152944. Based on observations, interviews, record reviews, and 7 (R1, R14, R27, R29, R34, R46, R67) reviewed for untimely meal delivery service, the facility failed to provide sufficient dietary staff to ensure a timely meal service affecting 103 residents who consume food products, resulting in the increased likelihood for delayed meal tray service and resident emotional/physical discomfort. Findings include: On 05/14/25 at 09:25 A.M., An interview was conducted with Director of Food and Beverage (DFB) M regarding daily mealtime service parameters. (DFB) M stated: We serve Breakfast from 7:30 AM to 8:30 AM, Lunch from 12:00 PM to 1:30 PM, and Dinner from 5:30 PM to 6:30 PM every day. On 05/14/25 at 09:30 A.M., An interview was conducted with (DFB) M regarding resident food product meal options. (DFB) M stated: We provide a main menu option, alternate menu option, and an always available menu option for each meal. On 05/14/25 at 10:05 A.M., An interview was conducted with (DFB) M regarding current dietary staffing levels. (DFB) M stated: The full and part time employee totals should be 75. (DFB) M also stated: The full and part time employee total currently is 63. (DFB) M additionally stated: The plan for staffing replacement is underway. (DFB) M further stated: I have six interviews today. (DFB) M also stated: I have three new employees for orientation tomorrow. (DFB) M additionally stated: We are looking for servers, specifically PM servers. (DFB) M further stated: Weekends are staffed about the same as Monday thru Friday. On 05/14/25 at 11:55 A.M., An interview was conducted with Dietary [NAME] (DC) N regarding the Centers for Health and Rehabilitation (CHR) 3rd Floor Satellite Kitchenette operation. (DC) N stated: The 3rd floor kitchen is closed due to staffing. (DC) N also stated: We are having trouble with servers. (DC) N additionally stated: We are currently serving 3rd floor from the 2nd floor kitchen. On 05/14/25 at 03:58 P.M., An interview was conducted with (DFB) M regarding how dietary staffing levels are determined. (DFB) M stated: Staff are either full, part-time, or contingent. (DFB) M also stated: Contingent staff select their individual schedule based upon open areas within the schedule. (DFB) M further stated: Contingent staff must work a minimum of shifts throughout the month, including weekends. On 05/15/25 at 08:15 A.M., Record review of the Policy/Procedure entitled: Food and Nutrition Services dated (no date) revealed under Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Record review of the Policy/Procedure entitled: Food and Nutrition Services dated (no date) further revealed under Policy Interpretation and Implementation: (5) The food and nutrition staff will be available and adequately staffed to assist residents with eating as needed. Nurse aides and feeding assistants will provide support to enhance the resident experience, but not as a critical component to the functioning of the department. On 05/15/25 at 08:30 A.M., Record review of the Policy/Procedure entitled: Staffing Patterns dated (no date) revealed under Standards: Proper staffing levels should be set to ensure adequate levels of food production and service staff. Record review of the Policy/Procedure entitled: Staffing Patterns dated (no date) further revealed under Purpose: Proper staffing levels will enable the department to provide all the services required by the residents and their guests. 38383 Resident #R27: Review of the medical record reflected R27 admitted to the facility on [DATE] and readmitted [DATE]. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/25/25, reflected R27 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 05/13/25 at 11:52 AM, R27 was observed seated in a wheelchair, in their room. R27 reported their breakfast was one hour late that morning, and their dinner was two hours late the prior Saturday (5/10/25). R27 reported they had heard reports from staff of the kitchen being short-staffed. R27 reported breakfast was supposed to be served at 8 AM, and dinner was supposed to be served at 5:00 PM. During a dining observation of the third floor dining room, which began on 05/13/25 at 12:02 PM, one staff member was observed to serve trays to three residents. At 12:07 PM, there were 13 residents seated in the dining room, with three of those residents having received their trays. One of the three residents was receiving feeding assistance from a visitor, one was receiving feeding assistance from a staff member, and one was eating independently. Staff were observed in the hallway, serving room trays. At 12:08 PM, a fourth tray was delivered to the dining room. At 12:14 PM, R1 began yelling due to not having their tray yet, despite other residents at their table having already received their meals. R1's tray was delivered at 12:15 PM. R29's tray arrived at 12:15 PM. R67's tray arrived at 12:17 PM, after they had been watching other resident's, seated at the same table, eating. At 12:17 PM, 13 residents were seated in the dining room, and eight of those residents had received a meal tray. At 12:26 PM, R14 and R34 had not yet received their lunch trays, although the other residents seated at their tables had received their meals. R14 was notified by staff that their grilled cheese was still being made. At 12:30 PM, R14 was observed to have a tray with a grilled cheese sandwich. At 12:31 PM, a staff member notified R34 that they were going to check on their food and thanked them for their patience. At 12:32 PM, R34's tray was delivered to the table. Resident #R46: Review of the medical record reflected R46 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included heart failure. The Quarterly MDS, with an ARD of 2/24/25, reflected R46 scored 15 out of 15 (cognitively intact) on the BIMS. On 05/13/25 at 1:04 PM, R46 was observed lying in bed. According to R46, a couple days prior, the food was not ready (on time). R46 believed it was at the dinner meal but was unable to recall which particular day. Resident #R29: Review of the medical record reflected R29 admitted to the facility on [DATE], with diagnoses that included heart failure. The Quarterly MDS, with an ARD of 3/17/25, reflected R29 scored 14 out of 15 (cognitively intact) on the BIMS. On 05/14/25 at 9:58 AM, R29 was observed seated in their wheelchair. They reported the prior Friday night (5/9/25), they were sent to the dining room at 5:00 PM and remained there until 6:00 PM. R29 reported asking the nurse where their food was, and at 8:30 PM, staff brought a ham sandwich to their room. During an interview on 05/15/25 at 10:08 AM, with Community Dining Manager (CDM) X and Assistant Dietary Manger (ADM) Y, it was reported that there had been a kitchen staffing shortage, and third floor meals were coming from the second floor. It was reported that all meals came from the first floor on Saturday (5/10/25), and residents on the third floor had received their dinner meals by 7:45 PM to 7:50 PM that day. It was reported that the expectation for serving meal trays was that all residents seated at the same table should have been served together or close to the same time.

Based on observations, interviews, record reviews, and 1(R307) of 1 reviewed for food product temperatures, the facility failed to provide palatable food products affecting 103 residents who consume food products, resulting in the increased likelihood for decreased resident food acceptance and clinical nutritional decline. Findings include: On 05/14/25 at 09:25 A.M., An interview was conducted with Director of Food and Beverage (DFB) M regarding specific mealtime parameters. (DFB) M stated: We serve Breakfast from 7:30 AM to 8:30 AM, Lunch from 12:00 PM to 1:30 PM, and Dinner from 5:30 PM to 6:30 PM. On 05/14/25 at 12:48 P.M., Resident lunch meal food trays were observed leaving the Centers for Health and Rehabilitation (CHR) 1st Floor Satellite Kitchenette, within a Rubbermaid 4-tier plastic resin non-insulated transport cart. On 05/14/25 at 12:50 P.M., Resident lunch meal food trays were observed arriving to B-Hall, within a Rubbermaid 4-tier plastic resin non-insulated transport cart. On 05/14/25 at 12:52 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for R307's lunch meal food tray: Pork Loin - 121.9 degrees Fahrenheit* Fried [NAME] - 113.2 degrees Fahrenheit* Snap Peas - 116.4 degrees Fahrenheit* Egg Roll - 121.8 degrees Fahrenheit* Beverage (Water) - 42.1 degrees Fahrenheit* Mocha Blend Brownie - Room Temperature (*) The 2022 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 C (41 F) or less. On 05/15/25 at 07:45 A.M., Record review of the Policy/Procedure entitled: Tray Service dated (no date) revealed under Purpose: The purpose of this policy is to ensure that the quality of takeout meals received by a resident, or a guest meets high quality standards that mirror the food quality of meals served in the main dining room. Record review of the Policy/Procedure entitled: Tray Service dated (no date) further revealed under Guidelines: (1) The Food & Beverage Director will develop a system for taking room service orders. This system will include who will be assigned to take the orders, the times that orders will be taken, and the time meals will be delivered. On 05/15/25 at 08:00 A.M., Record review of the Policy/Procedure entitled: Food and Nutrition Services dated (no date) revealed under Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Record review of the Policy/Procedure entitled: Food and Nutrition Services dated (no date) further revealed under Policy Interpretation and Implementation: (7) Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. (a) If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. (b) Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded.

Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively date mark all potentially hazardous ready-to-eat food products affecting 103 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 05/14/25 at 09:10 A.M., A comprehensive tour of the food service was conducted with Director of Food and Beverage (DFB) M. The following items were noted: On 05/14/25 at 09:25 A.M., An interview was conducted with (DFB) M regarding specific mealtime parameters. (DFB) M stated: We serve Breakfast from 7:30 AM to 8:30 AM, Lunch from 12:00 PM to 1:30 PM, and Dinner from 5:30 PM to 6:30 PM. On 05/14/25 at 09:30 A.M., An interview was conducted with (DFB) M regarding resident food product meal options. (DFB) M stated: We provide a main menu option, alternate menu option, and an always available menu option for each meal. On 05/14/25 at 09:45 A.M., An interview was conducted with (DFB) M regarding facility satellite kitchenettes. (DFB) M stated: The Centers for Health and Rehabilitation (CHR) has three satellite kitchenettes. (CHR1) Satellite Kitchenette Two unopened half-gallon containers of Prairie Farms fat free milk were observed in the Victory 2-door reach-in cooler with a manufacturer's use-by-date that read 4-27-25. On 05/14/25 at 09:55 A.M., An interview was conducted with (DFB) M regarding potentially hazardous ready-to-eat food date marking practices. (DFB) M stated: We use day of plus 6 for a total of 7 days not to exceed the manufacture's use-by-date. The 2022 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (CHR3) Satellite Kitchenette The Scotsman ice machine ice dispensing spout was observed with accumulated and encrusted mineral (lime and calcium) deposits. The Bunn coffee machine (dispensing spouts, undersplash, backsplash, drip tray assembly) was observed soiled with accumulated and encrusted food residue. (DFB) M was queried regarding how often the coffee machine was cleaned. (DFB) M stated: Daily. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 05/15/25 at 09:00 A.M., Record review of the Policy/Procedure entitled: Cleaning Kitchenettes in Health Center dated 06/20/2001 revealed under Policy: Kitchenette cupboards, drawers, refrigerators, and other equipment will be cleaned on a regular basis, by Nursing and Hospitality Services staff. Record review of the Policy/Procedure entitled: Cleaning Kitchenettes in Health Center dated 06/20/2001 further revealed under Procedure: Hospitality Services/Kitchen Staff Responsibilities: Clean/Sanitize: (6) Juice/Cocoa/Coffee Makers, (7) Ice Machines. On 05/15/25 at 09:15 A.M., Record review of the Policy/Procedure entitled: Perishables Storage dated (no date) revealed under Standard: Perishables will be stored in a safe manner that retains maximum nutrient quantity, product freshness, and aesthetic quality. Record review of the Policy/Procedure entitled: Perishables Storage dated (no date) also revealed under Purpose: To ensure compliance with HAACP, maintain nutrient content, maintain aesthetic quality, and ensure food safety of all perishable food items through proper storage and labeling. Record review of the Policy/Procedure entitled: Perishables Storage dated (no date) further revealed under Procedure: (1) All perishables will be labeled with item name, employee initials, date and time of preparation, and USE BY date. The USE BY date for perishable items is today's date plus six days or less.

Based on observations, interviews, and record reviews, the facility failed to: (1) maintain 2 of 5 outdoor waste receptacles, and (2) effectively clean the waste receptacle concrete pad surface effecting 105 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and pest attraction/harborage. Findings include: On 05/14/25 at 10:00 A.M., An environmental tour of the facility outdoor waste receptacles and storage pad area was conducted with Director of Food and Beverage (DFB) M. The following items were noted: 2 of 5 waste receptacles were observed with 1 of 2 broken plastic lids. (DFB) M stated: I will submit a work order into the maintenance software system. 1 of 5 waste receptacles were observed with 1 of 2 broken plastic slider panels. (DFB) M stated: I will submit a work order into the maintenance software system. Miscellaneous items (wooden pallet, vinyl gloves, paper products, etc.) were observed resting on the concrete pad surface, adjacent to the five outdoor waste receptacles. On 05/15/25 at 08:45 A.M., Record review of the Policy/Procedure entitled: Garbage and Trash Cans dated (no date) revealed under Procedure: (I) Operation of Equipment: (5) The dumpster area must be free of debris on the ground and the lid must be closed.

This citation pertains to intake MI00151684. Based on interview and record review, the facility failed to ensure sufficient nursing staffing to meet resident needs timely for three (R29, R46 and R61), from a census of 105 residents. Findings include: Resident #R29: Review of the medical record reflected R29 admitted to the facility on [DATE], with diagnoses that included heart failure. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/17/25, reflected R29 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 05/14/25 at 9:58 AM, R29 was observed seated in a wheelchair, in their room. R29 stated the facility did not have enough help, and it was difficult to get assistance to the dining room due to needing assistance to propel their wheelchair. R29 reported using their call light for assistance to the bathroom and waiting approximately five to six minutes before going to the bathroom independently. R29 reported they then waited approximately ten additional minutes for assistance with their bathroom call light on when finished. Resident #R46: Review of the medical record reflected R46 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included heart failure. The Quarterly MDS, with an ARD of 2/24/25, reflected R46 scored 15 out of 15 (cognitively intact) on the BIMS. On 05/13/25 at 1:04 PM, R46 was observed lying in bed. R46 reported the facility was understaffed. At least once per day, they waited for an hour and a half for their call light to be answered after bowel incontinence, due to staff providing feeding assistance or performing other tasks. Resident #R61: Review of the medical record reflected R61 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included heart failure. The Quarterly MDS, with an ARD of 2/24/25, reflected R61 scored nine out of 15 (moderate cognitive impairment) on the BIMS. On 05/13/25 at 12:55 PM, R61 was observed lying in bed. They reported assistance on midnight shift was sometimes non-existent. Call light response time ranged from almost spontaneous to three hours. R61 reported delayed response times occurred more in the evening. During a phone interview on 05/14/25 at 3:38 PM, Certified Nurse Aide (CNA) U reported the second floor of the facility had approximately 34 residents and was usually staffed with two nurses and two CNAs on the 11:00 PM to 7:00 AM shift. The expectation was that nurses helped with resident care, but agency staff nurses did not help the CNAs. CNA U indicated if nurses helped, they were able to keep up with resident care needs. CNA U reported they were able to provide quality care when staffed with three CNAs at night. According to CNA U, the second floor of the facility had residents that exhibited behaviors and were at risk for falls. CNA U reported that about a month and a half prior, they worked the second floor as the only CNA with one nurse due to additional staff being pulled to the first floor of the facility. During a phone interview on 05/14/25 at 3:54 PM, CNA K reported the second floor of the facility typically had 34 residents. They reported there had been times when the second floor had one CNA for third shift. On Easter (4/20/25), the second floor was staffed with two CNAs on first and second shifts. CNA K reported there were too many residents to care for and many that required assistance to consume meals. CNA K stated staff also had to assist the kitchen with serving food. On 05/14/25 email requests were sent to Nursing Home Administrator (NHA) A for actual working schedules for CNAs and Nurses for the dates of 3/16/25 through 3/30/25, 4/19/25 through 4/21/25 and 5/1/25 through 5/14/25. Review of nursing staffing schedules included but was not limited to the following pertaining to staffing: -The second floor of the facility was staffed with two CNAs from 7:00 AM to 3:00 PM on 3/22/25. -On 3/25/25, the second floor of the facility was staffed with two CNAs for the 3:00 PM to 11:00 PM shift and one CNA from 11:00 PM on 3/25/25 to 7:00 AM on 3/26/25. -On 3/26/25 and 3/27/25, the second floor was staffed with two CNAs on the 3:00 PM to 11:00 PM shift. -The third floor of the facility was staffed with one CNA from 11:00 PM on 3/27/25 to 7:00 AM on 3/28/25. -The second floor of the facility was staffed with one CNA from 11:00 PM on 3/29/25 to 7:00 AM on 3/30/25 and from 11:00 PM on 3/30/25 to 7:00 AM on 3/31/25. -On 4/20/25, the second floor was staffed with two CNAs from 7:00 AM to 11:00 PM. -The second floor of the facility was staffed with one CNA from 11:00 PM on 4/20/25 to 7:00 AM on 4/21/25. -The second floor of the facility was staffed with one CNA from 11:00 PM on 5/3/25 to 7:00 AM on 5/4/25. -The second floor was staffed with one CNA from 11:00 PM on 5/9/25 to 7:00 AM on 5/10/25. In an interview on 05/15/25 at 9:45 AM, Staffing Coordinator (SC) W reported schedules were based on occupancy (census) and acuity. According to SC W, with 32 or more residents, it was ideal to staff the second and third floors of the facility with four CNAs on first shift (7:00 AM to 3:00 PM) and second shift (3:00 PM to 11:00 PM), but they could staff with three CNAs. The second and third floors were to be staffed with two CNAs on third shift (11:00 PM to 7:00 AM). 46954 During an interview conducted on 5/15/24 at 11:31 AM, Certified Nursing Assistant (CNA) EE indicated that staffing levels remain inadequate, particularly on weekends. CNA EE described multiple shifts where only two CNAs are assigned to the entire unit. Compounding the issue, CNAs have also been tasked with meal service due to ongoing dietary staff shortages. As a result, CNA EE reported that it is not feasible to deliver care in alignment with residents' care plans. In an interview on 5/15/24 at 11:40 AM, CNA I confirmed the pattern of working weekend shifts with just two CNAs. CNA I stated that the lack of staffing has made it unmanageable to meet residents' care plan requirements. Critical care activities, including turning and repositioning residents, as well as performing daily hygiene routines, are reportedly not being completed due to insufficient staffing.

This Citation Pertains To Intake MI00152786 Based on interview and record review the facility failed to immediately report abuse allegations to the Nursing Home Administrator for one allegation of a resident to resident altercation (Residents #63 and #88) of one abuse allegation reviewed. Findings include: Resident #R63 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed R63 was scored 14 out of 15 (cognitively intact) of on the Brief Interview for Mental Status. Resident #R88 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected R88 had intact long and short term memory. A BIMS score was not obtained for R88. Upon an interview with Social Worker CC on 5/15/25 at 1:00 PM she reported a BIMS was not obtained due to R88 being on frequent leave of absences but in her opinion R88 was alert and oriented to person, place and time. Review of the Facility Reported Incident (FRI) dated 5/05/25, revealed Licensed Practical Nurse (LPN) C received a telephone call on 5/4/25 from R63's family member alleging R63 had just been physically assaulted. On 05/14/25 01:49 PM during an interview with LPN C she reported she was assigned to both R63 and R88 on 5/4/25. LPN C reported R63 had been yelling out at about 4:30 PM, R63 wanted someone to go to the lobby and get his door dash order. LPN C stated she observed R88 in R63's doorway and overheard R88 tell R63 to stop yelling and then slammed R63's door shut. (R88 lived across the hall from R63 at the time of the incident.) LPN C stated on 5/4/25 at approximately 4:30 PM she received a phone call from R63's friend. The friend reported she overheard R63 being assaulted during her daily phone call with R63. LPN C stated she observed R63 and he did not have any red marks bruises and did not verbalize any alleged abuse to her. LPN C stated a few hours later the police arrived (police were called by R63's family). LPN C stated at that time R63 reported R88 struck him in the head. When queried why the Nursing Home Administrator (NHA) A or Director of Nursing (DON) B were not notified of the allegation of 5/4/25, LPN C stated because R63 seemed fine and she didn't think anything really happened. On 05/15/25 12:45 PM during an interview with NHA A who also serves as the facility's abuse prevention coordinator, she reported the expectation was to be notified of any abuse allegation immediately. When queried how she was made aware of the allegation she stated she was made aware by the DON B who attended a care conference with R63 and his family on 5/5/25 which was when the investigation was started.

Based on interview and record review, the facility failed to transmit Minimum Data Set (MDS) assessment timely in one of 21 reviewed for MDS assessments (Resident #95). Findings include: Review of the clinical record revealed R95 was admitted to the facility on [DATE] with diagnoses that includes kidney failure and diabetes. R95 was transferred to the hospital on 3/15/24. Further of R 95's clinical record reflected no discharge MDS had been completed or transmitted. On 05/15/25 at 12:03 PM, MDS Coordinators D and E were interviewed. MDS Coordinator E reported that MDS Nurse F was not working today but responsible for all discharge MDS's and their submissions. MDS Coordinator E stated he too tracked the discharge MDS's and it should have been completed and transmitted within 14 days of R95's discharge. MDS Coordinator E stated R95's discharge MDS was overlooked.

Based on interview and record review, the facility failed to ensure the accuracy of one discharge Minimum Data Set (MDS) assessment for one resident (resident #103) of three reviewed for discharge. Findings include: According to the clinical record, R103 was admitted to the facility on [DATE]. Nursing progress notes dated [DATE] reflected R103 was found unresponsive and transferred to the hospital. Review of the discharge MDS dated [DATE], question A2105 was coded that R103 went home. On [DATE] at 12:03 PM, MDS Coordinators D and E were interviewed. MDS Coordinator E reported that MDS Nurse F was not working today but responsible for all discharge MDS's . MDS Coordinator D reported she was certain R103 was sent to the hospital and later died and was not discharged home. MDS Coordinator D reported question A2105 should have been coded as a 4 which was acute care hospital.

Based on observation, interview and record review, the facility failed to provide showers/baths for one (Resident 50) of two residents reviewed for activities of daily living. Findings include: A review of the clinical record revealed R50 was admitted into the facility on [DATE], with diagnoses that included: depression, seizure disorder, fracture and required one person assistance for bathing. On 5/14/25 at 8:36 AM, R50 was observed sitting up at the edge of her bed. Her hair was observed to be greasy and unkempt. R50 reported that she had only received one shower since being admitted to the facility. R50 reported that she required assistance with showers and that her hair feels greasy (which she did not like). A review of R50's Task record for showers/Baths revealed no documentation indicating that the resident had received any showers since her admission. The only documented responses in the Task record were not applicable. On 5/15/25 at 10:51 AM, during an interview with Director of Nursing (DON), she reported that showers should be offered twice per week, when she first started at the facility, they were only offering them once per week, floors 2 and 3 have transitioned to twice weekly and the first floor is in the process of being transitioned to twice weekly showers. DON reported that if a resident refuses a shower, it should be documented in the electronic health record and that if a resident refuses a shower they should receive a full bed bath. When notified that R50 reported only having one shower since her admission to the facility, DON reported that R50 tell staff she wasn't getting her showers. R50 reported that staff was aware that her showers had not been completed. Reviewed R50's Task record with DON, no showers documented, only not applicable was marked. DON reported that there was a different screen (Task Care Record) that looked like they were being documented as completed. DON was asked to provide that documentation if applicable, no additional documentation was provided prior to survey end. A review of the facilities policy titled Activities of Daily living (ADL's), documented in part Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with .hygiene (bathing, dressing, grooming and oral care) .

Based on observation, interview, and record review, the facility failed to ensure wound treatments were in place as ordered for one resident (Resident 60) and failed to administer medication as ordered for one resident (Resident 305) of 21 residents reviewed for quality of care. Findings include: Resident #R305 A review of the clinical record revealed R305 was admitted into the facility on [DATE], with diagnoses that included: Type 2 Diabetes Mellitus with diabetic neuropathy, major depressive disorder and anxiety disorder. On 5/13/25 at 1:17PM, R305 was observed sitting in her manual wheelchair in her room. R305 reported that the facility had not been consistently administering her weekly diabetes medication, Mounjaro. R305 reported concern related to potential diabetes related complications due to not receiving her Mounjaro regularly. A review of physician's orders for R305 revealed: 4/5/25 Mounjaro Subcutaneous Solution 5mg/0.5ML, inject subcutaneously (under the skin) one time a day, every Saturday for DM (diabetes mellitus) A review of R305's April 2025 Medication Administration Record (MAR) revealed Mounjaro was scheduled to be given every Saturday and on dates 4/12/25 and 4/19/25 doses were not administered as ordered. Associated progress notes read as follows: 4/12/25 Medication is unavailable at the facility. It is not in the refrigerators or in the StatSafe 4/19/25 out of med. And reordered A review of R305's May 2025 MAR revealed the medication was scheduled to be given every Saturday and on 5/10/25 a dose was not administered. Associated progress note read as follows: 5/10/25 not available in the facility, onecare (facility pharmacy provider) was called by nurse, onecare said they will email DON (Director of Nursing) to get approval. Patient is aware of it. It should be noted that of the 6 doses R305 was scheduled to receive while being admitted to the facility, she only received 3. It should also be noted that there was no documentation that the facility physician was notified of any of the 3 missing doses. A review of the progress notes indicated that on 4/12/25 the progress note related to the missing dose, was written by LPN FF. On 5/15/25 at 12:57 PM, during an interview with LPN FF, when asked what she could tell me about the missing dose, reported that she believed that they did not have the medication in the facility. When asked what the expectation is when a medication is not available, LPN FF reported that they are expected to reach out to the doctor and the pharmacy. It should be noted that LPN FFs progress note did not indicate she called either the pharmacy or the physician. On 5/15/25 at 1PM, during an interview with DON, when asked what the expectation is for follow-up and documentation when a medication is not available to be administered as ordered, she stated that the staff should contact the pharmacy to see if it is something that can be pulled from the backup supply or if the pharmacy can get it delivered. DON reported that the pharmacy makes multiple deliveries per day. DON further reported that attempts to contact the pharmacy should be documented in the electronic health record. When asked if medication administration is audited, DON reported that the unit managers should be auditing medication administration five days per week. A review of the facilities policy titled Medication Administration, documented in part If a medication is not available to be administered, the nurse will contact the pharmacy for clarification and the physician/nurse practitioner will be notified as necessary. 38383 Resident #R60: Review of the medical record reflected R60 admitted to the facility on [DATE], with diagnoses that included dementia, peritoneal abscess, cutaneous abscess of abdominal wall, major depressive disorder and bipolar disorder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/17/25, reflected R60 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for open lesion(s) other than ulcers, rashes or cuts. On 05/13/25 at 11:46 AM, R60 was observed in bed. They reported having a wound on the lower left side of their abdomen, which was supposed to have a dressing change every three hours, per their report. R60 reported the dressing was not always being changed as it should be, and they would miss one of the dressing changes. The May 2025 Treatment Administration Record (TAR) reflected an order with a start date of 5/2/25 at 10:00 PM and a discontinue date of 5/8/25 at 1:51 PM for, Alternate dressing: abdominal draining tract: NS [normal saline] cleanse, pat dry, skin protectant to periwound [around wound], Aquacel under superabsorbent dressing (bordered or tape in place). Abdominal binder for added dressing securement, as tolerated. every 8 hours. The treatment was scheduled for 6:00 AM, 2:00 PM and 10:00 PM. The treatment was not documented as being completed for the 10:00 PM scheduled time on 5/2/25, 5/3/25, 5/4/25 and 5/6/25. There was no documentation pertaining to the reason for the treatment not being completed. The May 2025 TAR reflected an order with a start date of 5/8/25 at 2:00 PM for, Abdominal draining tract: NS cleanse, pat dry, skin protectant to periwound, Aquacel under superabsorbent dressing (bordered or tape in place). Abdominal binder for added dressing securement, as tolerated. every 8 hours. The treatment was scheduled for 6:00 AM, 2:00 PM and 10:00 PM. The treatment was not documented as being performed on 5/13/25 at 2:00 PM and 10:00 PM. There was no documentation pertaining to the reason for the treatment not being completed. Attempts to contact night shift Registered Nurse (RN) Z and night shift RN AA via phone during the survey were unsuccessful. During an interview on 05/15/25 at 9:17 AM, Director of Nursing (DON) B reported R60's wound was a fistula with copious amounts of drainage that made R60 uncomfortable and self-conscious. DON B stated she did not see documentation pertaining to the rationale for R60's treatments not being completed as ordered.

Based on observation, interview and record review, the facility failed to ensure medications were safely stored and administered for one (R7) of one reviewed. Findings include: Review of the medical record reflected R7 admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/7/25, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 05/14/25 at 9:22 AM, R7 was observed seated in a wheelchair, in their room. A medication cup containing six pills was observed on the stand, under their TV. On 05/14/25 at 9:24 AM, Registered Nurse (RN) R was at the medication cart, in the hallway, and reported the pills in R7's room were from that morning. RN R stated R7 had an order not to hover over him while he took his pills. R7's medical record reflected an order dated 9/23/16 for, Resident prefer [sic] that nursing do not stand over him while taking medication, may observe resident from a visual distance to ensure all medication has been taken. The May 2025 Medication Administration Record (MAR) reflected R7's morning medications included 81 milligrams (mg) of chewable Aspirin, 100 mg of Colace (stool softener), 10 mg of lisinopril (for high blood pressure), 500 mg of extended release metformin (for diabetes), Thera-M (multi-vitamin) and 5 mg of Eliquis (blood thinner). In an interview on 05/15/25 at 9:17 AM, Director of Nursing (DON) B reported unless a resident was assessed to self-administer medications and had an order from the Physician, the nurse should observe residents taking their medications. DON B reported approval was not granted for R7 to self-administer medications, which was the reason there was an order that R7 preferred that nurses did not stand over him.

Based on interview and record review, the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention and control. Findings include: On 5/14/25 at 2:47 PM, Registered Nurse (RN) DD reported that she was the facilities Infection Preventionist. RN DD stated that she could not locate her training certificate for her Infection Preventionist role. On 5/15/25 at 12:32 PM, RN DD reported that she had recently began retaking the course, however, was not completed with the training. On 05/15/25 at 1:21 PM, Director of Nursing (DON) B reported that the facility was unable to locate the certificate of completion for RN DD and the program was not overseen by any other employee.

This citation pertains to Intake Number MI00151168. Based on observation, interview, and record review, the facility failed to treat one resident (Resident #3) with dignity and respect out of three residents reviewed. Findings include: Review of the medical record revealed R3 was admitted to the facility on [DATE] with diagnoses that included: traumatic subdural hemorrhage with loss of consciousness and muscle weakness. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/25 revealed R3 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and required substantial/maximal assistance with lower body dressing. On 3/17/25 at 9:28 AM, during a telephone interview with Family member D they reported that on 2/28/25 RN A sent R3 to an outside appointment without any pants, hat or coat on. When Family member D met R3 at his appointment his lap was covered with only a sheet and on the bottom of his torso he was only wearing a brief. On 3/18/25 at 8:02 AM, R3 was observed sitting up in a recliner. When queried about his outside appointment on 2/28/25, he confirmed that he was sent out without any pants, coat or hat on. He further stated that RN A was more concerned about getting him to the transportation provider than his wellbeing and that nobody would go outside without pants, hat and a coat themselves. On 3/18/25 at 11:55 AM, R3 was observed sitting up in a recliner with Family member D also present. When asked how he felt the day he was sent out to his appointment without pants/hat and coat, he replied he felt cold and humiliated. R3 stated that the only way he could have felt more humiliated was if they had dressed him in a pink dress. Family member D stated and R3 confirmed that his coat/hat were set out on the love seat (oversized chair) that is positioned next to the recliner. They both reported the coat and hat were easily visible and not buried under anything. Family member D reported that a pair of clean pants was also with his coat/hat. Family member D reported that the resident had 3 pairs of pants with him at the facility. The coat was observed to be a men's, size large, charcoal colored winter coat and the hat was observed to be a charcoal colored, herringbone pattern, stocking style hat. On 3/18/25 at approximately 4:20 PM, RN A was interviewed regarding R3 being sent to an outside appointment not being properly dressed. RN A stated that she remembered this event because R3's wife was upset. RN A reported that she changed R3 twice due to incontinence of urine and that he did not have any additional clean/dry pants. RN A reported that she felt rushed because the transportation driver was already there and she did not want R3 to miss his appointment. RN A felt her only option was to wrap him in a blanket. She was unable to recall if the linen that was used was a blanket or a sheet. She admitted that it was not ideal and that it could be humiliating but her focus was on him not missing his appointment. RN A reported looking in the resident's closet and drawers for pants and stated that she did not see his coat/hat or any clean/dry pants. On 3/19/25 at 10:22 AM, Laundry Team Lead E, stated that the facility does keep clothes for residents to keep or borrow in cases of emergency's or when they are in need. A hanging rack with several articles of clothing was observed. Laundry Team Lead E, reported that they are always able to find requested items in an emergency. On 3/19/25 at 12:18 PM, Director of Nursing (DON) was interviewed regarding R3 being sent to an outside appointment without being properly dressed. DON reported that she had discussed the incident with RN A, who had reported that the resident did not have any clean/dry clothes available. DON reported that she had let RN A know that this could be considered a dignity issue and education was provided on reaching out to laundry to find proper attire for resident prior to sending them out for an appointment. DON added that R3's family member was asked to bring in additional clothes. A review of the CHR Concern Form dated 2/28/25 revealed in part Concern: res (resident) was sent to doc. apt (doctors appointment) without pants, after urinating on pants (no other clothing available). According to the website Weather Underground (wunderground.com) the temperature outside on 2/28/25 (the date of R3's outside appointment) was 39 degrees Fahrenheit at 11:53 AM and 44 degrees at 12:53 PM. R3's appointment time was 12pm. It should be noted that R3 is bald. Review of the facilities policy titled Resident right and responsibilities updated 10/19/23, documented in part The Resident has the right to be treated with dignity and the right to courteous, respectful and considerate treatment from all with who he/she comes in contact .The Resident has the right to privacy, to the extent feasible, in treatment and in caring for personal needs with consideration, respect and full recognition of his/her dignity and individuality .

This citation pertains to intake MI00149664. Based on interview and record review, the facility failed to 1) assess and monitor respiratory status for one (Resident #3); and 2) administer respiratory medications as ordered for one (Resident #6) of six reviewed. Findings include: Resident #3 (R3): Review of the medical record reflected R3 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and dependence on supplemental oxygen. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R3 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R3 died in the facility on [DATE]. A Physician's Order, with a start date of [DATE], reflected R3 was to receive oxygen, titrated at a rate of two to five liters per minute, to maintain blood oxygen saturation levels between 88 and 92 percent (%). A Progress Note for [DATE] at 4:45 AM reflected R3's oxygen saturation was 73%, and new oxygen tubing and a new nebulizer kit were provided. R3's vitals signs documentation reflected their oxygen saturation was 83% while receiving oxygen at four liters per minute on [DATE] at 4:45 AM. According to the medical record, there was no follow-up for R3's oxygen saturation levels until [DATE] at 7:38 AM, when it was recorded as 89% while receiving oxygen. Review of the [DATE] Medication Administration Record (MAR) reflected R3 had an order for Ipratropium-Albuterol Inhalation Solution (respiratory medication) 0XXX,d+[DATE].5 (3) milligrams (mg) per 3 milliliters (mL) to be inhaled orally, via nebulizer, every two hours as needed for COPD. The MAR reflected that lung sounds were to be auscultated (listened to/assessed) before treatment, indicated as LSB, and after treatment, indicated as LSA. The nebulizer was administered 57 times during the month of December. Documentation reflected that R3's lung sounds were assessed 17 out of 57 times that the medication was administered. The [DATE] MAR reflected R3's Ipratropium-Albuterol Inhalation Solution every two hours as needed was administered nine times between [DATE] and [DATE]. Lung sounds were not documented as being assessed before or after administration for any of nine the doses. R3's medical record reflected their blood oxygen saturation level was 86% while receiving oxygen, on [DATE] at 7:40 AM. The [DATE] MAR reflected R3 received an as needed Ipratropium-Albuterol Inhalation Solution nebulizer at 8:20 AM, with a recorded blood oxygen saturation level of 86%. The medical record did not reflect that R3's blood oxygen saturation level had increased to 88% to 92%, per their orders, and did not reflect further follow-up until [DATE] at 3:02 PM. On [DATE] at 3:02 PM, R3's blood oxygen saturation level was 80% on room air (without the use of oxygen). On [DATE] at 3:08 PM, R3's blood oxygen saturation level was 82% with oxygen in place. The [DATE] MAR reflected an as needed Ipratropium-Albuterol Inhalation Solution nebulizer was administered on [DATE] at 3:02 PM, with a recorded oxygen saturation level of 80%. The medical record did not reflect that R3's blood oxygen saturation level had increased to 88% to 92%, per their orders, and did not reflect further follow-up until [DATE] at 8:43 PM, when their blood oxygen level was 90% with oxygen in place. On [DATE] at 2:13 PM, R3's blood oxygen saturation level was 86% while receiving oxygen. The [DATE] MAR reflected an as needed Ipratropium-Albuterol Inhalation Solution nebulizer treatment was administered. The medical record did not reflect that R3's blood oxygen saturation level had increased to 88% to 92%, per their orders, and did not reflect further follow-up until [DATE] at 7:27 PM, when their blood oxygen saturation was 88% with oxygen in place. According to the [DATE] MAR, R3 received as needed Ipratropium-Albuterol Inhalation Solution nebulizer treatments on [DATE] at 7:38 AM and 2:10 PM. A Progress Note for [DATE] at 3:43 PM reflected R3 was observed removing their nebulizer right after it was provided, stating they could not breathe and needed another breathing treatment. In an interview on [DATE] at 10:26 AM, Licensed Practical Nurse (LPN) G reported they were unaware of what LSA and LSB meant pertaining to R3's as needed Ipratropium-Albuterol nebulizer order documentation. LPN G reported they did not always remain with R3 when administering their nebulizer treatments. LPN G stated they went back after the nebulizer treatments were complete and disassembled the nebulizer kit. LPN G reported they did not remain with R3 when administering their as needed nebulizer treatment in the morning on [DATE] or in the afternoon of [DATE], despite being aware that R3 removed their nebulizer mask at times, including that day. In an interview on [DATE] at 12:49 PM, Director of Nursing (DON) B indicated that lung sounds should have been assessed with administration of R3's as needed nebulizer treatments. DON B reported nurses should have remained with R3 when their nebulizer treatments were being administered. DON B reported LSB stood for lung sounds before, and LSA stood for lung sounds after (administration of R3's as needed nebulizer treatment). DON B reported R3 removed their oxygen at times. Regarding the expectation for monitoring and follow-up of blood oxygen saturation levels, DON B reported they would expect the nurses to assess first. If the resident had their oxygen off, they could replace the oxygen and recheck the resident in a few minutes. If they had their oxygen in place but continued to have lower blood oxygen saturation levels, DON B stated the expectation was that the nurse would call the physician. Resident #6 (R6): Review of the medical record reflected R6 admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure with hypoxia, influenza due to identified novel influenza A virus with pneumonia and asthma. The 5-day Medicare MDS, with an ARD of [DATE] reflected R6 scored 15 out of 15 (cognitively intact) on the BIMS. R6 died in the facility on [DATE]. The [DATE] MAR reflected an order for Budesonide Inhalation Suspension (respiratory medication) 0.5 mg per 2 mL to be inhaled orally, twice daily, for asthma. The MAR reflected the medication was not administered in the evening on [DATE], the morning or evening of [DATE], the evening of [DATE] or the morning and evening of [DATE] and [DATE]. R6 received five of their 13 scheduled doses of Budesonide between [DATE] and [DATE]. A Progress Note for [DATE] at 10:26 PM reflected the Budesonide was on order. There was no documentation that the Physician was notified that the dose was not administered. A Progress note for [DATE] at 12:53 PM reflected Budesonide was not available. There was no documentation that the Physician was notified that the dose was not administered. A Progress Note for [DATE] at 10:33 PM reflected Budesonide was n/a. There was no documentation that the Physician was notified that the dose was not administered. A Progress Note for [DATE] at 10:07 PM reflected Budesonide was not available. There was no documentation that the Physician was notified that the dose was not administered. A Progress Note for [DATE] at 10:50 AM reflected Budesonide was not available. There was no documentation that the Physician was notified that the dose was not administered. A Progress Note for [DATE] at 10:33 PM reflected Budesonide was not available. According to the note, the pharmacy was made aware and would ship the medication. There was no documentation that the Physician was notified that the dose was not administered. A Progress Note for [DATE] at 8:35 AM reflected Budesonide was n/a. There was no documentation that the Physician was notified that the dose was not administered. A Progress Note for [DATE] at 7:39 PM reflected Budesonide was not available, and the facility was awaiting shipment. There was no documentation that the Physician was notified that the dose was not administered. In an interview on [DATE] at 12:49 PM, DON B reported if a medication was not in a residents supply, the expectation was for pharmacy to be contacted to see when the medication was expected to be delivered. DON B reported they expected nurses to administer medications that were available in the facility's backup supply. DON B stated their expectation was for the Physician to be notified that R6's respiratory medications were not given, for any reason, for guidance on how to proceed.

This citation pertains to Intake #MI00147551. Based on interview and record review, the facility failed to educate non-clinical staff regarding wander guards, alarmed exit doors and staff reliabilities during an elopement, resulting in Resident #102 exiting the facility on 9/5/24 at 1:35 p.m., the likelihood for severe injury, and an increase in anxiety and fear. Findings Include: Review of the Face Sheet, progress notes dated 9/5/24 through 9/10/24, and care plans dated 9/3/24 revealed Resident #102 was [AGE] years-old, admitted to the facility on [DATE], and required supervision due to wandering with a history of attempts to exit the building. The resident was alert with a BIMS (cognitive assessment tool) of 8 (alert, able to be interviewed), and was assessed to be an elopement risk with a wander device placed on her wrist (on 9/3/24). The residents diagnosis included, difficulty walking with unsteadiness, seizures, history of stroke, Cognitive Communication Deficit, Dementia, Anxiety Disorder, Psychotic Disturbance and Mood Disturbance. Review of the residents Elopement Risk care plan dated 9/3/24, revealed the wander device was placed on the reisdnet's wrist. After she walked out of the facility on 9/5/24, the care plan was up-dated to include monitor location throughout shift. Review of the facility Community Emergency Operations Missing Resident procedure (un-dated), revealed upon activation of doors with wander guard devices, staff were to, immediately search area; staff persons and other available personnel will immediately go to the site of activation (notification comes on staff phones), and account for all resident's. Review of the facility Incident Report and Investigation Report revealed on 9/5/24, revealed on 9/4/24 at 1:35 p.m., 3 visitors left the building and Resident #102 followed close behind them, exiting out the front door when Admissions Director C used her badge to open the front door. She was fully clothed, shoes on and had a purse over her shoulder. The resident was out of the facility for approximately 1 minute; she was seen by Receptionist D who brought her back into the facility without any harm. When Admissions Director C opened the front door to let the visitors out, Resident #102 exited with them. The door alarm went off when she went past it, activating it with the wander device on her wrist. Admissions Director C did not fully understand what the alarm indicated and did not go outside to identify and bring the resident back into the building. Admissions Director C had never worked Long Term Care and was not aware of what a wander guard was or how it worked. Review of the facility nursing progress notes dated 9/5/24 at 14:00 (2:00 p.m.), stated Writer was notified that resident was outside in parking lot. Writer immediately went outside to assess resident. Resident was being escorted back into building by 2 staff members. Resident was wearing her own clothing, had purse over her shoulder, she was dressed appropriately for a clear, warm summer day. Wonder guard remains in place. Review of the facility nursing progress notes dated 9/5/24 at 14:42 (2:42 p.m.), stated Resident has a wander guard. Staff members assisted resident back into building. Per secretary (Receptionist D) resident was observed walking in the parking lot. Resident stated she was looking for downstairs. During an interview done on 10/28/24 at 1:18 p.m., Receptionist D stated I was sitting in my car (on break) and saw (Resident #102) walking (near the main door in the parking lot). I grabbed my phone and ran down there and talked to her. She had her purse but no coat. It was not cold; it was approximately 300 feet (from her car to the resident). She came in easily with me. She walks ok and she had [NAME] on. During an interview done on 10/28/24 at 1:30 p.m., Admissions Director C stated I opened the doors for visitors and she was behind them, she walked out. I heard the alarm but I did not fully understand what to do. I was orientated but not given details on what to do (regarding elopement, wander devices and door alarms). During an interview done on 10/28/24 at 9:55 a.m., Maintenance I stated We don't educate anyone on the doors and alarms. Maintenance I educated new staff during orientation. Upon request, no documentation of his part of the orientation was given to this surveyor, he said he did not document it. During an interview done on 10/28/24 at 11:40 a.m., Director of Maintenance and Grounds F stated I do not cover that (roam alert/wander guard system and alarming doors); I tell them it is their responsibility to read it (the policy). Director of Maintenance F denied giving new employees during orientation any handouts regarding wander alert devices or wander alert doors with staff responsibilities upon elopement. During an interview done at 10:30 a.m., Director of Nursing/DON (New DON 3 days at facility) stated (Director of Maintenance & Grounds F) talked about the doors a little bit, I did not sign anything. The DON denied being taught during orientation what to do if the door alarms go off or given any handouts regarding the facility elopement policy. During an interview done on 10/28/24 at 10:25 a.m., Infection Control/Staff Development, RN stated I only orientate the clinical staff, I don't do the non-clinical; we should document education on the roam alert (wander guard). Admissions Director C was non-clinical staff. During an interview done on 10/28/24 at 12:00 p.m., Administrator and DON at 12:00 p.m., stated We need to improve orientation. Review of the facility Resident Wandering Elopement policy dated 10/19/23, stated If a resident should elope, follow the elopement procedures in the community emergency operations plan located at all nursing stations. Review of the facility Wandering Resident Monitoring System policy dated 10/19/23, revealed Wandering Resident books were at the front desk across from the front door. All resident's with wandering devices were to be in the books and they needed to be frequently up-dated. The Director of Admissions was not informed during orientation of wander guards, alarmed doors, or staff responsibilities during attempts or actual elopements.

This citation pertains to intake: MI00146060 Based on observation, interview, and record review the facility failed to prevent accidents (falls) by not following the plan of care, for two Resident (#2, #3) out of three Residents reviewed for accidents and hazards resulting in actual harm, fractured bones resulting in decline in Activities of Daily living for Resident #3 and potential for injury for Resident #2. Findings Included: Resident #3(R3) Review of the medical record revealed R3 was admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), type 2 diabetes, lung cancer, unstageable sacral pressure ulcer, fibromyalgia (widespread and long term body pain), epilepsy, anemia (low red blood cells), gastro-esophageal reflux disease, hypomagnesemia (low magnesium levels in blood), hyperlipidemia (high fat content in blood), sleep apnea, right foot drop, bipolar disorder, anxiety, nicotine dependence, and history of falls. R3's medical record demonstrated she was discharged from the facility on 07/29/2024 and was readmitted [DATE] that included new diagnoses of a closed fracture of upper end of the right tibia and a fracture of the upper end and lower end of right fibula. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2024, revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During an interview on 08/07/2024 at 11:29 a.m. R3 was observed sitting up in first floor conference room. R3 explained that she had come to the facility so that she could get stronger and return home. She explained that she was in a lot of pain because of a fall which had resulted in a fracture of her right leg. R3 explained that the fall happened at the facility. R3 explained that she was being transferred from the toilet in her bathroom, with the assistance of one person, her leg gave out and she fell to the floor. R3 explained that the recent fracture of her right leg has set her back in her progress to return home. R3 also explained that it was now necessary for her to be transferred using a total mechanical lift. Review of R3's medical record demonstrated a plan of care which stated, Risk for falls r/t (related to) deconditioning, which was implemented as of 05/18/2024. R3's plan of care also stated, (Resident name) has ADL (Activity of Daily Living) deficits r/t recent hospitalization for pressure ulcer unstageable to sacrum, deconditioning, which was implemented 05/18/24. The same plan of care demonstrated an intervention that stated, Transfer: 2-person max assist, which was implemented 05/18/24 and was revised on 08/06/2024 to state Transfer: Hoyer (mechanical lift), NWB (Non-wt. bearing) on right lower extremity. Review of facility incited report demonstrated R3 had sustained a fall on 07/29/2024 at 09:00 p.m. Review of that incident report demonstrated Resident transferring from toilet to wheelchair, right leg gave out, patient fell to ground. Resident in pain ++, unable to move patient at time. Description of the incident demonstrated Physical/pain assessment, vitals, sheet placed under resident/pillow against right leg for support in non-movement, physician notified telephone message left,. Resident son notified, ambulance called. Resident transferred to (name of hospital) ED (emergency department) on stretcher, via (by) ambulance. Review of R3's hospital discharge summary, dated 8/25/24, revealed R3 had presented to the emergency department for a fall from standing with a closed right tibial fracture, a closed fracture of proximal end of right fibula, and closed fracture of proximal end of right tibia. The same discharge summary revealed R3 had required open reduction internal fixation right tibia on 08/02/2024. During an interview on 08/07/2024 at 11:35 a.m. Nurse Manger (NM) I explained that she was aware of R3's fall that had occurred on 07/29/2024. NM I explained that she had investigated R3's fall. NM I explained that her investigation demonstrated that R3 was being transferred from the toilet to her wheelchair by Certified Nurse Aide (CNA) D. NM I explained that according to R3's plan of care, she was to be transferred with the assistance of 2 staff. NM I explained that CNA D did not follow the plan of care. NM I agreed that by not following the plan of care, R3 had sustained right a closed fracture of upper end of the right tibia and a fracture of the upper end and lower end of right fibula. NM I explained that staff is expected to read the plan of care and the Kardex before providing care. NM I explained that that expectation was not followed by CNA D During a telephone interview on 08/08/2024 at 09:34 a.m. Certified Nurse Aide (CNA) D explained that she had worked at the facility for a month. CNA D explained that she was working with R3 on 07/29/2024 and was assisting her to transfer from the toilet to her wheelchair when R3's right leg gave out and R3 fell to the floor CNA D explained that she was not aware that R3 required to be transferred by 2 person max assistance . CNA D explained that she does not usually read the Kardex of residents and only relies on what she is told about resident care from other CNA's. CNA D was asked if she was educated on the necessity of reading the Kardex of Residents prior to providing care. CNA D explained that she was not taught to read the Kardex prior to providing Resident care. Record review of the facility staff personnel records demonstrated Certified Nurse Aide (CNA) D was hired by the facility 06/17/2024. The personnel record of CNA D had not demonstrated a completed competency evaluation upon completion of her orientation. Resident #2 (R2) Review of the medical record revealed R2 was admitted [DATE] with diagnoses that included peripheral vascular disease (PVD), Alzheimer's disease, dementia, hypertensive kidney disease, stage 3 chronic kidney disease, hypothyroidism (low thyroid hormone), hyperlipidemia (high fat content in blood), polyneuropathy (damage or disease affecting peripheral nerves), second degree atrioventricular block (delayed cardiac conduction in cardiac node), venous insufficiency, osteoarthritis, low back pain, depression, absence of right leg below knee. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2024, revealed a Brief Interview for Mental Status (BIMS) of 12 (mildly impaired cognition) out of 15. During an interview on 08/07/2024 at 01:55 p.m. R2 was observed setting up in a chair. R2 explained that he recently had a fall that had occurred in the bathroom. He explained that he needed assistance to get off the toilet and that a Certified Nursing Aide (CNA) was assisting him, and she was unable to hold him up and another CNA assisted him and lowered him to the floor. R2 explained that he was supposed to be transferred with an easy stand but that the staff did not use it at that time. R2 explained that it was a new CNA and she did not know that he was to be transferred with the easy stand. R2 explained that he did not sustain any injury. Review of R2's medical record demonstrated a physician order mechanical lift for transfers which was entered 08/08/2024. Review of R2's plan of care demonstrated . is at risk for falls r/t(relate to) spondylosis, R (right) BKA (below the knee amputation) polyneuropathy, Alzheimer's disease. R2's plan of care demonstrated an intervention EZ stand, which was entered 07/08/2024. Review of R2's Kardex (document used by staff that are providing care of the resident) demonstrated Transfer-Mobility- Transfer EZ stand. Review of facility incident report demonstrated R2 had experience a fall on 07/29/2024 at 04:30 p.m. The report demonstrated Resident was being toileted, unable to continue standing by self-using safety bars, fell to floor. The same incident report demonstrated that R2 did not sustain any injuries. Review a provided facility summary demonstrated Certified Nurse Aide (CNA) D was assisting R2 while he was standing up holding onto the assistance bar when he was non longer able to stand. The summary then identified that CNA E arrived in the bathroom and lowered R2 to the floor. During a telephone interview on 08/08/2024 at 09:34 a.m. Certified Nurse Aide (CNA) D explained that she had worked at the facility for a month. CNA D explained that she was assisting R2 in the bathroom on 07/29/24. During the transfer from the toilet R2 was unable to stand. CNA D explained that CNA E arrived in the bathroom and observed R2 being unable to stand and asked CNA D to remove the wheelchair while CNA E lowered R2 to the floor. CNA D explained that she was not aware that R2 required to be transferred with a mechanical device called a EZ-Stand. CNA D explained that she does not usually read the Kardex of residents and only relies on what she is told about resident care from other CNA's. CNA D was asked if she was educated on the necessity of reading the Kardex of Residents prior to providing care. CNA D explained that she was not taught to read the Kardex prior to providing Resident care. Record review of the facility staff personnel records demonstrated Certified Nurse Aide (CNA) D was hired by the facility 06/17/2024. The personnel record of CNA D had not demonstrated a completed competency evaluation upon completion of her orientation. During a telephone interview on 08/08/2024 at 10:31 a.m. Certified Nurse Aide (CNA) E explained that she had worked at the facility for almost a year. CNA E explained that she was working with CNA D on 07/29/24. CNA E explained that she was aware that R2 was on the toilet when she first arrived for her shift. She explained that she was aware that R2's Kardex demonstrated that R2 needed a EZ-Stand for the use of transfers. CNA E explained that she had told CNA D to contact her when R2 was ready to be transferred from the toilet to the wheelchair. CNA E explained that it had been a prolonged amount of time and CNA D had not contacted her for the transfer yet, so she went to R2's bathroom. CNA E explained that when she entered the bathroom, she observed that R2 could not stand while being helped by CNA D so she asked her to move and CNA E assisted R2 to the floor. CNA E explained that an EZ-Stand was not in the bathroom and because R2 was observed falling she assisted him to the floor.

Based on observation, interview, and record review the facility failed to prevent the development and worsening of a pressure ulcer for three (Resident #13, 24, and 45) of seven reviewed, resulting in multiple facility acquired pressure ulcers and the potential for infection and increased pain. Findings Include: Resident #13 Review of the medical record revealed Resident #13 (R13) was admitted to the facility on [DATE] with diagnoses that included hypertension, anxiety, and depression. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R13 was cognitively intact, did not have a pressure ulcer, and was at risk for pressure ulcer development. Review of the same MDS revealed R13 required assistance of one for most activities of daily living. On 05/21/24 at 12:56 PM, R13 was observed in her room. R13 was dressed, nicely groomed, and seated in her wheelchair. Gauze bandages were observed on both of R13's feet and heels. When queried what the purpose of the bandages were, R13 reported that she had cuts (pressure ulcers) on both of her feet. When asked how the cuts on her feet were obtained, R13 replied that the cuts (pressure ulcers) were from her heels resting on her bed for too long. R13 reported that she could not feel her feet due to a chronic peripheral neuropathy (nerve damage that often causes weakness, numbness, and pain, usually in the hands and feet) diagnosis. R13 stated that prior to the development of her pressure ulcers, she did not utilize any devices to assist with keeping her heels off the mattress for pressure reduction purposes. She stated that after staff had discovered the pressure ulcers, they offered her some boots to offload pressure from her heels, but those made her feet very sweaty. R13 stated that after the boots, the facility provided her with a foam wedge to aide in keeping her heels off the bed and she regularly utilized that. Review of an active Physician Order dated 9/8/23 reflected Monitor skin daily with care and full skin checks weekly with shower. Review of the Skin assessment task dated 4/10/24 revealed that R13 was marked for no skin issues. Review of a Shower sheet dated 4/13/24 revealed R13 had received a shower and there were no suspicious skin areas determined. Review of a Progress Note dated 4/15/2024 at 2:12 PM reflected CNA [certified nursing assistant] alerted this writer of skin issue to BIL [bilateral] heels. both heels have what appears to be pressure injuries. R [right] heel is discolored and appears to have been a blister that has popped open. the L [left] heel is discolored but not with a blister. physician and wound nurse notified to assess and set treatment. CNAs and resident were advised to elevate heels whenever in bed. heel foam dressing applied to BIL heels to alleviate possible further breakdown. Review of a Skin/Wound dated 4/16/2024 at 1:46 PM revealed Wound nurse notified of skin breakdown to bilateral heels. On assessment, left heel presents with elongated purple discoloration, consistent with deep tissue injury. Right heel presents with large, irregular shaped blister with small pinpoint opening distally, scant serosanguinous [Serosanguineous fluid is a type of wound drainage typically in response to wound damage. The drainage is typically thin and watery with a light red or pink hue] area consistent with a stage two pressure injury. Skin prep applied to intact skin of bilateral heels with foam bordered dressing to cover. Resident initially resistant to offloading heels with pillow or foam boots. With staff encouragement, resident agreeable to use pillow to offload heels or foam boots when in bed . Review of a Skin assessment dated [DATE] revealed R13's left heel was an in house acquired deep tissue injury. The left heel had an area of 0.8 centimeters (cm), length of 2.0 cm, and a width of 0.6 cm. Review of a Skin assessment dated [DATE] revealed R13's right heel was an in house acquired stage two (partial tissue skin loss with exposed dermis). The right heel had an area of 5.8 cm, length of 3.4 cm, and a width of 2.5 cm. A note at the bottom of the skin assessment stated that staff reported that R13 was resistant to change in routine such as offloading heels with pillows in bed. Review of R13's Behavior MDS dated [DATE] revealed that R13 did not have any refusals in care. Review of the Physicians Orders for R13 revealed new orders which included offloading heels at rest which was initiated on 4/15/24, achilliease (wedge) to bed of loading heels which was initiated on 4/19/24, and foam boots to bilateral heels when in bed, as tolerated with an active date of 4/26/24 and a discontinued date of 4/29/24. These orders were implemented after the development of the bilateral heel pressure injuries. Review of a Skin/Wound Note dated 4/23/2024 at 1:12 PM revealed Weekly wound assessment: Deep tissue injury to left heel presents with reduced redness, slight reduction in measurements .Right heel presents with partially ruptured blister (10% open, 90% epithelium), with light serosanguinous drainage .Resident using Achillease to end of bed to float heels, reporting comfort and ease of use . Review of a Skin/Wound Note dated 5/1/2024 at 2:31 PM revealed Weekly wound assessment: Right heel stage two presents with ruptured blister, light serous drainage, no sign of infection. Left heel deep tissue injury presents with stable measurements, epithelium intact. New scab to left heel noted with assessment. Resident reports no pain . Review of a Skin/Wound Note date 5/14/2024 1:56 PM revealed Weekly wound assessment: Left heel pressure injury presents with scabbing along achilles and small open area to heel with light serous exudate. Left heel measurements stable. Right heel pressure injury presents with slough to 90% of wound bed and 10% granulation tissue. Light serous exudate noted . Review of a Skin assessment dated [DATE] revealed R13's left heel fit the description of a Stage Two pressure ulcer. The left heel pressure ulcer had an area of 0.8 cm, a length of 0.9 cm, a width of 1.2 cm, and a depth of 0.1 cm. Review of a Skin assessment dated [DATE] revealed R13's right heel fit the description of a Stage Three pressure ulcer. The right heel pressure ulcer had an area of 3.2 cm, a length of 2.9 cm, a width of 1.4 cm, and a depth of 0.3 cm. In an interview on 05/24/24 11:16 AM, Registered Nurse (RN) F stated that she was the Wound Nurse for the facility and was familiar with R13. RN F reported that prior to the development of the bilateral heel pressure ulcers, the intervention for pressure ulcer prevention in place included a foam mattress. After the discovery of the pressure ulcers on R13's heels, an order was placed to offload her heels with foam boots initially, and then a foam wedge on the end of her bed. RN F stated that just prior to the development of the bilateral heel pressure ulcers, R13 had a health decline which caused her to stay in bed more frequently. RN F stated that she was unaware that R13 had been spending additional time in bed and would have liked to see the intervention of offloading heels in bed implemented during that time. Resident #24 Review of the medical record revealed Resident #24 (R24) was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, muscle weakness, myasthenia gravis, schizoaffective disorder-bipolar type, anxiety disorder, major depressive disorder, displaced bimalleolar fracture of left lower leg, closed fracture with routine healing, dislocation of left ankle joint, and orthostatic hypotension. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R24 was cognitively intact with a Brief Interview for Mental Status of 12, did not have a pressure ulcer, and was at risk for pressure ulcer development. Review of R24's Care Plan revealed R24 required limited assistance by one person for bed mobility and utilized the Hoyer lift for transfers. On 5/21/24 at 11:20 AM, R24 was observed in bed. R24 had an ACE wrap on his lower left extremity along with a hard boot. His left lower extremity was resting directly on the mattress. R24 was pleasantly confused and did not appear to answer questions appropriately. When asked how R24 notified staff if he needs anything, R24 held up his bed remote and stated, well I don't know, I haven't thought about that before. When asked what happened to his left leg, R24 stated oh, I don't know. They say I have a bad habit. Review of the Hospital Discharge Summary dated 2/22/24 revealed R24 admitted to the trauma service after experiencing a fall at home resulting in a left ankle dislocation and fracture. An external fixator device (a device which consists of a metal frame and pins surgically placed into the bone to help maintain the length, alignment, and rotation of the fracture) was placed on 2/15/24. Post-operative assessments revealed that R24's left external fixator device was in place and wrapped with an ACE bandage to protect the skin from the device. R24 was able to wiggle his toes and had no visible injury. Review of the After Visit Summary dated 2/22/24 revealed orthopedic instructions which stated, non weight bearing on left lower extremity . Keep left foot elevated above heart level while at rest: only allow left foot to be in a dependent position for 10-to-15-minute intervals while up/active . Sponge bath only keeping pin sites and surrounding dressings dry . please change out dry dressings on pins daily as needed when saturated. Review of a Physician Order dated 2/22/24 revealed R24 was to maintain a non-weight bearing status on his left lower extremity. Additionally, the order stated May reinforce or replace ACE wrap as needed. Use foam cushion to elevate LLE (left lower extremity). Bed bath only. This order was discontinued on 5/17/24. Review of an After Visit Summary from a follow up orthopedic appointment on 3/1/24 revealed the following instructions: no weight bearing left lower extremity .Xeroform, Kerlix, and ace wrap to LLE. Change daily or more if drainage . apply ice to site several times per day . Review of an After Visit Summary dated 5/17/24 revealed R24 had the external fixator device removed from his left lower extremity. The post operative instructions included instructions to apply ice to the left lower extremity several times a day and to elevate the left lower extremity above heart level while at rest. In an observation on 5/21/24 at 12:36 PM, R24 was observed in bed. R24 had an ACE wrap on his lower left extremity along with a hard boot. His left lower extremity was resting directly on the mattress. R24's left foot was in a relaxed position and was observed to be tilted over and resting on the left lateral side of his foot. In a wound care observation on 05/23/24 at 10:23 AM R24 was observed in bed. R24 had an ACE wrap on his lower left extremity along with a hard boot. His left lower extremity was resting directly on the mattress. R24's left foot was in a relaxed position and was observed to be tilted over and resting on the left lateral side of his foot. Review of a Progress Note dated 5/10/2024 at 6:19 PM Some tenderness noted today when performing dressing change on LLE. Discharge noted on both medial and lateral aspects of the ankle. Used an ABD pad when bandaging today, as it looks like the hardware is being pressed into the left side of the foot, causing pain. Redness noted on tissue surrounding insertion site. Cleaned area with NS, xeroform, ABD for extra cushioning, and Curlix. Wrapped with ACE bandage . Review of a Progress Note dated 5/11/2024 3:44 PM When the nurse did the wound dressing change today, nurse found a pressure injury on the left foot which was related with the medical device .Nurse will notify the wound care nurse to evaluate the skin changes on Monday. Nurse cleansed the pressure injury with normal saline, put the pad in between the pressure injury for protection . Review of a Physician order dated 5/11/24 revealed LLE wound care: NS cleanse, Xeroform, ABD pad to lateral side of foot to protect from hardware pressing in, kerlix and ACE wrap. Change daily or more if drainage . This order was discontinued on 5/17/24. Review of the initial pressure ulcer photograph revealed a pressure ulcer on the lateral side of R24's foot that was caused from the screw and nut of the external fixator device digging into the lateral side of R24's left foot. The pressure ulcer was the same size as the screw and nut and appeared to have an indentation on the skin. The wound bed was covered with slough. Review of a Skin/Wound note dated 5/21/2024 at 1:34 PM revealed Weekly wound assessment: left lateral foot pressure injury presents with slough to ~80% of wound bed and and [sic] pink granulation tissue to remaining wound bed. Light serosanguinous drainage. Depth reduced, remaining measurements stable . Review of The Skin and Wound evaluation dated 5/21/23 revealed R24's pressure ulcer was classified as a medical device related unstageable wound. The wound had an area of 1.7 cm, a length of 1.8 cm, a width of 1.3 cm, and a depth of 0.2 cm. In an interview on 05/23/24 at 2:31 PM, Certified Nursing Assistant (CNA) T stated familiarity with R24. CNA T denied seeing a foam cushion used to elevate R24's left lower extremity when R24 had his external fixator applied. In an interview on 5/24/24 at 8:55 AM Certified Nursing Assistant (CNA) D stated familiarity with R24. CNA T denied seeing a foam cushion used to elevate R24's left lower extremity when R24 had his external fixator applied. In an interview on 5/24/24 at 09:07 AM Certified Nursing Assistant (CNA) R stated familiarity with R24. CNA T denied seeing a foam cushion used to elevate R24's left lower extremity when R24 had his external fixator applied. Review of the Kardax (portion of medical record where CNA's access care needs) revealed no instruction to elevate R24's left lower extremity. Review of the Care Plan revealed no instruction to elevate R24's left lower extremity. In an interview on 5/24/24 at 11:33 AM, Registered Nurse (RN) F stated that she was the Wound Nurse for the facility and was familiar with R24. RN F stated that she as unaware of how the medical device related pressure injury developed. RN F stated that the pressure injury should have been prevented if all preventative orthopedic instructions were implemented. RN F stated that R24 was not always compliant. Review of the Progress Notes revealed no refusals for propping R24's foot or refusals of protective ace bandage application. In an interview on 5/24/24 at 3:07 PM, Licensed Practical Nurse (LPN) E stated that she was unsure how R24's medical device related pressure injury developed. Resident #45 Review of the medical record revealed Resident #45 (R45) was admitted to the facility on [DATE] with diagnoses that included overactive bladder, cognitive communication deficit, vascular dementia, severe, with anxiety, and dysphagia. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R45 was cognitively impaired, did not have a pressure ulcer, and was at risk for pressure ulcer development. Review of the Activity of Daily Living Care Plan revealed R45 required assistance of two people for bed mobility and transferred with the use of a Hoyer. On 5/21/24 at 11:11 AM, R45 was observed lying in bed, positioned toward the left side. R45's right leg was extended straight out with pillow under her lower legs with her heel resting directly on mattress. R45's left leg was bent at the knee and her lateral leg and foot was resting directly on a pillow. A foam dressing was noted on R45's left heel. R45 did not respond when spoke to. Review of the Physician Order's revealed an active order implemented on 12/6/2023 which stated Keep LLE [left lower extremity] elevated on a pillow r/t [related to] edema. Review of a Skin/Wound Note date 4/17/2024 at 9:06 AM revealed CNA [certified nursing assistant] alerted wound nurse of skin breakdown to left heel. On assessment, small, deep tissue injury noted to medial left heel with small area of blanchable redness just superior .Foam mattress in place, pillow beneath heels (flattened), new foam boots for use in bed to be supplied . Review of a Skin and Wound Evaluation dated 4/17/24 reflected R45 had an in house acquired deep tissue injury on her left heel which had an area of 1.4cm, length of 1.7cm, and a width of 1.2cm. Review of the Care Plan revealed a focus area which stated R45 has a deep tissue injury to the left medial heel and stage two pressure injury to the coccyx related to pressure. A foam mattress intervention was implemented on 4/17/24. Offload heels at rest was implemented on 4/17/24 after the development of the deep tissue injury on the left heel. Review of a Progress Note dated 4/27/2024 at 3:19 PM revealed R45 has a 2cm open area on coccyx area . Review of the Skin and Wound assessment dated [DATE] revealed an in house acquired stage two pressure ulcer. The pressure ulcer had an area of 5.9 cm, a length of 3.7 cm, a width of 3.2 cm, and a depth of 0.1 cm. In an interview on 5/24/24 at 9:43 AM, Certified Nursing Assistant (CNA) W stated that she was familiar with R45's care needs. CNA W stated that R45 required frequent turning and repositioning. In an interview on 5/24/24 at 11:27 AM, Registered Nurse (RN) F stated that she was the Wound Nurse for the facility and was familiar with R45. RN F was notified of her left heel pressure ulcer on 4/17/24. About two weeks later, RN F was notified of the wound on the coccyx. RN F stated that R45's situation and staffing played a role in R45's development of her pressure ulcers. R45's regularly assigned CNA was on vacation causing an irregularity in R45's usual staff, which may have played a role. When asked how R45 developed a pressure ulcer to her left heel when an order for elevating her left foot was already implemented, RN F stated that the use of flat pillows may have contributed. RN F reported that she provided staff education regarding offloading, turning, and repositioning.

Based on observation, interview and record review, the facility failed to implement timely interventions, provide appropriate supervision and ensure that staff assisted with transfers to prevent recurrent falls for two resident (Resident #70 and #547) of three reviewed for falls, resulting in a head laceration requiring emergency care and staples. Finding include: Resident #70(R70) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R70 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease, polyosteoarthritis, wedge compression lumbar fracture, spinal stenosis, radiculopathy, disc degeneration, low back pain, unsteadiness on feet, reduced mobility, repeat falls, assistance with personal care and anxiety. The MDS reflected R70 had a BIM (assessment tool) score of 13 which indicated his ability to make daily decisions was cognitively intact, and he required max assist with transfers. R70 MDS reflected no behaviors including rejection of care. During an observation and interview on 5/21/24 at 9:24 AM, R70 was observed sitting in chair with wife at side. R70 reported currently planning on surgical procedure this week and elevated pain related for need for back surgery. R70 and family reported R70 had history of falls prior to admission that contributed to current pain and had a fall at the facility on 4/15/24, three days after admission on 4/12/24. R70 and family reported R70 was admitted into room toward end of hall, room [ROOM NUMBER], and door was closed and R70 called wife from cell phone to say he had fallen and hit his head on 4/15/24 and did not no how to get help. R70 family reported she had been home ill and attempted to call the facility to assist R70 but no one answered at the facility. R70 family reported called friend to go to facility an check on R70 and continued several attempts to reach facility by phone and spoke to someone who attended to R70 after several calls and R70 remaining on the floor in room. R70 family reported after staff found R70 he was transferred to the hospital related to head laceration that required several staples. R70 family reported did not want R70 to fall again so family hired one on one sitter to supervised R70 to prevent additional falls to ensure there would not be delay in needed surgical procedure because facility did not have enough staff. Review of the Nursing Progress Note, dated 4/15/2024 at 6:53 p.m., reflected, Staff was called to patient's room after receiving a phone call from patient's wife who was called by patient and stated he had fallen. Patient was observed on the floor in front of his recliner on his right side with obvious lacerations to right side of head. Patient stated I was on my way to the dining area to brush my teeth [named physician] was notified and order received to send patient to ER for further evaluation. Patient's daughter [named], called this nurse for more information, questions answered. Review of the History and Physical, dated 4/15/24, reflected, [named R70] is a [AGE] year-old man with Parkinson ' s disease with Osteoarthritis, osteopenia, history of thoracic compression fracture with history of L1 vertebral compression fracture repair by [named surgeon] and history of left femoral neck fracture on 01/15/2024 with status post ORIF by [named physician]. The patient had mechanical fall at home. The patient had x-rays shows pain on the low back and the patient was taken to the hospital. The patient was diagnosed with L4 compression fracture. The patient had kyphoplasty in setting of the Parkinson ' s disease. The patient is following with neurosurgery. The patient is stabilized. After stabilizing his condition on 04/12/2024, the patient desired to be transferred to the subacute rehabilitation at [namded facility] . Review of R70's Nurse Progress Note, dated 4/15/2024 at 10:03 a.m., reflected.Client was admitted to [named] for rehabilitation on 4/12/24. Client had a fall on 3/13. C/o back pain. Went to [named ] hospital, studies showed a L4 compression fracture. Kyphoplasty was performed on 3/27/24. Went to inpatient rehabilitation and then discharged to facility .Client is asking for a stronger pain medication with codeine. Has Ibuprofen scheduled for pain management. Has order for Tylenol PRN. BAT to ABLE. Client requires 2 person assist for transfers . Review of the N ADV Clinical Admission Note dated, 4/12/2024 at 6:44 p.m Level of cognitive impairment: Alert (some forgetfulness). Mental Status Note: Known to get confused at times through the night .Safety Note: Occasionally wakes up confused during the night .Gait is unsteady. Balance is poor . Review of the Fall Risk Evaluation, dated 4/12/2024 at 5:07 p.m., reflected R70 had a high risk for falls with score of 20(>10 equals fall risk). Review of the Fall Incident/Accident Report, dated 4/15/24 at 5:30 p.m., reflected R70 had an unwitnessed fall in room with head laceration to right side of head. The reported reflected R70 was oriented to self. The provided information did no mention when the resident was last observe, toileted, or if intervention was in place or if call light was on. The reported was competed by Licensed Practical Nurse(LPN) Q. During an interview on 5/23/24 at 9:05 AM, LPN Q reported was present for R70 fall on 4/15/24. LPN Q reported was alerted to room when wife called facility by phone and there was a delay because call went to general line first. LPN Q reported eventually R70 wife spoke with Unit Manager on the phone and R70 was then found on the floor in his room with a lot of blood related to head laceration and transfer to hospital via Emergency Medical Services(EMS). LPN Q reported pressure was held to head to control bleeding and EMS transfer R70 from floor to gurney. LPN Q reported R70 returned to the facility with 7 staples that were removed 10 days later. LPN Q reported was unable to recall what other staff were present and verified completed Fall Incident Accident Report the next day because had for got to complete prior to end of shift. LPN Q reported no witness statements were part of investigation. LPN Q reported was unsure how long R70 had been on the floor before alerted by wife on phone and was unsure if investigation completed. LPN Q reported design of rehab rooms makes it difficult for residents to be seen from hall and can not physically visualize all rooms from one area. During an interview on 5/23/24 at 12:52 PM, Director of Nursing (DON) B reported no witness statements for falls including R70 and R547 falls with injury who both required hospital transfers for staples within 72 hours of admission. DON B reported recent identified need for improvement with root cause analysis and additional information gathered at the time of the falls. DON B reported IDT note should be part of fall report and progress notes. During an interview on 5/24/24 at 9:54 AM, Registered Nurse (RN) F reported was responsible for completing fall investigations at facility. RN F reported R70 had fall on 4/15/24 in room and was unable to answer how long resident was on the floor prior to staff arrival and reported R70 room was moved closer to Nurse Station after returning from the hospital for increased supervision. RN F verified R70 was at high risk for falls on admission. Resident #547 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R547 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included Hypotension(low blood pressure), history of falls including fall with traumatic subdural hematoma and craniotomy in 2023, acute rash, bilateral lower leg edema, weakness, and abnormal gait. The MDS reflected R547 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required one person physical assist with transfers. R547's MDS reflected no behaviors. During an observation on 5/21/24 at 10:17 AM, R547 was noted sitting in recliner, unable to view from hall, in room and appeared calm and able to answer questions with minimal confusion. R547 had a large border dressing over left temple area and reported was related to fall. R547's room was located at the beginning of A Hall about 7 room down from the nurse station. Review of the facility Matrix, dated 5/21/24, reflected R547 admitted to the facility on [DATE] and had a fall with injury. Request for all R547 incident/accidents(I/A) with complete investigations was sent via email to the Nursing Home Administrator(NHA) A on 5/22/24 at 3:34 PM. Received two fall with injury I/A reports for R547, dated 5/17/24 and 5/20/24, on 5/22/24 at 4:33 p.m. The provided documents included I/A report with no evidence of witness statements. Review of the facility, Fall Risk Evaluation,, dated 5/15/24, reflected R547 had a score of 14 that indicated high risk for fall. Review of the Intra Disciplinary Team(IDT) Progress Note, dated 5/16/2024 at 9:42, reflected, Client was admitted to facility for rehabilitation on 5/15/24. Went to [named] hospital on 5/10 from [named adult foster care] for generalized weakness and a rash. Also had edema to BLE[bilateral lower extremities] and increased confusion. Primary diagnosis .Metabolic Encephalopathy. Also diagnosed with Malaise, Failure to Thrive, Edema, Rash, Leukocytosis. PMH[past medical history]: Hypotension, Subdural Hemorrhage, Neurocognitive Deficits .2 Person for transfers . Review of the Physician Progress Note, dated 5/16/24, reflected, She was seen today for admission assessment in her room. She was sitting in a chair, comfortably reports no pain, but feels concerned about her risk of falls. She is a [AGE] year-old female, who had a history of subdural hematoma last year and had a craniotomy XXX[AGE] year female with history of subdural, hematoma status post craniotomy, hypertension and falls, is admitted for skilled care after being in the hospital for worsening leg edema, contact, dermatitis, and mental status changes .Her goal is to be able to return home after improving her balance, Gait and strength .PT and OT evaluation and treatment . Review of the Incident Progress Note, dated 5/17/24 at 4:27 p.m., reflected, Staff alerted nurses to patient's room via emergency call light system, patient observed on her left side, bleeding from her head, pressure dressing applied to the laceration to the upper left side of her head. VSS, neurochecks WNL, AxO x4 at time of incident, EMS transport service arrived for transport to [named emergency room ] for further tx, [named physician] notified, [named], patient's son, returned call and was updated on patient's incident. Review of the facility I/A Fall with Injury Report, dated 5/17/24 at 4:35 p.m., reflected R547 was alert and oriented and had an unwitnessed fall coming out of bathroom and found in doorway of room bleeding from left temple area. The report did not mention when resident was last observed or if call light was on at the time of the fall. The reported reflected, Upon return from ED and IDT review: intervention to education on importance of call light use. AXOx4, able to demonstrate use of call light and understanding of when to use. Review of the Baseline Care Plan(BLCP) Summary, dated 5/15/24, reflected R547 fall prevention measure in place that included, oriented to room, encouraged use of call light, and ensure items in place/reach. The BLCP included interventions that included one to two persons assist with toileting, transfers and two person assist with bed mobility. The BLCP indicated R547 used a wheelchair for mobility and included, Fall Risk under other care plan considerations. Review of the facility Working Schedules, dated 5/17/24, reflected 2 nurses and 3 cna staff for 45 rooms on first floor including one cna call in. During an interview on 5/24/24 at 9:00 AM, Licensed Practical Nurse (LPN) Q reported was R547 nurse on 5/17/24 at the time of the fall. LPN Q reported R547 had self transferred to bathroom and fell in room coming out of bathroom and hit head and was found in doorway with laceration to left temple with a large pool of blood on floor. LPN Q reported pressure was held to head to control the bleeding and vitals taken and EMS transferred R547 off the floor to the emergency room . LPN Q was unsure when resident last observed prior to fall or if call light was on. LPN Q reported R547 returned to the facility with 7 to 8 stable to left side of head and reported was very concerned post fall related to history of fall with subdural hematoma and craniotomy and decision to send R547 directly to hospital for follow up. LPN Q reported was unable to recall other staff present. LPN Q reported unfortunately the facility layout had a poor design for rehab because not able to physically be in view of all rooms from any one location. LPN Q reported rehab unit with several new admissions and with large turn over rates. LPN Q reported poor decision to place new residents with high acuity and high risk for falls at end of unit with less foot traffic because increases the risk for residents who need more supervision. LPN Q reported example of current resident in furthest end of hall(not visible from main nurse station) was new admission post hospital admission for respiratory failure, extubated the day prior, with confusion and high risk for falls. Review of the Nursing Progress Note, dated 5/20/2024 2:10 PM, reflected, CNA alerted this writer to resident's room. resident had fallen when ambulating from the BR back to room, hitting head on the floor. CNA was present and witnessed fall but unable to stop fall. resident remained alert and talking to staff. laceration to L temple area. resident assisted up to w/c. laceration cleansed with NS and dry dressing applied. vitals obtained and are wnl, no other injuries observed and pain denied. staff will continue to monitor. Review of the facility I/A Fall with Injury Report, dated 5/20/24 at 1:30 PM, reflected, CNA alerted this writer to resident's room. resident had fallen when ambulating from the BR[bathroom] back to room, hitting head on the floor. (Same type of fall as on 5/17/24) resident was walking with walker. CNA was present and witnessed fall but unable to stop fall. resident remained alert and talking to staff. laceration to L temple area. The report reflected, IDT review of fall: intervention to encourage non-slip footwear when up, as patient had removed shoes. Continue with therapy efforts to address gait impairments (has crisscross step patterns). The report did not mention the last time R547 was observed prior to the fall, last toileted, if the call light was on or off or if gait belt had been used during the transfer. Review of the Care Plans, dated 5/17/24 through 5/20/24, reflected no new interventions post 5/17/24 fall that required hospital visit and several staples to left temple area related to laceration. Review of the Progress Notes, dated 5/17/24 to 5/20/24, reflected no mention of follow up fall documentation. During an interview on 5/24/24 at 9:54 AM, Registered Nurse(RN) F reported was responsible for fall investigations along with Director of Nursing(DON) B and also verify appropriate interventions in place. Reported R547 had history of fall upon admission on 5/15/24 and had unwitnessed fall on 5/17/24 post self transfer that caused left head laceration and staples. RN F reported intervention was to remind R547 to use call light. RN F was unable to answer if that same intervention was effective prior to the 5/17/24 fall. RN F reported staff were expected to document fall Progress Note every shift for 3 days post fall and verified R547 did not have any post fall progress notes in the medical record and was unsure why. RN F reported R547 had additional fall with similar situation and hit head that caused another head laceration on 5/20/24(3 days after prior fall with head laceration, hospital transfer and staples). RN F verified R547 did not have any new interventions added to the fall care plan after the 5/17/24 fall with injury and should have. RN F verified nurse staff had indicated post fall charting had been completed in the Treatment Administration Record after the 5/20/24 fall but was unable to locate complete post fall charting every shift for 3 days.

This citation pertains to intake MI00139554 Based on interview and record review, the facility failed to provide timely cardiopulmonary resuscitation (CPR) per the standards of practice and according to facility policy for one (Resident #2) of two reviewed for emergency resuscitation, when Resident #2 was found unresponsive without pulse or respiration with a 1 hour 58-minute delay prior to the initiation of CPR with the deficient practice resulting in death for Resident #2. Findings include: Review of the medical record revealed that Resident #2 (R2) was admitted to facility [DATE] with diagnoses including secondary malignant neoplasm of prostate, severe protein-calorie malnutrition, paranoid schizophrenia, and anemia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] reflected a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 6 (severe cognitive impairment). Section G of the same MDS revealed that R2 required one-person limited assist for bed mobility, supervision for toilet use, and was independent with eating after set up. Review of a second MDS dated [DATE] reflected that R2 deceased while at the facility. Review of R2's medical record completed with the following findings noted: Order dated [DATE] at 9:33 AM stated, Full Code (CPR) [cardiopulmonary Resuscitation]. Multidisciplinary Care Conference form dated [DATE] stated, .(R2's name) was to be admitted with hospice following his hospitalization . Family declined. Hospice nurse present and gave additional options for support with chronic disease. Family is electing to enroll (R2's name) in palliative care [specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness]. Transfer/Discharge Report dated 1 Sep, 2023 ([DATE]) indicated within section titled Other Information, R2's Advance Directive as Full Code (CPR). Progress Note dated [DATE] at 7:52 AM completed by Registered Nurse (RN) H stated, Resident passed away during night shift and found during shift change around 7am. Resident body was cold with no pulse or respiration. Floor manager (Licensed Practical Nurse/Nurse Manager D's name) contacted and instructed to call Hospice. Hospice nurse (nurses name) contacted and he stated thatresident [sic] is transitioning to palliative care under (name of company) care. Night nurse aware. Progress Note dated [DATE] at 10:27 AM completed by RN H stated, DON (Director of Nursing B's name) instructed to start CPR on resident due to Full code states [sic]. Around 0900 [9:00 AM] CPR started on resident, CPR completed between (DON B's name), Night nurse (LPN O's name), and day time nurse (RN H's name). EMT [Emergency Medical Technician] arrived and take [sic] over CPR and announced death at 0924 [9:24 AM]. Order Note dated [DATE] at 12:11 PM completed by RN H stated, Okay to transfer resident body to funeral home .Resident body transfer to (name of funeral home) at 1145 [11:45 AM]. In an interview on [DATE] at 10:25 AM, CNA (Certified Nurse Aide) F stated that she had arrived to assigned unit at approximately 7:15 AM on [DATE], was informed by night shift CNA G that R2 had passed away that morning, and upon completion of report with CNA G was approached and informed by RN H that R2's postmortem care (care provided after death including a bed bath, clean gown, and positioning) could be completed. CNA F stated that at least a good hour after she had completed R2's postmortem care, a code alarm was activated, she entered R2's room, observed RN H at bedside, exited room and obtained crash cart. CNA F stated that R2 had a bracelet on his right wrist that indicated that he was a DNR (Do Not Resuscitate) but that she had heard discussion among the nurses that morning that R2 was really a full code. In a telephone interview on [DATE] at 2:03 PM, CNA G confirmed familiarity with R2 and that she was his assigned CNA from [DATE] at 11:00 PM to [DATE] at 7:00 AM. CNA G stated that R2 was incontinent of both bowel and bladder, required one-person extensive assist for incontinency care and repositioning, and therefore checked on him every 2 hours. CNA G stated that she initially entered R2's room at approximately 11:30 PM on [DATE] at which time he was awake, followed commands to assist with turning, completed a brief check for incontinency and assisted R2 to reposition. CNA G stated that she checked on R2 again at approximately 1:30 AM, completed incontinency care as he had a loose bowel movement and that he remained alert. Per CNA G, R2 was checked on again at approximately 3:30 AM at which time he remained alert, she elevated head of bed, provided sip of water, and then repositioned him so that he seemed comfortable. Per CNA G, sometime after 5:00 AM R2's roommate activated call light to complain that R2 was being loud. CNA G stated that R2 was awake at that time, that he followed commands to assist her with checking his brief but that he was moaning and seemed uncomfortable. CNA G stated that upon completion of care she exited room, updated Licensed Practical Nurse (LPN) O that R2 was moaning and seemed to be in pain and that LPN O stated that she would check on him. CNA G stated that she then proceeded to the other end of the hall and had no further contact with R2. CNA G stated that at approximately 7:05 AM, day shift RN H approached her, stated that R2 was unresponsive but provided no further direction prior to walking away to find LPN O. CNA G stated that at approximately 7:15 AM, she gave report to CNA F and left unit. In a telephone interview on [DATE] at 10:44 AM, RN H stated that she had been employed at the facility for [AGE] years but was terminated from her position because of the [DATE] occurrence with R2. RN H stated that she arrived to unit on [DATE] at approximately 6:55 AM, clocked in, proceeded to complete unit rounds at which time she observed R2's door to be closed. RN H stated that upon entering room, observed R2's privacy curtain to be halfway closed around his bed and upon approach observed R2 to be without respirations, his mouth to be open, no pulse could be detected, and his body was cold to touch. RN H stated that R2 had a DNR bracelet on his right wrist and assumed that as R2's privacy curtain was partially closed, and the room door had been closed that staff had prior awareness of R2's passing. RN H stated that after approximately ,d+[DATE] minutes she exited room, located night shift nurse (LPN O), and as LPN O denied prior awareness of R2's passing, reentered room with LPN O and both confirmed that R2 was without pulse or respirations. RN H stated that LPN O denied need for assist with contacting R2's physician and family for further instruction and therefore RN H stated that she sat in the nursing office to check her emails at which time she received a call from Licensed Practical Nurse/Nurse Manager (LPN/NM) D, informed her that R2 had passed away during night shift at which time RN H stated that LPN/NM D provided guidance to contact hospice as she believed that he had recently been admitted to hospice services. RN H stated that sometime between 7:40 AM and 7:50 AM, she relayed to LPN O that hospice should be contacted, dialed hospice number, placed call on speaker and that the hospice nurse informed them that that because of religious reasons, R2 was under palliative/comfort care and not hospice care. RN H stated that she still believed that R2 was a DNR and did not check R2's medical record to verify code status. RN H stated that LPN O again denied need for assistance addressing R2's death, provided her with the medication cart keys, they completed narcotic count together, and that she then began morning medication pass. RN H stated that sometime after 8:00 AM, Director of Nursing (DON) B approached her at medication cart, informed her that R2 was a Full Code and that CPR needed to be initiated. RN H stated that was the first knowledge she had of R2's full code status, and upon verifying full code status in R2's medical record, expressed concern to DON B regarding initiation of CPR as was unknown when R2 passed away as he had clearly been deceased at 6:55 AM, upon her arrival to unit, as his body was already cold. RN H stated that she was next approached by NHA A sometime after 8:30 AM, and that she then entered R2's room with LPN O and DON B and that she initiated chest compressions and DON B placed AED (Automatic External Defibrillator) and provided rescue breaths. RN H stated she then received a return call from R2's spouse, that LPN O assumed chest compressions, and she exited room to take call. RN H stated that she informed R2's spouse of his passing and that CPR had been initiated, reentered room, and as DON B inquired whether spouse wished CPR to continue, recontacted spouse and as spouse confirmed desire for ongoing CPR, reentered room and informed the EMT, now present in R2's room, of spouse's desire that R2 receive continued CPR. Upon conclusion of telephone interview, RN H stated that as R2 was a cancer patient, there had been talk that he had enrolled in hospice, and as he had a DNR wrist band in place, she thought that he was a DNR and therefore never thought to verify R2's code status in his medical record upon finding him unresponsive at 6:55 AM and unfortunately did not know that he was actually a full code until informed by DON B after 8:00 AM. In a telephone interview on [DATE] at 12:57 PM, LPN O stated that [DATE] was the first time that she had worked with R2, that she started her shift at 7:00 PM on that date, received report from day shift nurse that R2 was declining, and initially entered R2's room between 8:00 and 8:30 PM for medication pass. LPN O stated that R2 was easy to awaken upon room entry, that he was alert and responded to questions with pain denied, and that his extremities were warm to touch. Per LPN O, R2 was resting in bed and not noted to be in any distress when she next checked on him between 1:00 and 2:00 AM. LPN O stated that at approximately 6:00 AM, CNA G reported to her that R2 was making noise but that she did not ask any additional questions, did not ask CNA G to obtain R2's vital signs, and did not check on R2 at that time as it was her plan to complete an assessment and discuss R2's status with the day shift nurse once she arrived. LPN O further stated that she thought R2 was receiving hospice care as he had terminal prostate cancer and therefore assumed that he was a DNR and that it never crossed her mind to verify his code status in his medical record. LPN O stated that as she was completing her shift at the medication cart, day shift RN H approached her and stated that R2 had passed. LPN O stated that she proceeded to room and upon assessment verified that R2 was not breathing and stated that it appeared that he had been gone for approximately 20 to 25 minutes due to skin coloring and coolness. LPN O stated that she then returned to medication cart, texted night RN/Former Nurse Supervisor (RN/FNS) C at approximately 7:15 AM to inform that R2 had passed and to inquire about the protocol at that point. LPN O stated that RN/FNS C did not text back right away, that she and RN H updated hospice nurse regarding R2's passing, at which time they were informed that R2 had not been admitted to hospice as family had declined. LPN O stated that she then referenced facility report sheet and noted that R2 was indicated to be a full code. LPN O stated that RN/FNS C also texted back at about the same time, confirmed that R2 was a full code and that compressions should be initiated and 911 called. LPN O stated that although she had confirmed R2 to be a full code, had received direction to start compressions and call 911, that she did not activate a code, start compressions, or call 911 as thought that it was too late to initiate CPR as it had been over 30 minutes since the time that R2 was first noted to be unresponsive. LPN O stated that as she was trying to tie up loose ends with R2 including offering to call family, physician, and assuring postmortem care had been completed, DON B and then Nursing Home Administrator (NHA) A arrived to unit and took over. LPN O stated that she reentered R2's room well after 8:00 AM to assure that R2 was presentable, that postmortem care had been completed, and that room was tidy when she noted RN H at R2's chest starting compressions and DON B placing the AED. LPN O stated that she stood by to offer assistance at which time DON B instructed her to assume chest compression which she did until EMS (Emergency Medical Services) arrived. Upon conclusion of telephone interview, LPN O stated that in retrospect she should have checked the report sheet provided to her by the off going nurse on [DATE] at 7:00 PM that indicated that R2 was a full code but reiterated that as she thought R2 was receiving hospice care as had terminal prostate cancer, assumed that he was a DNR and that verifying R2's code status in his medical record never crossed her mind. In a telephone interview on [DATE] at 4:16 PM, Registered Nurse/Former Night Supervisor (RN/FNS) C stated that she was the assigned nurse on the first floor of the facility on the night shift of [DATE]. RN/FNS C stated that as she was providing report to the day shift nurse at approximately 7:30 AM on [DATE], she received a text from LPN O that R2 had passed away. RN/FNS C stated that she did not respond to the text as she had been in the middle of report, finished report, left facility and that approximately 10 to 15 minutes later texted LPN O back to inquire about R2's code status. RN/FNS C stated that LPN O texted right back stating that he was a full code and that she then replied that if he was a full code that compressions must be started and 911 called. RN/FNS C stated that LPN O did not respond following the directive to initiate compressions. RN/FNS C stated that she called DON B at approximately 7:50 AM on [DATE], informed her that she had been notified that R2 had passed away, had initially thought that he was a DNR but had since confirmed with LPN O that he was a full code, but that LPN O had not responded to the final text and was not certain that CPR had been initiated. In an interview on [DATE] at 2:31 PM, Director of Nursing (DON) B stated that the expectation upon observing a resident to be unresponsive would be to first verify code status via the EMR (electronic medical record) and that if an individual was determined to be a full code, code blue would be activated within that resident's room, CPR would be initiated, and crash cart and AED obtained. DON B confirmed familiarity with R2, stated that on [DATE] at approximately 8:11 AM was notified by RN/FNS C that R2 had expired, that he was a full code, and that she was not sure that CPR had been initiated. DON B stated that she was enroute to facility at that time, arrived to facility at approximately 8:20 AM, went to unit, did not observe CPR in process, discussed with RN H and LPN O for better understanding of situation, referenced R2's chart with full code status verified and directed RN H and LPN O to start CPR. DON B stated that as she was under the impression that RH H and LPN O were going to initiate CPR, called Nursing Home Administrator A to notify of situation. DON B stated that RN H had not initiated CPR, disputed decision that CPR should be initiated as in her view R2 was deceased , cold, and too much time had passed and that she could not understand the rationale as to why CPR would now be initiated. DON B stated that R2's physician was called at 8:40 AM, advised of situation, and that he provided order to initiate CPR. DON B stated that RN H was again advised to initiate CPR, that RN H remained hesitant as stated that R2's spouse knew he was end of life and would not want CPR initiated. DON B stated that she then called spouse and left message at approximately 8:45 AM, instructed RN H again to start CPR and that she called 911. DON B stated that she then entered R2's room at 8:53 AM, observed RN H to begin chest compressions and that she applied AED and provided rescue breaths. Upon conclusion of interview, DON B stated that in hindsight she would have initiated CPR after arriving to unit and validating R2's full code status at approximately 8:25 AM but that as R2 had initially been observed without pulse or respirations at 6:55 AM, did not believe that the outcome would have been any different. In an interview on [DATE] at 3:30 PM, Nursing Home Administrator (NHA) A stated that code status was reviewed with each resident/family at admission, code status order was written, and that when a resident was determined to be unresponsive, code status would be checked in the EMR, CPR initiated for a full code, and the in-room code activated. NHA A stated that R2's hospital referral information had indicated that he was a DNR and was receiving hospice services but upon admission to facility, spouse had changed her mind, declined hospice services and that R2 was a full code. NHA A stated that she received a call from DON B on [DATE] at approximately 8:35 AM, was updated regarding confusion over R2's code status, and informed DON B that if R2 was a full code that CPR must be initiated, and EMS called. NHA A stated that she arrived to the unit at approximately 8:50 AM, observed DON B to be on the phone with R2's physician, and RN H at the medication cart. NHA A stated that DON B confirmed R2's full code status with her and that she then notified RN H that R2 was a full code, and that CPR must be initiated. NHA A stated that she obtained the crash cart and that DON A, RN H, and LPN O entered R2's room and initiated CPR. NHA A confirmed that R2 was initially noted to be unresponsive at 6:55 AM but that CPR was not initiated until 8:53 AM and that the expectation would have been that when R2 was initially noted to be unresponsive at 6:55 AM, that his code status should have been verified in the EMR, CPR initiated, code activated, and EMS called. According to the American Heart Association, CPR-or Cardiopulmonary Resuscitation-is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest .Out-of-hospital Chain of Survival .Recognition of cardiac arrest and activation of the emergency response system, Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions, Rapid defibrillation, Advance resuscitation by Emergency Medical Services . (https://cpr.heart.org/en/resources/cpr-facts-and-stats/) Review of the facility policy (in place at the time R2 was observed to be unresponsive) titled CPR dated [DATE] stated, Policy: Upon admission a Scope of Treatment declaration specifying administration or withholding CPR interventions will be completed for each resident. It is the guiding principle of (name of facility) to respect each individual's informed decision regarding advance directives and code status. (Name of facility) ensures that there is at least one qualified American Heart Association (AHA) certified person capable of carrying out cardiopulmonary resuscitation (CPR) in the facility at all times. (Name of facility) must provide basic life support including, initiating CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with the resident's advance directives .CPR will be initiated for residents who have requested CPR .Procedure .The admitting nurse will write a physician order indicating code status preference .4. In the event a resident goes/is found unresponsive and upon a thorough circulation, airway and breathing assessment determines that there is no pulse or respiratory activity AND the resident is declared a full-code status or code status unknown that staff member will activate/announce a code blue . During onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1) Investigation initiated immediately. 2) All residents with full code status have the potential for being affected. 3)All residents currently in facility had code status reviewed and verified the code status matched the order. 4) All residents currently in facility were reviewed for the presence of any wristbands, any found were removed. 5) Nurses involved were immediately provided with verbal education regarding the initiation of CPR. 6) All nurses on duty were reeducated on CPR, following code status orders, and actions when a resident is found unresponsive. 7) Every nurse was educated at the beginning of the shift there after. 8) The Code Status Protocol Policy was reviewed and revised. 9) Mock code drill performed on [DATE]. Monitoring to ensure compliance: 1) Mock code drills to continue weekly x4, then monthly x3. Results presented at QAPI for review and improvement opportunities. 2) All newly admitted residents will be evaluated for wristbands at admission and any found will be removed. 3) Accuracy of code status for new admissions will be audited weekly x4, then monthly x 3. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake MI00132620 Based on observation, interview, and record review, the facility failed to ensure appropriate monitoring of blood glucose (sugar) levels and ensure insulin was administered according to physician's orders for one (Resident #494) of 20 reviewed for quality of care, resulting in insulin not being administered per physician's orders and hospitalization . Findings include: Review of the medical record revealed Resident #494 (R494) admitted to the facility on [DATE] with diagnoses that included atrial flutter, acute kidney failure, hypo-osmolality and hyponatremia, type 2 diabetes, congestive heart failure, epilepsy, anxiety, and long term use of insulin. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/1/22 revealed R494 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R494 was transferred to the hospital on 11/7/22 and did not return to the facility. In a telephone interview on 3/7/23 at 11:38 AM, Family Member (FM) I reported R494 was admitted to the facility with a Freestyle continuous glucose monitor, but that the facility was not familiar with the device so staff used the facility's glucometers to monitor R494's blood sugar levels. FM I reported R494 was sent to the hospital on 11/7/22 and when she checked R494's Freestyle glucose monitor, R494's blood sugars had been 600 all weekend. FM I reported when R494 arrived to the hospital, her blood sugar level was over 1000. A Freestyle Libre includes a small sensor applied to the back of the upper arm with a small tip that is inserted just under the skin. The sensor continuously measures and stores glucose readings. A smartphone app is used to track glucose levels. (https://www.freestyle.abbott/us-en/what-is-cgm.html) Review of the Clinical Admission Evaluation dated 10/25/22 revealed R494 had a glucose meter patch to posterior left arm (placed 10-23 and good for 2 weeks, family to provide replacement) .Declared valuables on admit: Glucometer and charger . Review of the Physician's Order dated 10/25/22 revealed Okay to use client's glucose meter (Freestyle Libre) to monitor blood glucose. Ensure device is charged at night. There was no order to change the monitor after 14 days. The Physician's Order dated 10/25/22 revealed Humalog (short acting insulin) 5 units was to be given before meals for blood sugars of 100-150. If the blood sugar was over 150, the sliding scale was also to be administered. The Physician's order dated 10/25/22 revealed R494's Humalog sliding scale was as follows: 0-200 (blood sugar level) = 0 units (of Humalog) 201-250 = 2 units before meals 251-300 = 4 units before meals 301-350 = 6 units before meals 351-400 = 8 units before meals 401+ Call physician There was no documentation regarding the discrepancy of the scheduled Humalog order indicating the sliding scale started for levels over 150 and the order for sliding scale Humalog starting for levels over 200. On 10/29/22, R494's Lantus (long-acting insulin) was changed from 17 unit daily to 19 units daily. Review of the facility's mealtime provided at survey entrance revealed breakfast was served between 8:00 AM-9:15 AM, lunch was served between 12:00 PM-1:15 PM, and dinner was served between 5:00 PM-6:15 PM. Review of the Medication Administration Records (MARs) revealed R494's blood sugar checks and Humalog insulin was schedule for 7:30 AM, 11:30 AM, and 4:30 PM. The Lantus was scheduled to be administered daily at 9:00 AM. Review of R494's Blood Sugar Summary and MARs revealed the following documented: On 11/5/22 at 12:03 PM, R494's sugar was 243. This was recorded on the MAR in the section for 7:30 AM. On 11/5/22 at 2:18 PM, R494's sugar was 364. This was recorded on the MAR in the section for 11:30 AM. On 11/5/22 at 5:49 PM, R494's sugar was 231. This was recorded on the MAR in the section for 4:30 PM. On 11/6/22 at 8:22 AM, R494's sugar was 253. This was recorded on the MAR in the section for 7:30 AM. On 11/6/22 at 12:30 PM, R494's sugar was 198. This was recorded on the MAR in the section for 11:30 AM. On 11/6/22 at 6:14 AM, R494's sugar was 266. This was recorded on the MAR in the section for 4:30 PM. On 11/7/22 at 07:48 AM R494's sugar was 380. Review of the Location of Administration Report revealed the following late insulin administration times: On 10/29/22 the two Humalog doses (routine and sliding scale) scheduled for 7:30 AM were given at 9:54 AM and 9:55 AM. On 10/29/22 the two Humalog doses scheduled for 11:30 AM were given at 12:52 PM and 12:53 PM. On 10/30/22 the two Humalog doses scheduled for 11:30 AM were given at 12:59 PM and 1:01 PM. On 11/1/22 the two Humalog doses scheduled for 7:30 AM were given at 9:08 AM. On 11/1/22 the two Humalog doses scheduled for 4:30 pm were given at at 5:52 PM and 6:00 PM. On 11/5/22 the two Humalog doses scheduled for 7:30 AM were given at 11:39 AM and 12:04 PM. On 11/5/22 the Lantus scheduled for 9:00 AM was given at 11:27 AM. On 11/5/22 the two Humalog doses scheduled for 11:30 AM were given at 2:18 PM and 2:20 PM. On 11/5/22 the two Humalog doses scheduled for 4:30 PM were given at 5:49 PM. On 11/6/22 the two Humalog doses scheduled for 7:30 AM were given at 8:22 AM and 8:24 AM. On 11/6/22 the two Humalog doses scheduled for 4:30 PM were given at 6:14 PM and 6:16 PM. There was no documentation as to why R494's blood sugars were checked, and insulin administered after scheduled mealtimes. Review of the laboratory results dated [DATE] at 6:04 AM revealed R494's blood glucose was a critically high level of 756 mg/dL (milligrams per deciliter). Normal values were 70-100 mg/dL. The facility's documented blood sugar level on 11/7/22 at 7:48 AM was 380. Review of the Progress Note dated 11/7/23 at 9:29 AM revealed Notified MD [physician] observed patient having Altered mental status symptoms. Ordered to sent [sic] patient out to hospital .Patient left facility at 9:25 AM . The laboratory called the facility on 11/7/22 at 11:51 AM (after R494 transferred to the hospital) to report the critically high laboratory results. There was no documentation as to why there was such a large discrepancy between the laboratory sample that was drawn at 6:04 AM and the facility's level that was checked at 7:48 AM. Review of R494's hospital records dated 11/7/22 revealed R494 was admitted to the hospital for HHS (Hyperosmolar hyperglycemic state)/DKA (Diabetic Ketoacidosis). The hospital records revealed Vital signs in ED include temperature 36.5 (Celsius), heart rate 59, respiratory to 25, blood pressure initially of 94/45 then improved to 128/50 and oxygen saturation at 98% on 3 L nasal cannula (No O2 at home) .blood glucose of >999 .transferred to the ICU for management of insulin drip . High anion gap metabolic acidosis .likely secondary to combination of HHS, starvation ketoacidosis, lactic acidosis. Patient presents from [name of facility] where patient may not have been given timely medication and may have developed HHS with acute encephalopathy leading to starvation ketoacidosis .upon arrival glucose reading was >999. According to the Centers for Disease Control and Prevention (CDC), .Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening .DKA develops when your body doesn ' t have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body .Causes of DKA Very high blood sugar and low insulin levels lead to DKA. The two most common causes are .Illness .Missing insulin shots, a clogged insulin pump, or the wrong insulin dose . (https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html) According to the Cleveland Clinic, Hyperosmolar hyperglycemic state (HHS) is a life-threatening complication of diabetes - mainly Type 2 diabetes. HHS happens when your blood glucose (sugar) levels are too high for a long period, leading to severe dehydration and confusion. HHS requires immediate medical treatment. Without treatment, it can be fatal. (https://my.clevelandclinic.org/health/diseases/21147-hyperosmolar-hyperglycemic-state#:~:text=Hyperosmolar%20hyperglycemic%20state%20(HHS)%20is%20a%20life%2Dthreatening%20complication,treatment%2C%20it%20can%20be%20fatal.) The Progress Note dated 11/8/22 revealed Writer and additional manager called and spoke with client's daughter about questions and concerns that were raised after her mother was sent out to the hospital .daughter had requested her coat and freestyle libre [glucose monitor] be sent with her to the ED [Emergency Department]. Daughter had asked for clarification on blood sugar checks throughout the weekend. Writer reviewed numbers that were documented .Client's daughter stated that her freestyle Libre was reading high throughout the weekend. Writer informed daughter that when there was a question about the accuracy of the Freestyle libre the nurses checked a finger stick for blood sugar levels and treated per order with insulin. Writer also reviewed labs that were drawn on day of hospitalization . In an interview on 3/7/23 at 2:20 PM, RN/Unit Manager (UM) F reported she spoke with R494's daughter on 11/8/22. UM F reported if she remembered correctly, the nurse was double checking R494's sugar levels with the facility's glucometer because the nurse questioned the accuracy of the Freestyle Libre. UM F stated our numbers differed from what the Freestyle said. UM F reported on 11/4/22 R494's laboratory drawn glucose level was 392 and on 11/7/22, it was 756. UM F reported R494's Humalog insulin was scheduled before meals at 7:30 AM, 11:30 AM, and 4:30 PM, but staff had an hour window either way, indicating the insulin could be given as early as 6:30 AM, 10:30 AM, and 3:30 PM or as late as 8:30 AM, 12:30 PM, and 5:30 PM. When asked about the accuracy of the facility's glucometer and quality controls, UM F reported quality controls on glucometers were performed weekly on midnights. UM F reported the logs were kept in the controlled substance sign out books. UM F was unable to locate any quality control logs on the second and third floors of the facility. Review of the glucometer quality control binders at each of the nurse's station on the first floor revealed one binder did not have any documented quality controls and the other binder had two documented quality controls on 12/16/2017 and 1/1/2018. There were no further documented quality controls. On 3/6/23 at 4:31 PM, Registered Nurse (RN) J performed a blood glucose check on a resident. The glucometer strips had an opened date of 2/20/23. When asked about quality controls, RN J reported night shift performed the quality controls and that they were never performed at any other time. RN J reported if the glucose levels seem to be off, she would get a new glucometer. On 3/7/23 at 7:58 AM, RN K reported the facility performed quality controls on glucometers every 30 days, however RN K was not able to verbalize the procedure. On 3/7/23 at 2:06 PM, RN K reported she educated herself on the process. RN K reported quality controls should be performed each time a new bottle of strips was opened, the glucometer was dropped, or the glucometer seemed to not work properly. Two unopened boxes of quality control drops were observed in the medication room. RN K reported there were no quality control logs. In an interview on 3/7/23 at 1:54 PM, Licensed Practical Nurse (LPN) C reported she believed night shift performed the glucometer quality controls. LPN C was unable to find any further documented quality controls. In an interview on 3/7/23 at 2:17 PM, LPN L reported she did not know how to perform quality controls on the glucometers. In an interview on 3/7/22 at 3:02 PM, Director of Nursing (DON) B reported glucometer quality controls should be performed daily on night shift. When asked where the quality controls were documented, DON B reported she would have to check with the Unit Manager. In a telephone interview on 3/7/23 at 4:19 PM, LPN M reported dayshift had never performed quality controls on glucometers and believed it was a nightshift task. LPM M reported she recalled a resident with a continuous glucose monitor that would report the levels to a phone. LPN M reported she documented those numbers in the medical record instead of using the facility's glucometer. LPN M reported on 11/7/22, R494's sugar level was reading high on the Freestyle Libre and R494 had to be transferred to the hospital. LPN M reported when she checked R494's sugar with the facility's glucometer, the level was in the 300s. LPN M reported R494 was not her normal self around 8:00 AM on 11/7/22 and stated, something was wrong. In a telephone interview on 3/8/23 at 9:13 AM, RN N reported she was not aware of the facility's process of quality controls on glucometers. RN N reported she knew there were testing strips and solution but was not aware of how to perform or when to perform quality controls. When asked about late blood sugar checks and insulin administrations for R494, RN N reported there were always concerns with the heaviness [of the workload] of certain sections which caused issues with blood sugars and insulin administration. RN N reported she had to administer insulin late because the workload was too heavy. RN N reported there were also times when lunch trays were not served until 1-1:30 PM and then dinner was served at 5:00 PM. RN N reported R494's insulin was obviously late if it's documented on the MAR like that. In a telephone interview on 3/8/23 at 10:36 AM, LPN P reported it was a struggle to get meds [medications] and assessments done on time. LPN P reported on weekends there were always scheduling issues to deal with in the middle of medication pass which resulted in late medication administrations. LPN P reported they were not familiar with the Freestyle Libre, yet they had cared for R494. Review of the facility's glucometer (Assure) Quality Assurance/Quality Control (QA/QC) Reference Manual revealed You should check your meter and test strips using Assure Prism Control Solutions (Control 1 and 2). Assure Prism Control Solutions contain known amounts of glucose and are used to check that the meter and the test strips are working properly .Before using a new meter or a new vial/box of test strips, you should conduct a control solution test following the procedure with two different levels of solutions (Control 1 and 2) .You should do a control solution test: -To practice the test procedure using the control solution instead of blood. -When using the meter for the first time. -Whenever a new vial of test strips or box of individually wrapped test strips is opened. -If the meter or test strips do not function properly. -If the patient's symptoms are inconsistent with the blood glucose test result and you feel that the meter or test strips are not working properly. -If the meter is dropped or damaged. In an interview on 3/8/23 at 1:01 PM, DON B reported when R494 was admitted to the facility, it was the first time she or any of the nurses had a resident with a Freestyle Libre continuous glucose monitor. DON B stated, We didn't have a policy and procedure for that. DON B reported she decided the facility would use their own glucometers instead of using R494's Freestyle Libre so that staff would not have to access R494's smartphone. When asked if the Freestyle Libre sensor/monitor was changed after 14 days, DON B stated, couldn't tell you. DON B reported staff had an hour leeway for medication administration and was not sure why R494's glucose was checked, and insulin was given late, after meals.

This citation pertains to intake MI00129402. Based on interview and record review, the facility failed to ensure residents were free from significant medications errors in one of 5 reviewed for medication regimen review (Resident #93), resulting in medication order changes, laboratory blood draws, intravenous fluids, and weight loss. Findings include: Resident #93 (R93) In review of R93's Minimum Data Set (MDS) assessment dated [DATE], he was [AGE] years old, was admitted to the facility on [DATE], had severely impaired cognition, his pain was assessed based on non-verbal sounds (crying, gasping, moaning). R4 had a diagnosis of stroke, seizure disorder, communication deficit, and high blood pressure. R93's MDS dated [DATE] revealed his death occurred in the facility. Physician Order for R93 dated 2/28/22 revealed Oxycodone Hydrochloride (HCl) (opioid) solution 5 milligrams (MG)/5 milliliters (ML), give 5 mg by mouth every 4 hours for pain; order to hold medication from 03/07/22 at 5:52 PM to 03/08/22 5:51 PM. In review of a Medication Error incident report dated 3/07/22 at 4:58 PM, R98 received a greater dose than ordered on 4 occasions by 2 different nurses. The same report indicated the nurse had received a code from the pharmacist to remove oxycodone medication from the back-up supply; R93's oxycodone order was a different concentration than what was available in the back-up pharmacy supply. Nurses progress note dated 3/07/22 at 5:41 PM revealed after looking closer at the oxycodone bottle and R93's order, she had noticed R93 had received a larger dose than ordered for 4 doses. The same noted indicated the pharmacist and physician were notified; orders received to hold oxycodone and monitor respiratory status. The same noted indicated R93's respiration rate was 16 (normal 12 to 20 breaths per minute). Controlled Substance Proof-of-Use Record dated 3/07/22 revealed a handwritten order under R93's name: oxycodone HCL oral solution 100 mg/5 ml, 20 mg/5 ml; Give 1 teaspoonful (5 mg) by mouth every 4 hours. The same form indicated on 3/ 07/22, R93 received 5 ml of oxycodone HCL at 1:55 AM, 5:45 PM, 8:00 AM, and 1:00 PM. R93 received 400 mg of oxycodone HCL over an 11-hour period (R93 should have received 20 mg of oxycodone). The same form indicated R93 received 100 mg of oxycodone HCL at 5:45 AM, and received another dose at 8:00 AM, less than 4 hours between doses. The 3/07/22 dose at 8:00 AM was given 2 hours and 15 minutes between doses. Medication Error incident report dated 3/07/22 at 4:58 PM did not indicate the medication was also administered at the wrong time. Nurses Progress Note dated 3/08/22 at 5:00 AM indicated the physician was notified, one time Reglan (speeds up muscle movements in gut to relieve stomach related symptoms) was ordered and administered. A chest x-ray was ordered. R93's respirations were irregular, 10 to 11 breaths per minute. Lung sounds were abnormal. Interdisciplinary team note dated 3/08/22 at 7:49 AM indicated a medication dose error noted, R93 was at baseline with minimal verbal communication, minimal signs and symptoms of pain or discomfort. Root cause of medication error was a discrepancy in dosage from order and back up from pharmacy. Interventions/follow up included increased monitoring, and STAT labs ordered. Interdisciplinary Note dated 3/09/22 at 10:59 AM indicated R93 had weight loss at 3.6 percent (%) over 7 days, loss due to poor oral intake (average less than 25 % of meals) and discontinuing his tube feeding. The same note indicated R93 current body weight was 124.8 pounds. Physician Progress Note dated 3/10/22 revealed R93 had inadvertent overdose of oxycodone over the weekend due to a change in formulation from 5 mg/5 ml to100 mg/ 5 ml. Opiate was held initially and was resumed only as needed. The same note indicated R93 was less alert on 3/10/22, and it was suspected that it was related to decreased nutrition, fluids, and medications. R93's potassium level was low on this same day and potassium medication was increased on 3/10/22. The same note indicated the physician spoke with the dietician about carefully resuming tube feeds at a slow rate and ramp up carefully over the weekend and next week, watching for aspiration. Plan was to follow daily labs and monitor for electrolyte abnormalities/re-feeding syndrome. The 3/07/22 Medication Error report indicated as a result of the oxycodone overdose, R93 had orders for a laboratory blood draws, chest x-ray for aspiration concern, abdominal x-ray for nausea and absence of urine/bowel movement, intravenous fluids were administered, and continued resident monitoring. Registered Nurse (RN) J was interviewed on 3/08/23 at 11:02 AM and recalled the night shift nurse received an order from an on-call physician and removed the medication from the pharmacy back up. The night nurse wrote information on the control sheet of how much to give. The oxycodone dose was different than what the facility normally used. Director of Nursing (DON) B was interviewed on 3/08/23 at 1:31 PM and stated there had been no educational in-services on medication error prevention since she was DON (hired 8/01/22). DON B indicated performance reviews and competencies were to be completed annually but had not completed any yet since date of hire. Any recent medication pass observations/education was requested from DON B at this same time. DON B provided a medication pass quiz for RN J that was not dated. In review of RN J employee file, the last medication pass observation was completed on 1/21/21.

Based on observation, interview and record review the facility failed to, (1) timely notify the physician of continued elevated fever, pulse, headache, confusion, agitation for Resident (R86); (2) answer call lights in a timely manner for 5 of 9 residents from confidential resident group; (3) maintain proper care planned positioning for Resident (R30), resulting in delayed emergency services, uncontrolled pain, [CONDITION(S)], and increased likelihood of unmet care needs. Findings include: Resident #86 (R86) According to the facility, Change of Condition Policy and Procedure, dated 5/13/18, reflected, POLICY: When a resident is assessed as having a change of condition, the licensed nurse will follow through in documenting notification to family/responsible part, the physician and other licensed nurses who shall be caring for the resident. PURPOSE: To provide a current report of changes to the residents care for all staff . Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R86 was a [AGE] year old male admitted to the facility on [DATE], with recent transfer to hospital 11/3/21 and re-admission 11/13/21 post severe [CONDITION(S)] and brain abscess, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R86 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required two person physical assist with bed mobility, transfers, locomotion on unit, dressing, toileting, hygiene, bathing and one person physical assist with eating. During an observation and interview on 11/15/21 at 2:30 p.m., R86 was laying in bed with R86 mother Z visiting at bedside. R86 appeared calm and pleasant and able to answer questions. R86's Mother Z reported R86 had recent transfer to the hospital after complications post cranial bone flap procedure. R86 Mother Z reported on 11/2/21 was very concerned when R86 developed a fever and sudden onset of headache and increased agitation. R86 Mother Z reported Registered Nurse (RN) AA, that was working day shift 11/2/21, made several attempts to transfer R86 to the hospital but was advised by management and providers to continue to monitor R86 after informing them Tylenol had not been effective to lower fever. R86 Mother Z reported R86 was transferred to the hospital 11/3/21 and admitted related to [CONDITION(S)] and brain abscess and had emergency bone flap removal procedure and returned to the facility 11/13/21. R86 Mother Z reported had requested R86 be tested for Covid-19 during the day shift on 11/2/21 and reported felt like long delay for staff to perform test. R86 Mother Z was upset that she had not insisted that R86 be sent to the hospital on 11/2/21 or called 911 because she knew something was wrong. Review of the Nursing Progress Notes, dated 11/2/2021 at 5:00 p.m., for R86, reflected, RN called [named Nurse Practitioner (NP) CC], regarding the fact that resident remains febrile despite receiving both PRN and scheduled doses of Tylenol. Also informed NP that resident c/o severe HA over prior craniotomy area that has now been replaced with a prosthetic portion of skull roughly 2 weeks ago. NP states, Well, we'll just continue to monitor him for now and see if the Tylenol helps at all. NP also informed RN that she is not on call, as she is ill, thus, [named PA BB has been assigned call for [named physician DD] group. Review of the Nursing Progress note, dated 11/2/2021 at 5:40 p.m., reflected, RN called [named Physician Assistant (PA) BB], as resident [R86] continues to decline, and now has increased agitation and acute mental status changes. [Named PA BB] ordered STAT CBC, CMP, and Procalcitonin. Also ordered blood glucose check, and to bladder scan resident to check for [CONDITION(S)]. States to call back if resident continues to decline. Note was written by RN AA. Review of the Nursing Progress note, dated 11/2/2021 at 6:00 p.m., reflected, RN talking with resident's mother, who is at bedside. Mother of resident (R86) states that she would like us to call resident's neurosurgeons office, which is [Named Neurosurgeon] to let them know what is going on. RN placed call to office and left voicemail for on-call RN to please call back. Details regarding resident's condition were left in voicemail as well. Note was written by RN AA. Review of the Nursing Progress note, dated 11/2/2021 at 6:30 p.m., reflected, on-call RN from resident's neurosurgeon office returned RN's phone call. States that if resident (R86) continues to decline (i.e. remains febrile despite treatment with anti-pyretics and continued acute mental status changes, it would be best to send him to the ER for emergency MRI. States to continue to monitor resident for now. This information was communicated to resident's mother. Review of the Nursing Progress Note, dated 11/2/2021 at 7:00 p.m., reflected. RN has continued discussion with resident's mother regarding his[R86] current condition. Resident's mother is asking if it would be wise to perform rapid COVID test. RN agrees that it may be best, considering resident's condition. RN informed resident's mother that will place a call to [named DON B regarding this issue. Note written by RN AA. Review of the Nursing Progress Note, dated 11/2/2021 at 8:10 p.m., reflected, RN placed call to [named Director of Nursing (DON) B]regarding resident's mother's request for rapid COVID swab. [Named DON B] is agreeable to this. States she will have [named Night Nurse Supervisor R], night shift supervisor complete this test. This information was communicated to resident's mother, who states that she is relieved that we are testing for COVID. Note written by RN AA. Review of the Nursing Progress Notes, dated 11/2/2021 at 9:20 p.m., reflected, Writer performed [MEDICATION(S)] text per residents mothers request. Test was negative, mother and resident were notified as well as DON. Review of the Administration Notes, dated 11/3/21 at 12:40 a.m., reflected R86 was given as needed Tylenol 500 mg that was not effective. Review of the Nursing Progress Notes, dated 11/3/21 at 2:53 a.m., for R86, reflected, Writer assessed resident due to increased temp and agitation. Resident was resting well in bed, no signs of agitation or AMS, BP134/72 HR 105 T 101 Spo2 93% on RA. Notified nurse in charge of resident. Will monitor. Review of the Administration Note, dated 11/3/21 at 4:49 a.m., reflected R86 was given as needed Tylenol 500 mg. Review of the Nursing Progress note, dated 11/3/21 at 7:23 p.m., for R86, reflected, Res had temp of 100 this am, having anxiety and pain. N.O. to send to [named hospital] ED for eval. POA notified and agrees. Res. transported via [named ambulance service]at 1025. 100 129 18 127/90 O2 sat 95% on room air. Review of the R86's Vitals, dated 10/25/21 through 11/1/21, reflected heart rates between 66 and 85 beats per minute and temperatures between 96.4 and 98 degree Fahrenheit. Review of R86's heart rates, dated 11/2/21 through 11/3/21, reflected four documented heart rates greater than 129 and ranged from 103 to 136 beats per minute and three temperatures greater than 100 and ranged from 99.3 to 101.1 degrees Fahrenheit. Review of the Nursing Progress Notes, dated 11/2/21 at 6:30 p.m. through 11/3/21 at 10:25 a.m., reflected no documentation that Physician had been contacted about continued symptoms including elevated temperature and heart rate with continued use of Tylenol. Review of the facility Transfer Form, dated 11/3/21, reflected R86 had an unplanned transfer to the hospital at 10:35 a.m. related to fever and was a full code. Review of the Hospital Discharge Summary, dated 11/13/21, reflected discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R86's History and Physical, dated 11/15/21, reflected, [Named R86] is seen after readmission to [named hospital] for [CONDITION(S)] related to abscess at bone flap site. He has history of MI requiring CABG in 12/20/20, follow by R MCA hemorrhagic [CONDITION(S)] that required craniotomy in 1/2021 .He then transitioned to LTC at [named facility] and awaited stability so as to have bone flap procedure. This was performed on 10/6/21 and he did quite well during the immediate post-operative period. However, his mom noticed he was starting to lean to the LEFT side again and within 1-2 more days he was noted to have new onset HA(headache), fever, and AMS. He was sent to the ER and imaging revealed fluid collection at the bone flap site. He was taken for removal of flap on 11/5/21 .Surgical cultures were + for [CONDITION(S)] . During an interview on 11/17/21 at 12:30 p.m., Registered Nurse Unit Manager (UM) C reported was Unit Manager for 2nd and 3rd floor for about one month and reported R86 lived on the third floor. UM C reported was not aware of R86's condition until arrived for shift on 11/3/21 morning and worked on 11/2/21. Was informed by staff on 11/3/21 that R86's Neurologist had been called and reported told staff they were not waiting to transfer R86 to the hospital. UM C reported R86 complained of headache, had increased agitation, yelling out and fever. UM C reported called R86's mother as soon as she arrived on 11/3/21 around 9:30 a.m. and informed of R86 condition and plan to transfer to the hospital. During an interview on 11/17/21 at 1:06 p.m., MDS Coordinator/3rd Floor assistant Unit Manager (UM) EE reported working at the facility for over ten years as MDS coordinator. UM EE reported was assisting as 3rd Floor Unit Manager for last month. UM EE reported he mostly assisted with answering call lights, assist staff, assist family and often filter issues. UM EE reported UM C was 2nd floor Unit Manager and covering as 3rd floor Unit Manager and often dealt with the clinical issues. UM EE reported had not heard about R86's condition until after R86 had already transferred to the hospital on 11/3/21. UM EE reported R86 had increased pain, very restless and need for frequent position changes on 11/3/21. UM EE reported facility staff must contact doctor and get an order to transfer a resident to the hospital unless it is an emergency. During an interview on 11/17/21 at 2:22 p.m., DON B reported had received call on 11/2/21 at 8:17 p.m. from RN AA and was informed of R86's Family Z was concerned about R86's fever after Tylenol was not effective. DON B reported was informed that the Neurological Surgery Physician on call nurse had been notified and that R86's Mother had requested Covid-19 test for R86. DON B reported would expect nurse staff to contact Physician prior to sending residents to to hospital. DON B verified R86's Medical Record did not reflect documentation after 11/2/21 at 6:30 p.m. that physician was notified of scheduled and as needed dose of Tylenol administered and not effective with continued symptoms of fever, elevated heart rate, restlessness, increased agitation and headache through 11/3/21 day shift. DON B reported nursing staff should have reported R86's continued fever, pain, and elevated heart rate to the Physician after Tylenol continued to not be effective between 11/2/21 at 6:30 p.m. and 11/3/21 at 10:25 a.m. when R86 was transferred to the hospital and documented in Progress Notes. During a telephone interview on 11/18/21 at 8:56 a.m., RN AA reported had noticed R86 had elevated temperature of 101.5 on 11/2/21 in the morning. RN AA reported had administered Tylenol and re-evaluated R86 about 1.5 to 3 hours later and R86 had a temperature of 102.4, with increased anxious, diaphoretic, and not acting himself and R86's mother was at bedside. RN AA reported called Nurse Practitioner CC and Physician Assistant BB and received orders for labs. RN AA report had informed providers of elevated fever after both scheduled and as needed doses of Tylenol had been administered, mental changes, and head ache. RN AA reported was given orders to monitor. RN AA reported R86's mother Z was worried about R86 changes and asked about calling the ambulance. RN AA reported called Neurosurgeon office and spoke with nurse on call who advised to continue to monitor R86. RN AA reported asked, Do we want to sent to ER? RN AA reported on call nurse advised to monitor and if no change could transfer R86 to the hospital. RN AA reported was the end of the shift and reported to Nurse Supervisor R. RN AA reported found out later that R86 was admitted to the hospital 11/3/21 with [CONDITION(S)] brain abscess. RN AA reported spoke with UM EE on 11/15/21 about concerns she had with R86 change in condition on 11/2/21 who told her nurses could call Emergency Medical Services if needed but had always been told in past to get an order from the Physician first. In an observation on 11/15/2021, at 10:22 AM, a resident room on the 100 hall was observed with the room call light on, as indicated by the light being lit up outside of the room door. During the observation five staff members were observed to walk past the lit up call light and all five did not stop to answer the call light. In an observation on 11/16/2021, at 8:50 AM, resident room [ROOM NUMBER] was observed to have the call light turned on, as indicated from the light being lit up outside of the room, and an audible call bell sounding. Three staff members were observed to pass room [ROOM NUMBER], however, none of the three staff members stopped to answer or address the call light. Two nurses were observed standing at two different medication carts that were observed to be directly across the hall from room [ROOM NUMBER], however, neither nurse responded to the call light, or requested another staff member to answer the call light. In an observation on 11/16/2021, at 11:24 AM, resident room #'s 101 and 103 were observed with the call lights lit up, and had the audible call bells sounding. Two staff members were observed to walk past both of the two rooms, however did not answer or address the call lights. At 11:25 AM another staff member was observed to walk past both rooms [ROOM NUMBERS], but did not to answer the two call lights. Another staff member was also observed to be sitting at the nursing station down, but did not respond to either 101 or 103's call lights sounding. In an interview on 11/17/2021, at 1:59 PM, Director of Nursing (DON) B stated that her expectations were that all staff, nurse aides and nurses, were to answer or respond to resident call lights. Record Review of the facility policy and procedure, titled Resident Call light and Staff response, dated 10/15/2019, revealed the Purpose of the policy was To ensure a residents needs are accommodated, and under Procedure the policy revealed, #2) All staff members are responsible for answering resident call lights. Resident #30 (R30): Per R30 Electronic Medical Record (EMR) he was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an observation on 11/15/2021, at 9:55 AM, R30 was observed in his room sitting up in a recliner leaning to the right side with his head leaning forward. Another brown recliner was observed in R30's room, next to the recliner chair R30 was sitting in, that had a sign attached to it that read, Use (facility) recliner for positioning, and Place a pillow on each side to prevent leaning. No pillows were observed to be on either side of R30 in the recliner he was sitting in. In an observation on 11/16/2021, at 08:28 AM, R30 was observed sitting in his recliner without pillows on each side, and was also observed to be leaning forward and to his right side while asleep in the recliner chair. Certified Nurse Aid (CNA) U entered into R30's room during the observation and pulled R30 up in his recliner chair, however CNA Udid not place pillows on each side of R30 for positioning and prevention of leaning prior to exiting his room. In another observation on 11/16/2021, at 8:52 AM, R30 was observed sitting up in his recliner. R30's head was observed to be leaning forward towards his lap and to his right side. No pillows were observed to be in place on either side of R30. In an observation on 11/16/2021, at 11:12 AM, R30 was observed to be sitting in his recliner chair, with his head tilted forward and leaning to his right side. No pillows were observed to be in place on either of R30's sides. CNA U was observed to enter R30's room again, and clean and clip his fingernails. Upon CNA U completing the task R30 remained sitting up in his recliner, and prior CNA U exiting his room she did not place pillows on either of R30's sides. In an observation on 11/16/2021, at 12:45 PM, R30 was observed to be sitting up in his recliner. R30's head was observed to be bent downwards towards his lap, and he was leaning to his right side. No pillows were observed to be in place on either side of R30 for proper positioning. In another observation on 11/16/2021, at 12:58 PM, R30 was observed to be sitting in his recliner leaning to his right, with his head lying on the right arm rest of the chair. No pillows were observed to be in place on either side of R30 for positioning. In an observation on 11/16/2021, at 2:36 PM, R30 was observed sitting in his recliner and was leaning to his right side, with his head resting on the arm of the chair. No pillows were observed to be in place on either of R30's sides for positioning. In an observation on 11/17/2021, at 8:27 AM, R30 was observed to be sitting up in his recliner, and was leaning to his right side. No pillows were observed to be in place on either side of R30 for positioning. Continued observation on 11/17/2021, at 08:31 AM, revealed R30 remained sitting in his recliner in his room, eating his breakfast that was on his over the bed table. No pillows were observed to be on either side or R30 for positioning. Review of a care plan in place for R30 titled, ADL (activities of daily living) deficit r/t (related to) Deconditioning, and was dated 06/03/2021.The care plan revealed an intervention that R30 was independent when eating, however revealed, .patient (R30) to sit in w/c (wheelchair) with R (right) lateral (side) support for proper positioning during all meals. The care plan also revealed an intervention that R30 was to have a SOFT CERVICAL COLLAR for head/neck positioning: on when up in recliner, off for meals and when in bed. Observation on 11/16/2021, at 1:13 PM, revealed the soft cervical collar was in R30's room closet. The soft cervical collar had not been observed to be on R30 during any of the observations made on 11/15, 11/16, or 11/17/2021. Further review of R30's care plans revealed R30 was at risk for falls, and had a care plan in place titled, The resident (R30) is at risk for falls r/t (related to) history of falls due to Confusion and Gait/balance problems related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan was dated as initiated on 5/31/2021, and revised on 6/1/2021. The care plan revealed an intervention of, Trial use of (facility) recliner instead of personal recliner to address positioning, if patient leans to the side place pillow on that side. The intervention was dated 10/5/2021. In an interview on 11/17/2021, at 8:49 AM, Occupational Therapist (OT) V stated that the brown recliner chair in R30's room was his own personal recliner, and stated that the recliner R30 sat in was the facility's recliner. OT V said R30 always would lean to his right side while sitting in the recliner, and stated that the cervical collar was used but that was only used if he wanted to wear it., OT V stated that R30 was at risk for contractors due to his leaning to his right and poor positioning while sitting in his recliner chair. OT said the therapy department had placed the note on R30's own personal recliner, the brown recliner, obtained the facility recliner because R30 was safer sitting in the facility's recliner than his own recliner. OT V said the pillow placement on each side of R30 while he was sitting in the recliner was necessary for when he would lean to the right side. In an interview on 11/17/2021, at 9:03 AM, Registered Nurse (RN) W said R30 was supposed to have pillows on both sides of him while he was sitting up in the recliner chair. In an interview on 11/17/2021, at 9:11 AM, CNA U stated she had cared for R30 for the past two weeks, and said she had never placed or seen pillows on either side of R30 while he sat in his recliner chair for positioning, nor had she ever seen nor place a soft cervical collar on R30. CNA U said the only way she knew the care needs for R30 was when she would receive report on the residents she was going to care for from the off going CNA. CNA U stated that she was aware R30 had a Kardex in place in his EMR, however stated that she was not able access to R30's Kardex to review it, because she did not have the code to unlock the computer tablet where the Kardex information was stored, and did not have a printed copy of R30's Kardex. CNA U said this was because she was agency staff (staff not employed by the facility, but employed by an agency that provide staff for work hours at the facility), and not employed by the facility, therefore she had to ask a staff member to put in the code if she wanted to access a resident's Kardex. In an interview on 11/17/2021, at 9:18 AM, Director of Nursing (DON) B stated that she expected that all the CNAs, including agency staffed CNAs, to review all resident Kardex's prior to providing care for a resident. DON B said R30 would lean to much to his right side while sitting in his personal recliner. DON B said the idea was for R30 to sit in the facility's recliner for proper positioning. DON B said R30's plan of care was for him to trial the use of the facility recliner, and place pillows on R30's right side if he leaned to the right while in sitting in the recliner, and stated that was a therapy intervention. DON B also stated that the soft cervical collar was to be placed on R30 while he was sitting up in the recliner, and taken off for meals. Record review of R30's Kardex that was in place revealed the intervention of, SOFT CERVICAL COLLAR for head/neck positioning: on when up in recliner, off for meals and when in bed., and Trial use of (facility) recliner instead of personal recliner to address positioning, if patient leans to the side place pillow on that side. was listed on his Kardex as part of his plan of care for CNA's to follow. Review of the Resident Council Minutes dated 10/26/2021 reflected 3 of 8 residents complained of staffing levels and call light response time. On 11/16/2021 at 10:30 am, during the Resident Council meeting, 5 of the 9 residents that participated reported their call light was routinely left on for over an hour , another resident reported he is left alone in the bathroom on the toilet and he will frequently wait over 30 minutes for someone to help him off the toilet. The 5 residents that shared the concern reported that while their call light is on, they can see staff (Nurses and Certified Nursing Assistants) standing in the hall or at the Nurses station, the 5 residents all stated they overhear staff talking about who their significant others, their kids, their weekend plans etc all while they are waiting for help. The 5 residents all stated they find this extremely frustrating and have complained previously.

This citation pertains to MI 871 and MI 537. Based on interview and record review, the facility failed to ensure interventions were in place to prevent accidents in 2 (Resident #6 and #7) of 3 reviewed for falls, resulting in a wrist fracture (Resident #6) and [MEDICAL CONDITION] along with facial injuries (Resident #7). Findings include: Resident #6 (R6) R6's Admission Minimum Data Set (MDS) assessment, indicated she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance based cognitive screener for nursing home (NH) residents, score of 14 (13-15 Cognitively intact). The same MDS indicated R6 required limited assistance (resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight bearing assistance) in bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), and walking in her room. R6's Care Plan dated 6/23/20 indicated she was at risk for falls due to a history of falls and [MEDICAL CONDITION] (temporary loss of consciousness caused by a fall in blood pressure). physician progress notes [REDACTED]. R6's Post Fall Investigation indicated she was getting ready for her son to pick her up for an appointment at 9:00 AM on 7/06/20, and at 8:45 AM, sustained an unwitnessed fall. The same report indicated R6's blood pressure was 110/55 (120/80 considered normal) at 8:15 AM. R6's July 2020 Medication Administration Record [REDACTED]. According to drugs.com, common side effects include dizziness, low blood pressure, and orthostatic [MEDICAL CONDITION]. Neurological Evaluation Flow Sheet, handwritten and dated 7/06 revealed R6's blood pressure, right after her fall, at 8:45 AM was 88/48. R6's blood pressure was not transferred to the post fall evaluation information. The same sheet indicated R6 left for her appointment at 9:00 AM and did not return until 3:30 PM. Neurological assessment checks were not re-started until 7:00 PM. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019, indicated A previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls. Post Fall Evaluation revealed R6 fell again on 7/06/20 at 8:40 PM while attempting to transfer from her wheelchair to her bed. In a staff statement dated 7/08/20, Licensed Practical Nurse (LPN) M assigned to R6 at the time of the fall on 7/6/20 at 8:45 AM, indicated R6 complained of mild pain to her left wrist following her fall. In a staff statement dated 7/08/20, LPN N indicated R6 had no complaints of pain following her fall on 7/6/20 at 8:40 PM and following her fall a sensor alarm device was immediately implemented. R6's Incident Report dated 7/08/20 at 8:40 PM indicated several hours following the second fall, R6 complained of pain in her left upper extremity. In her Staff Statement dated 7/08/20, LPN M indicated on 7/07/20 it was reported to her from the off-going nurse that R6 was complaining of pain. The same statement indicated the physician was in to assess R6's left wrist and gave orders to contact him if pain worsened. Orders were received a few hours later for a stat x-ray on 7/6/20 of R6's left wrist. Radiology Report dated 7/07/20 revealed R6 had a fracture of her left wrist. Fall investigation dated 7/08/20 indicated orders were received to transfer R6 to the hospital for evaluation and treatment. physician progress notes [REDACTED]. The same note indicated staff reported R6 had periods of time where she was painful. The same noted indicated the visit was about 10:00 AM, R6 was lying in bed and had not had anything to eat. The same note under plan indicated the physician had talked to the nurse about getting R6 up and feeding her one-on-one. The plan also included decreasing R6's [MEDICATION NAME], adding pain medication ([MEDICATION NAME] 15 milligrams) on an as needed basis, discontinuing Atorvastatin (cholesterol medication), and decreasing Mermantine (cognition enhancing medication). Director of Nursing (DON) B was interviewed on 2/25/21 at 8:40 AM and stated the immediate intervention put in place after R6's fall on 7/06/20 at 8:45 AM was to assess orthostatic blood pressures beginning the next day on 7/07/20. DON B stated she was not able to determine that the physician was notified of R6's 88/48 blood pressure following her fall on 7/06/20 at 8:45 AM. DON B confirmed R6 had orthostatic blood pressures assessed on 6/23/20 through 6/26/20. DON B stated the nurse would have put a note in for the physician to assess if orthostatic blood pressures were abnormal. There was not an immediate invention in place to prevent a reoccurrence of a fall later the same day. During the same interview DON B stated the facility's policy for orthostatic procedure was to wait a minimum of 5 minutes before taking the blood pressure after position change. R6's June 2020 MAR indicated [REDACTED] history of positive orthostatic blood pressure for 3 Days, start date was 6/23/20 at 7:30 PM. Blood Pressure's documented on R6's June 2020 MAR, reflected a lying, sitting, and standing blood pressure, in all positions was never documented. The same MAR indicated [REDACTED]. According to Nursing 2005's article titled Assessing for orthostatic [MEDICAL CONDITION], Nursing2005: January 2005, Volume 35, Issue 1, page 30; retrieved from https://journals.lww.com/nursing/Citation/2005/ /[MEDICAL CONDITION].aspx; wait two to three minutes after position change (lying to sitting, sitting to standing) to obtain the blood pressure and pulse. R6's MDS revealed she was discharged on [DATE]. Resident #7 (R7) R7's MDS admission assessment dated [DATE] indicated she was admitted to the facility on [DATE] and her cognitively skills for daily decision making were moderately impaired (decisions poor; cues/supervision required). The same MDS assessment dated [DATE] revealed R7 required extensive (staff provided weight-bearing support) assistance of two plus persons physical assist for bed mobility, transfers, dressing and personal hygiene. The same MDS indicated R7's primary medical condition were debility and cardiorespiratory conditions; and she had the [DIAGNOSES REDACTED]. MDS dated [DATE] reflected R7 had a history of [REDACTED]. Incident Report and facility fall investigation indicated R7 fell on [DATE] at 4:13 PM; R Certified Nurse Assistant (CNA) alerted the nurse R7 was lying on her left side, on the floor between the bed and window. The same investigation report indicated R7 had been last seen in her bed, she had removed her tab alarm prior to the fall, and fell to the floor. R7's February 2020 Treatment Administration Record (TAR) indicated an order for [REDACTED]. R7's 2/29/20 fall investigation revealed the nurse's witness statement that R7 had a history of [REDACTED]. The same statement indicated the nurse could not recall the last time she had seen R7's fall mats in her room. The same note indicated the Director of Nursing provided education on importance of following the plan of care. Licensed Practical Nurse (LPN) C was interviewed on 2/24/21 at 3:15 PM and confirmed R7's floor mats were not in place per care plan prior to her fall from bed on 2/29/20. LPN C stated R7's alarm was not sounding at the time of her fall and confirmed R7 had a history of [REDACTED]. Situation/Background/Assessment/Recommendation (SBAR) Transfer to emergency room (ER)/Appointment dated 2/29/20 and signed as completed on 3/01/20, revealed R7 had sustained a large, hardened hematoma on her forehead and her nose was red and swollen. R7's skin assessment prior to transfer indicated she had various bruising some healing from previous falls. The same form indicated the time of transfer was 2/29/20 at 5:05 PM. R7's hospital record dated 3/01/20 revealed she had an orthopedic consultation in which revealed she had some slight tenderness at the tip of her trochanter (near hip bone joint). R7's hospital record revealed a computerized tomography (CT) scan showed an isolated greater trochanteric fracture with some gapping, was unable to determine the exact age and recommended to follow-up was as needed. R7's hospital records revealed she returned to the facility on [DATE] and had a [DIAGNOSES REDACTED]. R7's hospital discharge instructions dated 3/01/20 included [MEDICATION NAME], pain medication to be administered as needed. R7's Medical Certificate of Death and discharge MDS assessment, dated 9/28/20, revealed her death in the facility, due to COVID-19 infection.

This Citation pertains to Intake MI 255. Based on interview, and record review, the facility failed to implement care planned interventions for 1 (Resident #200) of 2 residents reviewed for falls, resulting in Resident #200 being transfered improperly and sustaining multiple fractures. Findings include: Review of the Medical Record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 was an [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #200 had clear speech, was understood, understands, was moderately impaired cognitively, was totally dependent on 2 staff members for transfers and used a wheelchair for a mobility device. Review of the investigation summary dated 11/25/19 revealed, On November 1st in the morning (Registered Nurse (RN) I) approached (DON B) in the hall way with (Resident #200). (RN I) was concerned (Resident #200's) complaint of left arm pain. (Resident #200) expressed pain with movement of her left arm and left shoulder. The aides (Certified Nursing Assistants (CNA) JJ and EE) had indicated that an EZ stand was used for (Resident #200's transfer) (her care plan stated an EZ lift). (DON B) informed (RN I) to update the NP (Nurse Practitioner) and obtain orders for an x-ray of (Resident #200's) shoulder. The nurse assessment of the area noted that (Resident #200) was moaning and c/o (complain of) pain to touch in Left leg and arm, no bruising noted to area. (The NP) assessed the resident and ordered 2 view X-ray of the left humerus, left elbow, and left ankle .(Resident #200's) x-ray results were received on [DATE]. X-ray of left shoulder impression: [MEDICAL CONDITION]. Old fracture deformity of the left humeral neck. Moderately severe [MEDICAL CONDITION] of the left glenohumeral articulation. Diffuse soft tissue [MEDICAL CONDITION]/swelling of the upper extremity. X-Ray of left ankle impression: severe [MEDICAL CONDITION]. Possibly a subtle nondisplaced [MEDICAL CONDITION] fibula/base of the lateral malleolus. Soft tissue swelling of the left extremity and the ankle. (Resident #200) presented with bruising and swelling to left arm .On 11/15/19, (Resident #200's doctor) assessed resident again and ordered X-ray (2 views) of left humerus for [DIAGNOSES REDACTED].#200) has resided at (facility) since 1/11/16, during her time .she has essentially been bedfast and has not ambulated during her stay. Prior to admit to (Facility) she was not ambulatory .She requires extensive to total assist with all her activities of daily living .Summary: After interviewing of staff member's and review of (Resident #200's) medical [DIAGNOSES REDACTED]. Review of Resident #200's care plan initiated 1/11/16 revealed, (Resident #200) has ADL (Activity of Daily Living) deficit r/t (related to) dementia, incontinence, impaired mobility, deconditioning Interventions: TRANSFER: EZ lift . Review of the medical record revealed the following notes: 11/1/2019 10:49 a.m. Progress Note Late Entry: Note:: CNA notified to this writer that resident c/o pain in left arm and leg. upon assessment, resident moaning and c/o pain to touch in Left leg and arm, no bruising noted to area. Nurse practitioner notified. NP assessed resident and new order received, 2 view X-ray left humerus, left elbow, and left ankle for (Diagnosis): acute new onset pain . 11/2/2019 10:57 p.m. Order Note Note Text: NWB to LLE (non-weight bearing Left Lower Extremity) every shift for X-ray report showing [MEDICAL CONDITION] fibula base 11/3/2019 2:34 p.m. Progress Note Note:: resident resting in bed; resident was yelling out help me ~940am; resident in pain when arm is moved, doesn't want L arm moved, arm is purple and harden in antecubital space; moved and elevated on pillow; left leg elevated. Resident received 2 pain pill for pain .resident turned slightly d/t pain; will continue to monitor . 1[DATE]19 6:14 a.m. Progress Note Note:: Resident overheard moaning. In to administer (Pain medication) as ordered . During an interview on [DATE] at 8:55 a.m., when asked about Resident #200's injury, and the transfer that took place on [DATE], CNA EE stated, I was being trained that night, it was like my second night, the girl (CNA JJ) made it clear that she did not want to train me and that she wanted me to take my own assignment and I said no. We were getting residents up and we came to (Resident #200). CNA JJ did not know Resident #200's transfer status, and I said she should check in the (computer system) but (CNA JJ) didn't. When asked why she did not look in the computer system herself, CNA EE stated, I did not have my login so I could not. CNA EE continued, (CNA JJ) said there was no sling (for a hoyer lift/EZ lift in the room), so (Resident #200) should be a sit to stand (EZ Stand Transfer). As soon as (Resident #200) got up her face turned blue, her hands were on the bar, but I don't think she was supporting any of her weight. When asked how she found out about Resident #200's injuries, CNA EE stated, The other aide admitted to transferring the wrong way. I was told that (Resident #200) was in extreme pain the following shift, and they told me that (Resident #200) had been injured. CNA EE further stated, I did not have my login for (computer system), and the nurse was unavailable .You know, you assume the person that is training you knows what to do . During an interview on [DATE] at 3:55 p.m., when asked about the improper transfer and the injury to Resident #200, DON B stated, As we back tracked, there was the episode that the transfer took place and then the pain. (Resident #200) had pain and was complaining of pain. The nurse that was on that day had increased concern about that pain she had that day. When asked why CNA JJ did not look at the computer/care plan, DON B stated, She felt that (Resident #200) was a sit to stand. (CNA JJ) did not follow the care plan. CNA JJ was not available for interview.

Based on interview, and record review, the facility failed to ensure updated and accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for four (Resident #97, #79, #69, #7) of 22 reviewed, resulting in immediate jeopardy when Resident #97's Michigan Physician order [REDACTED].#97's guardian, the likelihood for preferences for medical care to not be followed by the facility or other healthcare providers, the likelihood for a delay in life sustaining treatment, the likelihood for serious harm, serious injury, serious impairment or death, and the potential for Resident #79, #69, and #7's preferences for medical care to also not be followed. This deficient practice places all 109 residents whom reside in the facility at risk for serious harm, serious injury, serious impairment, or death. Findings include: According to Public Act 154 of (YEAR), The POST form contains medical orders that are jointly agreed to by the patient and the attending health professional or the patient representative and the attending health professional. The medical orders on the POST form reflect both the patient's expressed wishes or best interests and the attending health professional's medical advice or recommendation .Before a patient and an attending health professional or a patient representative and an attending health professional sign a POST form, the attending health professional shall provide the patient or the patient representative with the information form and, if the patient does not have a patient representative, the attending health professional shall recommend to the patient that the patient consider designating an individual to serve as the patient's patient advocate to make future medical decisions on behalf of the patient if the patient becomes unable to do so. The attending health professional shall also consult with the patient or patient representative and explain to the patient or patient representative the nature and content of the POST form and the medical implications of the medical orders contained on the POST form. (https://www.legislature.mi.gov/documents/,[DATE]/publicact/pdf/2017-PA-0154.pdf) Resident #97 (R97) Review of the Resident Profile revealed R97 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], revealed R97 was moderately cognitively impaired. Review of R97's census history revealed R97 was hospitalized from[DATE] until [DATE], [DATE] until [DATE], [DATE] until [DATE], [DATE] until [DATE], and [DATE] until [DATE]. The hospital records revealed the hospitalization s were due to abdominal distention, ileus, and R97 required decompressive colonoscopies. Review of the MI-POST, revealed R97's Daughter/Guardian S electronically signed the form on [DATE] with the following choices: Section A: Cardiopulmonary resuscitation (CPR): Person has no pulse AND is not breathing. Attempt Resuscitation /CPR was checked. Section A revealed (NOTE: If Attempt Resuscitation/CPR is checked in Section A, Advanced Interventions must also be checked in Section B). Section B: Medical Interventions: Person has pulse and/or is breathing. Comfort measures only was checked. Comfort measures were pre-defined on the MI-POST as use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction manual treatment of [REDACTED]. Only transfer to hospital if comfort needs cannot be met in current location. The MI-POST revealed First follow these orders, then contact physician. This is a Medical Order Sheet based on the person's medical condition and treatment decisions . Registered Nurse (RN) N and Licensed Practical Nurse (LPN) O signed as witnesses but did not date their signatures. R97's MI-POST was signed by Nurse Practitioner (NP) R on [DATE]. The MI-POST revealed Send form with person whenever transferred or discharged . In an interview on [DATE] at 11:33 AM, when asked about R97's code status, LPN Q reported it was documented in three places: on the nurse's report sheet, in the electronic medical record, and on the MI-POST. In an interview on [DATE] at 11:59 AM, NP R reported R97 was supposed to be a full code and comfort measures should not be checked on the MI-POST. NP R stated I missed that when I signed it. The form is not correct. NP R reported R97 had been in and out of the hospital due to her chronic ileus. In a telephone interview on [DATE] at 03:12 PM, R97's Daughter/Guardian S reported R97 was supposed to get CPR if needed. When asked about section B on the MI-POST, Daughter/Guardian S stated now that part was confusing to me .if advanced interventions cannot be done, I would want comfort measures. Daughter/Guardian S reported she did not really understand the MI-POST and did not recall the physician or Nurse Practitioner explaining the choices to her. Daughter/Guardian S stated I would see if she were already dead and you needed to come in and do CPR. Not when she is asking for help and you just watch her die. I don't want that. If she is struggling and needs to get to the hospital, I want her to go. Daughter/Guardian S reported R97's goes out to the hospital often and stated, we are very concerned about her stomach blowing up. In an interview on [DATE] at 03:34 PM, Paramedic T and Emergency Medical Technician (EMT) U reported the facility transferred residents with a face sheet, the MI-POST and a medication list. When asked about R97's POST and what would be done for a resident with the choices marked, Paramedic T stated we would need those comfort measure spelled out, but you can't have both CPR and comfort measures. That's like saying don't do compressions too hard because it's not comfortable. In an interview on [DATE] at 04:16 PM, Nursing Home Administrator (NHA) A and RN N reported the MI-POST form was emailed to Daughter/Guardian S because she was not always available in person. RN N reported Daughter/Guardian S checked the boxes with the choices (CPR and comfort measures) and stated, so at some point there was a misunderstanding. When asked what her witness signature represented, RN N stated she was checking to make sure the form was completed and signed. RN N reported she did not check to make sure section A and B were accurate. NHA A reported when a resident was transferred to the hospital, the facility sent the MI-POST and a face sheet. Review of the facility's MIPOST (Scope of Treatment) Policy revised [DATE], revealed Policy .Michigan Physicians Orders of Scope of Treatment (MIPOST) is a document designed to help health care professionals honor the treatment decisions of the clients. Purpose: -Promote a person's autonomy by creating medical orders that reflect his/her current treatment decisions. -Facilitate appropriate treatment by emergency medicine and emergency medical services (EMS) personnel. -Be compliant with HIPPA in the transfer of patient records between health care settings. Procedure: 1. The MIPOST form should be completed after careful discussion with the skilled, trained MIPOST facilitator and the patient or the patients authorized surrogate decision maker, based on the patient's current treatment preferences. [NAME] The discussion may include: patient (when patient has capacity), patient advocate (durable power of attorney for healthcare), court-appointed guardian with probate court approval to make healthcare decisions or other authorized representatives . C. The MIPOST is a medical order based on the patient medical condition and wishes right now. If the patient requires treatment, the caregiver should first institute any emergency treatment orders recorded on the MIPOST, and then contact the physician .2. The legally valid signers of MIPOST document are physicians, Nurse practitioners (NP) and physician assistants (PA) .3. The MIPOST document must be easily accessible and available for EMS personnel. The MIPOST document should accompany the patient upon transfer from one setting to another. A copy is valid. A copy should be kept in the individuals medical record. HIPPA permits disclosure of MIPOST orders to other health care professionals across treatment setting. 4. When receiving a client with completed MIPOST document, MIPOST should be reviewed with client/family at their earliest opportunity. A physician/NP/PA should sign in section G that the MIPOST form was reviewed and accepted. Until such time that the orders are reviewed the MIPOST form shall be honored . On [DATE] at 2:23 PM, NHA A was notified of the Immediate Jeopardy that was identified on [DATE] and began on [DATE] due to the facility's failure to ensure accurate completion of R97's MI-POST. A corrective action plan was requested from the facility to remove the immediate jeopardy. Immediate Jeopardy was removed on [DATE] when the facility had implemented the following interventions: - Resident 97 continued to reside in the community. On [DATE], The MI-post has been corrected to reflect Full Code in section A and Advanced Interventions in Section B. - On [DATE], All residents code status and MI-Post have been reviewed to ensure that MI-Post are completed accurately to reflect the resident and/or representative wishes. - Staff education related to the MI-Post completion process has been provided to social services and licensed nurses on [DATE]. -An immediate chart audit of all residents was completed on (MONTH) 16, 2019. MI-POST for R97 was immediately corrected. Two other resident records indicated a discrepancy and will be addressed within 24-hours. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency. Resident #79 (R79) Review of the Resident Profile revealed R79 admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], revealed R79 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). According to the electronic medical record, R79's code status was Do-Not-Resuscitate (DNR). Review of the MI-POST revealed R79 chose DNR. Review of the Do-Not-Resuscitate Order revealed R79 signed on [DATE] and NP R signed on [DATE]. The order did not have any witness signatures. Review of all of R79's DNR orders back to (YEAR), revealed no witness signatures. In an interview on [DATE] at 03:07 PM, RN N and LPN O agreed none of R79's DNR orders included witness signatures and reported Social Worker (SW) H was the one responsible for re-evaluating code status. Resident #69 (R69) Review of the Resident Profile revealed R69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], revealed R69 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of R69's MI-POST revealed Section D Documentation of Discussion was not completed. R69 was a marked as a DNR, the guardian was spoken to on [DATE] by the witnesses, but there was no signature from the guardian on the form. NP R signed the form on [DATE]. On [DATE] at 03:07 PM, RN N reported section D was missed, but it the form was discussed with R69's son who was her guardian. When asked why the physician information was not completed in section D, RN N reported she never looked at the form after it went to the physician. LPN O, who was also present for the interview, stated it would be the physician's responsibility to fill that part out (section D). When asked about R69's guardian not signing the MI-POST, RN N and LPN O reported there were two witnesses over the phone since R69's guardian was in the hospital. Resident #7 Review of the Resident Profile revealed R7 admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], revealed R7 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). According to the electronic medical record, R7's code status was Do-Not-Resuscitate (DNR). Review of the MI-POST revealed R7's guardian chose DNR. Review of the Do-Not-Resuscitate Order revealed R7's guardian signed on [DATE], the Nurse Practitioner signed on [DATE], and the physician signed on [DATE]. The order did not have any witness signatures. In an interview on [DATE] at 03:07 PM, RN N and LPN O could not explain why R7's DNR order did not have any witness signatures and reported possibly SW H initiated the DNR order paperwork. In an interview on [DATE] at 09:41 AM, SW H reported she was unaware that two witness signatures were required for DNR orders. SW H reported she was educated on [DATE] about witness signatures. Review of the MICHIGAN DO-NOT-RESUSCITATE PR[NAME]EDURE ACT, Act 193 of 1996 (Revised [DATE]), revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir. (3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence. Further review of this Act revealed, Sec. 4. A do-not-resuscitate order executed under section 3 or 3a shall include, but is not limited to, the following language, and shall be in substantially the following form: DO-NOT-RESUSCITATE ORDER This do-not-resuscitate order is issued by _______________________________________, attending physician for _________________________________________. (Type or print declarant's or ward's name) Use the appropriate consent section below: [NAME] DECLARANT CONSENT I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. _______________________________________ _______________ (Declarant's signature) (Date) _______________________________________ _______________ (Signature of person who signed for (Date) declarant, if applicable) _______________________________________ (Type or print full name) B. PATIENT ADV[NAME]ATE CONSENT I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Patient advocate's signature) (Date) _______________________________________ (Type or print patient advocate's name) C. GUARDIAN CONSENT I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Guardian's signature) (Date) _______________________________________ (Type or print guardian's name) _______________________________________ _______________ (Physician's signature) (Date) _______________________________________ (Type or print physician's full name) ATTESTATION OF WITNESSES The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the declarant has (has not) received an identification bracelet. ______________________________ ______________________________ (Witness signature) (Date) (Witness signature) (Date) ______________________________ ______________________________ (Type or print witness's name) (Type or print witness's name) THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PR[NAME]EDURE ACT.

This citation includes intake MI 5473. Based on observation, interview and record review the facility failed to provide incontinent care, clean & comfortable beds, monitor call light assistance device placement and monitor resident to resident altercations for 3 of 9 residents (Residents #64, #68 and #74) reviewed for abuse resulting in, neglect, burning sensation, resident to resident physical abuse, the potential for skin breakdown, psychosocial feelings of dehumanization, loss of dignity, emotional distress, restriction of freedom of movement from bodily waste to a reasonable person, the potential for falls/injuries. and the potential for neglect for 15 additional residents residing in rooms #200 through #208. Findings Include: Resident #64 On 09/17/19 at 03:17 PM R64 was observed in his room laying in bed, and appeared to be asleep. R64 was dressed in a hospital gown with a sheet on top of him. An air mattress was attached to his bed that was against the wall. R64 had oxygen infusing via nasal cannula at 2 liters, and tube feeding was noted infusing at a rate of 85 cubic centimeters an hour. When conversation was attempted, R64 was observed not to talk or move his body (other than his head) voluntarily. On 09/17/19 review of the Electronic Medical Record (EMR) for R64 reflected he was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. R64's most recent quarterly Minimum Data Set (MDS: resident assessment tool) dated 08/27/19, reflected R64 was cognitively impaired with memory problems, required total assistance of 2 persons for transfers, toilet use and bathing. Also, R64 required extensive assistance of 2 persons for bed mobility, dressing, bowel/bladder incontinence and extensive assistance for 1 person for hygiene. It was discovered during the survey process that the facility had reported to the state agency, a concern of neglect by a staff person towards two residents (R64 and R74) on 09/06/19. The file containing the incident and investigation reflected the concern occurred on 09/06/19 at around 01:00 AM, but was discovered until 09/06/19 at 07:00 AM. Staffing records reflected Registered Nurse (RN V) and Certified Nursing Assistant (CNA X) worked the third shift, on 09/06/19-09/07/19 from 11:00 PM to 07:00 AM on the second floor, and cared for the residents in rooms #200 to #208, which included a total of 17 residents. RN W and CNA's Y and Z were assigned to rooms #200 to #208 the morning of 09/07/19 starting at 07:00 AM. On 09/17/19 at 03:27 PM CNA Y was interviewed. He was asked if he had ever worked with CNA X and revealed, he did not think he had worked with her before, but had to report her for neglect. CNA Y was asked to recall the morning of 09/07/19. CNA Y revealed she (CNA X) did not check and change all the people throughout the night starting 09/06/19 from 11:00 PM to 07:00 AM 09/07/19. When he arrived at work, R74 in room [ROOM NUMBER]-B was covered in bowel movement and had been for a while. The bowel movement was dry and sticking to R74's skin. CNA Y revealed, CNA X took care of the whole hall rooms #200 to #208 and had given him report that everybody was just checked, changed and dry. I would assume that had been done within the last 2 hours. CNA Y stated, R74 can usually call for help but his call light was under his bed. Also, that he reported the concern to RN W, she took it up the chain and he gave a statement later that day. CNA Y's statement dated 09/06/19 at 2:36 PM taken by Social Worker (SW I) reflected: He had checked on R74 who stated, Finally I'm burning and I've been sitting in diarrhea for hours. Multiple bowel movements were in his brief, dried to skin and soaked through his bed pad. R74's indwelling Foley catheter collection bag was completely full, R74's call light was on the floor under his bed and the CNA Z had the same problem with R64 who smelled like stale urine. On 09/17/19 at 03:33 PM CNA Z was interviewed. She was asked if she had ever worked with CNA X before, and denied. CNA Z was asked how did CNA X leave her residents the night of 09/06/19 from 11:00 PM to 07:00 AM 09/07/19. CNA Z revealed, she had not worked with CNA X. CNA Z revealed, A resident's sheets were yellow in color. The odor was overwhelming when you walked in and overpowering. They were so soaked they could be wrung out, it was bad. His gown was wet were it touched the bed, the bottom of his pillowcase was wet. He had a pillow underneath his boots and the pillow underneath his boots was wet. He was awake when I came in. CNA Z revealed the resident was R64, and that he required total assistance. He should be checked and changed at least every 2 hours, but I go in there every hour at least to check on him. CNA Z was asked how would she feel if left in the position as R64 and replied, Upset and angry. CNA Z stated she gave R64 a complete bed bath, cleaned and disinfected his mattress, and changed his sheets. CNA X had just left, and she was the aide on that section. She left and did not give report. I heard she was agency. I have not seen her since . I came in at 07:00 AM. I probably got to his room between 07:15 AM - 07:20 AM. I was walking down the hall, smelled the urine and went in his room. CNA Z's statement dated 09/06/19 at 02:56 PM taken by SW I reflected: R64 was soaked from urinating on himself, and smelled like old urine. On 09/17/19 at 04:45 PM RN W was interviewed and asked to recall the incident she discovered on 07/07/19. RN W stated, We came in to work when the shift had just started within 20 minutes, and they (CNA's Y and Z) told me they thought the aides did not change these people. One aide CNA Y told me R74 had a #2 (poop) dried on him, R74's call light was on the floor, and his bed was soaked with pee. We had to end up giving him a shower and change his bedding. We (CNA Z) walked in and could smell the Pee. She (CNA Z) showed me his bedding and it was the same way wet, but no bowel movement. We had to end up, having to clean him up and change his bedding. His sheet was soaking wet. I asked them like okay, when shift changed and they got the report form the aide, what did she tell them. She (CNA X) told them everyone had been changed in the past 1 hour. I reported it to Director Of Nursing (DON B) and the Social Worker. We did a whole skin assessment for all the residents . RN W revealed R64 could not use the call light or make his needs known, wore briefs and it took 2 people to change his brief or bath/shower him. RN W revealed, Everything on him that touched his bed sheets was wet . I was worried about R74, he is easy to get skin irritation and has Allevyn (cream to treat disruption in skin integrity) for his coccyx area, and his front groin area was reddened and for the groin site that was newer. RN W's statement dated 09/06/19 and un-timed taken by SW I reflected: R64 smelled of urine, R74 was covered in bowel movement and his call light was on the floor, R74 did not yell because he did not want to wake up his room-mate and he looked relieved after the bed was changed and clean. On 09/18/19 at 02:05 PM RN V was interviewed by phone and asked to recall the night of 09/06/19 11:00 PM to 07:00 PM 09/07/19 related to CNA X. RN V revealed, I was not aware of any incidents at all. CNA X did not typically work that floor. She went in /out of rooms and did not make me aware of anything. RN V was informed that R64 and R74 had been left soiled. RN V stated, To be honest that would not surprise me, she (CNA X) was on her tablet watching a movie on Netflix. I was in/out of residents room throughout the night. RN V was asked if she talked to CNA X related to her tablet use and replied, I would delegate to her, so and so's call light is going off can you address it, and ask to have her help me turn residents. One resident's call light was going off most of the night, that is normal. She did not answer it and I had to tell her several times to answer it. RN V revealed R64 could make facial expressions, and that it took 2 people to change him. RN V's written statement dated 09/10/19 taken by SW I reflected, CNA X did not seem familiar with the residents, spent a lot of time on her phone watching Netflix and stated she could not wait to go home. CNA AA's undated/un-timed statement taken by SW I reflected she worked the night of 09/06/19 with CNA X. The statement reflected CNA AA was assigned to rooms 209-217, CNA X brought her laptop and watched Netflix and had did that a week before when working, care is not being provided when she is on her laptop, R74 uses his light if he needs anything, and usually put his call light on before he needs to be changed. CNA X who was a contractual worker, was unable to be contacted during the survey. CNA X's statement taken on 09/06/19 at 11:00 PM by SW I reflected: She was not sure who were 2 Person Assist (2PA), when a resident was a 2PA she went ahead and took care of them herself, and with an easy stand (mechanical lift) she would use one person. No one assisted her with 2PA residents, she was unaware of where the nurse and other aide were at, she did not remember R64 and thought he was dry when she left. Also that, R74 I didn't check I thought he would us his call light, her laptop was connected to her phone, she was on Netflix, and got on Netflix in between changing residents. The facility wrote a note to the contract company where CNA X worked on 09/12/19 reflecting: The facility had concerns related to the lack of care provided, it was determined CNA X would no longer be allowed to work at the facility, CNA X had not sought out assistance, acknowledged she transferred 4 people that were 2 person assist by herself, did not provide care or check on a client for the entire shift, left a client without an accessible call light, and CNA X reported she was often on her phone or laptop watching Netflix. On 09/18/19 at 10:01 AM SW I revealed he did the investigation, was the abuse specialist, hand wrote the statements and then typed the statements. Also that, CNA X admitted to using her phone and laptop during work and watched a series show on Netflix. Also, that it was substantiated that CNA X provided a lack of care due to being on Netflix. 09/18/19 10:34 AM R64's EMR reflected a note written by SW I dated 9/10/19 at 11:01 AM reflecting: Note Text: Late Entry: 9/6/19 Staff brought to Nurse Managers attention that resident's brief soaked with urine and the bed sheets were soaked at the beginning of their shift at 7am. Investigation initiated, LARA, Administrator, Doctor and Family notified. Care plan reviewed and current. No other notes by Social Services (SS) were noted available in EMR prior to 9/10/19. Progress notes reviewed from 09/06/19 to 09/09/19 were without documentation reflecting mood/behavior were monitored. On 09/18/19 at 11:27 AM SW I was asked where were the SS assessments for R64 and R74, related to being left soiled, body language, facial signs and/or comments. SW I revealed the behavior log was started on 9/10/19 and there had not been one prior to that date. Also that, If an allegation occurs or an allegation is made, that is when we start this (pointed to behavior log). The behavior log was to be used as a tool to track behaviors for behaviors displayed to address. However, the incident occurred on 09/06/19 and no SS assessment was initiated to monitor any psychosocial issues within the first four days of the occurrence. On 09/18/19 at 11:44 AM the Director of Social Services SW H (joined the discussion with SW I) and revealed, R64 did use gestures and that the behavior log was used to monitor him psychosocially. Both Social Workers were asked where were the interviews of like residents who were provided care by CNA X, to assess for neglect of care. It was relayed none had been done. Resident #74 Review of the Resident Profile revealed R74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], revealed R74 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assistance of one person for bed mobility and toilet use. R74 had an indwelling urinary catheter. The first entry made by Social Services was dated 09/10/19 at 11:04 AM and read, Late Entry: 9/6/19 staff brought to nurse managers attention that resident's brief soaked with feces and the bed sheets were stained with feces at the beginning of their shift at 7 am. Investigation initiated. No psychosocial assessments or monitoring related to the incident with CNA X had taken place. Review of R74's care plans revealed he experienced frequent bowel incontinence related to decreased mobility due to right above knee amputation. Interventions dated 9/10/19, included: check for incontinence, monitor and record BMs (bowel movements) each shift, and wear briefs for incontinence. The Activities of Daily Living (ADL) care plan dated 5/14/19, revealed R74 required maximum assistance with bed mobility. The risk for falls care plan dated 5/14/19, revealed interventions that included pin call light to clothing and place call light within reach. On 09/17/19 at 08:42 AM, R74 was observed in his bed. R74 was unable to recall the incident where he was left wet and soiled. The facility's ABUSE, NEGLECT AND EXPLOITATION POLICY updated 08/14/2017 defined the following: 7. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident #68 (R68) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R68 was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected R68 had a IBM (assessment tool) score which indicated his ability to make daily decisions was severely impaired, and he required one person physical assist with dressing, hygiene, and toileting. During an observation on 9/17/19 at 10:38 AM R68 was observed independently ambulating down hall toward his room. R68 appeared pleasant and confused. Staff in area addressed R68 by name with no concerns. Review of the Facility Reported incident, dated 8/1/19 at 2:00 a.m., reflected R68 was involved in a resident to resident incident involving his roommate R23. The Incident report reflected R68 and R23 were found on the floor in their room with R23 on top of R68. Review of the incident report included an interview with R68 that reflected, named resident (R68) was asleep, named resident (R23) tugged blankets off named resident (R68), named resident (R23) tried getting into bed with R68 and they ended out off the bed and on the floor. R23 was holding R68 down . During an interview on 9/19/19 at 8:41 a.m. Medical Social Worker (MSW) I reported he had been employed at the facility for three months. MSW I reported he was responsible for completing the investigation for the Facility Reported Incident dated 8/1/19 for R68 and R23. When ask if he could recall the incident MSW I stated, which one R23 has had several incidents, three with R68. MSW I reported on 8/1/19 at 1:45a.m., staff reported hearing a commotion, found R68 on the floor and R23 on top of R68. MSW I reported residents were easily redirected and reported Certified Nurse Aide(CNA) JJ and Registered Nurse(RN) KK were on duty. MSW I reported the incident was reported to the State of Michigan on 8/2/19 at 4:29 p.m. by the Director of Nurses (DON) B. MSW I reported at that time because MSW I was unsure if he had access. SW H present during interview and reported the facility has always reported abuse allegation between two and 24 hours to the the State of Michigan. MSW I reported he did not think the resident to resident incident between R23 and R68 on 8/1/19 was an allegation of abuse. MSW I agreed that he was unsure abuse until investigation was completed, therefore agree incident was allegation of abuse. SW H reported all staff can report allegations of abuse number but overall MSW I, DON B and Administrator A have access to reporting programs. MSW H reported the resident to resident Facility Reported Incident for R23 and R68 on 8/1/19 did not include other resident interviews or documented social work follow up visits for either resident involved. SW H and MSW I reported the 8/1/19 incident was not reported within two hours to the State of Michigan. During an interview on 9/19/19 at 10:47 a.m. Licensed Practical Nurse (LPN) J reported R68 had an incident on 9/5/19 and R68 was not redirectable and was sent to the hospital where he currently still was after grabbing grabbed another nurses wrists and then bumped into LPN J with the nutrition cart. LPN J reported R68 usually pleasant and frequently wandered but easily redirected. During a telephone interview on 9/23/19 at 9:32 a.m. CNA JJ reported to RN KK resident to resident incident on 8/1/19 who reported to RN LL. CNA JJ reported the MSW I called CNA JJ the next day for interview about incident. CNA JJ reported she entered R68 room after hearing noise and yelling and found R23 was sitting on top of R68 physically hitting R68 and R23 had intent because R23 continued to swing closed fists toward R68 when staff separated residents. CNA JJ reported immediate interventions were initial 15 minute checks then continued with times of neurological checks. CNA JJ reported incident was example of an allegation of abuse. CNA JJ reported R23's baseline was confused with history of [MEDICAL CONDITION] and had history of reporting roommate(R68) was trying to kill him(R23).

Based on observation, interview, and record review, the facility failed to implement preventive measures to prevent the development of a pressure ulcer in 1 of 2 residents (R34) reviewed for pressure ulcers, resulting in the development of a stage 3 facility acquired pressure ulcer. Findings include: According to the facility Skin Assessment Protocol Policy and Procedure, dated (MONTH) 13, (YEAR), reflected, Policy: All nursing staff shall adhere to the skin asessment protocol as part of out systematic approach for pressure ulcer prevention and for the promotion of healing of various skin conditions., including pressure ulcers .Weekly .Nurse will do skin assessment weekly and document in PCC(EMR) under Weekly Skin Assessment .Notify MD/NP/Wound nurse of any new or worsening skin conditions . According to the facility Pressure Ulcer Prevention/Management Policy and Procedure, dated (MONTH) 23 (YEAR), reflected, A skin check will be completed weekly by a nurse and kept as part of the clinical record .Weekly progress will be documented by in nurse to assess to location, stage, size, shape, depth size and depth of sinus track, surrounding tissue, and drainage (type, color, odor, and amount), wound bed, wound edges, and related pain. PUSH scale may be used for clinical validation of healing .If progress is not noted in 3 weeks or deterioration is present, Physician is notified for treatment order review. For Stage 3 or 4 Pressure Ulcers, consider referral to Wound Specialist . According to the facility Physician Services Physician Visits Policy and Procedure, dated (MONTH) 15, 2012, reflected, PURPOSE: To ensure the physician takes an active role in supervising the care of a resident while maintaining State and Federal regulations .The resident's attending physician must review the resident's total program of care, including medications and treatments, at least quarterly .9. The resident's attending physician must review the resident's total program of care, including medications and treatments, at least quarterly. Resident 34 (R34) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], R34 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected R34 had a BIM (assessment tool) score of 12 which indicated his ability to make daily decisions was moderately impaired, and he required one person physical assist with dressing, locomotion, hygiene, and two person physical assist with bed mobility, transfers, and toileting. The MDS reflected R34 never refused care. During an observation and interview on 9/16/19 at 9:25 a.m. R34 was noted to be in room laying on air mattress and appeared pleasant and well groomed. R34 reported had open area on left heel that developed at the facility with a dressing in place. R34 reported recent infection and wound not healing. During an observation and interview on 9/18/19 2:53 p.m. Licensed Practical Nurse (LPN) D reported plan to provide wound care for R34 left heel. LPN D reported R34 had received pain medications 30 minutes prior. This surveyor observed LPN D collect supplies from supply room in hall and placed in bag clear bag that included, [MEDICATION NAME] ag, foam dressing, tape, alcohol pads, gauze wrap. LPN D entered R34 room and started to prepare for dressing change. LPN D removed old dressing from R34's left heel. R34 had an oblong open area to left posterior heel with about 60% beefy red wound bed and 40% white slough noted and peri wound intact. LPN D applied [MEDICATION NAME] ag to wound bed and covered with foam dressing and gauze wrap. R34 tolerated dressing change well. LPN D completed dressing change and exited R34's room at 3:37 PM. Review of the Physician Orders, dated 9/5/19, signed by physician 9/6/19, reflected R34 had an order the included, [MEDICATION NAME] to wound bed only, apply barrier cream prn to periwound if maceration present, cover with foam dressing, secure with gauze wrap prn. (triangle)((change)) Q(every) day & PRN. During an interview and observation on 9/18/19 at 4:06 p.m. Registered Nurse Unit Manager (RNUM) K was asked by this surveyor what R34's current orders for wound care were. RNUM K unlocked the third floor supply closet and picked up the [MEDICATION NAME] ag. RNUM K was asked by this surveyor if R34 had an order for [REDACTED]. RNUM K verified that was the only box of [MEDICATION NAME] in the supply room. (no regular [MEDICATION NAME] without silver was noted). During an observation and interview on 9/18/19 at 4:36 PM, Director of Nursing (DON) B unlocked the third floor supply room and reported there was no plain [MEDICATION NAME] available in the supply room only [MEDICATION NAME] AG(silver). DON B reported would expect nurse to follow Physician Orders. During an observation and interview on 9/19/19 10:10 AM LPN J reported R34 has own wound supplies in his room and LPN J verified she recognized [MEDICATION NAME] in supply room had silver and different than regular [MEDICATION NAME] that was ordered. RNUM K delivered regular [MEDICATION NAME] at that time into third floor supply closet. Review of the MDS assessment, dated 4/8/19 and 9/7/19, reflected R34 had a Stage 3 facility acquired pressure ulcer. The previous MDS assessment, dated 1/24/19 reflected no pressure ulcers. Per the National Pressure Ulcer Advisory Panel a Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer 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. During an interview on 9/19/19 10:30 AM Wound Care Nurse (WCN) G reported she wrote order for R34 [MEDICATION NAME] on 9/5/19. WCN G reported order was written for regular [MEDICATION NAME] not silver(AG). WCN G reported she would expect nurse to follow the Physician order [REDACTED]. During an interview on 9/19/19 at 11:32 a.m. Wound Care Nurse (WCN) G reported R34 left heel wound started 11/8/18 related to interventions in place 11/8/18. WCN G reported would expect wound nurse assessment close to 11/8/18 and nurse to add to R34 to communication board. WCN G reported no wound assessments noted in R34's medical record until 2/8/19. WCN G reported R34 was at risk for developing pressure ulcer. During an interview on 9/19/19 at 12:22 p.m. Wound Care Nurse (WCN) G reported being the facility wound care nurse for four months. WCN GG reviewed the MDS and skin assessments for R34, dated 1/17/19 and 1/14/19 that noted open wound left heel and right heel and on 1/10/19 left heel noted with notes that wound cleaned and covered per physician orders. WCN G verified MDS dated [DATE] did not reflect pressure ulcer. During an interview and record review on 9/23/19 at 10:30 a.m. WCN G reported was unable to locate documentation of R34 refusals to elevate heels, and would expect weekly wound assessments between 11/18/18 and 2/19/19 and was unable to locate in R34 medical record. WCN G stated, we could have done better for this resident. WCN G provided timeline for R34's left heel facility acquired pressure ulcer wound was first documented on 11/3/18 skin assessment and incident report that measured 1.5cm diameter, moist area L:3cm x W: 2/5cm and Progress Note that reflected wound nurse and nurse manager notified and wound care orders initiated. WCN G reported and verified Nurse Progress Noted, dated 2/4/19, reflected R34 wound declined with no treatment changes noted between 4/12/19 and 7/23/19. Review of the facility, Braden Scale for Prediction Pressure Sore Risk, dated 3/6/18, reflected R34 had a score of 17, which indicated R34 was at risk for developing pressure ulcers. Review of the Nursing Progress Notes, dated 11/3/19, for R34, reflected, CNA alerted nurse that Res was requesting heel to be cleaned. Nurse entered room to assess. Upon assessment open area to [MI] heel noted. Res stated his skin was dry and cracking. States lotion has been applied but was bleeding .Area assessed while Res in bed. Open area to L heel with moist white outer area .Wound bed red but no bleeding noted. Area cleansed with NS, dried wit gauze and allevyn heel applied. Wrapped with kerlix and taped to keep in place. Res notified will continue to monitor .Order written for Aleyvn drsg change q 3 days. PN left on physician clipboard for review .Emailed Wound Nurse and nurse manager . Review of the facility, Weekly Skin Assessment, dated 11/8/18, reflected R34 had a stage 2 left heel pressure sore. Review of the facility, Skin & Wound Evaluation, dated 2/8/18, reflected R34 had a stage 3 left heel facility acquired pressure ulcer that had been present for 1 to 3 months with a pain scale of 8 out of 10. Review of the Skin/Wound Progress Note, date 2/8/19, for R34, reflected, Res c/o pain 8/10 to wound site intermittently . Review of the Progress noted, dated 9/13/2019 at 1:51 p.m., reflected, IDT Risk Meeting Note Reason for Review (e.g infection, wound, : Left heal healing slowly continuing with current treatment Current Status: healing slowly; Root Cause (as applicable): pressure; Interventions/Follow Up: cont with current treatment as ordered; Care Plan Updated? : yes; Resident/Family/Responsible Party Updated: yes; Physician/Physician Extender Notified?: yes; Next Review (e.g. weekly, DC from IDT): 1 wk (linked). Reviewed complete Electronic Medical Record, dated 7/2018 through 7/2019, for R34, with no record of Physician visits and no mention of R34's left heel facility acquired pressure ulcer until 2/12/19. Review of facility Treatment Administration Record, dated 11/2018 through 2/2019, reflected R34 had dressing change orders every three days with documentation of dressing change daily. During an interview on 9/23/19 at 1:00 p.m., WCN G reported orders had poor wording and reported dressings should have been changed every three days, depending on date of dressing. This surveyor asked, how do you know when dressing were changed? WCN G reported staff were not able to determine by reviewing the Treatment Record. WCN G reported nurse should document dressing change in Progress Notes. During an interview on 9/23/19 at 2:35 p.m. DON B verified R34 no did not have any Physician visits between 7/2018 and 7/2019 in medical record. DON B reported facility had contacted Physician office that day to and were waiting response. DON B reported residents should be seen by Physician at least quarterly. According to the State Operation Manual, reflected Supervising the medical care of residents means participating in the resident's assessment and care planning, monitoring changes in resident's medical status, and providing consultation or treatment when contacted by the facility. It also includes, but is not limited to, prescribing medications and therapy, ordering a resident's transfer to the hospital, conducting required routine visits or delegating to and supervising follow-up visits by NPPs. During an interview on 9/23/19 at 3:45 PM, Hospitality Services (HS) C reported Physician TT office had no record of physician visits for R34 between 7/2018 and 7/2019. Review of EMR Care Conferences, dated 10/29/18, 1/30/19, and 4/9/19, reflected errors with the Certified Dietary Manager as only member present and no mention of R34s wound. R34's EMR reflected he had one Care Conference in the past twelve months, dated 7/9/19. During an interview on 9/23/19 at 4:20 p.m. DON B reported she would expect staff to follow the facility Skin Assessment Protocol Policy and perform wound monitoring weekly for R34s pressure ulcer.

This citation pertains to MI 235 and MI 431. Based on interview and record review, the facility failed to appropriately assess, monitor and treat changes in condition for two (Resident #1 and #4) of two reviewed for infections, resulting in hospitalization . Findings include: Resident #1 (R1) Review of the medical record reflected that R1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with a date of 12/24/18, reflected that R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) assessment. He required supervision for eating and extensive to total staff assistance for all other Activities of Daily Living (ADL's). Review of R1's progress notes reflected the following: -12/30/18 at 6:50 PM: R1 reported that he felt weak and rotten the past few days, and has had no appetite. The progress note reflected that a note was going to be left for the physician. R1 stated that he will probably be dead before physician reads progress note. -12/31/18 at 8:26 AM: R1 stated that he had something caught in his throat and that he was not taking his medication that morning. 12/31/18 at 4:20 PM: R1 was complaining of increased difficulty breathing. BS (breath sounds/lung sounds) coarse, [MEDICATION NAME] (nebulizer) breathing tx (treatment) given with no change. On call physician paged. -12/31/18 at 10:26 PM: R1 was concerned about his health and stated he had trouble breathing and swallowing. R1 wanted to go to the hospital but wanted to wait until the morning when the rush hour was over. The note also reflected that an x-ray had been completed and had been placed on the communication board. -1/1/19 at 1:11 PM: The note reflected that going to the hospital was discussed with the resident, but he wanted to think about it. On Assessment: Res. (resident) has been coughing quite a bit and unable to cough up phlegm. Res. lungs upper and lower sound coarse. Res. ate very little breakfast this morning, states that it's hard to swallow . The note also reflected that R1 was able to chew and swallow his turkey for lunch. -1/1/19 at 10:09 PM: The note reflected that the x-ray results were reviewed with the on call physician who reported that they were going to assess R1 in the morning. -1/3/19 at 5:30 PM: The note, authored by Licensed Practical Nurse (LPN) V, reflected that R1 presented with pneumonia exacerbation. His oxygen saturation was documented as 85%, and he had shortness of breath and difficulty speaking due to his inability to catch his breath. R1's medical record did not reflect that there had been regular nursing assessments and monitoring of his condition and respiratory status. A chest x-ray dated for 12/31/18 reflected that R1 had an enlarged heart and mild [MEDICAL CONDITION]. A progress note by Physician TT for 1/2/19 reflected that R1 was seen at R1's request. He had gotten a message to me through staff on New Year's Eve I believe that he was short of breath and wanting to go to the hospital. We had the lab come out as well as x-ray. I started him on [MEDICATION NAME]. He was 3 pounds up in his weight. Those labs had shown no significant abnormality. X-ray showed early congestive (heart) failure .HEART: With irregularly irregular rhythm . The progress note did not reflect a respiratory assessment by Physician TT. A progress note by Nurse Practitioner (NP) W on 1/3/19 reflected that she went in to see R1 due to the staff nurse's report that R1 was having some difficulty breathing. .Upon my arrival, into (sic) see the patient he is in respiratory distress. He is using his accessory muscles. The patient is unable to speak in sentences. He is conversationally dyspneic .he does tell me that he is not getting any relief from the [MEDICATION NAME] treatments. He is not able to cough up his secretions .His cough has increased in the recent past .Oxygen saturation is 94% now on 5 liters (of oxygen) .LUNGS: With scattered rhonchi throughout and occasional wheeze high pitched expiratory (when breathing out) .He is using accessory muscles .1. Dysphagia likely aspiration pneumonia. 2. Acute [MEDICAL CONDITION] requiring oxygen titrated now to 5 liters . Review of R1's MDS history reflected that a discharge-return anticipated assessment was dated for 1/3/19. During an interview on 1/24/19 at 11:16 AM, LPN V reported that (on 1/3/19, the day that R1 was sent to the hospital) R1 had been having more difficulty talking and was kind of gasping a little more. She reported that R1 had the need to wear oxygen. He was starting to weaken and was having more difficulty speaking. When asked what time of day she noticed the changes with R1, LPN V reported R1 was progressively getting worse during the day. She reported that she gave him a breathing treatment and things that were ordered, hoping they help. LPN V reported that she did not listen to R1's lung sounds. She then stated that she could not recall if she listened to R1's lungs or if she would have documented it because I do so much. LPN V reported that NP W performed a respiratory assessment on R1. When asked what type of assessment should have been done on someone presenting with difficulty talking, gasping or requiring oxygen, LPN V reported that she would have typically listened to their lungs and checked their oxygen saturation. LPN V reported that she could not recall exactly what she did. She stated, I know that I would increase oxygen and get the NP in to assess. LPN V stated if it wasn't documented, it wasn't done. According to LPN V, when she knew R1 was in trouble, her priority at the time was to get the NP in the room. During an interview on 1/24/19 at 12:50 PM, NP W reported that on paper, R1 did not look that bad (laboratory and x-ray results), but to see him, he was really working. I had never seen him that short of breath . According to NP W, R1 was using all of his accessory muscles and was struggling to breathe upon her assessment on 1/3/19. During a phone interview on 1/24/19 at 3:37 PM, Certified Nurse Aide (CNA) JJ stated that she had reported that R1 was not breathing well the night before he went to the hospital. According to CNA JJ, we kept an eye on it. CNA JJ stated that R1 had used oxygen on her last shift before R1 discharged to the hospital. During a phone interview on 2/4/19 at 9:11 AM, CNA PP reported that their shift started at 3:00 PM on 1/3/19. CNA PP reported that R1 was on lots of oxygen because he was having a hard time eating and breathing. According to CNA PP, the nurse (not named, but LPN V authored a progress note at 5:30 PM on 1/3/19) gave them report about R1, that he was not doing well and that he might be sent out (to the hospital). CNA PP reported that R1 was sent out around dinner and had been having a hard time being able to talk. During a phone interview on 2/4/19 at 11:00 AM, CNA OO reported that they had worked with R1 the day before he went to the hospital (1/2/19). CNA OO reported that there was a really big change with R1 and that he was super short of breath and could not feed himself. According to CNA OO, R1 tried to talk but was so short of breath and would drift off during stories. CNA OO stated, he got to be super out of it one to two days before he was sent to the hospital. CNA OO reported that R1 was not doing well, and that they had reported it all to the nurse (name not reported). According to CNA OO, R1 was unsure if he wanted to go to the hospital. CNA OO had also reported that R1 had been coughing more the last couple of days. During an interview on 2/4/19 at 4:08 PM, the progress note for 1/1/19 at 1:11 PM was reviewed with Director of Nursing (DON) B. When asked if she would have expected continued monitoring and documentation (of R1) based on contents of note, DON B reported that she would have. According to an Emergency Department (ED) provider note from (Hospital Name) for 1/3/19 at 7:04 PM, R1 had a moderate severity productive cough that was constant and worsening for a duration of one day. His physical exam reflected that he had decreased breath sounds. The (Hospital Name) Physician Discharge Summary reflected that R1 presented to the ED with shortness of breath. He was confused and suddenly got obtunded while in the ED and required intubation. He was taken to the Intensive Care Unit (ICU) for respiratory management and was placed on mechanical ventilation. He was treated for [REDACTED]. R1 passed away on 1/5/19. Discharge [DIAGNOSES REDACTED]. Resident #4 (R4) Review of the medical record reflected that R4 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The significant change in status assessment dated for 7/18/18 reflected that R4 was non-ambulatory (did not walk) and required extensive to total assistance with ADL's. Review of R4's progress notes reflected that he vomited on the following dates/times: -One time around 8:00 PM on 8/20/18 -Two times around 5:00 PM on 8/22/18 -At 5:10 PM on 8/25/18 -At 5:00 PM on 8/26/18 -One time around 6:00 PM on 9/8/18 A progress note, authored by Registered Nurse (RN) Q on 8/21/18 at 4:14 AM, reflected that R4 requested the nurse at 4:00 AM. R4 reported that he felt he hurt something when he vomited at 8:00 PM. R4 believed that he hurt his left clavicle or rotator cuff. A progress note by NP W for 8/24/18 reflected that R4 was seen due to left rib pain. There was some pain to touch on the left lateral (side) rib area. The note reflected that R4's blood sugars had been running high in the 200's. His heart rate was recorded as 114 beats per minute. It was noted that his heart rate was running in the 90 (beats per minute (bpm)) range for most of August. This 114 reading is new. His lungs were noted to be clear with slightly diminished bases bilaterally. He had decreased (respiratory) effort. A progress note on 8/28/18 at 5:56 PM reflected that R4 still had rib pain when he rolled onto his left side. A progress note on 8/30/18 at 3:52 PM reflected that a chest x-ray was ordered for left rib pain. Chest x-ray results for 8/31/18 reflected that R4 had modest left basilar infiltrate and slight pleural effusion (fluid around the lung). A progress note by NP W on 8/31/18 reflected that R4 was seen due to the results of his chest x-ray. His lungs sounds were documented with basilar crackles that were greater on the left than the right. Progress notes for 8/31/18 reflected that R4 was started on [MEDICATION NAME] nebulizer treatments twice daily for seven days for difficulty breathing, 600 milligram (mg) [MEDICATION NAME] Tablets by mouth every 12 hours for congestion and [MEDICATION NAME] (antibiotic) 100 mg every 12 hours for seven days for pneumonia. Review of progress notes for 8/31/18 to 9/8/18 reflected that nurses had only documented an assessment of R4's lung sounds twice. On 9/2/18 at 10:43 PM, it was documented that R4 had diminished respirations bilaterally. On 9/3/18 at 7:22 PM, it was documented that R4's lungs sounds were clear to auscultation x4. According to the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The medical record did not reflect that a physical assessment or respiratory assessment had been performed on R4 upon completion of the antibiotics. A progress note on 9/10/18 at 7:02 AM reflected that R4 had a temperature of 100.8 degrees and a pulse of 139 bpm. A note on 9/10/18 at 11:05 PM reflected a temperature of 100.5 degrees and a recheck of 99.1 degrees 30 minutes later. The medical record did not reflect any further monitoring of R4's temperature until 9/17/18 (101.7 degrees). During a phone interview on 1/24/19 at 2:55 PM, RN S reported that she could not recall if she notified the physician or Nurse Practitioner of the elevated temperature and elevated pulse. She reported that they usually document it if they notify the provider. RN S reported that signs of infection/sepsis included fever, change in mental status and other than labs, she would look for pallor of skin, temperature of skin and appetite. A progress note by NP W on 9/13/18 reflected that R4 was seen due to complaints of left chest pain. His lungs sounds were documented as diminished on the left side. He had good air movement on the right side with a diminished base on the right. There was pain to palpation on the left lower rib area at the lateral aspect. A progress note on 9/14/18 at 6:00 PM reflected that R4's spouse had a phone conversation with Registered Nurse (RN) M regarding R4's left rib pain. The note also reflected that RN M had called NP W, and a follow-up chest x-ray was ordered for 9/20/18 to make sure R4's pneumonia had resolved after the antibiotic treatment (last dose of antibiotics were given on 9/7/18). According to the note, R4's spouse had visited that same evening and reported that R4 looked tired. Nurse stated yes he seems a little weaker these days and he seems to be eating a little less. The progress note reflected that RN M worked all weekend, and there were no health or behavioral concerns for R4. He did complain of left rib pain from time to time, according to the note. A progress note for 9/17/18 at 10:27 AM reflected .at Approx. (approximately) 8:00 am this writer was walking down the hall when (R4's first name) yelled out (RN D's first name), please. When this writer approached (R4's first name) he was observed to be dry heaving and slightly having difficulty catching his breath. Wheezing and crackling in chest/lungs could be heard at bedside without stethoscope. Care Giver came to assist to roll (R4's first name) over so both and (sic) front and back of lungs could be auscultated. Front and back had diminished Lung Sounds with crackles throughout. V.S. (vital signs) biox (oxygen saturation) 82%, pulse of 145 (bpm) and Temp (temperature) 101.7 (sic) During assessment (R4's first name) did have a medium emesis. N.P. was notified and she came to floor to assess (R4's first name) within 2-3 minutes. (R4's first name) was started on 2L (2 liters) O2 (oxygen) at this time and order was given to transport to E.R. (emergency room ) for further eval (evaluation) . A progress note by NP W on 9/17/18 reflected that R4 was seen due to staff's concern of his respiratory status. .The patient appears to be in respiratory distress. He tells me that it is hard to breath (sic). He does find that his heart is pounding, unsure whether he has had a temperature, but he believes that he has had chills .Continue to have intermittent nausea with emesis and tells me he has had quite little to drink or eat in the last few days .heart rate of 145 (beats per minute), and respirations are 32 (breaths per minute). Oxygen saturation on room air is 82% .LUNGS: With coarse crackles throughout .1. Respiratory distress with dyspnea and low biox. 2. [MEDICAL CONDITION]. 3. [MEDICAL CONDITION] 4. [MEDICAL CONDITION]. 5. Recent pneumonia . (Hospital Name) Hospitalist Discharge Summary for 9/26/18 reflected that R4's discharge [DIAGNOSES REDACTED]. The summary reflected that R4 was admitted for multilobar pneumonia with large left loculated pleural effusion/Empyema (pus between the lung and chest wall). A chest tube was placed on 9/18/18 with drainage of 1300cc (cubic centimeters) of turbid pleural fluid. He was transferred to the ICU. R4 was also noted to have acute [MEDICATION NAME] (inflammation of the gallbladder). Review of R4's pulses from 8/20/18 to 9/16/18 reflected the following: 09/16/2018 17:37 100 bpm (Regular) 09/16/2018 11:21 121 bpm (Regular) High of 100.0 exceeded 09/15/2018 18:09 110 bpm (Regular) High of 100.0 exceeded 09/15/2018 11:00 133 bpm (Regular) High of 100.0 exceeded 09/14/2018 10:13 133 bpm (Regular) High of 100.0 exceeded 09/12/2018 16:01 72 bpm (Regular) 09/11/2018 18:40 68 bpm (Regular) 09/11/2018 11:13 136 bpm (Regular) High of 100.0 exceeded 09/10/2018 18:03 120 bpm (Regular) High of 100.0 exceeded 09/10/2018 14:40 108 bpm (Regular) High of 100.0 exceeded 09/09/2018 16:49 108 bpm (Regular) High of 100.0 exceeded 09/08/2018 18:15 97 bpm (Regular) 09/08/2018 16:24 78 bpm (Regular) 09/08/2018 15:35 105 bpm (Regular) High of 100.0 exceeded 09/08/2018 10:51 95 bpm (Regular) 09/07/2018 16:22 103 bpm (Irregular - new onset) High of 100.0 exceeded 09/07/2018 10:30 125 bpm (Regular) High of 100.0 exceeded 09/06/2018 15:56 103 bpm (Irregular - new onset) High of 100.0 exceeded 09/06/2018 10:45 94 bpm (Regular) 09/04/2018 18:28 100 bpm (Regular) 09/04/2018 10:53 122 bpm (Regular) High of 100.0 exceeded 09/03/2018 19:21 118 bpm (Regular) High of 100.0 exceeded 09/03/2018 18:15 104 bpm (Regular) High of 100.0 exceeded 09/03/2018 10:24 118 bpm (Regular) High of 100.0 exceeded 09/02/2018 18:12 106 bpm (Regular) High of 100.0 exceeded 09/02/2018 10:15 122 bpm (Regular) High of 100.0 exceeded 09/01/2018 15:35 114 bpm (Irregular - new onset) High of 100.0 exceeded 09/01/2018 08:18 90 bpm (Regular) 08/31/2018 16:46 114 bpm (Regular) High of 100.0 exceeded 08/30/2018 17:19 95 bpm (Regular) 08/30/2018 10:05 132 bpm (Regular) High of 100.0 exceeded 08/29/2018 15:52 113 bpm (Regular) High of 100.0 exceeded 08/28/2018 15:42 109 bpm (Irregular - new onset) High of 100.0 exceeded 08/28/2018 14:23 66 bpm (Regular) 08/28/2018 13:19 120 bpm (Regular) High of 100.0 exceeded 08/28/2018 11:06 120 bpm (Regular) High of 100.0 exceeded 08/28/2018 06:38 86 bpm (Not Applicable) 08/27/2018 22:36 112 bpm (Regular) High of 100.0 exceeded 08/27/2018 16:28 112 bpm (Regular) High of 100.0 exceeded 08/27/2018 14:16 90 bpm (Regular) 08/27/2018 10:02 90 bpm (Regular) 08/27/2018 02:38 108 bpm (Regular) High of 100.0 exceeded 08/26/2018 23:40 115 bpm (Regular) High of 100.0 exceeded 08/26/2018 17:45 92 bpm (Regular) 08/26/2018 10:22 107 bpm (Regular) High of 100.0 exceeded 08/25/2018 21:35 115 bpm (Regular) High of 100.0 exceeded 08/25/2018 21:30 118 bpm (Regular) High of 100.0 exceeded 08/25/2018 17:15 89 bpm (Regular) 08/25/2018 10:30 92 bpm (Regular) 08/24/2018 16:25 114 bpm (Irregular - new onset) High of 100.0 exceeded 08/24/2018 11:00 98 bpm (Regular) 08/23/2018 09:19 98 bpm (Regular) 08/22/2018 16:45 99 bpm (Regular) 08/21/2018 17:55 85 bpm (Regular) 08/21/2018 10:02 90 bpm (Regular) 08/20/2018 20:20 91 bpm (Regular) . During an interview on 1/24/19 at 12:03 PM, RN M reported that symptoms [MEDICAL CONDITION] included a high fever and lethargy. She reported that CNA's obtained vital signs and we know that person's baseline. RN M reported that if something was way out of whack, they would contact the NP. During an interview on 1/24/19 at approximately 1:00 PM, RN O reported that signs [MEDICAL CONDITION] included a low BP, high pulse, low biox and elevated temperature. During an interview on 1/24/19 at 1:14 PM, NP W reported that she started seeing R4 about his rib pain on 8/24/18. R4 reported that he injured his ribs as a child and occasionally had flares. According to NP W, R4 was painful with palpation, and pain with palpation for pneumonia was not typical. She reported that R4 did not complain of rib pain while he was being treated with antibiotics for pneumonia. After completion of antibiotics, he began having rib pain again. The plan was to repeat a chest x-ray for R4. NP W reported that when she saw R4 on 9/17/18, he was significantly short of breath, had crackles throughout his lungs, oxygen saturation was low and he was [MEDICAL CONDITION] (had an elevated heart rate). NP W reported that R4 was in acute [MEDICAL CONDITION]. She reported that she had seen R4 the week prior, and R4 did not look like he was in distress. NP W reported that if R4 spiked a temperature, had increased symptoms or if his oxygen saturation levels dropped, they likely would have made a call. NP W reported that signs [MEDICAL CONDITION] included a high heart rate, a temperature, increased respiratory rate and [MEDICAL CONDITION]. According to NP W, R4's [MEDICAL CONDITION] have been a flag, but for the nurses, it had a lot to do with how he looked and what he was saying. She reviewed the report of R4's pulses and reported that it looked like his pulse was in the 80's to 90's for months. During a phone interview on 1/29/19 at 11:14 AM, LPN AA reported signs [MEDICAL CONDITION] included a high pulse rate and low blood pressure. She stated that she would also check what their responsiveness was. LPN AA stated other than that I honestly don't know (signs [MEDICAL CONDITION]). She reported that she would notify the physician and NP immediately. During a phone interview on 1/29/19 at 11:54 AM, RN R reported that signs [MEDICAL CONDITION] included increased heart rate, decreased blood pressure, elevated temperature and change in mental status. During an interview on 2/4/19 at 11:43 AM Clinical Manager Registered Nurse (CMRN) SS reported that training for changes in condition was provided in skills reviews yearly. She reported that when someone was on antibiotics, progress notes should have been completed every shift for 72 hours after starting the antibiotics and then with the last dose to make sure that the antibiotics treated the bacteria. She reported that the assessment for someone with pneumonia should have included lung sounds, oxygen saturation, malaise, fever, chills and heart rate because having an infection can change all that. She reported additional things to document were vital signs and cough. CMRN SS reported that the facility was working on [MEDICAL CONDITION] pathway. She stated that signs [MEDICAL CONDITION] included a high or low temperature, increased heart rate, low blood pressure and confusion. CMRN SS reported that if there were signs [MEDICAL CONDITION], the practitioner and family should have been contacted immediately. During an interview on 2/4/18 at 2:18 PM, RN D reported that they should have notified the provider (physician or NP) of the increased temperature and elevated heart rate after R4's antibiotics were completed. RN D stated that notification to the provider should have been in the progress notes. According to https://www.cdc.gov/sepsis/signs-symptoms.html, A patient [MEDICAL CONDITION] might have one or more of the following signs or symptoms .High heart rate, Fever, shivering, or feeling very cold .Confusion or disorientation, Shortness of breath, Extreme pain or discomfort, Clammy or sweaty skin .

This citation pertains to complaint intake MI 859. Based on interview and record review, the facility failed to ensure proper food consistency and appropriate monitoring during meals for 1 (Resident #2) of 3 total sampled residents reviewed for assistance with and mechanically altered meals, resulting in immediate jeopardy which began on [DATE] when Resident #2, who required 1 to 1 assistance with meals and a mechanically altered meal texture of pureed foods, ate solid foods, unsupervised, choked on the food that was provided to him by the facility, resulting in Resident #2 choking on the food, becoming unresponsive, and death. The deficient practice placed 35 residents that required mechanically altered food texture for injury or death. Findings include: Review of the Admission Record and the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was a [AGE] year old male resident readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #2 had unclear speech, usually understood, understands, vision was highly impaired, does not wear glasses, and was severely impaired cognitively. Further review of this assessment revealed Resident #2's difficulty with focusing attention fluctuated, required extensive physical assistance of one staff member for eating and required a mechanically altered diet. Review of the complaint received by the State Agency on [DATE] revealed, (Resident #2) was a resident of (name of facility). On (MONTH) 9, (YEAR), (Resident #2) was transported from (Name of facility) to (name of [MEDICAL TREATMENT] center) for treatment. (Resident #2) was transported by (name of ambulance company). (Name of facility) packs him a lunch on the days that he has [MEDICAL TREATMENT]. It was supposed to be pureed because of his eating problems .Apparently my dad did not eat his lunch at [MEDICAL TREATMENT]. After he was brought back to the facility .Sometime later, he was found in his room choking. [MEDICATION NAME] was attempted but the food was lodged too far down. He died that day. Review of Resident #2's summary of orders dated [DATE] revealed, Diet Order Summary: Renal Diet Pureed (foods that require no chewing .foods may be blended to make them the right consistency) texture, Nectar consistency .1:1 assist with meals . Review of Resident #2's record reflected resident#2 has factors of nutritional risk care plan created [DATE] revealed the intervention of, 1:1 assistance with meals. and the intervention of Diet per orders: renal, puree, NTL (nectar thick liquids). No straws. Allow regular consistency bananas. Allow dental soft consistency: spaghetti sauce with ground meat, desserts, fruit cup, cheese omelet, scrambled eggs, pasta, cookies. Review of the Death Certificate dated [DATE] revealed Resident #2 passed away on [DATE], with the cause of death being, Obstruction of Upper Airway .Aspiration (breathing in) of Food .Aspirated on food and choked while eating. Review of the nurses note dated [DATE] revealed, This writer (Registered Nurse (RN) C) was approached by (Resident #2's) caregiver (Certified Nursing Assistant (CNA) D). Caregiver vocalized upon returning to his room after transportation back from [MEDICAL TREATMENT], the resident was noted by the caregiver to have tears streaming down his cheek and did not appear right. Caregiver vocalized come and look at him. While quickly walking to (Resident #2's) room, caregiver vocalized that the EMT (Emergency Medical Technician) that brought the resident back vocalized that (Resident #2) was eating while being transported back to the facility. Upon entering the room (3:35 pm), (Resident #2) found to be unresponsive. This writer instructed the caregiver to call 911 and get the AED (Automated External Defibrillator). (Resident #2) had a pulse but was not breathing. Resident had food in his mouth. After giving multiple abdominal (thrust), food flew out of (Resident #2's) mouth. (Resident #2) was at this time lowered to the floor and the code button was pushed. (Resident #2) had no pulse and was not breathing at this time. This writer began CPR (cardiopulmonary resuscitation) . (local) fire dept. (department) arrived and began hooking up an IV (intravenous fluid) at (3:52 p.m.), Paramedics took over CPR from this writer. Paramedics continued CPR and called (Time of Death) after talking to the physician. During a telephone interview on [DATE] at 10:54 a.m., Driver (D) E stated that during the return trip from [MEDICAL TREATMENT] to the facility, Resident #2 started to eat a lunch that was provided by the facility. D E stated, He (Resident #2) had a couple pieces of bread that were in a plastic bag .he also had two hardboiled eggs that he started eating as I was taking him into the facility. D E confirmed that what he saw was actual bread, and not pureed bread, as well as two whole hardboiled eggs. During an interview on [DATE] at 2:48 p.m., when asked about Resident #2's diet requirements, Speech Language Pathologist (SLP) G stated, If I recall correctly I added some dental soft items, just to make it more interesting for him He was on a pureed diet, but some dental soft items I added. SLP G reviewed the order, Renal diet, Pureed texture, Nectar consistency .Assist table, 1:1 assist with meals. Allow regular consistency bananas. Allow dental soft consistency: spaghetti sauce with ground meat, desserts, fruit cup, cheese omelet, scrambled eggs, pasta, cookies. and then when asked if he was able to eat dental soft foods, or if the order was for those specific dental soft foods, SLP G stated, Those are foods that he has been tested on by me. Anything beyond those specific items he would not do good with. When asked if Resident #2 could have bread, SLP G stated, No, he would not do well with bread. Review of the [MEDICAL TREATMENT] Box Lunch List undated, revealed that there were to be two box lunches made to accompany 2 different residents to [MEDICAL TREATMENT] on Thursdays. One box was to include: 2 Hard-Boiled eggs, 1 slice rye bread, butterscotch pudding, and diet ginger ale. The box that was supposed to accompany Resident #2 to [MEDICAL TREATMENT] was to include: Ham Sandwich on white bread, yogurt (WITHOUT FRUIT), applesauce, 2 vanilla pudding. The sandwich was to be pureed. Review of photographs from Resident #2's room dated [DATE], provided by the local police department, revealed a picture of what appears to be a partially eaten hard-boiled egg laying on Resident #2's bed. During an interview on [DATE] when asked about the incident with Resident #2 on [DATE], Registered Nurse (RN) C stated, (Resident #2) had come back from [MEDICAL TREATMENT] .I remember putting my hand on (Resident #2's) shoulder, there was nothing. I checked for a pulse, got a faint pulse, and he was not breathing, I could see there was food in his mouth. When asked about what food came out when he performed the [MEDICATION NAME] maneuver, RN C stated, I do remember the food, it went right on his pillow that was beside his bed, it looked scrambled eggs. During a follow up interview on [DATE] at 1:00 p.m., when asked if the food that came up from Resident #2 when the [MEDICATION NAME] maneuver could have been chewed up hard-boiled egg, RN C stated, Yes, that could be possible. During an interview on [DATE] at 1:00 p.m., when asked about the day Resident #2 had returned from [MEDICAL TREATMENT] and was choking, Certified Nursing Assistant (CNA) D stated, (Residnet #2) came back from [MEDICAL TREATMENT], and the guy (ambulance driver) was pushing him into the room. I was in the room already, giving his roommate cares. I opened the door for them, he was holding his lunch bag and eating a sandwich. So I asked the guy if he just started eating, he said no, (Resident #2) was eating all this way coming here from [MEDICAL TREATMENT] .I welcomed him in and went to take off his outdoor outfit, and when I took his sunglasses off he had some tears coming from his eyes, and called him (Name of Resident #2) a couple of times, he is not saying anything, so I run down to the nurse at the nurses station, and asked him to come in. (RN) C came right down, and I told him he was eating and that he did not look to good. Then the nurse took over. When asked where the food came from that Resident #2 was eating, CNA D stated, It comes from here, when we send him out we give them the lunches. When asked if he looked inside the box before providing for the Resident, CNA D stated, No, we only had one resident that goes to [MEDICAL TREATMENT]. CNA D further stated, (Resident #2) probably should have someone help him with the lunch box because he is supposed to be supervision when eating. During an interview on [DATE] at 1:35 p.m., when asked about the box lunch that was prepared for Resident #2 on [DATE], Cook M stated, Yes, I couldn't believe what happened, I heard he got a piece of bread I believe I made two (box lunches). When asked if she remembered what she made, Cook M stated, If this was pureed one, then it would have been a pureed sandwich, the other had hard boiled eggs. The only thing I can think of is I got the boxes switched. The only thing I can think is I put the pureed sandwich in the wrong box, especially if he had a piece of bread. During a telephone interview on [DATE] at 10:18, when asked about what happened to Resident #2 on [DATE], Resident #2's daughter/guardian (Guardian K) stated, We were getting different stories on what he choked on, we were told it was a sandwich maybe .(Resident #2) was supposed to be a 1:1 feed. The day he died he went to the [MEDICAL TREATMENT] then back to the room .this was not the first time he was left alone to eat, I have seen him a couple of times in the dining room without any assistance with eating. Guardian 'K stated, I used to go to [MEDICAL TREATMENT] with him, there were three separate occasions that they sent him a sandwich and not a pureed meal .I was under the impression he was given an actual sandwich .that has happened on at least three occasions that they packed him an actual sandwich, and not a pureed sandwich. Immediate Jeopardy began on [DATE], date of resident #2's death and was identified on [DATE] during onsite complaint survey. NHA A was presented with Immediate Jeopardy Notification on [DATE] at 11:50 a.m. due to the facility's failure to ensure proper food consistency and appropriate monitoring during meals for Resident #2, resulting in Resident #2 choking on the food, becoming unresponsive, and death. A corrective action plan was requested from the facility to remove the immediate jeopardy. The facility submitted the following plan of correction to remove the Immediate Jeopardy: The [MEDICAL TREATMENT] box lunch process was reviewed by the Director of Hospitality Services with the Registered Dietitian. The Director determined the list needed to be reformatted in order to have the contents of the boxes to be verified by a second culinary team member prior to delivery to a resident. New education was developed for all staff. Timeline for education to staff is provided below. 5 of 5 managers, 10 of 10 supervisors, 1 of 1 clinical nutrition staff and 16 of 16 culinary staff all received this education. 100% of the dining room server staff received the education via the Hospitality Services Management Team Education as follows: Element #1 As of [DATE] Resident #2 no longer resided in the facility. On [DATE] the [MEDICAL TREATMENT] box lunch process was reviewed by the Director of Hospitality Services with the Registered Dietitian and the Executive Chef . The Director determined the list needed to be reformatted in order to have the contents of the boxes to be verified by a second culinary team member prior to delivery to a resident. On [DATE] Director of Hospitality Services verified contents of box lunches for resident number 3 as new process was not in place yet On [DATE] Director of Hospitality Services verified contents of box lunches for resident number 8 and resident number 3 as new process was not in place yet Element #2 Hospitality Services Director and Registered Dietitian confirmed that all residents receiving boxed lunches had appropriate diet orders and reviewed care plans for level of assistance required during meals. On [DATE] Director of Hospitality Services verified the care plan for 1 of 1 residents receiving [MEDICAL TREATMENT] box lunches (resident number 3) to verify the level of assistance needed at meals was independent. It was verified that resident number 3 could feed self. On [DATE] Director of Hospitality Services verified the care plan for 1 of 1 residents that was added to the [MEDICAL TREATMENT] box lunch list (resident number 8) to verify the level of assistance needed at meals was independent. It was verified that resident number 8 could feed self. On [DATE] the new [MEDICAL TREATMENT] box lunch list was utilized by the kitchen staff signed by (saff name) who was trained on the same date by Director of Hospitality Services on the new process. The contents were verified by Director of Hospitality Services for both resident number 8 and resident number 3 On [DATE] the Policy was made available for Box Lunches and the One Point Lesson on the new process for box lunches was made available in printed format for community-wide use. The dietitian will verify the level of assistance needed with meals. If assistance is needed a care plan will be put into place with the nurse manager to ensure appropriate assistance is provided outside of the community. The policy provides for a double check system for verification of all boxed lunch contents to be compliant with diet orders. On [DATE] Registered Dietitian verified the care plan for 1 of 1 resident who was added to the [MEDICAL TREATMENT] box lunch list (resident number 3) to verify the level of assistance needed at meals was independent. It was verified that resident number 3 could feed self. On [DATE] Registered Dietitian verified the care plan for 1 of 1 resident who was added to the [MEDICAL TREATMENT] box lunch list (resident number 0) to verify the level of assistance needed at meals was independent. It was verified that resident number 0 could feed self. Element #3 New education was developed for all staff. 5 of 5 managers, 10 of 10 supervisors, 1 of 1 clinical nutrition staff and 16 of 16 culinary staff all received this education. 100% of the dining room server staff received the education via the Hospitality Services Management Team Education. On [DATE] five culinary and management staff were educated by Director of Hospitality Services on the new process for [MEDICAL TREATMENT] box lunches due to being scheduled prior to the education materials being available. On [DATE] Another management staff were educated by Director of Hospitality Services due to being scheduled prior to the education materials being available. On [DATE] the following culinary staff were educated by Director of Hospitality Services due to being scheduled prior to the education materials being available. On [DATE] Fourteen culinary and supervisory staff were the first group to be educated by Director of Hospitality Services using the One Point Lesson on the new process for box lunches On [DATE] 100% of the hospitality department staff received the education via the Hospitality Services Management Team Education The Scoop which was reviewed at daily huddle meetings with the teams, posted in the community and placed into mailboxes. On [DATE] Two culinary staff were educated by Director of Hospitality Services using the One Point Lesson on the new process for box lunches On [DATE] Seven management and culinary staff were educated by Director of Hospitality Services using the One Point Lesson on the new process for box lunches On [DATE] Three supervisory staff were educated by Director of Hospitality Services using the One Point Lesson on the new process for box lunches On [DATE] - It was confirmed that 5 of 5 managers, 10 of 10 supervisors, 1 of 1 clinical nutrition staff and 16 of 16 culinary staff all received education on the new process for the box lunch preparation. Exact dates of each of the individuals is outlined above. Policy Boxed Lunch Policy was created to ensure a double check system is in place for verification of all boxed lunch contents are compliant with diet orders. See attachment. Element #4 Registered Dietitian or designee completes weekly audits of boxed lunches to ensure contents are compliant with diet orders and level of assistance needed. Results of findings were discussed with director overseeing QAPI for the community. Results will continue to be reviewed at QAPI meetings on a quarterly basis. On [DATE] Registered Dietitian performed her weekly audit of [MEDICAL TREATMENT] lunch lists which includes verifying diet orders are correct on the lunch list and verifying the level of assistance needed with meals. If assistance is needed at meals Registered Dietitian would consult with the nurse manager. During this audit it was determined 1 of 1 residents did not need feeding assistance. On [DATE] Registered Dietitian performed her weekly audit of [MEDICAL TREATMENT] lunch lists which includes verifying diet orders are correct on the lunch list and verifying the level of assistance needed with meals. If assistance is needed at meals Registered Dietitian would consult with the nurse manager. During this audit it was determined that 2 of 2 residents did not need feeding assistance. On [DATE] Executive Chef verified the contents of the box lunches for resident number 8 and resident number 3 On [DATE] Registered Dietitian verified the contents of the box lunches for resident number 3 On [DATE] Registered Dietitian performed her weekly audit of [MEDICAL TREATMENT] lunch lists which includes verifying diet orders are correct on the lunch list and verifying the level of assistance needed with meals. If assistance is needed at meals Registered Dietitian would consult with the nurse manager. During this audit it was determined that 1 of 2 residents did not need feeding assistance. Resident resident number 8 was at the hospital. On [DATE] Director of Hospitality Services verified the contents of the box lunches for resident number 3 On [DATE] Director of Hospitality Services verified the contents of the box lunches for resident number 3 On [DATE] Executive Chef verified the contents of the box lunches for resident number 8 and resident number 3 On [DATE] Executive Chef verified the contents of the box lunches for resident number 8 and resident number 3 On [DATE] Registered Dietitian performed her weekly audit of [MEDICAL TREATMENT] lunch lists which includes verifying diet orders are correct on the lunch list and verifying the level of assistance needed with meals. If assistance is needed at meals Registered Dietitian would consult with the nurse manager. During this audit it was determined that 2 of 2 residents did not need feeding assistance. On [DATE] Registered Dietitian verified the contents of the box lunches for resident number 8 and resident number 3 On [DATE] Registered Dietitian performed her weekly audit of [MEDICAL TREATMENT] lunch lists which includes verifying diet orders are correct on the lunch list and verifying the level of assistance needed with meals. If assistance is needed at meals Registered Dietitian would consult with the nurse manager. During this audit it was determined that 2 of 2 residents did not need feeding assistance. On [DATE] Executive Chef verified the contents of the box lunches for resident number 8 and resident number 3 On [DATE] Registered Dietitian performed her weekly audit of [MEDICAL TREATMENT] lunch lists which includes verifying diet orders are correct on the lunch list and verifying the level of assistance needed with meals. If assistance is needed at meals Registered Dietitian would consult with the nurse manager. During this audit it was determined that 2 of 2 residents did not need feeding assistance. On [DATE] Executive Chef verified the contents of the box lunches for resident number 3 On [DATE] Registered Dietitian performed her weekly audit of [MEDICAL TREATMENT] lunch lists which includes verifying diet orders are correct on the lunch list and verifying the level of assistance needed with meals. If assistance is needed at meals [NAME REDACTED] would consult with the nurse manager. During this audit it was determined that 2 of 2 residents did not need feeding assistance. On [DATE] Registered Dietitian verified the care plan for 1 of 1 resident who was added to the [MEDICAL TREATMENT] box lunch list (resident number 3) to verify the level of assistance needed at meals was independent. It was verified that resident number 3 could feed self. On [DATE] Executive Chef verified the contents of the box lunches for resident number 3 and resident number 3 On [DATE] Director of Hospitality Services verified the contents of the box lunches for resident number 3 On [DATE] Registered Dietitian verified the care plan for 1 of 1 residents that was added to the [MEDICAL TREATMENT] box lunch list (resident number 0) to verify the level of assistance needed at meals was independent. It was verified that resident number 0 could feed self. On [DATE] Registered Dietitian performed her weekly audit of [MEDICAL TREATMENT] lunch lists which includes verifying diet orders are correct on the lunch list and verifying the level of assistance needed with meals. If assistance is needed at meals Registered Dietitian would consult with the nurse manager. During this audit it was determined that 3 of 3 residents did not need feeding assistance. On [DATE] Executive Chef verified the contents of the box lunches for resident number 3 and resident number 3 On [DATE] Registered Dietitian performed her weekly audit of [MEDICAL TREATMENT] lunch lists which includes verifying diet orders are correct on the lunch list and verifying the level of assistance needed with meals. If assistance is needed at meals Registered Dietitian would consult with the nurse manager. During this audit it was determined that 2 of 3 residents did not need feeding assistance. Resident number 0 was at the hospital. On [DATE] Director of Hospitality Services verified the contents of the box lunches for resident number 3 On [DATE] Registered Dietitian performed her weekly audit of [MEDICAL TREATMENT] lunch lists which includes verifying diet orders are correct on the lunch list and verifying the level of assistance needed with meals. If assistance is needed at meals Registered Dietitian would consult with the nurse manager. During this audit it was determined that 2 of 2 residents did not need feeding assistance. On [DATE] Director of Hospitality Services verified the contents of the box lunches for resident number 3 On [DATE] Registered Dietitian performed her weekly audit of [MEDICAL TREATMENT] lunch lists which includes verifying diet orders are correct on the lunch list and verifying the level of assistance needed with meals. If assistance is needed at meals Registered Dietitian would consult with the nurse manager. During this audit it was determined that 2 of 2 residents did not need feeding assistance. On [DATE] Executive Chef verified the contents of the box lunches for resident number 3 and resident number 3 On [DATE] Executive Chef verified the contents of the box lunches for resident number 3 and resident number 3 Results of findings were discussed with director overseeing QAPI for the community on [DATE]. The RD and/or designee will continue to conduct audits. Results will be reviewed at QAPI meetings on a quarterly basis. The Immediate Jeopardy was removed on [DATE], based on the providers implementation of the plan of removal as verified onsite on [DATE].

This citation pertains to complaint intake MI 859. Based on interview and record review, the facility failed to ensure proper food consistency and appropriate monitoring during meals for 1 (Resident #2) of 3 total sampled residents reviewed for assistance with and mechanically altered meals, resulting in immediate jeopardy which began on [DATE] when Resident #2, who required 1 to 1 assistance with meals and a mechanically altered meal texture of pureed foods, ate solid foods, unsupervised, choked on the food that was provided to him by the facility, resulting in Resident #2 choking on the food, becoming unresponsive, and death. The deficient practice placed 35 residents that required mechanically altered food texture for injury or death. Findings include: Review of the Admission Record and the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was a [AGE] year old male resident readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #2 had unclear speech, usually understood, understands, vision was highly impaired, does not wear glasses, and was severely impaired cognitively. Further review of this assessment revealed Resident #2's difficulty with focusing attention fluctuated, required extensive physical assistance of one staff member for eating and required a mechanically altered diet. Review of the complaint received by the State Agency on [DATE] revealed, (Resident #2) was a resident of (name of facility). On (MONTH) 9, (YEAR), (Resident #2) was transported from (Name of facility) to (name of [MEDICAL TREATMENT] center) for treatment. (Resident #2) was transported by (name of ambulance company). (Name of facility) packs him a lunch on the days that he has [MEDICAL TREATMENT]. It was supposed to be pureed because of his eating problems .Apparently my dad did not eat his lunch at [MEDICAL TREATMENT]. After he was brought back to the facility .Sometime later, he was found in his room choking. [MEDICATION NAME] was attempted but the food was lodged too far down. He died that day. Review of Resident #2's summary of orders dated [DATE] revealed, Diet Order Summary: Renal Diet Pureed (foods that require no chewing .foods may be blended to make them the right consistency) texture, Nectar consistency .1:1 assist with meals . Review of Resident #2's record reflected resident#2 has factors of nutritional risk care plan created [DATE] revealed the intervention of, 1:1 assistance with meals. and the intervention of Diet per orders: renal, puree, NTL (nectar thick liquids). No straws. Allow regular consistency bananas. Allow dental soft consistency: spaghetti sauce with ground meat, desserts, fruit cup, cheese omelet, scrambled eggs, pasta, cookies. Review of the Death Certificate dated [DATE] revealed Resident #2 passed away on [DATE], with the cause of death being, Obstruction of Upper Airway .Aspiration (breathing in) of Food .Aspirated on food and choked while eating. Review of the nurses note dated [DATE] revealed, This writer (Registered Nurse (RN) C) was approached by (Resident #2's) caregiver (Certified Nursing Assistant (CNA) D). Caregiver vocalized upon returning to his room after transportation back from [MEDICAL TREATMENT], the resident was noted by the caregiver to have tears streaming down his cheek and did not appear right. Caregiver vocalized come and look at him. While quickly walking to (Resident #2's) room, caregiver vocalized that the EMT (Emergency Medical Technician) that brought the resident back vocalized that (Resident #2) was eating while being transported back to the facility. Upon entering the room (3:35 pm), (Resident #2) found to be unresponsive. This writer instructed the caregiver to call 911 and get the AED (Automated External Defibrillator). (Resident #2) had a pulse but was not breathing. Resident had food in his mouth. After giving multiple abdominal (thrust), food flew out of (Resident #2's) mouth. (Resident #2) was at this time lowered to the floor and the code button was pushed. (Resident #2) had no pulse and was not breathing at this time. This writer began CPR (cardiopulmonary resuscitation) . (local) fire dept. (department) arrived and began hooking up an IV (intravenous fluid) at (3:52 p.m.), Paramedics took over CPR from this writer. Paramedics continued CPR and called (Time of Death) after talking to the physician. During a telephone interview on [DATE] at 10:54 a.m., Driver (D) E stated that during the return trip from [MEDICAL TREATMENT] to the facility, Resident #2 started to eat a lunch that was provided by the facility. D E stated, He (Resident #2) had a couple pieces of bread that were in a plastic bag .he also had two hardboiled eggs that he started eating as I was taking him into the facility. D E confirmed that what he saw was actual bread, and not pureed bread, as well as two whole hardboiled eggs. During an interview on [DATE] at 2:48 p.m., when asked about Resident #2's diet requirements, Speech Language Pathologist (SLP) G stated, If I recall correctly I added some dental soft items, just to make it more interesting for him He was on a pureed diet, but some dental soft items I added. SLP G reviewed the order, Renal diet, Pureed texture, Nectar consistency .Assist table, 1:1 assist with meals. Allow regular consistency bananas. Allow dental soft consistency: spaghetti sauce with ground meat, desserts, fruit cup, cheese omelet, scrambled eggs, pasta, cookies. and then when asked if he was able to eat dental soft foods, or if the order was for those specific dental soft foods, SLP G stated, Those are foods that he has been tested on by me. Anything beyond those specific items he would not do good with. When asked if Resident #2 could have bread, SLP G stated, No, he would not do well with bread. Review of the [MEDICAL TREATMENT] Box Lunch List undated, revealed that there were to be two box lunches made to accompany 2 different residents to [MEDICAL TREATMENT] on Thursdays. One box was to include: 2 Hard-Boiled eggs, 1 slice rye bread, butterscotch pudding, and diet ginger ale. The box that was supposed to accompany Resident #2 to [MEDICAL TREATMENT] was to include: Ham Sandwich on white bread, yogurt (WITHOUT FRUIT), applesauce, 2 vanilla pudding. The sandwich was to be pureed. Review of photographs from Resident #2's room dated [DATE], provided by the local police department, revealed a picture of what appears to be a partially eaten hard-boiled egg laying on Resident #2's bed. During an interview on [DATE] when asked about the incident with Resident #2 on [DATE], Registered Nurse (RN) C stated, (Resident #2) had come back from [MEDICAL TREATMENT] .I remember putting my hand on (Resident #2's) shoulder, there was nothing. I checked for a pulse, got a faint pulse, and he was not breathing, I could see there was food in his mouth. When asked about what food came out when he performed the [MEDICATION NAME] maneuver, RN C stated, I do remember the food, it went right on his pillow that was beside his bed, it looked scrambled eggs. During a follow up interview on [DATE] at 1:00 p.m., when asked if the food that came up from Resident #2 when the [MEDICATION NAME] maneuver could have been chewed up hard-boiled egg, RN C stated, Yes, that could be possible. During an interview on [DATE] at 1:00 p.m., when asked about the day Resident #2 had returned from [MEDICAL TREATMENT] and was choking, Certified Nursing Assistant (CNA) D stated, (Residnet #2) came back from [MEDICAL TREATMENT], and the guy (ambulance driver) was pushing him into the room. I was in the room already, giving his roommate cares. I opened the door for them, he was holding his lunch bag and eating a sandwich. So I asked the guy if he just started eating, he said no, (Resident #2) was eating all this way coming here from [MEDICAL TREATMENT] .I welcomed him in and went to take off his outdoor outfit, and when I took his sunglasses off he had some tears coming from his eyes, and called him (Name of Resident #2) a couple of times, he is not saying anything, so I run down to the nurse at the nurses station, and asked him to come in. (RN) C came right down, and I told him he was eating and that he did not look to good. Then the nurse took over. When asked where the food came from that Resident #2 was eating, CNA D stated, It comes from here, when we send him out we give them the lunches. When asked if he looked inside the box before providing for the Resident, CNA D stated, No, we only had one resident that goes to [MEDICAL TREATMENT]. CNA D further stated, (Resident #2) probably should have someone help him with the lunch box because he is supposed to be supervision when eating. During an interview on [DATE] at 1:35 p.m., when asked about the box lunch that was prepared for Resident #2 on [DATE], Cook M stated, Yes, I couldn't believe what happened, I heard he got a piece of bread I believe I made two (box lunches). When asked if she remembered what she made, Cook M stated, If this was pureed one, then it would have been a pureed sandwich, the other had hard boiled eggs. The only thing I can think of is I got the boxes switched. The only thing I can think is I put the pureed sandwich in the wrong box, especially if he had a piece of bread. During a telephone interview on [DATE] at 10:18, when asked about what happened to Resident #2 on [DATE], Resident #2's daughter/guardian (Guardian K) stated, We were getting different stories on what he choked on, we were told it was a sandwich maybe .(Resident #2) was supposed to be a 1:1 feed. The day he died he went to the [MEDICAL TREATMENT] then back to the room .this was not the first time he was left alone to eat, I have seen him a couple of times in the dining room without any assistance with eating. Guardian 'K stated, I used to go to [MEDICAL TREATMENT] with him, there were three separate occasions that they sent him a sandwich and not a pureed meal .I was under the impression he was given an actual sandwich .that has happened on at least three occasions that they packed him an actual sandwich, and not a pureed sandwich. Immediate Jeopardy began on [DATE], date of resident #2's death and was identified on [DATE] during onsite complaint survey. NHA A was presented with Immediate Jeopardy Notification on [DATE] at 11:50 a.m. due to the facility's failure to ensure proper food consistency and appropriate monitoring during meals for Resident #2, resulting in Resident #2 choking on the food, becoming unresponsive, and death. A corrective action plan was requested from the facility to remove the immediate jeopardy. The facility submitted the following plan of correction to remove the Immediate Jeopardy: 1 The [MEDICAL TREATMENT] box lunch process was reviewed by the Director of Hospitality Services with the Registered Dietitian. The Director determined the list needed to be reformatted in order to have the contents of the boxes to be verified by a second culinary team member prior to delivery to a resident. New education was developed for all staff. Timeline for education to staff is provided below. 5 of 5 managers, 10 of 10 supervisors, 1 of 1 clinical nutrition staff and 16 of 16 culinary staff all received this education. 100% of the dining room server staff received the education via the Hospitality Services Management Team Education. 2 - Hospitality Services Director and Registered Dietitian confirmed that all residents receiving boxed lunches had appropriate diet orders and reviewed care plans for level of assistance required during meals. 3. New education was developed for all staff. 5 of 5 managers, 10 of 10 supervisors, 1 of 1 clinical nutrition staff and 16 of 16 culinary staff all received this education. 100% of the dining room server staff received the education via the Hospitality Services Management Team Education. Policy Boxed Lunch Policy was created to ensure a double check system is in place for verification of all boxed lunch contents are compliant with diet orders. See attachment. 4. Registered Dietitian or designee completes weekly audits of boxed lunches to ensure contents are compliant with diet orders and level of assistance needed. Results of findings were discussed with director overseeing QAPI for the community. Results will continue to be reviewed at QAPI meetings on a quarterly basis. The Immediate Jeopardy was removed on [DATE], based on the providers implementation of the plan of removal as verified onsite on [DATE].

This citation pertains to intake MI 679 and MI 749. Based on interview and record review the facility failed to ensure that 2 of 6 residents reviewed (#51 and #52) were free of any significant medication errors resulting in Resident #51 developing mental status changes, depressed breathing and low blood pressure requiring hospitalization after receiving Resident #56's medications which included a narcotic and a central nervous system depressant and Resident #52 developing a drugged feeling, low blood pressure and shortness of breath after receiving two times the prescribed dose of the skeletal muscle relaxant [MEDICATION NAME] for three days. Findings include: Resident #51 Based on the Minimum Data Set (MDS) assessment, dated 7/8/16, Resident #51 was a [AGE] year old alert and oriented male whose [DIAGNOSES REDACTED]. Based on the above MDS Resident #51 was admitted to the facility on [DATE] and required assistance with all activities of daily living. Review of the physician orders dated 7/3/16 reflected the only medication prescribed for pain for Resident #51 was [MEDICATION NAME] 650 mg every four hours as needed. The Medication Administration Record (MAR) dated 7/1/16-7/31/16 reflected Resident #51 had received one dose on 7/3/16 and 7/5/16. Based on the incident report from the electronic medical record (EMR), dated 7/8/16 at 4:24 PM and signed by Registered Nurse (RN) E, Resident #51 had been given medications prepared for Resident #56 at 4:00 PM. The medications were [MEDICATION NAME] 40 mg (a narcotic), [MEDICATION NAME] 150 mg (a [MEDICATION NAME], anticonvulsant and central nervous system depressant) and [MEDICATION NAME] 300 mg (a central nervous system stimulant). Based on the manufacturer's information in Specialized Long-Term Care Nursing Drug Handbook 2008, pages 636-640, [MEDICATION NAME] is a narcotic with a long half-life (the time it takes to be processed out of the body) and has a risk of accumulating in the body. [MEDICATION NAME] has a Black Box Warning for side effects of respiratory depression, severe low blood pressure, prolonged electrical intervals in the heart leading to irregular rhythms and use in the elderly related to increased susceptibility to the side effects of the medication. The recommended dose for residents who have no history of narcotic use is 2.5-10 mg every 8-12 hours to begin treatment. Resident #51 received four-sixteen times the single recommended initial dose on 7/8/16 at 4:00 PM. The onset of the medication effect is 30-60 minutes and the peak effect (most effective action) is 3-5 days with continuous dosing. Based on the manufacturer's information in Specialized Long-Term Care Nursing Drug Handbook 2008, pages 812-815, [MEDICATION NAME] (pregabalin) is an [MEDICATION NAME] and anticonvulsant. [MEDICATION NAME] may cause central nervous system depression (decreased breathing, blood pressure, pulse and mental alertness) and the effect may be additive with the use of other sedative type drugs like narcotics. Based on the manufacturer's information in Specialized Long-Term Care Nursing Drug Handbook 2008, pages 675-676, [MEDICATION NAME] (modafinil) is a central nervous system stimulant which may cause confusion, agitation, dizziness and nervousness. The nursing progress note, dated 7/9/16 at 4:40 PM by RN E, reflected Note: Late entry for 7/8/16 Resident (#51) given another residents (sic) medication by another nurse (identified by the facility as RN F) in error at 1600 (4:00 PM) on 7/8/16. The resident received 300mg of [MEDICATION NAME], 40mg of [MEDICATION NAME], and 150mg [MEDICATION NAME]. Nurse informed nurse practitioner (NP) of the medication error. Intervention Two doses of 0.4mg [MEDICATION NAME] (a medication to reverse narcotic effects) were given to resident in along with starting 3L O2 nc (nasal cannula). The first dose was given to the resident IM (intramuscularly) at 1730 (5:30 PM) and an IV (intravenous) of D5NS was started and the nurse practitioner gave the second [MEDICATION NAME] dose at 1743 (5:43 PM) IV push. The residents (sic) V/S (vital signs) began to improve (systolic BP improving from mid 70's to mid 80's and respirations improving) and he was arousable at the time EMS (Emergency Medical Services) arrived to take him to the (hospital name) ED (Emergency Department). The emergency contact son, (son's name) was notified by the NP (Nurse Practitioner). The MAR dated 7/1/16-7/31/16 reflected no documentation of the [MEDICATION NAME] being given. The clinical record reflected no documentation of Resident #51 blood pressure, pulse, respiration, oxygen saturation levels or mental status when he was first assessed or during the treatment in the facility other than the nursing progress note on 7/9/16 from RN E and vitals signs recorded at 10:26 PM (after the resident went to the hospital) Temperature 101.2, pulse 120/beats per minute, respirations 40/minute and oxygen saturation level 93%. On 7/27/16 at 11:05 AM the Director of Nursing (DON) B stated the vitals were taken earlier in the shift around the time of the medication error and charted at the end of the shift (10:26 PM). On 7/27/16 at 9:15 AM RN E was interviewed privately. RN E stated Resident #56 came up to his medication cart with RN F, who was orienting with RN E, about 4:00 PM on 7/8/16 and RN E decided to prepare the scheduled 4:00 PM medications for Resident #56. RN E stated he told Resident #56 and RN F what he was doing and they both verbally acknowledged with an ok. RN E stated RN F then took Resident #56 to his room and when RN F returned to the medication cart RN E handed RN F the cup of pills containing [MEDICATION NAME] 300 mg, [MEDICATION NAME] 40 mg and [MEDICATION NAME] 150 mg. RN E stated he did not watch RN F go into Resident #56's room as he went to work on orders at the B-hall nursing station. RN E stated that at about 4:30 PM Resident #56 came out of his room and asked where his medications were and RN E stated I gave them to (RN F's name) to give to you. RN E stated he immediately found RN F and asked if she had given the medications to Resident #56 and she replied no then could not recall who she had given the medications to. RN E stated he went down the hall with RN F and checked all the male residents on their assignment and other residents on the hall. RN E stated about 10 minutes later RN F told him she had given the medications to Resident #51 who was not assigned to either RN E or RN F. RN E stated he did not know Resident #51 and he immediately told RN G who was caring for Resident #51 what had happened. RN E stated he requested a set of vital signs STAT and informed NP H who was at the A-hall nursing station of the medication error and she needed to see Resident #51 right away. RN E stated he then got two doses of [MEDICATION NAME] (a medication that reverses the effects of narcotics) from the medication room. RN E stated the first dose was given IM as Resident #51 was sedated and groggy. RN E stated NP H then started an IV and gave the second dose of [MEDICATION NAME] through the IV. RN E stated Resident #51 was more awake after that and the ambulance arrived about 10 minutes after the second dose of [MEDICATION NAME] was given to transport Resident #51 to the hospital. RN F was no longer employed at the facility as of 7/22/16 and was not interviewed. Review of the telephone interview of RN F by the Director of Nursing (DON) B on 7/8/16 (no time documented) reflected RN F had taken Resident #56 outside and when she returned with the Resident RN E stated he would pull his (Resident #56) medications. RN F stated she took Resident #56 to his room then returned to the medication cart where RN E handed her a cup of pills and told her they were for room Resident #51's room number. RN F stated RN E turned and walked away from RN F and RN F asked if the medications were for Resident #51's room number. RN F stated RN E turned back slightly but RN F didn't hear a response so RN F proceeded to Resident #51's room number and gave the medications. Review of a second written interview of RN F by DON B on 7/11/16, no time recorded, reflected the same information with the addition of RN F stating she checked the name on the door of Resident #51's room and it was Resident #51's name. RN F stated Resident #51 was in the room and she checked his arm band and stated I have your pills (Resident #51's first name) and the client took the medications then RN F returned to the medication cart. Review of a written interview of RN F by Nursing Home Administrator (NHA) A on 7/11/16 (no time) reflected RN F acknowledged that Resident #51 was not assigned to RN F and RN E that day and that after administering the medications to Resident #51 RN F returned to the nursing station. Review of the MAR reflected there was no evidence RN F documented the medications she had just given. RN F stated that shortly after her return to the nursing station Resident #56 came from his room to inquire about his medications. RN F stated to NHA A that RN E seemed concerned and immediately started asking RN F questions then RN F walked up and down the hall attempting to recall who RN F had given the medications to. When RN F saw another nurse in resident # 51's room RN F recognized Resident #51 as the resident she had given Resident #56's medications to. According to the above documented interview RN F stated she was familiar with the 5 Rights (of medication administration) and stated she did not use appropriate judgement in passing medications that she had not prepared. On 7/27/16 at 11:03 AM NP H stated she had not met Resident #51 prior to seeing him on the afternoon of 7/8/16. NP H stated RN E came to her and stated Resident #51 had received another resident's medications, specifically [MEDICATION NAME] and RN G told me I needed to see Resident #51. NP H stated on her first assessment of Resident #51 he was easily awakened but I was not convinced he was going to stay that way, his respiratory rate was slow, I don't recall what it was exactly, his BiOx (oxygen saturation, normal range above 92%) was in the 80s. Resident #51 had not needed oxygen during his stay and his color was good, no cyanosis (bluish color related to decreased oxygen to the cells). NP H stated she was concerned as Resident #51 had no history of taking narcotics so the side effects of the medications could be significant. NP H stated one of the nursing aides told her Resident #51 had been talking with family recently so I knew he was verbal. NP H stated at the time of her assessment Resident #51 was slow to respond but was able to follow directions to take deep breaths as his breathing was shallow. NP H stated one dose of [MEDICATION NAME] was given IM and staff stayed with Resident #51 while she notified the Resident's son of the need to transport Resident #51 to the hospital for further treatment. NP H stated Resident #51 was a little less responsive when she returned to the room so she started an IV and gave a second dose of [MEDICATION NAME] through the IV and ran IV fluids wide open (fast rate) for blood pressure support. NP H stated Resident #51's oxygen saturation was in the 90s after the second dose of [MEDICATION NAME]. NP H stated she did not recall what Resident #51's blood pressure was but it was not in her alarm zone of the 80s for the systolic (top number) reading. NP H stated the ambulance came just after the second dose of [MEDICATION NAME] was given. On 7/27/16 at 1:32 PM RN G was interviewed by telephone. RN G stated that between 4:40-5:00 PM on 7/8/16 the nursing aide assigned to Resident #51 came to him to report the Resident's temperature was 101 degrees Farenheit (F) (usual range for Resident #51 was 97.1-98.7 degrees F in the vital signs section of the EMR). RN G stated I went to see him (Resident #51) and there is something wrong. RN F was passing by the room and I asked her to look at him. When RN F went in the room she said oh my god, I gave him some meds. Resident #51's BiOx was 88% and his blood pressure was 90/50 (Resident #51's usual range was 97-112/58-80). RN G stated he put oxygen on Resident #51 at 2L/min and noticed a period of apnea (a time when respirations stop then resume, occurs with respiratory depression) and a respiratory rate less than 12 breaths/min (Resident #51's usual range was 14-19 breaths/min). RN G stated Resident #51 was not responding as usual as he had been speaking and joking and was oriented earlier in the shift but was not responding to verbal stimulus when he entered the room after the nursing aide told him about the Resident's elevated temperature. RN G stated the oxygen was increased to 3L/min during the emergency treatment and the BiOx was then greater than 90%. RN G stated NP H asked for [MEDICATION NAME] and IV fluids and both were given. RN G stated he kept NP H informed of the Resident's vital signs during the emergency treatment but did not record any of the information. Based on the hospital clinical record, dated 7/8/16-7/15/16, Resident #51 was treated in the Emergency Department with both bolus (one time injection) and continuous IV infusion of [MEDICATION NAME] prior to being admitted to the Neuro Intensive Care Unit. The continuous [MEDICATION NAME] infusion continued until 7/9/16 at 7:00 PM and Resident #51 was discharged to a different long term care facility on 7/15/16. During the interview on 7/27/16 at 9:15 AM RN E was asked if he would normally prepare medications for a Resident and give the medications to another person to administer. RN E stated he had been orienting a new staff member RN F for the first time on 7/8/16. RN E stated the two of them had been passing medications separately during the shift. RN E stated RN F had been right there at the medication cart when he was preparing Resident #56's medications. RN E stated he was not sure if RN F was looking at the MAR and stated she didn't see the medication packaging as far as he could recall. Later in the interview RN E stated if you prepare something (medication) you should give it. Review of the facility policy for Medication Administration, revised 7/11/16, reflected under Procedure: .3. The RN/LPN (Licensed Practical Nurse) or other lawfully authorized personal (sic) that prepares the mediation for the resident/client must be the person who administers the medication. The person administering the medication(s) is responsible for recording the administration, or refusal of the medication(s) in the medication administration record or treatment record, after the medication or treatment is administered . Review of the Licensed Nurses Orientation Record for RN E, hired 2/25/16, reflected the Medication Administration section which included the headings; MAR documentation, TAR (treatment administration record)documentation, PRNs (as needed medications) documentation, pre/post pain assessment, practice of 5 rights, identification of residents, policy for administering [MEDICATION NAME], medication pass observation with manager, medication error policy and procedure and medication reconciliation at the end of the month, had been initialed by trainers on 2/29/16, 3/7/16 and 3/15/16. The instructions on the first page of the record reflected .The instructor and orienteer (sic) are not to sign off on an item until both agree the new employee is knowledgeable and proficient in each particular area . Based on the Communication/Counseling form, dated 7/18/16 and reviewed from the Personnel Record on 7/27/16 at 10:30 AM, RN E had .violated the standards of nursing practice concerning med pass. In addition, he failed to comply with (facility name) Medication Administration policy, which states: The RN/LPN or other lawfully authorized personal (sic) that prepares the medication for the resident/client must be the person who administers the medication. Moreover, (RNE's first name) did not follow the 6 rights of medication administration (see below) and thereby contributing to the significant error. To ensure safe medication administration, the RN/LPN or other lawfully authorized personal (sic) will follow the 'six rights' of medication administration consistently every time he/she administers a medication: a. Right medication-(includes verifying resident does not have allergy to medications) b. Right dose c. Right client/resident d. Right route e. Right time f. Right documentation (includes any vital signs that must be obtained prior to administration of medications). On 7/18/16, ten days after the error, RN E received an eight hour training related to medication administration which included an observed medication pass by RN Unit Manager/Staff Educator (RN UM/SE) J. On 7/20/16 RN E was observed during a medication pass by the facility Registered Pharmacist I. Review of the Licensed Nurses Orientation Record for RN F, hired 6/24/16, reflected the Medication Administration section which included the headings; MAR documentation, TAR (treatment administration record)documentation, PRNs (as needed medications) documentation, pre/post pain assessment, practice of 5 rights, identification of residents, policy for administering [MEDICATION NAME], medication pass observation with manager, medication error policy and procedure and medication reconciliation at the end of the month, had been initialed by RN UM/SE J on 7/13/16. The item Observed Competencies-Peg/J tube (stomach tube) Med (medication) Administration had been initialed by RN UM/SE J on 6/28/16. The instructions on the first page of the record reflected .The instructor and orienteer (sic) are not to sign off on an item until both agree the new employee is knowledgeable and proficient in each particular area . On 7/13/16, five days after the medication error, RN F received an eight hour training related to medication administration which included an observed medication pass by RN UM/S E J. Resident #52 Based on the MDS assessment, dated 6/1/16, Resident #52 was an alert and oriented [AGE] year old female whose [DIAGNOSES REDACTED]. Based on the face sheet in the EMR Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the After Visit Summary from the hospital, dated 7/13/16, reflected .[MEDICATION NAME] (a skeletal muscle relaxant) 4 mg tablet take 4 mg by mouth three times daily as needed for muscle spasms. Review of the physician orders entered for 7/13/16 in the EMR reflected an order for [REDACTED]. Review of the MAR, dated 7/1/6-7/31/16 reflected Resident #52 received the [MEDICATION NAME] every eight hours from 6:00 AM 7/14/16-2:00 PM 7/16/16 (eight doses). Review of the same MAR reflected the [MEDICATION NAME] was ordered 4 mg every eight hours as needed from 7/1/16-7/11/16 and no doses were administered. The manufacturer's information in Specialized Long-Term Care Nursing Drug Handbook 2008, pages 973-975, reflected significant low blood pressure, low pulse rate and sedation were potential side effects and the drug should be used with caution for residents with [MEDICAL CONDITION]. In addition, use with other central nervous system depressants (like the narcotic pain medication [MEDICATION NAME] Resident #52 was taking) could result in an additive effect to sedation. Review of the nursing progress notes reflected the entry for 7/16/16 at 8:24 PM by Agency Nurse K, Note: at 0830 (8:30 AM) guest complained I feel drugged as she was brought back to her room after breakfast. Spoke with patient, she had no change in mental status, vitals were stable when questioned about possible reasons why, she stated she had received a [MEDICATION NAME] (narcotic pain medication) and muscle relaxant at the same time this morning at 0600 (6:00 AM). Helped resident into bed, and spoke about monitoring her for any changes. Resident then napped until 11:30, stated 'I still feel kinda tired, but I don't have much pain at all', . On 7/17/16 at 2:35 AM, RN L documented Since readmission from the hospital, resident had been ordered [MEDICATION NAME] ([MEDICATION NAME]) 4 mg scheduled every 8 hours. Pharmacy mistakenly supplied 8 mg per dose, Resident has received 8 mg [MEDICATION NAME] every 8 hours since readmission. Previously this medication had been PRN (as needed). Resident apparently experienced change in LOC (level of consciousness), shortness of breath and 'feeling drugged'. Resident supplied with supplemental oxygen as well as Proair inhaler ([MEDICATION NAME] medication). Resident assisted to bed to prevent falls. Resident difficult to rouse, requiring physical contact in addition to verbal stimulation. Resident denied pain or discomfort, last PRN pain at 6:00 AM on 7-16-16. night dose (10:00 PM) of [MEDICATION NAME] held. Review of the MAR dated 7/1/16-7/31/16 reflected the 6:00 AM dose of [MEDICATION NAME] was held on 7/17/17. On 7/17/16 at 3:43 AM RN L documented .Resident easily aroused, more coherent than at the beginning of shift. Resident reports feeling better . Review of the vital signs section of the EMR refected Resident #52's blood pressure was in the 150s/60s on 7/13/16 and 7/14/16 then went down to 137/62 on 7/15/16 at 5:54 AM , 125/63 at 12:44 AM and 108/65 at 2:56 AM on 7/16/16. The blood pressure returned to the Resident's baseline by 4:21 PM on 7/16/16. The Resident's pulse and respiratory rates remained the same during the same time period as the listed blood pressure readings. Review of an incident in the EMR, dated 7/16/16 at 7:09 PM by RN L reflected the pharmacy error of filling the [MEDICATION NAME] pouch with two 4 mg tablets in stead of the one 4 mg tablet that was ordered had been identified by the nurse and reported to the pharmacy provider. Review of the Pharmacy provider's Description of Event/Incident submitted on 7/27/16 reflected On 7-14-16 order on admit written as [MEDICATION NAME] 4mg give 4mg Q8H (every 8 hours). We entered, checked and dispensed 2 X 4mg (=8mg) PO Q8H. Order was corrected on 7-16-16. Correct order sent, RX with incorrect directions d/cd'd (discontinued). The reported by line reflected (Pharmacist's first name) RPh, Via email from nurse. Review of the physician order entry in the EMR dated 7/17/16 at 6:00 PM reflected the [MEDICATION NAME] order had been changed to 4 mg by mouth as needed for muscle spasms 1 tab (tablet) 3x/day (three times a day) as needed for muscle spasms. The nursing progress note dated 7/20/16 at 8:40 AM by DON B reflected late entry for 7/17/16. It was noted that clients orders per hospital discharge were for [MEDICATION NAME] 4 mg TID (three times a day) prn, currently receiving [MEDICATION NAME] 4 mg TID routine. contact with charge nurse to clarify order. Review of the facility Admission Checklist with DON B on 7/27/16 at 11:05 AM reflected under the Orders heading .verify medication orders with a second nurse . DON B stated the policy was in effect at the time of the transcription error by RN UM/SE J and there was no evidence a second nurse had reviewed the orders. On 7/27 16 at 11:05 AM DON B stated the pharmacy had notified the facility on 7/16/16 that the packaging machine had filled the [MEDICATION NAME] pouches with two 4 mg tablets instead of the one 4 mg tablet that was ordered. ( )

Based on observation, interview, and record review the facility failed to prevent the development of 1 (#4) sampled residents pressure ulcers and the worsening of 1 sampled resident (#4) pressure ulcer of 3 reviewed for pressure ulcers from a total of 21 residents resulting in avoidable skin breakdown, delayed healing, discomfort and the potential for infection. Findings include: According to Resident #4's 30 day Minimum Data Set (MDS) assessment dated [DATE] resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Brief Interview for Mental Status (BIMS) Resident #4 scored a 15/15 on the which indicated he was alert and oriented. According to Resident #4's care plan "Potential for alteration in comfort r/t immobility, [MEDICAL CONDITION], a-fib, pneumonia, open area to left buttock, diabetes," dated 5/27/14 revealed the intervention, "assess physical needs, ie: need for repositioning, toileting or thirst. " There was no patient education as to how he could relieve pain or skin break down by repositioning himself included with the intervention. According to Resident #4's care plan "Adjustment related to: admission to rehab care facility. Own Grd (guardian). Nephew is main advocate. Scored 13/15 on admit BIMS..." date revised 6/11/14, revealed "James will actively participate in making choices / decision for care. Own Grd. Staff to thank him for responding i positive outlook/ways and being polite and cooperative. Staff to present transitions slowly and in his timing. He has a very strong sense of independence and will." According to the admission assessment dated [DATE] documentation revealed "right buttock pressure (ulcer) 1.5 cm x 3.5 cm unstageable." Additional comments included coccyx area was deep red (11 cm x 10 cm all blanchable other than open area to right buttocks. Skin around buttocks open secondary to contact [MEDICAL CONDITION]." According to Resident#4's wound assessment form was documented as the following: 6/2/14 left buttock pressure ulcer was 2.2 cm (centimeters) x 2.5 cm and unstageable, purulent, slough. 6/12/14 left coccyx 1.9 cm x 1.0 cm unstageable,purulent, slough. right buttock 1.8 cm x 1.0 cm unstageable purulent, slough. 6/16/14 left coccyx 2.3 cm x 2.8 cm x 0.2 cm Stage III, granulation tissue, right buttock 2.0 cm x 1.1 cm unstageable, pink/beefy red, purulent, slough. 6/24/14 left sacrum 2.6 cm x 2.0 cm, unstageable, purulent, pink/beefy red, slough. right sacrum 2.0 cm x 2.0 cm unstageable, purulent, pink/beefy red, slough. 7/3/14 left sacrum 2.8 cm x 2.5 cm unstageable, purulent, slough, right sacrum 3.0 cm x 2.1 cm unstageable, purulent, slough. According to the skin assessment on 6/1/14 the documentation reflected, "right gluteal fold red / blanchable." One week later on 6/8/14 the skin assessment reflected, "right inner buttock black area drsg changed." According to physician orders [REDACTED]." The pressure ulcer measurements and wound locations were not clearly labeled and consistently performed and reported. For example the wound assessments and measurements were done on irregular intervals 6/2/14 to 6/12/14 (10 days) to 6/12/14 to 6/14/14 (4 days) and wound labeling was documented in an inconsistent manner from right (R) buttock, (R) coccyx (tail bone) (R) sacrum (triangular bone at the base of the spine), or Left (L) buttock, (L) coccyx or (L) sacrum causing such a confusion whether these were the same wounds or new or different wounds. The staging of the wounds were also not accurate. All the wounds were staged as unstageable. However, the wounds were described as having a varying degree of pink/red wound base with slough which would have categorized the wounds as a stage 3 rather than unstageable (covered with slough/eschar). On 7/10/14 at 3:45 pm, Wound Nurse "J" reported Resident #4 had been admitted on [DATE] and thought had been admitted with a pressure ulcer to the left buttock area and developed pressure ulcer to the right buttock on 6/7/14. RN "J" reported weekly measurements were completed by her with a weekly assessment done at that time. RN "J" reported she was RN "J" reported she had consulted dietary and the wound clinic and it was recommended by the wound clinic to provide education to Resident "J" to help prevent further decline of his pressure ulcers but reported education had not been provided. RN "J" stated Resident #4 was "very difficult to speak with and she had been told to shut up, therefore she had not readdressed the re-education with Resident #4. RN "J" stated he has all the interventions to prevent we can provide. RN "J" was asked if staff had included him on the preventive interventions or considered a different recliner for Resident #4 and RN "J" stated, "I guess I dropped the ball on this." On 7/8/14 at 1:40 pm and again on 7/11/14 at 4:45 pm, Resident was observed sitting up in his wheel chair watching TV. Resident #4 repositioned from the wheel chair to the bed for observation of a dressing change it was noted the wheel chair cushion was covered with a towel that was wrinkled up underneath Resident #4 potentially causing increased pressure to the wound areas. During the week of the survey Resident #4 was observed multiple times sitting in his room through out each day sitting in his wheel chair at his bed side watching TV. On 7/11/14 at 4:45 pm during an observation of Resident #4's wound care by wound nurse "J" Resident #4's right coccyx area pressure ulcer was observed to been approximately 3.0 cm x 2.7 cm x .2 cm, full thickness tissue loss, was beefy red, with yellow serosanguinous drainage present, upper and lower outer edges of the wound was noted to have been black / brown , surrounding tissue was pink red and blanchable. The left pressure ulcer was approximately 3.1 cm x 3.1 x. 2 cm with a similar appearance to the right pressure ulcer. Both wounds had an gradual increase in size over the last month. According to the facility policy, "Care and treatment of [REDACTED]. Sough may be present, but does not obscure the depth of tissue loss, may include undermining and tunneling. The bridge of the nose, ear occiput and malleolus do not have subcutaneous tissue and stage 3 ulcers can be shallow. In contrast, areas of significant adiposity may develop stage 3 pressure ulcers." ( )

This citation pertains to MI 517 Based on observation, interview, and record review, the facility failed to monitor and consistently implement nutritional interventions in 1 (Resident #2) of 1 reviewed for weight loss, from a total sample of 3, resulting in a significant weight loss. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 was an [AGE] year old female, initially admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. The discharge MDS dated [DATE] did not assess Resident #2's cognitive level. Review of the admission MDS dated [DATE], revealed Resident #2 scored 9/15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). The MDS dated [DATE], revealed Resident #2 required extensive assistance with eating. Review of the monthly Physician's Orders for April 2014, revealed Resident #2 was on a pureed diet as of 2/26/14. The Physician's orders revealed an order for [REDACTED]. The Physician's Orders also revealed a current order for "super potatoes" ([MEDICATION NAME] with nutrients) every day at lunch and dinner with gravy dated 3/2/14, magic cup (fortified supplement) three times a day with meals ordered 4/22/14, 2cal (high calorie supplement) 60 mL (milliliters) four times a day dated 3/12/14, and boost glucose control 8 oz (ounces) three times a day with meals ordered on [DATE]. The physician's orders revealed Resident #2 was prescribed appetite stimulants that included [MEDICATION NAME] 400 mg (milligrams) every morning and [MEDICATION NAME] 15 mg daily at bedtime. Review of the ADL (Activities of Daily Living) care plan dated 2/26/14, revealed an intervention dated 4/11/14 that read "no ice water, no frozen foods (yogurt/magic (sic) cup, etc) causes mouth pain". Review of the Nutritional Risk care plan initiated 2/27/14, revealed Resident #2 "has factors of nutritional risk including: medical dx (diagnosis) including :UTI (urinary tract infection), hydro[DIAGNOSES REDACTED], DM2 (diabetes type 2), [MEDICAL CONDITIONS], dementia, protein-calorie malnutrition, swallowing problems, abnormal labs (low alb ([MEDICATION NAME]), weight loss, chewing problems, inadequate intake, increased needs for healing, hx (history of) constipation". Interventions included: ? "Nutritional supplements per orders: boost glucose control PO (by mouth) TID (three times a day) w/meals; magic cup TID w/meals, 2cal 60 mL (milliliters) PO QID (four times a day) w/medpass, provide super oatmeal @ breakfast & super potatoes @ lunch/dinner w/gravy", dated 2/28/14 and revised on 4/22/14 ? Offer AM & PM snacks between meals and record % eaten, dated 4/22/14 ? Offer HS (bedtime) snack and record % of HS snack consumed ? Monitor intake, weights, labs, and follow up as needed ? Likes sweets, pork, beef, oatmeal, cream of wheat. Dislikes fish, no ice chips in drinks preference initiated 4/11/14 and updated 4/14/14 ? Encourage fluid intake initiated 3/2/14 ? Record cc's (cubic centimeters/milliliters) of nutritional supplement consumed at meals initiated 2/28/14 ? Record meal consumption: 0%, 25%, 50%, 75%, 100% at each meal initiated on 2/27/14. The Nutritional Risk care plan did not mention that Resident #2 disliked frozen foods. Review of the Resident #2's Kardex (Certified Nursing Assistant care guide) printed 4/23/14, revealed "no ice in water, no frozen foods (yogurt/magic (sic) cup, etc) causes mouth pain" under the meals section. The section titled nutrition revealed "supplement (magic cup) provided at meals". Review of the Nutrition Evaluation dated 3/2/14, revealed Resident #2 was willing to try super cereal and super potatoes. Review of the Nutrition note dated 3/13/14, revealed Resident #2's daughter reported that Resident #2 typically only took a few bites of food at meals. The note revealed that Resident #2 missed meals due to being too tired to eat or sleeping and Resident #2 was started on 2cal (supplement) 60 mL (milliliters) four times a day on 3/12/14 secondary to poor PO intake and to help aide in meeting her estimated needs. Review of the nutrition readmit note dated 4/11/14, revealed "appetite and intake:...boost glucose control-4 oz PO TID w/meals (strawberry or vanilla), super potatoes-PO QD (every day) @ lunch & dinner w/gravy, super oatmeal-PO QD @ breakfast". The comments section revealed Resident #2 had a history of [REDACTED]. Will re-start supplements as prior hospital, except boost glucose control will change from 4 oz to 8 oz..." Review of Resident #2's Weights and Vitals Summary, revealed Resident #2 was not weighed daily. The Weights and Vitals Summary revealed the following weights: 3/8/14 101.2 3/9/14 101.4 3/11/14 100.4 (loss of 1#) 3/12/14 98.3 (loss of 2.1#) 3/13/14 98.3 3/14/14 97.7 (loss of 0.6#) 3/18/14 99.3 (gain of 1.6#) 3/19/14 100.9 (gain of 1.6#) 3/20/14 101.1 (gain of 0.2#) 3/22/14 99.1 (loss of 1#) 3/23/14 100.1 (gain of 1#) 3/24/14 100 (loss of 0.1#) 3/25/14 100 3/26/14 98.3 (loss of 1.7#) 3/27/14 99.5 (gain of 1.2#) 4/1/14 99 (loss of 0.5#) 4/2/14 99.5 (gain of 0.5#) 4/3/14 99.5 4/4/14 99.5 4/5/14 99.5 4/12/14 100 (gain of 0.5#) 4/19/14 100.5 (gain of 0.5#) 4/21/14 93 (loss of 6.5# in 2 days and form identified Resident #2 as a significant weight change of 6.2% since 3/22/14) 4/22/14 92.5 (loss of 0.5%) Review of the Weekly Skin assessment dated [DATE], revealed Resident #2 weighed 94 pounds, which was a significant weight loss over one month, but was not identified as a significant weight loss at that time. Review of the Nutrition Note dated 4/22/14, revealed Resident #2 had a significant weight loss of 8% (8 pounds) in 3 days, overall 7.6% loss over one month. New interventions included magic cup with meals and offer snacks between meals Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no indication that the supplement was given at a different time or that another intervention was attempted. Review of the MAR indicated [REDACTED]. Resident #2 missed 30 out of 77 total documented attempts (subtracted out 4/7/14 thought 4/10/14 for hospitalization ). There was no indication that the supplement was given at a different time or that another intervention was attempted. An observation on 4/23/14 at 8:28 am, revealed Resident #2 was sitting in her wheelchair at a dining room table with two other residents. The two other residents had their breakfast finished and were away from the table by 9:00 am. Resident #2 was approached by a staff member at 9:05 am to discuss her breakfast options. At 9:15 am (at least 47 minutes after Resident #2 arrived in the dining room), a staff member sat down next to Resident #2 to assist with her meal. Resident #2 was served a frozen chocolate magic cup of which she ate 7 small bites, 2 bites of oatmeal, 2 bites of pureed eggs, and a few bites of pureed blueberry muffin, cranberry juice, water, and a chocolate supplement shake. Resident #2 consumed approximately 40% of her chocolate supplement shake. No other flavors were offered. Resident #2 mumbled a few times in between bites of food. Staff provided total assist with eating. At 9:40 am, Resident #2 refused to eat anymore and staff transported her to her room. An observation on 4/23/14 at 11:40 am with Registered Nurse (RN) "H", revealed Resident #2 received vanilla flavored 2cal supplement with her medications. Resident #2 took a sip of the 2cal and then grabbed the cup from the nurse and proceeded to drink the remainder on her own. An observation on 4/23/14 at 12:00 pm, revealed Resident #2 was sitting in her wheelchair at a dining room table. Resident #2 was holding her cup of chocolate shake supplement and drinking small sips. Resident #2 was also served a frozen chocolate magic cup, country fried steak and rice, and water. Resident #2 ate approximately 80-90% of the country fried steak and rice, approximately 50% of the chocolate shake, and 30-40% of the chocolate magic cup. There were no super potatoes served to Resident #2 during lunch. Resident #2 was not offered any other substitutes for the uneaten food. In an interview on 4/24/14 at approximately 10:10 am with Certified Dietary Manager (CDM) "D" and Registered Dietician (RD) "E", RD "E" reported that she cared for Resident #2 when she was first admitted to the facility and resided on the first floor. CDM "D" reported that she cared for Resident #2 while she resided on the third floor. RD "E" reported that Resident #2 liked oatmeal so the facility served her super oatmeal at breakfast and super potatoes at lunch and dinner. RD "E" reported that she remembered Resident #2 preferred the strawberry or vanilla supplement shakes and reported that the magic cup could be made into a pudding consistency so that it was not served frozen. CDM "D" agreed that the magic cup could be heated in the microwave and made into a pudding. CDM "D" reported that Resident #2 had a recent weight loss due to varied intake so she implemented the magic cup "to see if she (Resident #2) might like those". CDM "D" reported that Resident #2 was still to get super oatmeal at breakfast and super potatoes at lunch and dinner. RD "E" reported that when Resident #2 was on the first floor, if she did not finish her supplement shake, the family would take the shake back to her room so that it could be offered throughout the day. When queried if she thought Resident #2's weight loss was unavoidable, RD "E" stated "I think some weight loss is to be unavoidable, but that amount, I'm not sure". When queried if she knew what snacks were offered to Resident #2 between meals, CDM "D" stated "nursing offers the snacks...I don't know off hand". In a second interview on 4/24/14 at 11:20 am, when queried if Resident #2 should be offered something else if she did not finish her supplement shake, CDM "D" stated "yes, and we do offer a different flavor". When queried if she monitored Resident #2's acceptance of the 2cal supplement, CDM "D" reported she did and that if Resident #2 refused 2 cal, the facility would offer different supplements "like magic cup". CDM "D" reported that magic cup was implemented because of Resident #2's recent weight loss. When queried when she first noticed that Resident #2 refused the 2cal supplement, CDM "D" stated "when I did the most recent assessment on 4/22". When queried if she was aware prior to 4/22/14, CDM "D" stated "No, I was only aware of her intake at meals". In an interview on 4/24/14 at 1:45 pm, with CDM "D" and RD "E", when queried about the frequency of weight monitoring for Resident #2, RD "E" stated "as far as I know, she (Resident #2) should be on daily weights". RD "E" reported that sometimes the weights were entered into the nursing skin assessments and not always entered into the weights/vitals section. When queried how often Resident #2's weights were evaluated, CDM "D" stated "weekly and every time we have a significant change". When queried what was expected for the documentation of meal consumption, RD "E" reported that CNAs should be documenting the meal intake after every meal. RD "E" stated "obviously looking at that (Resident #2's consumption records), it's not always being done". Review of Resident #2's Food and Fluid Acceptance/Eating Performance Records dated 2/26/14 through 4/24/14, revealed food and fluid acceptance was not documented every meal. Resident #2's Food and Fluid Acceptance/Eating Performance, revealed documentation for 100 meals out of 157 meals served (3 meals a day, subtracted out 4/7/14 thought 4/10/14 for the time Resident #2 was at the hospital). ( )

This citation pertains to intake number #M 697. This Citation has 2 Deficient Practice Statements (DPS), A and B. A. Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers and provide treatment and services to promote healing in 3 (Resident # 101, Resident #111 and Resident #113) of 11 residents reviewed for pressure ulcers, from a total sample of 13 residents resulting in development of pressure ulcers and worsening and infection of pressure ulcers. B. Based on observation, interview and record review, the facility failed to adequately assess skin for prevention of developing pressure ulcers in 2 (Resident #102, #104) of 11 residents reviewed for pressure ulcers, from a total sample of 13, increasing the risk of developing pressure ulcers. Findings include: Deficient Practice Statement A: Resident #101 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #101 had moderately impaired cognition with a Brief Mental Score (BIMS) of 11, required extensive assist in bed mobility, transfers, ambulation, dressing, hygiene and bathing. Resident #101 had a surgical incision on the right knee due to post operative knee scope. Resident #101 was discharged from the facility on 2-23-13 to the local hospital. Review of the Pressure Ulcer Policy dated revised 4-8-13 revealed: #2. "Skin and bony prominences will be inspected at least daily, devices, shoes, socks, heel and elbow protectors should be removed for skin inspection. all bony prominences should be inspected including back of head, shoulders, rib cage, elbows, hips, ischium, sacrum, knees, ankles and heels. #3. Charge nurse will complete a "Pressure Ulcer Communication Form for any new pressure ulcer, this communication tool will be submitted to the nurse manager/resource nurse within 24 hours of wound identification. #4. The nurse manager/designee will measure, inspect, facilitate orders revision and update care plans on all incidents with pressure sores on a weekly basis. #5. Residents with new pressure ulcers will be discussed weekly interdisciplinary care meetings. #7. Wound measurement will be completed by the nurse manager weekly and documented in point click care (computer program). Review of the electronic medical record dated 1-21-13 through 2-23-13 revealed upon admission, Resident #101 had a Braden Scale (an assessment to indicate risk of developing pressure ulcers) of 16 which was low risk of developing pressure ulcers. Review of the initial physicians orders dated 1-21-13 revealed: foam boots, wheelchair cushion, turn and reposition every 1 hour while in chair, and every 2 hours while in bed, skin prep to heels every shift x 14 days. Review of Resident #101 Care Plan titled. "Resident has risk of skin breakdown" dated 2-1-13 revealed "Intervention: Monitor skin daily and report any abnormal findings to nurse, pressure reduction mattress, weekly skin assessments, elevate heels or protective boots on resident while in bed." There was no approach for any air mattress. Review of Resident #101 Care Plan was revised on 2-4-13 and again on 2-13-13 titled, "Ulceration or interference with structural integrity of layers of skin to bilateral heels caused by prolonged pressure related to impaired mobility, incontinence left heel wound, right calf wound." Goals were to "Show reduction in size and stage of pressure ulcer, and show no signs of infection." Interventions were: Achillease (a device put on bed to float the heels off of the bed to remove pressure) to bed at all times, assist with reposition every hour while in wheelchair, assist with turning and positing every 2 hours while in bed, ensure adequate nutrition, offer high protein foods, and notify nurse of any changes in skin such as redness, dark area." Review of the admission skin assessment dated [DATE] at 1:00 am, revealed Resident #101 had "skin intact, no discoloration." Review of the full nursing assessment dated [DATE] at 8:00 pm, revealed Resident #101 had "no skin issues." Review of the Nurse Practitioner progress note dated 1-25-13 (no time) revealed no mention of any pressure ulcers. Review of the Resident #101's daily full assessments dated 1-25-13 through 2-1-13 revealed the question, "Is there a pressure sore present?" All responses were "no, or not assessed." Review of Resident #101's full nursing assessments dated 1-25-13 through 2-4-13 revealed, "no skin issues." Review of the Nurse Practitioner progress noted for Resident #101 dated 1-29-13 (no time) revealed, "I am in today regarding concern about skin changes and pressure on his right heel. The patient is in a room in his wheelchair. The patient complains of bilateral heel pain, right greater than left. His heels are on the floor, as opposed to his feet. The wheelchair seems to be ill fitted for the patient at this time. The patients right heel is reddened and soft. It is a deeper red color than his left heel. The left heel is a bit soft but not of concern at this time. Both seem to be painful for the patient. Plan: We will use heel floats when in bed, we will relieve the pressure on his right heel by using Prafo (boots with cut out heel support to relieve pressure on the heels) boots. Therapy to obtain a different wheelchair for him." Review of the nurses notes and skin notes indicated no nursing documentation of any pressure ulcers through 1-29-13 for Resident #101. Review of a nurse progress note dated 1-31-13 at 6:30 am revealed Resident #101 had, "Blister broke open left heel, 2 x 2 cm (centimeters), 4 x 4 dressing and tape applied." Review of the Physicians orders dated 1-31-13 at 4:30 pm revealed Resident #101 had an order for [REDACTED]. Review of a nurse progress note for Resident #101 dated 2-2-13 (untimed) for Resident #101 revealed the question, "Is there a pressure sore present?" Response was "yes." There was a note written, "left ankle 5.8 x 2.5 x 0.3 cm (centimeters)." Review of the electronic medical record revealed there was no documentation as to what the wound looked like or what stage Resident 101's wound was. Review of the nurse progress notes for Resident #101, dated 2-4-13 (untimed) revealed, "Is there a pressure sore present?" Response was "yes." Review of the electronic documentation revealed there was no description of where the ulcer was or any documentation on the pressure sore. Review of the Physician orders [REDACTED]." Review of the electronic medical record revealed there was no progress note to correspond with the order, and no nurses notes to describe the right leg or reason for the ace wrap. Review of the nurse progress notes for Resident #101 dated 2-5-13 and 2-6-13 (untimed) revealed, "Is there a pressure sore present?" Response was "yes." Description was "left heel." Review of the electronic documentation revealed there was no measurements or description on the pressure sore. Review of Resident #101's vitals sign sheet dated 2-6-13 (untimed) revealed a temperature with a fever of 101 degrees Farenheit. Review of the electronic documentation revealed there was no nurses notes to asses the fever, and there was no documentation that the Physician was notified of the fever. Review of the Nurse Practitioner progress note for Resident #101 dated 2-6-13 (untimed) revealed, "He has [DIAGNOSES REDACTED] (redness) on the right heel that is suspicious for early [MEDICAL CONDITION]. He has bilateral stasis changes in his legs. They are deep in color secondary to pressure on both heels. No actual ulceration is noted." There was no mention of a fever. Review of the Physician orders [REDACTED]. Review of the nurse progress notes for Resident #101 dated 2-7-13 (untimed) revealed, "Is there a pressure sore present?" Response was "yes." Description was "L (left) heel. Tissue is black and necrotic. Nurse Practitioner is aware and assessed. Dressing changes performed." Review of the Nurse Practitioner progress note dated 2-7-13 (untimed) revealed, "I am in today to see (Resident #101) regarding his foot ulcers. It is noted that his left heel has broken down. There is some dark eschar (blackened dead skin tissue) looking tissue covering the majority of it. He does complain of some soreness still. There is also a small are on the right lateral aspect of his lower extremity that does appear to be open with a very small blister, fluid filled. We will watch these wounds closely, if they do not look as thought they are healing by the weekend, we will change our treatment plan." The Nurse Practitioner progress note also indicated a review of lab work for 2-7-13 revealed abnormal white count high, hemoglobin low, Blood Urea Nitrogen (BUN) and Creatinine risen from previous labs. Review of the weekly skin assessment dated [DATE] revealed, "No skin issues." In an interview with the Director Of Nursing (DON #2) on 4-18-13 at 2:30 pm, DON #2 reported that she had disciplined the nurse who wrote the 2-8-13 inaccurate note due to poor skin documentation. Review of the Occupational Therapy note for Resident #101 dated 2-8-12 (untimed) revealed, "Hold standing activities related to heel sores." Review of the weekly wound assessment dated [DATE] (untimed) written by Licensed Practical Nurse (LPN #6) revealed description of wounds: "Left heel 6 x 2.3 cm, necrotic tissue, unstageable. Right heel (no measurements) unstageable. Right lower leg 4 x 3 cm, unstageable." In an interview on 4-18-13 at 10:30 am, LPN #6 reported that "I had done 2 wound assessments on (Resident #101). I don't know if he had ulcers upon admission. He had ulcers on bilateral heels, they were hard, black necrotic tissue, and he had one ulcer on his outer calf." Reviewing weekly wound assessment dated [DATE], LPN #6 reported "He (Resident #101) had 100 % eschar black on the right heel. The left heel was dark red purple, the right lateral calf had black necrotic tissue and red tissue surrounding the area with a moderate amount of odorous drainage." LPN #6 reported that she did not report the odorous drainage to the Physician or Nurse Practitioner. In reviewing the physician progress notes [REDACTED].#101) or reassessed the wound as it worsened over the weekend." Review of the weekly wound assessment dated [DATE] written by LPN #6 revealed Resident #101's Left heel 6.2 x 4 cm (worsening from 2-9-13 measurements), right heel 4 x 1.5 cm necrotic tissue (worsening from 2-9-13) and right calf 5 x 4 cm (worsening from 2-9-13). Review of the electronic medical record revealed there was no documentation that the Physician or Nurse Practitioner was notified, no new orders were obtained and Resident #101 was not on an antibiotic at that time. In an interview on 4-16-13, LPN #16 at 10:30 reported that on 2-16-13 Resident #101's wounds "had a foul odor to them when she assessed them for the weekly wound assessment, and she did not report this to anyone." Review of the nurse progress notes dated 2-17-13, 2-19-13, 2-20-13 and 2-21-13 (untimed) revealed Resident #101 had"both heels have necrotic tissue, the right calf is also turning necrotic, dressing changes applied to all sites and dressing is CDI (clean, dry and intact)." There was no documentation that the Physician or Nurse Practitioner was notified. Review of the Dietary note dated 2-19-13 (untimed) revealed the first implementation of any dietary measures to heal the pressure sores, ProMod (a high protein supplement) was ordered for Resident #101. Review of the Nurse Practitioner note for Resident #101 dated 2-22-13 (untimed) revealed, "I am in to see the patient today in follow up regarding his wounds on his bilateral heels, achilles and right lateral lower extremity. Currently the wound to right lateral lower extremity is actually 2 wounds, he does have drainage which is foul smelling from those wounds. The center is black, the patient also has bilateral heel wounds, those are not draining at this time, they are larger than I have seen them, as well as his lower extremity wounds. These wounds are also dark but dry. I would recommend a wound clinic visit for the patient. The patient is recommended to have Podus boots on when he is in bed, he does tend to drag his heels on the floor when he is up." Review of Resident #101's Physicians order sheet dated February 2013 revealed treatment orders for: "Cleanse left heel wound with normal saline, apply [MEDICATION NAME] 2 % gel with siladene 1% on open area- DO NOT APPLY TO HEALTHY TISSUE-wrap with kerlix and secure with tape. Do treatment in evening when resident in bed. Start date 2-7-13 at bedtime. Everyday cleanse left heel wound with normal saline, apply [MEDICATION NAME]." "Cleanse right heel wound, clean with normal saline, apply [MEDICATION NAME] open area- DO NOT APPLY TO HEALTHY TISSUED- non -adhesive pad wrap with kerlix and secure with tape, Do treatment in evening when resident is in bed. Change q (every) day and PRN (as needed.) Start date 2-16-13 3-11 shift everyday." "Elevate legs when able during day. Start date 2-7-13 every shift, everyday." Float heels when in bed, start dated 1-29-13 every shift, everyday." Review of the TAR dated 2-1-13 through 2-23-13 revealed Resident #101 had no documentation that left heel wound dressing change was done on 2-10-13, 2-12-13, 2-13-13, and 2-19-13; no documentation of right heel wound treatment was done on 2-19-13; no documentation of elevate legs and float heels when in bed on 2-11-13 and 2-12-13; no documentation of skin prep to bilateral heels on 2-11-13 and 2-12-13. Review of the Physicians order on 2-23-13 (untimed) revealed Resident #101 was sent to the emergency room for evaluation after he vomited and had an episode of possible aspiration. Review of the Hospital admission history and physical for Resident #101 dated 2-23-13 revealed Resident was admitted with [DIAGNOSES REDACTED]. ( ) Resident # 111 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] reveal Resident #111 was an [AGE] year old male who was admitted to the facilty on 3-7-13 with [DIAGNOSES REDACTED]. Resident #111 was cognitively intact with a Brief Mental Score (BIMS) of 14, required extensive assist of 2 staff for transfers, bed mobility, hygiene, toileting, bathing and dressing. Review of the electronic medical record dated 3-7-13 through 4-19-13 revealed upon admission, Resident #111 had a Braden Scale (an assessment to indicate risk of developing pressure ulcers) of 18 which was low risk of developing pressure ulcers. Review of the hospital transfer papers dated 3-7-13 revealed Resident #111 had an existing stage 2 pressure ulcer on right and left gluteal folds. Review of Resident #111's preadmission screen dated 3-7-13 revealed right sacrum unstageable 1.4 x 0.9 cm, and a hospital physician order [REDACTED]. Review of Resident #111' care plan titled "Resident has risk of skin breakdown related to incontinence, dementia and decreased mobility" dated 3-7-13 had interventions listed: assist to turn and reposition every hour and prn (as needed) when in wheelchair, assist with turning and positioning every 2 hours and prn when in bed, elevate heels or put protective boots on resident while in bed, monitor skin daily and report any abnormal findings to nurse, provide assist to ensure that resident changes positing every 2 hours while in bed, weekly skin assessments, and a wheelchair cushion. Review of Resident #111"s care plan titled "Ulceration or interference with structural integrity of layers of skin caused by prolonged pressure related to immobility, incontinence, cognitive impairment" dated 3-20-12 revealed goals to show reduction in size and or stage of pressure ulcer, show no signs of infection. Interventions listed were assist with repositioning every hour while in wheelchair, assist with turn and positioning every 2 hours and prn while in bed, monitor wound for any signs or symptoms of infection, delayed healing, notify physician as needed. Review of the admission nursing assessment dated [DATE] revealed no skin assessment was completed for Resident #111. Review of dietary progress note dated 3-15-13 (untimed) made first mention of Prostat (a high protein supplement to promote wound healing) twice a day was ordered for Resident #111. Review of Resident #111's weekly wound assessment dated [DATE] revealed, "unstageable right sacrum 2.7 x 2.2 cm with a scant amount of serous drainage." Review of Resident #111's weekly wound assessment dated [DATE] revealed, "1.5 x 1.0 cm unstageable pressure ulcer to right sacrum with a scant amount of serous drainage." Review of the physicians orders for Resident #111 dated 3-23-13 (untimed) revealed Keflex (an antibiotic) was ordered for UTI (Urinary Tract Infection). Review of dietary progress note for Resident #111 dated 3-28-13 (untimed) revealed " Receives Prostat BID (twice a day), unstageable buttock wound increasing in size, increase Prostat to QID (four times a day)." Review of nursing progress note dated 3-31-13 (untimed) revealed, "Resident (Resident #111) has a 2.8 x 1.4 x 1 cm decub on buttock. Resident repositioned throughout day, requested air /sand mattress. Wound addressed with Nurse Practitioner 2 cm x 2.0 cm tunneling of wound. Resident educated on pressure points, encourage to alleviate pressure when possible. A new Physicians order was obtained for packing of the wound." Review of the weekly wound assessment for Resident #111 dated 4-5-13 (untimed) revealed, " 2.2 x 2.1 cm with tunneling of wound noted 2.0 cm at 2:00 (position on wound) unstageable pressure ulcer on right sacrum with moderate amount of serous drainage." Review of physicians order dated 4-9-13 (untimed) revealed Resident #111 had a wound culture of coccyx, lab report dated 4-9-13 revealed many gram positive cocci, moderate gram positive bacilli (bacterial infection), and orders were written for treatment with [MEDICATION NAME] (an antibiotic medication) for the wound infection of the coccyx pressure ulcer. Review of the physician order [REDACTED]. This order was 5 weeks after admission to the facility with an existing pressure ulcer. During an observation of Resident #111 on 4-19-13 at 10:10 am, an air mattress was on the bed. During an observation and interview on 4-19-13 at 10:10 am, Resident #111 was alert and oriented, and reported to surveyor, "No the staff don't reposition me, I cannot reposition myself, I need help from the aides. I have not been educated on repositioning, I have a cushion on my wheelchair, but it is not very cushiony." Resident #111 was sitting up in his wheelchair leaning to his right side. In an observation on 4-19-13 at 11:30, Resident #111 was sitting up in his wheelchair in the same spot, still leaning to the right side and he reported that he had not been repositioned in the past hour. Review of Resident #111's Physicians and Nurse Practitioners progress notes dated (untimed) 3-8-13, 3-12-13, 3-22-13 and 4-1-13 reveal no mention of any pressure ulcers. Review of Nurse Practitioner progress note for Resident #111 dated 4-4-13 (untimed) revealed open wound on right buttocks. This was the first mention by a doctor or Nurse Practitioner of any pressure ulcers, one month after admission. In an interview on 4-18-13 at 11:35, DON #2 provided the surveyor with 2 Certified Nursing Assistant weekly shower skin checks dated 3-13-13 and 3-27-13. No electronic or hard copy records were found to indicate any more weekly CNA shower sheets had been completed for Resident #111. Review of the electronic medical record for Resident #111 indicated no documentation by the nursing staff of any weekly skin documentation of healing or measurements on weeks between 3-22-13 and 4-5-13 and no weekly documentation of healing or measurements of skin between 4-5-13 and 4-18-13. Review of a report ran off the electronic medical records titled "Turned and Repositioned" provided to the surveyor by the DON #2, revealed Resident #111 was repositioned only for a total of 56 times since admission. Review of the Physicians order sheet for March and April 2013 revealed treatment orders for Resident #111: "Order for wound care to right sacrum pressure ulcer cleanse with normal saline and apply skin prep around wound, apply silver [MEDICATION NAME] cream to wound bed, cover with Allevyn gentle border, change daily and prn. Start date 3-8-13" "Cleanse with wound cleanser, pack with 1/2 inch to 1 inch [MEDICATION NAME] packing, cover with dry gauze, secure with tape change BID (twice a day) x 3 days then daily. Start date 4-16-13" Review of the TAR dated March 2013 and April 2013 for Resident #111, revealed the order for Silver [MEDICATION NAME] ointment apply to wound at right side of sacrum daily, was not signed off of the TAR as completed on 3-12-13, 3-13-13, 3-20-13, 3-27-13, 3-29-13, 3-31-13, 4-2-13, 4-12-13 and 4-13-13. Review of the TAR dated March 2013 and April 2013 revealed Resident #111's order for wound care to right sacrum pressure ulcer cleanse with normal saline and apply skin prep around wound, apply silver [MEDICATION NAME] cream to wound bed, cover with Allevyn gentle border, change daily and prn was not signed off of the TAR as completed on 3-10-13, 3-12-13, 3-13-13, 3-20-13, 3-27-13, 3-29-13, 3-31-13, 4-12-13, 4-13-13. Review of the TAR dated April 2013 revealed Resident #111's order for cleanse with wound cleanser, pack with 1/2 inch to 1 inch [MEDICATION NAME] packing, cover with dry gauze, secure with tape change BID (twice a day) x 3 days then daily, was not signed off the TAR as completed on 4-18-13 and 4-19-13 day shift. ( , ) Resident #113 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #113 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #113 had severe cognitive impairment, required minimal assist in transfers, hygiene, walking, was incontinent of bowel and Resident #113 had a tube feeding for nutrition. Review of the Braden score dated 3-27-13 revealed Resident #113 had a score of 16, low risk for developing pressure ulcers. Review of the electronic medical record dated 3-27-13 through 4-19-13 revealed Resident #113 had a history of [REDACTED]. Review of the admission screen for Resident #113's record dated 3-27-13 revealed, "Red, blanchable coccyx, EPC (a protective ointment) to be used." Review of the nursing progress notes for Resident #113 dated (untimed) 3-31-13 revealed the question, "Pressure ulcer present?" Answer check marked "No." Review of the nursing progress notes for Resident #113 dated 4-4-13 (untimed) revealed the question, " Pressure ulcer present?" Answer check marked "Yes." No further documentation of measurements or assessment was found. Review of Resident #113's Certified Nursing Assistant (CNA) weekly shower sheet and skin check dated 4-7-13 (untimed) revealed, " open area on coccyx". The nurse signed off on the form for 4-7-13 but review of the electronic medical record revealed that nothing was documented for further assessment in Point Click Care (electronic medical record). Review of Resident #113's nursing progress notes dated 4-8-13 (untimed) revealed, "Pressure ulcer present?" Answer check marked "Yes." Description was "coccyx, 2 small spots." Review of the electronic medical record revealed that no further documentation of measurements or assessment was found. Review of Resident #113's nursing progress notes dated 4-12-13 (untimed) revealed, "Resource nurse to assess." No further assessment, skin check or measurements were found. Review of the Physicians progress notes and orders dated 3-27-13 through 4-19-13, revealed no mention of any pressure ulcers or any orders for pressure ulcer treatment. Review of Resident #113's Treatment Administration Record (TAR) dated March 2013 revealed, "EPC cream to pinkend area on sacrum every shift and PRN (as needed) after wiping." Review of Resident #113's TAR dated April 2013 revealed, "[MEDICATION NAME] to pinkened are on sacrum every shift and PRN start date 4-10-13. Review of Resident #113 care plan titled, "Resident has risk of skin breakdown related to indwelling catheter, dementia and decreased mobility" dated 3-27-13 revealed interventions; assist with turning and repositioning every 2 hours and prn while in bed, EPC to affected are every shift and as needed, float heels off bed or boots while in bed, monitor skin daily and report any abnormal findings to nurse, wheelchair cushion." The care plan had not been updated to address the actual pressure ulcer and no new interventions were put in place when the open area had been identified by nursing. ( ) Deficient Practice Statement B Resident #104 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #104 was a [AGE] year old male who had been admitted to the facility on [DATE] and discharged home on 1-24-13. Resident #104 had [DIAGNOSES REDACTED]. Resident #104 required extensive assist of 2 staff for transfers, bed mobility, toileting, ambulation hygiene and bathing. Resident #104 had occasional incontinence of bowel and bladder. Review of the Braden scale dated 12-31-12 revealed Resident #104 was low risk of pressure ulcers. Review of Resident #104's electronic medical record, nursing physical assessment, revealed from 1-1-13 through 1-24-13 the question "Is there a pressure sore present?" was check marked not assessed 17 out of 26 times. Review of the Certified Nurses Aide (CNA) weekly shower skin check sheets revealed on 1-7-13, "Mole bleeding." The form was checked that the nurse documented an assessment in the Point Click Care, (electronic medical record), but no documentation of nurse assessment or follow up was found. Review of the Certified Nurses Aide (CNA) weekly shower skin check sheets revealed on 1-22-13, "Red coccyx and perineal area." The nurse signed off of the form 1-22-13 but no follow up note or assessment was documented in Resident #104's medical record. Review of the electronic medical record for Resident #104 revealed no weekly skin check by the nurse, for the week of 1-21-13. Review of Resident #104 skin care plan dated 12-31-12 revealed interventions of cushion to wheelchair and bed, turn and reposition every 1 hour while in chair, and every 2 hours while in bed. In an interview on 4-19-13 at 10:00 am, Licensed Practical Nurse (LPN #17) reported, "All residents get a bath once a week, the aides do a weekly shower sheet, and orthostatic blood pressures. It is the nurses responsibility for looking at skin during the bath. If the nurse finds something abnormal they document on the shower sheet and check the box for documented in Point Click Care. The nurse then documents the findings in Point Click Care. The nurse managers do weekly skin measurements. If I found a new wound, I would not do any measurements, I would go get the nurse manager to assess it and she would do the measurements. We have an on call manager on weekends." ( ) Resident #102 Review of the Face Sheet and Minimum (MDS) data set [DATE] revealed Resident #102 was a [AGE] year old female who had resided at the facility since 1-19-13, discharged home on 2-12-13, and had [DIAGNOSES REDACTED]. Resident of Concern was cognitively intact with a Brief Mental Score (BIMS) of 15. Review of the adl (activities of daily living) sheets for January 2013 and February 2013 revealed no documentation of a shower or weekly skin check sheets for Resident #102. Review of the electronic medical record revealed no weekly skin assessments were done by the nurse for Resident #102. In an interview on 4-18-13 with Director of Nursing (DON#2), DON #2 reported regarding Resident #102 "I was not able to find any shower sheets, I don't know how many showers she had taken." Review of a nurses note dated 2-6-13 (untimed) revealed Resident #102 reported to the nurse that she had taken 4 showers since she had been admitted that first 2 weeks. Review of the nurses note also revealed that Resident #102 had complained of skin issues with a right groin rash, drainage, redness and use of an ABD (dressing) pad to the area. This was the only mention of any skin issues in the medical record. There were no skin assessments found in the medical record. Review of Resident #102 careplan dated 1-19-13 revealed, "Resident has risk for skin breakdown related to decreased mobility. Interventions listed were: monitor skin daily and report any abnormal findings, apply triple antibiotic ointment to irritated skin at right groin and hip are and cover with ABD dressing every shift until healed, weekly skin assessments or as ordered." ( , )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO IMPLEMENT A CARE PLAN FOR APPROPRIATE TRANSFER TO PREVENT A FRACTURE FOR 1 OUT OF 1 RESIDENTS REVIEWED FOR FRACTURES (#5) AND A FALL FOR 1 OUT OF 5 RESIDENTS REVIEWED FOR FALLS (#7 ) FROM A TOTAL REVIEWED SAMPLE OF 23 RESIDENTS, RESULTING IN A LEFT LOWER LEG FRACTURE WITH INCREASED PAIN AND DECLINE IN ACTIVITIES OF DAILY LIVING FOR RESIDENT #5 AND POTENTIAL FALLS WITH INJURY FOR RESIDENT #7. FINDING INCLUDE: ACCORDING TO THE ADMISSION FACE SHEET DATED 10/02/2008, RESIDENT #5 WAS A [AGE] year OLD FEMALE WITH IMPAIRED COGNITION AND ACCUMULATIVE [DIAGNOSES REDACTED]. THE MDS (MINIMUM DATA SET- ASSESSMENT TOOL) DATED 09/03/2012 HAD THE BIMS (BRIEF INTERVIEW MENTAL STATUS) CODING RESIDENT #5 AS 99, MEANING SHE IS UNABLE TO ANSWER QUESTIONS. THE MDS ASSESSED HER NEEDING ASSISTANCE WITH SAFETY, TRANSFERS, EATING AND ACTIVITIES OF DAILY LIVING. DURING OBSERVATION OF RESIDENT #5 ON 10/02/2012 AT 3:00 PM, THE RESIDENT WAS IN HER ROOM 316-B LYING IN BED ON HER BACK. THE HEAD OF THE BED WAS UP 30 DEGREES AND A PILLOW UNDERNEATH BOTH FEET. OBSERVATIONS OF RESIDENT #5 ON 10/03/2012 AT 8:15 AM, 10/04/2012 AT 9:40 AM AND 10/05/2012 AT 8:20 AM, NOTED RESIDENT #5 WAS UP IN A RECLINING GERIATRIC CHAIR WHICH WAS PLACED IN FRONT OF TELEVISION ON UNIT 300. DURING AN INTERVIEW WITH STAFF (F) ON 10/03/2012 BETWEEN 11 AM TO 12 PM IN THE 300 DINING ROOM, STAFF (F) WAS ASKED IF RESIDENT #5 COULD STAND OR PIVOT. STAFF (F) STATED, " SHE HAS NEVER STOOD AND USES A MECHANICAL LIFT WITH 2 PERSON ASSIST". DURING AN INTERVIEW WITH STAFF (H) ON 10/02/2012 AT 9:30 AM ON THE 300 NURSING UNIT, STAFF (H) WAS ASKED IF RESIDENT #5 HAD A RECENT FALL OR INJURY AND STAFF (H) STATED, "SHE DID NOT FALL BUT SHE HAD A BROKEN LEG A WHILE BACK; SHE GOT THE BROKEN LEG DURING A TRANSFER AND IT WAS BROKE IN TWO PLACES". A REVIEW OF RESIDENT #5'S CARE PLAN INITIATED ON 10/06/2009 AND REVISED DATE 03/14/2012 HAD THE INTERVENTION..."2 PERSON TRANSFER USING EZ LIFT MECHANICAL LIFT". THE CNA (CERTIFIED NURSING ASSISTANT) CARE TRACKING GUIDE DATED 10/02/2008, REVEALED ..."2 PERSON TRANSFER USING EZ LIFT MECHANICAL LIFT, ENSURE SLING IS HIGH ENOUGH TO SUPPORT HEAD DURING TRANSFER, 2 STAFF ASSIST AND NON WEIGHT BEARING". THE NURSING PROGRESS NOTE DATED 03/18/2012 AT 4:30 AM, SHOWED ..."RES (RESIDENT) HAD SAID, " I BROKE MY LEG" ..." RES. WAS SENT OUT TO HOSPITAL ER (emergency room ) FOR FURTHER EVALUATION D/T (DUE TO) SUSPECTED FRACTURE OF HER LEFT LEG". FURTHER RECORD REVIEW OF THE NURSES PROGRESS NOTES ON 03/18/2012 AT 5:10 AM ..." CNA REPORTED RES. LEFT LEG WAS BROKEN, LOOSE AND SWELLING UP DURING TRANSFER FROM BED TO GERI CHAIR AT 0415". FURTHER REVIEW OF THE emergency room ASSESSMENT NOTES DATED 03/18/2012 REFLECTED..."LEFT TIBIAL SHAFT FRACTURE AND DISTAL TIBIA FRACTURE AND TORUS FRACTURE LEFT TIBIA PRESENT AND FRACTURE SHAFT LEFT FIBULA, FRACTURE DISTAL LEFT FIBULA". RESIDENT #5 HAS TWO BROKEN (FRACTURED) AREA'S IN HER LEFT LOWER LEG. THE INCIDENT/ACCIDENT REPORT DATED 03/18/2012 AT 4:15 AM ..." RESIDENT STATES, "I BROKE MY LEG" AND IMMEDIATE ACTION ... "RESIDENT TAKEN TO HOSPITAL". NURSES PROGRESS NOTES ON 03/18/2012 AT 1:14 PM ..."RES RETURNED FROM HOSPITAL ER SHORTLY BEFORE 1:00 PM. EMT'S REPORTED THAT SHE DOES HAVE A SPIRAL FRACTURE OF THE LEFT LEG. LEG IS IN A CAST". ACCORDING TO THE PHYSICIANS ORDER, DATED 03/20/2012 ...ULTRAM (TRAMADOL HCI) 50 MILLIGRAMS (MG) ORAL (PO) - TWICE DAILY FOR 4 WEEKS: GIVE 1 TABLET BY MOUTH TWICE DAILY FOR 4 WEEKS. PAIN. END DATE 04/17/2012". ULTRAM IS CLASSIFIED AS NON NARCOTIC ANALGESIC USED FOR MODERATE PAIN. NURSES /DRUG REFERENCE 2011 PAGE 326. PHYSICIAN ORDER [REDACTED]. REVIEW OF THE INVESTIGATION/FOLLOW UP ON 10/04/2012, RESIDENT #5 WAS TRANSFERRED ON 03/18/2012 IN THE EARLY AM AROUND 4:00 AM BY TWO STAFF CNAS. THE MECHANICAL EZ LIFT WAS NOT USED AND THE 2 STAFF CNA'S USED A PIVOT TECHNIQUE TO EASE RESIDENT #5 INTO A STANDING POSITION. ACCORDING TO THE RECORD " ...RESIDENT #5 WAS EASED INTO STANDING POSITION AND PIVOTED TOWARDS THE GERICHAIR, WHILE ONE CNA PLACED A GAIT BELT AROUND RESIDENT'S WAIST AND PLACED HER ARMS AROUND THE RESIDENT IN A BEAR HUG FASHION TO SUPPORT THE BULK OF HER WEIGHT DURING THE TRANSFER. ANOTHER CNA CLAIMED THAT UPON BEING SAT IN THE GERICHAIR, THE RESIDENT STATED THAT HER LEG WAS BROKEN", ONE CNA ACKNOWLEDGED THAT DURING THE PIVOT MOVEMENT, SHE THOUGHT THAT SHE HEARD A FAINT CRACK". THE CARE PLAN WAS NOT FOLLOWED DURING THE TRANSFER WHICH RESULTED IN THE PREVENTABLE FRACTURE. ON 10/03/2012 THE MDS SHOWED A SIGNIFICANT CHANGE TO A DECLINE IN ADLS (ACTIVITY OF DAILY LIVING) DATED 03/23/2012, REQUIRING INCREASED ASSISTANCE IN THE AREAS OF TRANSFERS, DRESSING, EATING AND PERSONAL HYGIENE. IN ADDITION THE PAIN MEDICATION WAS INCREASED ON 03/20/2012. RESIDENT #5 WAS GIVEN ULTRAM 50 MILLIGRAMS TWICE A DAY FOR 4 WEEKS FOR THE INCREASED PAIN RELATED TO THE FRACTURE. ( ) BASED ON NURSING PROGRESS NOTES DATED 10/4/12, RESIDENT #7 WAS A [AGE] year OLD FEMALE, LONG TERM CARE RESIDENT, AND WAS readmitted MOST RECENTLY WITH [DIAGNOSES REDACTED]. PER RESIDENT #7'S QUARTERLY MDS (MINIMUM DATA SET- AN ASSESSMENT TOOL) THE RESIDENT REQUIRED EXTENSIVE ASSIST (WEIGHT BEARING SUPPORT PROVIDED 3 OR MORE TIMES OR FULL STAFF PERFORMANCE OF ACTIVITY DURING PART BUT NOT ALL OF THE LAST 7 DAYS) OF 2 FOR TRANSFER. RESIDENT #7 WAS NOTED NOT TO BE ABLE TO AMBULATE IN OR OUT OF HER ROOM. ON 10/5/12 AT APPROXIMATELY 10:30 A.M. IN THE RESIDENT' S ROOM, RESIDENT #7 WAS OBSERVED TO BE TRANSFERRED WITH 2 STAFF ASSIST USING A GAIT BELT BY CERTIFIED NURSE AIDES (CNAS) STAFF "T" AND "U". RESIDENT #7 NEEDED MULTIPLE VERBAL CUES, DEMONSTRATED POOR STANDING BALANCE AND REQUIRED EXTENSIVE ASSIST FROM BOTH STAFF "T" AND "U" TO SAFELY TRANSFER FROM THE BED TO THE WHEELCHAIR. ON 10/4/12 AT APPROXIMATELY 10:00 A.M. IN RESIDENT #7'S ROOM WITH LICENSED PRACTICAL NURSE STAFF "I" AND CERTIFIED NURSE AIDE STAFF "L" BOTH CONFIRMED THAT RESIDENT #7 REQUIRED 2 ASSIST WITH TRANSFERS AT ALL TIMES. STAFF "I" STATED, " I HAVE WORKED UP HERE FOR A YEAR AND HALF AND SHE (RESIDENT #7) HAS ALWAYS BEEN 2 ASSIST WITH TRANSFER". A REVIEW OF RESIDENT #7'S INCIDENT AND ACCIDENT REPORT DATED 3/6/12 REFLECTED UNDER INCIDENT DESCRIPTION, "CNA ATTEMPTING TO TRANSFER RESIDENT BY HERSELF, USING A GAIT BELT. RESIDENT STARTED TO SIT DOWN DURING TRANSFER AND CNA FORCED (SIC) TO LOWER RESIDENT TO THE FLOOR. RESIDENT DID NOT HIT HEAD DURING INCIDENT. CNA CALLED FOR HELP, NURSE RESPONDED. RESIDENT AGREED WITH CNA DESCRIPTION OF INCIDENT." A REVIEW OF RESIDENT #7'S CARE PLAN FOR FALLS WITH A CREATION DATE OF 10/9/09 AND REVISION DATE OF 3/29/12, RESIDENT #7'S INTERVENTION FOR TRANSFERS WAS: " 2 PERSON ASSIST WITH ALL TRANSFERS- MAY USE EASY STAND ". THE INTERVENTION WAS CREATED 1/17/2011. RESIDENT #7'S KARDEX (TOOL USED BY CNA'S ON HOW TO CARE FOR RESIDENTS) DATED 3/25/11 INDICATED UNDER "TRANSFER" RESIDENT #7 WAS 2 PERSON ASSIST WITH ALL TRANSFER- MAY USE EASY STAND (MECHANICAL LIFT)". ON 10/4/12 AT APPROXIMATELY 10:00 A.M. IN THE ADMINISTRATION OFFICE REGISTERED NURSE CLINICAL DIRECTOR STAFF "R", INDICATED THAT RESIDENT #7 HAD BEEN IN THE HOSPITAL IN MARCH 2012 BUT NO CHANGES WERE NEEDED FOR RESIDENT # 7 RELATED TO TRANSFER OR AMBULATION STATUS. STAFF "R" CONFIRMED THAT RESIDENT #7 HAD BEEN A 2 PERSON TRANSFER SINCE 1/17/11 AS WAS INDICATED ON CARE PLAN. THE FALL INCIDENT ON 3/6/12 WAS PREVENTABLE SINCE THE CARE PLAN ON HOW TO TRANSFER WAS NOT CONSISTENTLY FOLLOWED. ( )