Every finding on record at Caretel Inns of Brighton

Based on observation, interview, and record review, the facility failed to prevent the development of a Stage 3 pressure injury for one Resident (R57) of one resident reviewed for pressure injuries, resulting in wound treatments, increased pain and discomfort, and the potential for further wound deterioration. Findings include: On 2/09/26 at 1:46 p.m., R57 was observed in their room in their hospital bed, lying on their left side, directly on the trochanteric (hip) area, with their legs bent at their knees. There was no offloading device behind them, including pillows or a wedge to support their back on their bed. No offloading devices were observed in their room. It was noted R57 was positioned on an air mattress. The bed had no footboard. On 2/09/26 at 1:47 p.m., R57 stated, You can see the bed does not fit my frame . R57 reported they had asked staff for a new bed as long as I have been here, and said staff did not get them one. R57 explained their legs were curled to stay on the bed. R57 said they laid on their left side as it was too painful to lay on their right side, where they had a surgical wound. R57 said when they laid on their back their legs came off the foot of the bed which was uncomfortable for them, since they were tall. R57 said sometimes they had pain on their left hip and back as well as their right hip. R57 confirmed they had a pressure injury and said they believed it was on their back (on their bottom). On 2/09/26 at 1:48 p.m., R57 demonstrated stretching out their legs out to lay on their back. Their legs were observed hanging about a foot off the foot of the bed, from their mid-calf to their toes, which were covered by yellow gripper socks. R57 said this was uncomfortable for them. R57 reiterated they struggled to be comfortable in their hospital bed during their stay for rehabilitation and said they were not sleeping well because their bed was uncomfortable. Review of the facility matrix, accessed 2/09/26, revealed R57 was marked as having a Stage 3 pressure injury. Review of R57's wound care nursing progress notes in the EMR (Electronic Medical Record) revealed R57 developed a facility-acquired new Stage 2 pressure ulcer to their left hip (trochanter) on 2/02/26, which deteriorated and progressed to a Stage 3 pressure ulcer to their left hip (trochanter) on 2/09/26. Review of R57's MDS assessment, dated 1/28/26, revealed R57 had been admitted to the facility on [DATE], with diagnoses including right femur (hip) fracture, interstitial lung disease (inflammation of lung tissue which may result in shortness of breath), insomnia (difficulty sleeping), depression, and anxiety. The assessment revealed that R57 required one-person assistance for toileting, transfers, and bed mobility, was incontinent of bladder and bowel, and had no behaviors. The BIMS assessment showed a score of 15/15, which showed R57 was cognitively intact. The assessment showed R57 was 73 tall (6'1 tall) and weighed 260 pounds. The skin assessment showed R57 was at risk for developing pressure ulcers and had no pressure ulcers upon admission. Review of R57's Care Plan revealed no interventions or education for offloading or positional supports to assist R57 to stay off (applying direct pressure to) their left hip with the new pressure injury. The interventions revealed a pressure reduction mattress, dated 2/02/26, a pressure relieving cushion when up in wheelchair, dated 2/02/26, and to remind resident to reposition frequently on 2/02/26. It was noted there was also no intervention for R57 to alternate laying on their back to offload their left hip, given their right hip (surgical wound) was reportedly painful for them to lay on. There was no mention of bed concerns or attempts at obtaining a replacement bed or mattress, given R57's concerns. Review of R57's Electronic Medical Record (EMR) including all progress notes, accessed 2/09/26, revealed no interventions or education for offloading R57 to stay off their left hip other than the pressure reduction mattress and cushion, and reminders to change positions (unspecified), as well as no interventions to replace or accommodate R57's bed, given their taller size. Review of R57's Braden Skin Assessment, dated 1/27/26, revealed a score of 18, which showed R57 was at risk for developing a pressure injury. Review of R57's Physical Therapy treatment note, dated 1/30/26, revealed R57 required supervision or touching assistance for bed mobility, including rolling, lying to sitting, and sitting to lying positions. On 2/10/26 at 2:47 p.m., the Wound Care Nurse, Registered Nurse (RN) J, was asked to review R57's wound care documentation, as there was no initial wound care assessment describing R57's pressure injury including a root cause, whether it was avoidable, or any wound care pictures. RN J clarified they were unaware if R57's pressure ulcer was avoidable or unavoidable and confirmed no outside wound care provider was seeing R57. RN J stated, I don't know if I can justify it (the wound) being unavoidable, as (R57) continuously favors the left side.(R57) doesn't have an underlying diagnosis for unavoidable. (R57) is choosing to lie on his left side. I got (R57) an air mattress . RN J said they did not look at R57 as a high risk for a pressure ulcer since R57 moved around. Surveyor asked why R57 could not be positioned on their back or offloaded. RN J stated, (R57) is too uncomfortable . however did not explain why. On 2/10/26 at approximately 3:00 p.m. RN J clarified the Nurse Practitioner (NP) followed R57's wounds in-house. RN J shared a wound section in their EMR, which was not accessible to surveyor. RN J reviewed their wound care documentation notes with Surveyor and confirmed R57's left hip pressure injury was a facility-acquired Stage 2 pressure injury, discovered and treated on 2/02/26, which deteriorated to a Stage 3 pressure injury on 2/09/26. RN J said they believed the NP had documented R57's pressure injury as unavoidable, although this was not found in the EMR with RN J. Review of R57's Care Plan with RN J during the interview showed no documentation regarding R57's pressure injury being unavoidable, or R57 being non-compliant with repositioning. There was no documentation of any education provided to R57 or by staff to offload their left hip by offering positional supports, or more frequent position changes, such as lying on their back or being up in a chair or wheelchair verses in their bed. Review of R57's Wound Care Picture report, printed and provided by the Wound Care nurse, Registered Nurse (RN) J, not accessible to surveyor in EMR, revealed: 2/02/26: A new Stage 2 pressure ulcer, partial thickness skin loss, in-house acquired, on their rear left trochanter. The wound report showed R57 had dull, aching pain, and they recommended positional changes, relaxation, and distraction techniques. The measurements were 1.75 cm (centimeters) length by 2.25 cm width, and 2.82 cm area, with 100% granulation, light exudate (drainage) and no tunneling. 2/09/26: Deteriorating Stage 3 pressure ulcer, full thickness skin loss, in-house acquired on their left rear trochanter. The wound report showed no pain. The measurements were 1.47 cm length, 1.14 cm width, and no depth, and 1.29 cm area, with 50% granulation (healing tissue), and 50% slough (necrotic tissue) with moderate exudate (drainage), no signs of infection. Review of R57's wound care nursing progress note, dated 2/09/26, showed R57's pressure injury deterioration to a Stage 3, revealed offloading with the air mattress only and a pressure relief wheelchair cushion (which was observed as a foam cushion), with no documentation of any offloading devices/methods being offered or recommended. The note further revealed R57's right hip was too painful to lay on, with no education on repositioning provided to lay on their back, as an alternate rotation positioning option. Review of R57's incident report, dated 2/02/26 at 1:30 p.m., revealed, .Nursing Description: Open area noted to L (left) hip with redness surrounding peri-wound. Resident Description: I noticed that it was starting to feel sore but my R (right) side is more sore (from surgery).Wound assessment performed. Would care provided. Low Air loss mattress ordered due to poor mobility.Injury location: Left trochanter (hip).The report showed R57 was alert and fully oriented to person, place, situation, and time.Other info: Recent R hip surgery 1.5 weeks ago. Guest favoring L side when lying in bed due to R hip discomfort s/p (status post) surgery. Guest is a side-sleeper and is not comfortable lying on his back. Writer encouraged guest to rotate sides while in bed, however, guest stated that it was too sore to lay on R (surgical) site. Low air loss mattress ordered. Review of R57's pain assessment report, dated 2/03/26 revealed, .Wound care treatment to left hip was cleansing with normal saline and (Name brand) wound treatment and cover with a bordered foam dressing, changing every other day and as needed. The report revealed R57's pain was 6/10 at worst (moderate) and 3/10 at best, with acceptable pain level of 2/10 (with 10 the worst pain), with no pain reported at that time. The interventions included repositioning and heat, with no positioning supports or education documented as provided. The report revealed R57 was receiving Acetaminophen pain medication and Oxy 5, a controlled narcotic pain medication, which they received since admission. Review of R57's Incident Note, dated 2/02/26 at 1:41 p.m., in the EMR, revealed, Objective Description: Open area noted to L hip.Interventions to Prevent Reoccurrence: Low air loss mattress ordered due to poor bed mobility and risk for further skin breakdown . The note showed the Director of Nursing (DON) was notified along with the physician, nurse practitioner, dietician and family member. There was no documentation of communication to therapy services or the rehabilitation director when R57's pressure ulcer was discovered. On 2/10/26 at 3:24 p.m., R57 was observed in their room on their back. R57 reported nursing staff had just educated them to lay on their right (surgical wound) side or their back, and not to lay on their left side. R57 said they would listen to them (nursing staff). R57 indicated they had not been educated to lay on their back prior. R57 again mentioned their bed was too short, and said it bothered them when their legs were hanging off the bed. During this observation, their legs were on the bed, as the head of bed was not elevated. R57 said they were made aware by RN J something was ordered to elongate their bed. R57 agreed to an observation of their left hip pressure injury care by nurse surveyor. R57 said they understood the pressure ulcer was on their left hip, not their back. On 2/10/26 at 3:45 p.m., RN J completed R57's pressure injury wound treatment, with nurse surveyor observing: Dressing change supplies were observed removed from treatment cart: normal saline (NS) vial, (name brand) paste-hydrophilic paste (to keep the wound moist) for light to moderate wound exudate (wound drainage), 4x4 gauze (pad), and foam pad bandage. R57 was placed on their right side in bed. Dressing was removed- left trochanter area revealed an approximate 1.5 centimeter (cm) square shallow ulcer with red granulated wound bed perimeter, and center observed with a small soft textured white colored material. Per wound care nurse (RN J) this was slough (a type of necrotic (dead) tissue that accumulates in a wound bed). Wound was observed cleansed with NS, (brand name wound) paste applied, 4x4 gauze layered on top, and large square foam bandage was applied. Further review of R57's Care Plan revealed new interventions, dated 2/10/26, which showed R57 preferred to lay on their left side while in bed, application of a specialty air mattress when in bed, and to offload their heels. There were no updated interventions for positional supports to offload R57 from directly applying pressure to their left trochanteric area, education to lay on their back, or to address their bed concerns. Review of R57's Nurse Practitioner (NP) progress note, dated 2/10/26 at 11:10 a.m., revealed R57 was an [AGE] year-old male recent hospitalization for a right femoral neck fracture after a fall following up today related to.pressure ulcer to left trochanter measures 1.4 (cm) x 1.1 (cm). This is a pressure injury wound (sic) bed 50% yellow slough and 50% granulation tissue (sic).(wound) is being cleaned with NS (normal saline) and (name brand wound) paste (showing a new wound treatment).Wound to left trochanter pressure (injury) -offload pressure, encouraged to turn every 2 hours .Chronic pain - pain management. There was no documentation about R57's bed being a concern, or interdisciplinary communication. On 2/11/26 at approximately 9:55 a.m., R57 was observed up and dressed in the Physical Therapy department on an exercise bike, supervised by their physical therapist. On 2/11/26 at 10:06 a.m., R57's bed was observed while R57 was out of the room. A beige foam bed extender was observed at the foot of their bedframe, which was about a foot long. The air mattress did not extend over this new bed extender. The top of the air mattress was about a foot above (depth) and in front of the attached foam extender. The new foam support would have provided no additional length for the bed occupant's legs, as the bed had the same air mattress length. There was no positioning wedge, supports, or pillows observed on R57's bed or in R57's room. On 2/11/26 at approximately 10:09 a.m., Physical Therapist Assistant (PTA) H was observed assisting R57 back to bed from their wheelchair after therapy. PTA H provided stabilizing assistance to R57 to transfer back into bed. R57 positioned themselves on their left side, directly on their left hip (trochanter), where they had the Stage 3 pressure ulcer. PTA H observed R57 and then left R57's room. No offloading to R57's pressure ulcer was completed or discussed. There were no offloading devices such as a wedge on their bed or in their room, and no pillows placed behind R57's back to offload their pressure ulcer. On 2/11/26 at approximately 10:15 a.m. PTA H was asked about R57's positioning in their bed, directly on their left hip, and if they were aware if R57 had any skin concerns. PTA H reported they had not heard of any new skin concerns during R57's stay, other than their right hip surgical wound. PTA H understood the positioning concern upon learning R57 had a left hip pressure injury. PTA H indicated they would ask R57 to lay on their back to offload their left hip to prevent pressure to an existing pressure injury. On 2/11/26 at approximately 10:23 a.m., PTA H was observed with R57, who confirmed they had a pressure injury on their left hip and agreed to repositioning. R57 repositioned themselves onto their back, after being asked by PTA H, to offload their left hip, and understood the concern. No pressure was observed to R57's left hip (trochanteric area) when they laid on their back. PTA H had cued R57 to move up higher when getting into bed, so their feet were not hanging off the mattress. On 2/11/26 at 10:33 a.m., the Director of Rehabilitation Services (DOR), Speech Language Pathologist (SLP) I, confirmed they did not recall being made aware R57 had a Stage 2 or Stage 3 pressure injury by the facility clinical staff, although they recalled hearing R57 had a new wound on 2/10/26. SLP I acknowledged they did not know the extent of this wound. SLP I was asked if they would have expected the clinical /nursing staff to have communicated to therapy R57 had a Stage 3 pressure injury. SLP I respectfully declined to comment. On 2/11/26 at 10:36 a.m., SLP I was asked how a new Pressure ulcer for a facility resident would typically have been communicated to them. SLP I said they attended the morning care coordination meetings routinely, where this would be conveyed. SLP I acknowledged a Stage 3 pressure injury for a resident would be a multi-disciplinary concern. SLP I explained R57 had not been reeducated by therapy staff to offload their left side until after R57's PT session on 2/11/26 when they became aware. SLP I confirmed (when asked) they or the treating therapy staff should be made aware of a new pressure injury, to incorporate any alterations or positioning education into R57's treatment. Review of R57's physical therapy / therapy documentation revealed no reflection of R57 having a pressure injury on their left trochanter (hip bone), or any education related to offloading, positioning, or positional changes. There was no documentation of R57's bed not accommodating their height. Review of R57's February (2026) Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed a missing wound care treatment on 2/08/26, which showed as a blank box, without an administration marked or initialed. Review of R57's EMR including nursing progress notes showed no documentation of why their daily wound treatment was not provided on 2/08/26, when the physician orders changed to an alternative wound care treatment on 2/09/26. On 2/11/26 at 11:09 a.m., concerns were reviewed with the DON related to R57's observed positioning themselves directly on their left hip (trochanteric area), their self-reporting their bed was too short from them, both observed, the lack of appropriate offloading measures, or documented attempts, such as onto their back, the use of positional wedges, supports, or pillows, and no clear documentation of education to R57, or nursing staff. Additional concerns were reviewed including lack of related care planning concerns showing no attempts or noncompliance, no clear documentation of pressure injury avoidability, care coordination concerns with therapy, and the progression of R57's pressure ulcer from a Stage 2 facility acquired pressure injury to a Stage 3 pressure injury, given the bed size concerns. The DON responded that R57 positioned themselves on their left side per their preference and said they had added a care plan intervention today (2/11/26) to reflect their positioning preference. The DON shared R57 was receptive to education when reminded, and concurred this was not found in the EMR and understood the concern. The DON concurred there was no documentation found of the pressure ulcer being unavoidable, per their record review, although R57 positioned themselves on their left hip. The DON shared they would have expected the rehabilitation director to have been aware of R57's pressure injury, since they attended the daily care coordination meetings. The DON reported they understood the concerns regarding lack of documentation of R57 being educated to offload their left hip, onto their back or being offered positional wedges, pillows, or positional supports. The DON shared they had not been made aware of the concerns with R57's bed size until 2/10/26 during the survey. The DON concluded this pressure injury was likely unavoidable and concurred this was not documented on a form or found in the EMR, as well as education not being clearly documented. Surveyor shared R57's concerns related to their bed not fitting them properly, and the likelihood of R57's left hip pressure injury resulting from side lying directly on their left side, as they self-reported they were uncomfortable laying on their back with their legs hanging off the standard sized bed, due to their height, and R57 reporting they had told multiple staff. The DON reported they had not been made aware, and declined to comment, as they wished to follow-up further. Review of R57's Care Plan on 2/11/26 showed updated interventions dated 2/11/26, as follows: .Behavioral problem r/t (related to) not performing self-repositioning in bed, continuously favoring L (left) side, leading to pressure wound.Assist/encourage guest to perform self-repositioning to relieve pressure from L (left) hip. Explain to guest the benefits of repositioning while in bed. Monitor behavior episodes and document behavior and potential causes. Praise guest when progress/improvement in behavior is observed. All interventions were dated 2/11/26. On 2/11/26 at approximately 12:20 p.m., concerns were reviewed with the DON regarding R57's MAR/TAR showing a wound care treatment was marked as not administered on 2/08/26, prior to their wound care treatment being changed on 2/09/26. The DON reviewed the MAR/TAR with Surveyor, and explained the facility had changed their documentation system, and this may not have been an omission. The DON reviewed the nursing schedule for the time of the documentation omission and identified the nurse who had worked on the night shift on 2/08/26 when R57's wound treatment was scheduled. The DON attempted to reach the scheduled nurse during the interview without success. The DON explained this was typically caught by them in an audit report, however they had not had the opportunity to review this report during the current annual survey. The DON acknowledged there was no other documentation found in R57's EMR to explain the blank MAR/TAR entry on 2/08/26. The DON did not believe this would have had an outcome for R57. It was discussed R57's wound progressed to a Stage 3 pressure ulcer on 2/09/26. On 2/11/26 at approximately 1:00 p.m., R57 was observed in their room in their hospital bed, lying on their back, with the Director of Nursing (DON) and the Maintenance Director, Staff G , present. It was observed that the air mattress was not supported by the bed frame extender. The air mattress appeared to be the same mattress, which was not any longer. R57's feet were positioned near the end (foot) of the air mattress. On 2/11/26 at approximately 1:01 p.m., R57 was asked about their hospital bed with the DON and Staff G present. R15 shared they had concerns with their bed, and stated, What it amounts to is this (bed) is not conducive to sleep for a person of my height. I am 6 foot, 3 inches (tall). R57 said the bed had weakened them. R57 was asked to explain and said their legs were hanging off the bed when they sat up (in their bed). It was discussed that R57 was in their bed more often than their wheelchair. R57 did not deny this. The DON shared with R57 they would be getting them a longer bed, and Staff G would be getting them a longer air mattress. R57 said, I am sorry. The DON explained this was not their fault and to let nursing management know of any concerns in the future, as they had not been made aware. Observations of R57 during the survey (2/09/26 through 2/11/26) showed they were lying in their hospital bed, except when they were in therapy or at an appointment. R57 was observed sitting up in physical therapy during treatment, and had the ability to sit up, which offloaded their left hip. Review of R57's psychiatric consult, dated 2/10/26, showed R57 had insomnia and symptoms of depression, with a score of 10/27 on the PHQ-9 (standardized depression assessment), which showed moderate symptoms of depression, which was ongoing. The report revealed R57 was hospitalized after their fall and fracture with acute alcohol intoxication. It was shown that R57 had ongoing nightly insomnia due to the environment (unspecified) and distractions and concluded gradual dose reductions of their psychiatric medications were contraindicated at that time, given their symptoms. Review of R57's 2/11/26 health status/progress note, at 7:05 (a.m.), revealed, Writer met with resident and inspected air mattress and bed extender. Equipment is in appropriate working condition. Resident was observed laying on his left side. Writer explained to the resident that his wound would benefit with little pressure applied during the healing process and that laying in a different position would benefit him. The resident stated that he prefers to lay on this left side and will do just fine. Writer inquired if the bed extender made his positioning more comfortable. Resident stated, 'No'; There were no offloading or positioning supports documented as offered, no asking R57 to sit up in their wheelchair or lounge chair in their room, and no documentation of follow-up when R57 said the bed extender was not more comfortable. Review of R57's nursing progress note, dated 2/11/26 at 10:46 a.m., confirmed R57 preferred to lay in their hospital bed throughout the day, and spent little time up in their wheelchair, except when they went to therapy. The progress note described it was resident preference to lay directly on their left hip. Further review revealed only the low-air loss mattress was noted for offloading, with no education or other offloading measures. Review of R57's Physical Medicine and Rehabilitation (PM & R) practitioner note, dated 2/11/26 at 9:38 a.m., revealed no documentation of R57's Stage 3 pressure ulcer, and no offloading of their left hip. The note showed to offload R57's right hip from their right hip surgical wound, with no mention of their left hip wound. Review of R57's additional PM & R visits during their stay showed no documentation related to R57 having a pressure injury since their admission. On 2/11/26 at approximately 1:05 p.m., both the DON and Staff G were asked about R57's air mattress not being supported by the bed extender. Both reported they understood the concerns after observing R57 in their bed and R57's interview. The DON shared a longer air mattress had been ordered by Staff G . Staff G clarified after they had not yet ordered a longer air mattress and would do so after the interview. Staff G described the hospital beds/mattresses were 80 long, and R57 was laying on a standard-length bed and mattress since their admission. Staff G explained R57 would benefit from a longer (tall) bedframe and air mattress per their observation. When asked about the process of bed and mattresses provision for newly admitted residents, Staff G said residents were typically placed on a standard bedframe and mattress upon admission, and nursing staff would let them know if an alternate bedframe and mattress was needed. Staff G confirmed this was the same standard bed/bedframe R57 had since their admission. Review of the policy, Care Standards, revised 4/25 (2025), revealed, All residents shall receive necessary care and services to assist them in attaining or maintaining the highest practicable level of physical, mental, and psychosocial well-being in accordance with a comprehensive assessment and plan of care. Care is documented to the medical record according to state and /or federal regulations Review of the policy, Equipment Care Policy, revised 2/2025, received 2/11/26, revealed, .POLICY: It is the policy of this facility that Guest care equipment will be inspected toensure that it is maintained to promote a safe environment for guests.PROCEDURE:1. All facility owned equipment that directly supports guest care is inspected prior toinitial use. Equipment is inspected to assure physical condition, functionality,guest/operator safety, and electrical safety if applicable.2. Equipment inspection will occur as stated in this policy and will be tracked throughthe equipment identification system stated in this policy. Review of the policy, Skin Management, revised 9/2024, revealed, POLICY: It is the facility's policy that a resident does not develop (a) pressure injury unless clinically unavoidable.GOALS: Residents with wounds and /or pressure injury and those at risk for skin compromiseare identified, assessed, and provided appropriate treatment to promote healing. Ongoingmonitoring and evaluation are provided to ensure optimal resident outcomes.PROCEDURE:1. Upon admission/readmission, all residents are assessed for skin integrity by completing abaseline head to toe skin assessment documented in the electronic medical record (EMR).2. A Braden Scale will be completed upon admission, weekly for 4 weeks, quarterly andwith any significant change of status by a licensed nurse to determine the risk of pressureinjury development.3. Appropriate preventative measures will be implemented on residents identified at risk (ascore of 18 or less on the Braden Scale) and the interventions documented on the careplan.4. Residents admitted with skin impairments will have:Appropriate interventions implemented to promote healing.A physician's order for treatment.Wound location, measurements and characteristics documented weekly.5. The licensed nurse is responsible for documentation in the EMR, including a descriptionof the pressure and non-pressure injury as follows: Skin assessment with measurements to be completed weekly.Skin/wound progress note to be completed weekly until healed with description ofwound and any updates and/or changes to plan of care.Care plan to be updated as necessary with any plan of care changes.6. The interdisciplinary team considers whether the resident exhibits conditions or isreceiving treatments that may place the resident at higher risk of developing pressureinjury or complicate their healing process. Such conditions may include:Cognitive impairments.Drugs such as steroids that may affect skin integrity and wound healing.Impaired/decreased mobility and decreased functional ability.Comorbidities such as end stage renal disease, thyroid disease, or diabetes.Impaired, diffuse, or localized blood flow, for example, generalized atherosclerosis, lower extremity arterial or peripheral insufficiency.Bowel and/or bladder incontinence.Abnormal labs, malnutrition, or hydration deficits.Guest behaviors/refusal of some aspect of care or treatment.A previous healed area of injury.7. An initial plan of care is developed upon admission if the resident is at risk or has a or has acurrent pressure or non-pressure injury, areas that should be addressed are as follows:Identifying the contributing risk factors for breakdown, including history of skin impairment.HydrationNutritionPreventative devices, including support surfaces for bed and chairsPreventative skin carePainPhysical activityPositioning requirementsProper body alignmentEducation, when appropriate8. The clinician will document preventative measures on the care plan.9. The licensed nurse will monitor, evaluate, and document changes regarding skincondition (to include dressing, surrounding skin, complications, and pain) in the medicalrecord.15. An At Risk meeting will be conducted weekly by the Interdisciplinary Team (IDT). During the meeting, the IDT will evaluate resident skin changes, review treatment modalities, interventions and will make recommendations as needed. Plan of care, orders,and resident accordingly, and a progress note documented under the heading of Plan of Care. 17. If the identified wound is a stage 3 or 4 and fails to show improvement or deteriorates, orif the individual guest has co-morbidities requiring consult of a wound care specialist, theattending physician or designee may recommend consult with local wound care clinic.Pressure Injury Evaluation of Avoidability1. The Director of Nursing or designee is responsible for ensuring that the Evaluation ofPressure InjuryResidents who should be reviewed for skin alterations are as follows:Newly developed vascular, diabetic/neuropathic and pressure injuries.Any pressure or non-pressure area that has shown no signs of healing within a two-three-week time frame.New admissions and readmissions with skin conditions (pressure related, non-pressure related, arterial, venous insufficiency and/or diabetic/neuropathic, surgical sites, rases, dermatologic conditions, skin tears, etc.).Pressure Injury Evaluation of Avoidability1. The Director of Nursing or designee is responsible for ensuring that the Evaluation ofPressure Injury form is completed accurately and timely if applicable to thecondition.Significant changes in conditionDecline in overall health statusHospice, Palliative and/or Comfort care is initiatedAnticipated development of pressure injuryFacility acquired pressure injuryWorsening condition of a pressure injury2. The completed form will be scanned into the patient's medical record under documents.3. The Evaluation of Pressure Injury form should be completed annually for anyunavoidable pressure related injury.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 02/11/26 at 8:14 AM observation of the kitchen two door cooler found a package of opened hot dogs with a facility marked date of 1/21/26. An interview at this time with Dietary Manager (DM) F found they use a seven-day discard for ready-to-eat, time/temperature control for safety foods.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (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.According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .On 02/11/2026 at 8:25 AM observation of an out of order two door cooler in the kitchen found an accumulation of residue on the shelving racks and bottom surface.On 02/11/2026 at 8:40 AM observation of the clean equipment storage revealed wet food residue on the surface of a sheet pan. DM F removed the sheet pan to be cleaned at the dish machine.On 02/11/2026 at 8:55 AM observation of the dining room service kitchen (sub kitchen) juice machine found built up colored residue on the upper portion of the nozzle dispensing area. During this observation, when asked how often the nozzle is cleaned, DM F stated that it is cleaned daily and a deep clean happens weekly. On 02/11/2026 at 8:57 AM observation of the sub kitchen ice machine found a black and green substance on the white ice guide in the dispenser where ice is released and drops into the cup. An interview at this time with DM F confirmed the presence of the buildup and said it would be mentioned to maintenance.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (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 02/11/2026 at 9:07 AM observation of a sub kitchen cabinet under the sink adjacent to the ice machine revealed an actively dripping leak from a drainpipe. A pool of water was observed on the surface of the cabinet floor with a towel placed at the cabinet edge absorbing some of the pooling water. Standing water was observed at the base of the cabinet and moving to the floor drain under the ice machine.According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.On 02/11/2026 at 9:11 AM observation of the sub kitchen found soiled buildup under all fixed in place equipment and the floor drain beneath the ice machine was observed with black residue on and around the floor drain where drain water had leaked and pooled. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent when two medication errors were observed (R3, R79) from a total of 29 opportunities resulting in an error rate of six percent.On 2/10/26 at 7:51 AM, Licensed Practical Nurse (LPN) C was observed for medication administration. R3 was ordered Miralax (medication to treat irregular bowel movements and constipation)17 grams. LPN C was observed pouring the medication granules into the measuring cap and was asked how to confirm the measure was 17 grams. LPN C was observed pointing to the inside of the measuring cap and indicated the white thread halfway in the white part of the cap cup was 17 grams.On 2/10/26 at 8:18 AM, LPN D was observed for medication administration. R79 was ordered Aspirin 81 milligrams (mg) oral tablet delayed release. LPN D was observed preparing Aspirin 81 mg chewable and administered to R79.On 2/10/26 at 10:45 AM, The Director of Nursing (DON) was asked to demonstrate how nurses measure 17 grams of Miralax. The DON retrieved a bottle of Miralax from the medication cart in the 100 hallway and proceeded to remove the cap. The DON pointed to the inside of the measuring cap and indicated the white thread halfway inside white part of the cup was 17 grams. The DON was shown the stamped measuring line with an arrow pointing upward indicating 17 grams. This measurement was the entire white portion of the cup, up to the purple part of cap. The DON acknowledged that measurement shown to the white thread of the cap was incorrect and not the full 17 grams of medication as ordered. The DON was informed the observation of chewable aspirin administered and order on the Medication Administration Record was documented as delayed release. The DON indicated both observations were opportunity for medication administration reeducation.Record review of the policy titled Medication Administration-General Guidelines dated November 2021, documented: .FIVE RIGHTS-Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.

This citation pertains to intake #2677940Based on observation, interview and record review, the facility failed to ensure ancillary services were provided in a timely manner for three residents (R6, R20 and R64) of three residents reviewed for medically related Social Services. Findings include: R6 On 2/9/26 at approximately 11:03 AM, R6 was observed lying in bed. The resident was alert and able to answer questions asked. When queried as to the care provided by the facility, R6 reported that they needed follow up with their hearing aid and outside dental care. They also reported that they had been seen by an ophthalmologist that recommended they needed cataract surgery, and nothing had been scheduled. They further noted that they were supposed to see an outside dentist and something happened with transportation and the appointment was cancelled. They were not aware that it had been rescheduled. With respect to the hearing aid, they noted that they were seen last year and were told that they were getting a new hearing aid. A review of R6's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: COPD (chronic obstructive pulmonary disease), type II diabetes and kidney failure. A review of R6's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 12/15 (moderately cognitively impaired). Continued review of R6's record did not indicate any scheduled follow-up appointments with dental and cataract surgery. A document from Audiology was located and documented, in part: Patient (R6).Date: 11/11/2025 .Reason for Visit: Hearing Exam, Hearing Aid Eval: The patient was referred by the facility for decreased hearing.Hearing tests were performed.testing showed mild to moderate hearing loss in both ears. The hearing loss and options for hearing aids were discussed. He would like to begin a trial with binaural receiver in the ear hearing aids.Follow-up: Hearing aid fitting in 1 month. R20 On 2/9/26 at approximately 11:13 AM, R20 was observed sitting in a wheelchair in their room. They were alert but not able to answer questions asked. R20's representative was interviewed and asked about the care provided by the facility. The representative noted that they were concerned that R20 had not been seen by podiatry and dental care since admission. A review of R20's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: cerebral palsy and epilepsy. Review of R20's MDS noted the resident had a BIMS score of 0/15 (severely cognitively impaired). There was no indication in R20's clinical record that they had been seen by podiatry and/or dental services since their admission 9/14/25. A consent form for ancillary services was signed by their legal guardian in January 2026. On 2/10/26 at approximately 10:50 AM, an interview and record review were conducted with TCC B. TCC B reported that they are responsible for scheduling ancillary services for residents that are long term care. They further reported that they provide consent forms for ancillary services to the residents/resident representatives upon admission. When queried about R6's concerns, TCC 'B recalled there was an issue concerning transportation to an outside appointment. On 2/10/26 at approximately 11:41 AM, TCC B was able to provide scheduling dates for outside dental care (March 2026) and cataract (May 2026). With respect to auditory services and new hearing aids, TCC B stated that the last visit indicated the resident did not have any hearing concerns. The form dated 11/11/15 was reviewed with TCC B and they reported that they did see the portion that talked about the hearing aid. TCC B was further queried about R20. They indicated that they were not certain if R20 was going to be a long-term resident, so they did not obtain consent until January 2026. The facility policy titled, Providing Ancillary Services (4/2025) was reviewed and documented, in part: Policy- it is the policy of this facility that ancillary services such as dentistry, audiology, podiatry, vision, etc., will be provided to the residents.Procedure: At the time of move in to the facility, the resident/responsible party will be given information regarding who is providing ancillary services. R64 On 2/9/26 a concern submitted to the State Agency was reviewed which alleged R64 had an issue with having long toenails. On 2/10/26 the medical record for R64 was reviewed and revealed the following: R64 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Congestive heart failure. A review of R64's MDS (minimum data set) with an ARD (assessment reference date) of 10/23/25 revealed R64 needed assistance from facility staff with most of their activities of daily living. R64's BIMS score (brief interview of mental status) was six indicating severely impaired cognition. A Physicians order dated 10/29/25 revealed the following: please place on list to be seen by podiatry A progress note dated 11/3/25 revealed the following: spoke to daughter regarding follow up with labs (laboratory diagnostics). Concerned for UTI (urinary tract infection). UA (urine analysis) dipstick negative. negative WBC (white blood cell count). no UTI suspected at this time. Was also asking about podiatry to see resident. Social work made aware. On 2/11/26 at approximately 10:39 a.m., during a conversation with the facility Transitional Care Coordinator-Social Services B (TCC B) was queried regarding the podiatry order for R64. TCC B indicated that R64 did not see the facility podiatry provider because they believed only the long term care residents were eligible for podiatry services. At that time, a request for the ancillary service contract was requested for review. On 2/11/26 at approximately 1:00 p.m., during a conversation with the Director of Nursing (DON), The DON was queried regarding R64's podiatry consult ordered by the Physician. The DON reported they were uncertain on how podiatry services were arranged. On 2/11/26 the contract for the facility's ancillary service provider contract was reviewed and did not dictate the provision of care for a resident's expected length of stay. No further documentation was provided by the end of the survey that documented R64 was provided podiatry services or that any podiatry services had been arranged for them per the Physicians order.

Based on observation, interview, and record review, the facility failed to accommodate the needs of two Residents (R57 and R77) when appropriate durable medical equipment was not provided to accommodate their functional medical care needs. Findings include: R77 On 2/09/26 at 1:56 p.m., R77 was observed dressed, seated upright in their wheelchair in their room. On 2/09/26 at 1:58 p.m., R77 reported they had notified staff since yesterday (2/08/26) their toilet safety frame over their toilet was crooked and said, nothing was done. R77 explained they felt nervous using their toilet. R77 described they sometimes waited extended periods (30 or more minutes) for assistance with toileting needs, which made them feel scared, being seated on an uneven commode seat. On 2/09/26 at 2:01 p.m., R77's bathroom was observed. There was a toilet safety frame which was worn and rusted at the base of one commode leg, on the right rear side. This caster was about a 1-inch difference in height (higher) than the others, so it did not rest on the ground. The legs were observed set to the same height. The commode seat/frame moved back and forth, and would be wobbly for the occupant, placing them at risk for falls. On 2/09/26 at approximately 2:15 p.m., Licensed Practical Nurse (LPN) L was asked to observe R77's toilet safety frame. LPN L saw the commode base was uneven and worn and reported they understood the concern. On 2/09/26 at 2:21 p.m., LPN K was asked about R77's toilet safety frame when they were removing the toilet safety frame from R77's bathroom. LPN K reported they understood the safety concerns. LPN K clarified the commode would be replaced. During this interaction, R77 was heard to state loudly, I don't want to fall. On 2/10/26 at approximately 1:20 p.m., the Director of Nursing (DON) was made aware of the concerns related to R77's toilet safety frame being worn and in disrepair. Surveyor shared R77 reported feeling unsafe and said they could fall as it was unstable. The DON reported they understood the concern and were made aware R77's toilet safety frame had been replaced. Review of R77's Minimum Data Set (MDS) assessment, dated 2/24/26, showed R77 was admitted on [DATE] with a femur fracture, dementia, and insomnia. The assessment revealed that R77 required moderate assistance for toileting hygiene, and supervision or touching assistance for transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 12/15, which showed R77 had moderate cognitive impairment. R77 was always continent bladder and bowel. Review of R77's Physical Medicine and Rehabilitation (PM & R) Practitioner Note, dated 2/5/26, revealed R77 had been placed on posterior hip precautions (avoiding hip flexion beyond 90 degrees) after their hip fracture. This would have justified the use of a toilet safety frame over their toilet seat, to raise the height for safe transfers within their hip precautions. R57 On 2/9/26 at 1:46 p.m., R57 was observed in their room in their hospital bed, lying on their left side, directly on the trochanteric (hip) area, with their legs bent at their knees. There was no offloading device behind them, including pillows or a wedge to support their back on their bed. No offloading devices were observed in their room. It was noted R57 was positioned on an air mattress. The bed had no footboard. On 2/9/26 at 1:47 p.m., R57 stated, You can see the bed does not fit my frame . R57 reported they had asked staff for a new bed as long as I have been here, and said staff did not get them one. R57 explained their legs were curled to stay on the bed. R57 said they laid on their left side as it was too painful to lay on their right side, where they had a surgical wound. R57 said when they laid on their back their legs came off the foot of the bed which was uncomfortable for them, since they were tall. R57 said sometimes they had pain on their left hip and back as well as their right hip. R57 confirmed they had a pressure injury and said they believed it was on their back (on their bottom). On 2/9/26 at 1:48 p.m., R57 demonstrated stretching out their legs out to lay on their back. Their legs were observed hanging about a foot off the foot of the bed, from their mid-calf to their toes, which were covered by yellow gripper socks. R57 said this was uncomfortable for them. R57 reiterated they struggled to be comfortable in their hospital bed during their stay for rehabilitation and said they were not sleeping well because their bed was uncomfortable. Review of the facility matrix, accessed 2/9/26, revealed R57 was marked as having a Stage 3 pressure injury. Review of R57's wound care nursing progress notes in the EMR (Electronic Medical Record) revealed R57 developed a facility-acquired new Stage 2 pressure ulcer to their left hip (trochanter) on 2/2/26, which deteriorated and progressed to a Stage 3 pressure ulcer to their left hip (trochanter) on 2/9/26. Review of R57's MDS assessment, dated 1/28/26, revealed R57 had been admitted to the facility on [DATE], with diagnoses including right femur (hip) fracture, interstitial lung disease (inflammation of lung tissue which may result in shortness of breath), insomnia (difficulty sleeping), depression, and anxiety. The assessment revealed that R57 required one-person assistance for toileting, transfers, and bed mobility, was incontinent of bladder and bowel, and had no behaviors. The BIMS assessment showed a score of 15/15, which showed R57 was cognitively intact. The assessment showed R57 was 73 tall (6'1 tall) and weighed 260 pounds. The skin assessment showed R57 was at risk for developing pressure ulcers and had no pressure ulcers upon admission. Review of R57's Care Plan revealed no interventions or education for offloading or positional supports to assist R57 to stay off (applying direct pressure to) their left hip with the new pressure injury. The interventions revealed a pressure reduction mattress, dated 2/2/26, a pressure relieving cushion when up in wheelchair, dated 2/2/26, and to remind resident to reposition frequently on 2/2/26. It was noted there was also no intervention for R57 to alternate laying on their back to offload their left hip, given their right hip (surgical wound) was reportedly painful for them to lay on. There was no mention of bed concerns or attempts at obtaining a replacement bed or mattress, given R57's concerns. Review of R57's Electronic Medical Record (EMR) including all progress notes, accessed 2/9/26, revealed no interventions or education for offloading R57 to stay off their left hip other than the pressure reduction mattress and cushion, and reminders to change positions (unspecified), as well as no interventions to replace or accommodate R57's bed, given their taller size. Review of R57's Braden Skin Assessment, dated 1/27/26, revealed a score of 18, which showed R57 was at risk for developing a pressure injury. Review of R57's Physical Therapy treatment note, dated 1/30/26, revealed R57 required supervision or touching assistance for bed mobility, including rolling, lying to sitting, and sitting to lying positions. On 2/10/26 at 3:24 p.m., R57 was observed in their room on their back. R57 reported nursing staff had just educated them to lay on their right (surgical wound) side or their back, and not to lay on their left side. R57 said they would listen to them (nursing staff). R57 indicated they had not been educated to lay on their back prior. R57 again mentioned their bed was too short, and said it bothered them when their legs were hanging off the bed. During this observation, their legs were on the bed, as the head of bed was not elevated. R57 said they were made aware by RN J something was ordered to elongate their bed. R57 said they understood the pressure ulcer was on their left hip, not their back. On 2/11/26 at 10:06 a.m., R57's bed was observed. A beige foam bed extender was observed at the foot of their bed, which was about a foot long. The air mattress did not extend over this new bed extender, which extended about a foot in length beyond the air mattress, at the end of the air mattress (length). It appeared these new interventions would not have provided any additional support to R57's legs per prior observation of R57 in their bed. The top of the air mattress was about a foot above (depth) the attached foam extender. The new foam support would have provided no additional length for the bed occupant's legs, as the bed had the same air mattress (length) which was well above the positional extender. There was no positioning wedge or support pillows observed on R57's bed or in R57's room. Review of R57's Electronic Medical Record (EMR) revealed no education was provided to staff or any implementation of interventions related to R57 positioning themselves directly on their left hip (trochanteric area), to prevent progression/deterioration of their left hip pressure ulcer, such as an offloading wedge, offloading pillows, lying on their back, or other options to assist them, given R15 was cognitively intact. There was no documentation of these types of interventions being declined by R15. On 2/11/26 at approximately 1:00 p.m., R57 was observed in their room in their hospital bed, lying on their back, with the Director of Nursing (DON) and the Maintenance Director, Staff G , present. It was observed that the air mattress was not supported by the bed frame extender. The air mattress appeared to be the same mattress, which was not any longer. R57's feet were positioned near the end (foot) of the air mattress. On 2/11/26 at approximately 1:01 p.m., R57 was asked about their hospital bed with the DON and Staff G present. R57 shared they had concerns with their bed, and stated, What it amounts to is this (bed) is not conducive to sleep for a person of my height. I am 6 foot, 3 inches (tall). R57 said the bed had weakened them. R57 was asked to explain and said their legs were hanging off the bed when they sat up (in their bed). It was discussed that R57 was in their bed more often than their wheelchair. R57 did not deny this. The DON shared with R57 they would be getting them a longer bed, and Staff G would be getting them a longer air mattress. R57 said, I am sorry. The DON explained this was not their fault and to let nursing management know of any concerns in the future, as they had not been made aware. Observations of R57 during the survey (2/9/26 through 2/11/26) showed they were lying in their hospital bed, except when they were in therapy or at an appointment. Review of R57's psychiatric consult, dated 2/10/26, showed R57 had insomnia and symptoms of depression, with a score of 10/27 on the PHQ-9 (standardized depression assessment), which showed moderate symptoms of depression, which was ongoing. The report revealed R57 was hospitalized after their fall and fracture with acute alcohol intoxication. It was concluded R57 had ongoing nightly insomnia due to the environment (unspecified) and distractions and gradual dose reductions of their psychiatric medications were contraindicated at that time. R57's reporting of not being able to be comfortable in their hospital bed may have contributed to their insomnia during their stay. Review of R57's 2/11/26 health status/progress note, at 7:05 (a.m.), revealed, Writer met with resident and inspected air mattress and bed extender. Equipment is in appropriate working condition. Resident was observed laying on his left side. Writer explained to the resident that his wound would benefit with little pressure applied during the healing process and that laying in a different position would benefit him. The resident stated that he prefers to lay on this left side and will do just fine. Writer inquired if the bed extender made his positioning more comfortable. Resident stated, 'No'. There were no offloading or positioning supports documented as offered, and no documentation of follow-up when R57 said the bed extender was not more comfortable. Review of R57's nursing progress note, dated 2/11/26 at 10:46 a.m., confirmed R57 preferred to lay in their hospital bed throughout the day, and spent little time up in their wheelchair, except when they went to therapy. The progress note described it was resident preference to lay directly on their left hip. Further review revealed only the low-air loss mattress was noted for offloading, with no education or other offloading measures. On 2/11/26 at approximately 1:05 p.m., both the DON and Staff G were asked about R57's air mattress not being supported by the bed extender. Both reported they understood the concerns. The DON shared a longer air mattress had been ordered by Staff G . Staff G shared they had not ordered a longer air mattress and would do so after the interview. Both reported they understood the concerns. On 2/11/26 at approximately 1:10 p.m, Staff G confirmed the hospital beds/mattresses were about 80 long, and R57 was on a standard-length bed and mattress (not a tall bed or mattress) since their admission and would benefit from a longer (tall) bedframe and air mattress. A policy for Accommodation of (Resident) Needs was requested twice during the survey. The following two policies were received: Review of the policy, Care Standards, revised 4/25 (2025), revealed, All residents shall receive necessary care and services to assist them in attaining or maintaining the highest practicable level of physical, mental, and psychosocial well-being in accordance with a comprehensive assessment and plan of care. Care is documented to the medical record according to static and /or federal regulations Review of the policy, Equipment Care Policy, revised 2/2025, received 2/11/26, revealed, .POLICY: It is the policy of this facility that Guest care equipment will be inspected toensure that it is maintained to promote a safe environment for guests.PROCEDURE:1. All facility owned equipment that directly supports guest care is inspected prior toinitial use. Equipment is inspected to assure physical condition, functionality,guest/operator safety, and electrical safety if applicable.2. Equipment inspection will occur as stated in this policy and will be tracked throughthe equipment identification system stated in this policy .Repairs: 11. Equipment identified to be in need of repair will immediately be removed from useuntil the repair can be performed.12. All repairs are prioritized and performed in a timely manner. To ensure thecontinuation of guest care in the event of equipment failure (facility owned as wellas guest owned), the equipment will be removed and backup devices may beprovided .

This citation pertains to Intake 2660312Based on interview and record review, the facility failed to implement a resident-centered intervention which required a two-person total assist for positioning onto a bedpan for one (R701) of one resident reviewed for falls, resulting in R701 falling to the floor, sustaining a left clavicle (collarbone) fracture, new pain and discomfort to their left upper extremity.Findings include:A concern was filed with the State Agency alleging on 9/18/25 prior to being transferred for their weekly outpatient paracentesis (procedure that involves the removal of fluid from the abdomen) appointment, two family members and two EMT's (Emergency Medical Technician) personnel were waiting outside R701's room while they (R701) were cared for by one Certified Nurse Assistant (CNA) to use the bedpan. While waiting, R701 was heard yelling I am going to fall, then a loud thump was heard and R701 was found lying on the floor.Clinical record review revealed R701 was admitted to the facility on [DATE] for advanced end-stage liver disease with ascites (fluid accumulation in the abdominal cavity) that required weekly outpatient peritoneal paracentesis. R701 had a Brief Interview of Mental Status (BIMS) score of 15/15 which indicated no cognitive impairment.Review of R701's care plan dated 8/23/25 documented R701 had a self-care deficit and had limited mobility. R701 was assessed and required .extensive assist with 2 people for with use of bed pan for toileting.Record review of the EMS (Emergency Medical Service) report dated 9/18/25, documented: . EVENTS LEADING UP TO THE CALL: CREW WAS ORIGINALLY AT THE FACILITY TO TRANSPORT THIS PATIENT TO THE HOSPITAL FOR INTERVENTIONAL RADIOLOGY, HOWEVER THE PATIENT (PT) WAS ON A BEDPAN UPON ARRIVAL, THE NURSING ASSISTANT CAME INTO THE ROOM, AND THE CREW WAITED OUTSIDE OF THE ROOM FOR THE AIDE TO COMPLETE THE REMOVAL OF THE BEDPAN AND CLEAN UP OF THE PATIENT. THE CREW HEARD A LOUD SOUND RESEMBLING A FALL IN THE ROOM AND ENTERED, AND FOUND THE AIDE IN THE BATHROOM, THE PATIENT WAS APPROXIMATELY 10 FEET AWAY, LAYING ON HER LEFT SIDE ON THE FLOOR. THE PT HAD KNOCKED OVER FLOWERS AND A LAMP. PT COMPLAINED OF PAIN TO THE LEFT ARM.PT WAS TRANSPORTED TO HOSPITAL.Record review of the emergency room Radiology Report dated 9/18/25 at 11:33 AM confirmed R701 had sustained a fracture to their left clavicle.Record review of a progress note authored by Physician C on 9/19/25 read R701, .is in some pain associated with the collarbone fracture.On 11/12/25 at approximately 1:00 PM, The Director of Nursing (DON), Nursing Home Administrator (NHA), Assistant Director of Nursing (ADON) B and Nurse A who was assigned to R701 on 9/18/25 were interviewed.Nurse A confirmed they were not in the room at time of incident and only one CNA (hereinafter CNA D) provided care to R701.ADON B commented R701 was care planned for two persons assist so they would have support to their enlarged abdomen due to ascites, not to roll off the alternating air mattress.The DON and NHA stated that CNA D who provided the care to R701was terminated because of the incident and review of the termination statement documented it was determined that the CNA D failed to follow care orders, follow the care plan designed to maintain R701's safety which resulted in a fall with injury.

This citation relates to Intake #MI00149071. Based on observation, interview, and record review, the facility failed to demonstrate professional standards of care related to one Resident (R807) of one resident reviewed for quality of care, when they did not provide a wheelchair cushion for a resident at risk for skin breakdown, resulting in pain and the potential for skin breakdown. Findings include: On 2/05/25 at 2:59 p.m., R807 was observed in their room, seated in a manual wheelchair, and appeared thin and underweight. This Surveyor observed they had no wheelchair cushion underneath them. On 2/05/25 at approximately 3:04 p.m., R807 reported they were uncomfortable and their bottom was hurting when they sat in their wheelchair. R807's Family Member (FM) F, who was present, and R807 reported they had no wheelchair cushion in their wheelchair since their admission. FM F explained R807 was admitted about a week prior with a wound on their bottom, which was the size of a quarter currently. FM F stated R807 had received the air mattress on their bed earlier today, on 2/05/25. R807 was interviewable and oriented to person, situation, and their surroundings. Review the Electronic Medical Record (EMR) revealed R807 was admitted to the facility on [DATE], with diagnoses including muscle weakness, malnutrition, depression, dementia, rhabdomyolysis (muscle breakdown), and a hip fracture. Review of R807's Care Plan, accessed 2/05/25, revealed R807 required extensive two-person assistance for transfers and toileting. The Care Plan further revealed R807 was at risk for pressure ulcers and was revised on 2/05/25 to include a Roho air pressure-relieving wheelchair cushion, and specialty air mattress to their bed. Review of R807's progress note, dated 2/02/25 at 14:40 (2:40 p.m.), revealed R807 had a wound on their coccyx, which R807's son stated was present on admission. There were no measurements and no further description of the wound. It was unclear if R807 was admitted with the wound, the type of wound, or when the wound developed. Review of the EMR revealed no earlier documentation of R807's wound on their coccyx prior to 2/02/25. Review of R807's progress note, dated 2/03/25 at 14:57 (2:47 p.m.), revealed the Brief Interview for Mental Status (BIMS) cognitive assessment was administered, with a score of 9/15, which showed R807 had moderate cognitive impairment. Review of R807's progress note, dated 2/05/25 at 9:47 (a.m.), revealed, .Guest (R807 presents) with (a) 3.5 cm (centimeter) x 2.4 cm x UTD (Unable to Determine) pressure injury to coccyx . The note showed R807 also had an UTD pressure injury to their left heel and an UTD pressure injury to their left outer ankle. There were no measurements found prior in R807's progress notes, or assessments describing these wounds. Review of R807's progress note, dated 2/05/25 at 16:31 (4:31 p.m.) , revealed a bariatric low air low alternating pressure mattress was delivered on 2/05/25. On 2/05/25 at approximately 3:40 p.m., the Director of Nursing (DON) was interviewed with the Nursing Home Administrator (NHA) present; concerns were shared related to no wheelchair cushion underneath R807 six days after their admission, significant pain reported by R807, and the risk of skin breakdown. Both reported they understood the concerns. When asked who was responsible for the missing wheelchair cushion, the DON reported the Interdisciplinary Team, including nursing and therapy. The DON conveyed either nursing or therapy staff could have placed a pressure-relief cushion under R807 upon admission, per facility standards of care. On 2/05/25 at approximately 3:45 p.m., the wound care nurse, Registered Nurse (RN) B, with the DON and NHA present, was asked about R807 not having a wheelchair cushion. RN B acknowledged an air wheelchair cushion was a standard of care for a resident with a pressure ulcer, and they did not understand how this was missed. RN B acknowledged this would have been their responsibility, in part, as well as the Interdisciplinary team including nursing and therapy. RN B reported they had just placed a Roho air cushion underneath R807 prior to this interview when they learned of the concern. On 2/05/25 at approximately 4:00 p.m., the DON and Surveyor went to R807's room to interview R807. R807 was observed a second time with no wheelchair cushion underneath them. Both RN B and R807's nurse was present, and reported they were about to stand R807 and place the air wheelchair cushion underneath them, which was observed on their bed. R807 reported their left leg hurt, and showed this Surveyor and the nurses how their wheelchair fabric edge was cutting into the back of their left thigh. R807's left leg, which was fractured, was observed with marked edema (swelling) in a dependent position, with their heel on the ground, and a pressure contact point where the wheelchair fabric seat edge (which had no cushion) was cutting into their left thigh. No footrest was observed, such as an elevating footrest, or other apparatus to elevate and support R807's left leg to prevent their leg from hitting the wheelchair fabric. The DON reported they would follow-up with therapy and ensure R807 was positioned appropriately for comfort and safe positioning, per therapy recommendations. The concerns were shared with RN B and R807's nurse. On 2/05/25 at approximately 4:10 p.m., the DON was asked if they observed there was no wheelchair cushion underneath R807, given RN B reported they had placed a wheelchair cushion in R807's wheelchair during the earlier interview. The DON acknowledged the observation and reported they understood the concern. On 2/05/25 at 5:15 p.m., the Rehabilitation Director, Speech Language Pathologist (SLP) G, was asked about R807 not having a wheelchair cushion underneath them, given they had a pressure ulcer to their coccyx. RD G reported this would be a team effort, and confirmed R807 was receiving physical and occupational therapy. SLP G stated the expectation would be for a wheelchair cushion to be on the wheelchair for every resident, including R807. RD G reported they would be following up with the therapists who were treating R807. On 2/05/25 at 5:19 p.m., Physical Therapist (PT) H was asked about R807 having a pressure ulcer to their coccyx, and no wheelchair cushion. PT H stated this would be a typical standard of practice, for each wheelchair to have a wheelchair cushion, and especially given a resident with a pressure ulcer, as without a cushion there would be more pressure on the wound. When asked about a pressure ulcer on R807's coccyx, PT H stated a pressure ulcer on the coccyx was a high risk for breakdown without a cushion, as the coccyx is a concern as (R807 was) sitting on it, and there would be more pressure on the wound, verses a wound on a resident's sacrum (pelvis) or lumbar (back) region. PT H clarified the expectation would be every resident with a would be started with a pressure-relieving cushion in their wheelchair, and the wound care nurse would notify them if a more effective pressure-relieving cushion was needed. PT H explained a Roho brand air cushion would be used for a pressure ulcer, and this was a standard of practice for pressure ulcer care and healing, and clarified a gel cushion could be used until a Roho air cushion was obtained. PT H understood the concern with R807 not having a wheelchair cushion in their wheelchair, given their risk of skin breakdown, and already having a pressure ulcer. Review of the policy, Care Standards, dated 3/18/24, revealed, All residents shall receive necessary care and services to assist them in attaining or maintaining the highest practicable level of physical, mental, and psychosocial well-being in accordance with a comprehensive assessment and plan of care. Care is documented in the medical record according to state and/or federal regulations. Goals: To ensure all residents receive necessary care and services that are evidence-based and in accordance with accepted professional clinical standards of practice. The Director of Nursing ensures care and services that are evidence-based and in accordance with accepted professional clinical standards of practice .The Administrator and Health Information Manager or designee ensures that documentation of observations and evaluation of therapeutic interventions is filled in the appropriate section of the medical record. The Administrator, Health information manager, or designee ensures the medical record is maintained for each resident according to state and federal regulations. Review of the policy, Skin Management Program, revised 7/2024, revealed, It is the facility's policy that a resident does not develop pressure injury unless it is clearly unavoidable. Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed, and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Policy. 1. Upon admission/readmission, all residents are assessed for skin integrity by completing a baseline head to toe skin assessment documented in the EMR .Pain: All residents with skin impairments will be assessed accurately for pain to assure appropriate regiment is in place.

This citation relates to Intake #MI00149608. Based on interview and record review, the facility failed to provide dignified care to answer call lights timely for two Residents (R804, R806) of five residents reviewed for dignity. Findings include: On 2/05/25 at 12:08 p.m., R804 was observed seated in a manual wheelchair, dressed, with a full mechanical lift body sling underneath them. An air mattress was observed on their bed. R804 was asked if they had any pressure ulcers, and responded, Yes. R804 was frowning and appeared ready to cry. On 2/05/25 at 12:13 p.m., R804 reported they felt upset and angry as they were waiting too long for their call light to be answered. R804 explained they always waited at least 15 to 20 minutes and sometimes they waited for at least a half hour, including today. R804 stated, This morning I had an accident (incontinence episode). I am left wet and having to sit in it. This is happening all the time . R804 further clarified this occurred anytime during the day or night. R804 looked at their clock and was able to tell the time accurately. R804 was interviewable and oriented to themselves, place, situation, and time. On 2/05/25 at 12:15 p.m., the wound care nurse, Registered Nurse (RN) B, was asked if R804 had a pressure ulcer. RN B stated R804 had a Stage 4 pressure ulcer, and required the air mattress. On 2/05/25 at 1:15 p.m., the Nursing Home Administrator (NHA) was asked if there was any way to ascertain call light wait times for residents. The NHA responded there was no way to tell call light wait times, and no logs with the current call light system. The NHA conveyed they were exploring other options. On 2/05/25 at 2:15 p.m., R806 was observed in their hospital bed, wearing a gown, with an oxygen nasal canula in their nose. R806 was observed with a standard call light, with a small button to activate. On 2/05/25 at 2:17 p.m., R806 stated, Sometimes the (call) light wait is on forever. It is at least a half an hour wait. It was three hours .It happened during the night. I think it was yesterday .My diaper was full of poop. It burned for a while. I was yelling for help. I am blind. There was a lady across the hall who looked for the nurse .I tell time by how many shows are on the TV. I watched two shows; that's an hour, and then I watched another show. When asked how this made them feel, when their call light was not answered over an hour and a half, R806 responded, Let's just say it made me feel real inhuman .not real good . R806 was interviewable and oriented to themselves, their situation, and place. R806 had no vision accommodations, such as a talking watch, clock, or other alternate sensory aide observed in their room to assist them in telling time, which R806 confirmed. R806 reported it would be helpful to have assistance with telling the time, since their hearing and memory were fine. R806 knew the time of day was mid-afternoon by the television and mealtimes. On 2/05/25 at approximately 2:30 p.m., Certified Nurse Aide (CNA) C was asked about R804's report of waiting over 30 minutes for their call light to be answered earlier today (on 2/05/25). CNA C stated they were assigned a split room assignment on 2/05/25, which divided their residents and care responsibilities between two halls, the 200 and 300 hall. CNA C explained when they were caring for a resident down the 300 hall, they could not see some of the call lights on the 200 hall, and similarly when they worked down the 200 hall, they could not see some of the call lights on the 300 hall. CNA C reported they were giving a resident on the 300 hall a shower for a half hour earlier and could not see or answer their call lights during that time. CNA C stated, (R804) complained their call light was on, and I was in (another resident's room) giving them a shower .My hall partner (another CNA) said three (call) lights were going off (on the 200 hall), and explained they could not answer them. CNA C acknowledged they were aware of R804's call light concerns earlier, and they had apologized to them. CNA C acknowledged R804 had waited at least 30 minutes for their call light to be answered. CNA C stated, When staffing is really low .they (the residents) wait, and sometimes they will wait anywhere from 30 to 45 minutes .(R804) was really upset with me . On 2/05/25 at approximately 2:40 p.m., CNA C was asked about R806's reported longer call wait times, CNA C stated, (R806) was waiting about a half hour (on 2/05/25); it has been 30 to 40 minutes (at times). (R806) is having accidents too .We (the facility) need more staff, and I find myself apologizing (to residents). I am so sorry I was on the other side (another hall) .CNA C stated , (R806) was upset with them also with the longer call wait time (to have their brief changed). Review of the Electronic Medical Record (EMR) confirmed R804's and R806's rooms were both on the 200 hall. Review of the facility Floor Plan revealed many of the rooms on the 200 hall could not be visualized from the 300 hall. The same applied to many of the rooms on the 300 hall could not be visualized from the 200 hall. On 2/06/25 at approximately 11:15 a.m., the concerns were reviewed with the Director of Nursing (DON) regarding R804 and R806 reporting extended call light times, while CNA C was reportedly covering a split hall room assignment, and giving showers to residents, without assistance from another staff to cover their residents while in the shower room. The DON reported they understood the concerns, as some staff had been calling off, especially on the night shift. On 2/06/25 at approximately 11:45 a.m., the DON returned and reported R806 had told them they could not find their call light, and they were providing a larger touch pad call light for them, which would make it easier to find their call light. R806 had reported to this Surveyor they were waiting extended periods when pushing their call light, and had not mentioned they were without it, which was shared with the DON. The DON acknowledged the extended wait time would be of concern (at least an hour and a half, depending upon how long the TV shows were) and found R806 to be a credible reporter. The DON reported they had followed up with R804, who had expressed concerns to them regarding extended call light wait times, which were occurring during the day and night shifts, and they were following up on their concerns, and found them credible. Review of R804's Minimum Data Set (MDS) assessment, dated 9/30/24, showed R804 was admitted to the facility on [DATE], with diagnoses including stoke, depression, and kidney disease. The assessment showed R804 was dependent for toileting, bed mobility, and transfers, and had incontinence. The Brief Interview for Mental Status (BIMS) assessment showed a score of 13/15, which showed R804 was cognitively intact. The skin assessment showed R804 had a Stage 4 pressure ulcer. Review of R806's MDS assessment, dated 1/27/25, revealed R806 was admitted to the facility on [DATE], with diagnoses including pneumonia and malnutrition. The assessment showed R806 required maximal assistance with toileting, bed mobility, and transfers, and had incontinence. The BIMS assessment showed a score of 15/15, which showed R806 was cognitively intact. Review of the policy, Call Light Answering, dated 10/2021, revealed, To provide the staff with guidance on responding to resident's request and needs. Responsible: IDT (Interdisciplinary Team). Procedure: 1. Explain the call light to the new resident. 2. Demonstrate the use of the call light to the new patient or resident. 3. Assess the call light ability .5. When the patient or resident is in bed .provide the call light within easy reach of the patient or resident 7. Answer the patient's call light as soon as possible .11. If assistance is needed when you enter the room, summon help to the room. 12. After meeting the patient/resident's needs, turn off the call light . Review of the policy, Dignity, revised 4/2024, revealed, General: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Responsible Party: IDT. Policy. 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted with maintaining and enhancing his or her self-esteem and self-worth .11. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by: .b. Promptly responding to the resident's request for toileting assistance . Review of the policy, Staffing, reviewed 3/2024, revealed, General: To have appropriate numbers of staff available to meet the needs of the residents. Responsible party: Administrator, DON, Nursing Supervisor. Guideline: 1. Staffing is based on the regulatory body (State and Federal) formula for determining numbers and levels of staff. 2. Staffing is then increased based on the needs of the resident population. 3. A schedule is made on a monthly basis and reviewed on an ongoing basis. 4. Staffing is supplemented as needed by outside agencies. 5. Staff are required to review their schedule and discuss any problems regarding their schedule with their supervisor. 6. It is the staff members responsibly to be at work when they are scheduled.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program, resulting in the presence of spiders and drain (sewer) flies throughout the facility. This deficient practice had the potential to affect all residents in the facility. Findings include: On 10/21/24 at 11:00 AM, 3:00 PM and 10/22/24 at 8:45 AM and 1:30 PM, the 200 hallway was observed to have multiple areas of live spiders and webs on and around the hallway love seat, and there were multiple live drain flies observed on the walls, baseboards and more heavily at the base of a door that was locked and marked for employees only. There were multiple (eight) dead drain flies observed on the window ledge in the hallway across from room [ROOM NUMBER]. Review of the pest control logs provided by the facility revealed there were monthly visits with the most recent visit on 9/16/24 which identified only house mice pest type in the main building. The remaining main interior building identified No Activity Found. There was no documentation of any preventative perimeter maintenance provided. On 10/22/24 at 2:30 PM, an interview was conducted with the Maintenance Director (Staff 'A') who reported they began to work at the facility on 4/24/24. They also reported they had recently taken over as the Housekeeping Manager in August. When asked about their housekeeping staff, Staff 'A' reported they were short three housekeepers and have a few starting in the next week but they also needed to go through several weeks of orientation before they started work on the floor. They also indicated the housekeeping staff worked between both the facility's long term and assisted living. During an observation of the 100, 200, and 300 hallways with Staff 'A' the same observations of the live spiders, and drain flies were confirmed. When asked how those items were not identified despite observing housekeeping in the hallways on both 10/21/24 and 10/22/24, Staff 'A' reported they had no explanation for that. When asked if pest control was coming monthly, how were there so many live bugs/insects, Staff 'A' reported they didn't recall pest control providing routine inside preventative perimeter provisions. They further reported they were not aware of concerns reported by staff. Staff 'A' was asked to observe the locked room on the 200 hall that had many sewer flies. They reported that was one of their sewer rooms and upon opening the door, there were many live drain flies observed throughout the flooring and walls and on top of the floor drain. Staff 'A' reported the facility had recently installed sewer grinders to help since some residents were putting larger items down the toilets. On 10/22/24 at 4:13 PM, an interview was conducted with the Administrator who reported he began working at the facility about three weeks ago. When asked about the concerns with the facility's pest control, they reported they were aware of the concerns observed with Staff 'A' and would be addressed. According to the facility's policy titled, Pest Control dated 10/2024: .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .Pest control services are provided by [Name Redacted] .Maintenance services assist, when appropriate and necessary, in providing pest control services. According to the facility's Commercial Pest Control Agreement dated 1/21/2005: .[Name Redacted] will perform regularly scheduled service at the above service address for the control of the following pests .Service Frequency Monthly .General Pest Control, Exterior & Interior Service . 49083 On 10/22/24 at 2:35 PM, an observation of the common area Mortlake Terrace revealed multiple areas of spider webs with live spiders in the corners of the right side of room around base boards, and around the base of the French doors. The picture window was observed with a dead wasp, and two dead flies. The fire extinguisher case mounted by the common door near room [ROOM NUMBER] was observed with dead insects and webs with live spiders around base of door. The glass showcase near room [ROOM NUMBER] was observed with dead insects resembling beetles scattered throughout, and spider webs.

Based on interview the facility failed to implement an active water management plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP) resulting in the potential for water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among residents in the facility. Findings include: On 10/23/24 at 1:45 PM, the facility's Water Management binder was reviewed with the Nursing Home Administrator (NHA), Maintenance Director A, and Corporate Director of Facility Management G was present to provide oversite. When questioned what measures were taken to monitor the water, the facility acknowledged only a quarterly water temperature monitoring was performed. The process involved the water being brought up to 140 degrees from the boiler and then let it flow. When questioned what measures were taken for the facility and monitoring for Legionella, the facility stated chlorine residuals are not measured, and unable to provide documentation of water monitoring.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen, sub kitchen, and dining room counter resulting in the potential to affect all residents that consume food from the kitchen, sub kitchen, and dining room counter. Findings include: On 10/21/24 at 9:17 AM, during an initial tour of the kitchen, the following items were observed with Dietary Director I (DD I): 1. Dried Food debris on the bottom of multiple refrigerators. 2.Food debris and frozen vegetables (peas) on bottom of the freezers. 3. Food debris on top of the stove and dried splattering on side of the stove. 4. Moderate amounts of debris around entire kitchen floor. 5. Floor mats soiled with food debris and sticky when stepped onto mat. On 10/22/24 at 8:00 AM, an observation of the sub kitchen during breakfast service was conducted and revealed: 1. Back sink next to dishwashers revealed under the sink, a Styrofoam cup, red straw, condiment papers and a white brush. 2. Ice machine grate and basin revealed dried brown splattered matter. 3. Juice dispensing machine basin was observed with a brown colored liquid with a moderate amount of thick coagulated substance. 4. Two of Two enclosed serving carts were observed with dried food debris, and meal tickets on the inside. The exterior of both carts was observed with dried food, spill drips. 5. Floor mats were observed soiled with food debris and sticky when stepped on. 6. Stainless steel shelving above serving station moderate amounts of dried substance underneath shelving. On 10/22/24 at 8:50 AM, the main dining room kitchen counter surface and face of all cabinet's doors were observed with dried splattered matter. The left side of counter was observed as a self-serve coffee station. The right side of the service counter was observed with dirty dishes, cups, and delivery trays. A white square basin was observed on top of the counter filled with brown liquid. On 10/23/24 at 10:30 AM, DD I acknowledged the floors and freezers needed cleaning. When inquired about the counter in dining room, DD I acknowledged it was used as a coffee service station and shared the counter for dirty dish return after meal service, and the basin with the brown liquid contained unused liquids (milk, coffee, juices). When questioned if that was sanitary, DD I confirmed it was not, then was observed removing the liquid container and used dishes and moved onto and roll cart. According to the 2017 FDA (Food and Drug Administration) Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.

Based on observation, interview and record review, the facility failed to consistently ensure medications were properly secured and that expired medications were discarded. Findings include: On 10/21/2024 at 11:38 AM an oblong-shaped, white tablet was observed on the floor in a resident's room (visible upon entering the room, located near his bed). The tablet was observed to still be on the floor at 3:11 PM. At 4:39 PM. LPN J was shown the tablet and reported that they believed it was a Tylenol. LPN J reviewed the resident's medication record which showed the last documented dose was on 10/2/2024. The tablet had L484 imprinted on one side, which is consistent with a generic 500 mg (milligram) Tylenol. A review of the resident's orders revealed an order for Tylenol 325 mg. On 10/22/24 at 8:30 AM, the Director of Nursing (DON) was informed of the medication observed on the floor of R16's room. The DON reported that they had discussed this with the resident, who reported they had brought in the Extra Strength Tylenol. R16 had not been approved for self-administration. On 10/23/24 at 10:43 AM, the 300 hall medication cart was reviewed with LPN B. An unidentified round, white pill was observed to be loose in the second drawer. LPN B picked up the medication with an ungloved hand and placed the medication in a drug buster bottle. A second pill was observed loose in the third drawer. It was observed to be white, rectangular and scored with the number 555 on one side and TV1003 on the opposite side. These markings are consistent with Buspar 15mg. Also observed loose in the third drawer was a round, white pill with SPIT on one side and 25 on the opposite side. These markings are consistent with spironolactone 25mg. In the fourth drawer an albuterol inhaler was observed outside of the box and without a cap (covering the mouthpiece of the inhaler, that comes in contact with the resident's mouth). In the bottom drawer of the cart there was a dried red substance which appeared to be from the bulk bottle of an oral protein supplement. LPN B was unsure whose responsibility it was to check and clean the medication carts. On 10/23/24 at approximately 10:55 AM LPN B informed Assistant director of nursing (ADON) C of loose medications and inquired how to handle the albuterol inhaler that was found outside of its box and without a cap. At that time she was queried on who is responsible for ensuring the medication carts are clean, organized and free of deficiencies. ADON C reported that each nurse assigned to the cart is responsible for their cart being clean/organized and that each nurse manager is assigned to a cart and should perform a medication cart audit. On 10/23/24 at 11:18 AM the facility's main medication room was reviewed with LPN B. A pack of albuterol nebulizer ampules were observed in a drawer which contained blood pressure cuffs. LPN B acknowledged that the medication should not be in that drawer and placed the medication in the bin of medications to be returned to pharmacy. On 10/23/24 at 11:28 AM, the backup medication room was reviewed with RN D. On the floor was a large, gray, plastic tote, that appeared to be locked with a pad lock, however the lock was locked without securing the box closed. Observed inside the box were several plastic bags containing various intravenous solutions. A large plastic baggie of sterile water vials was observed with an expiration date of August 2024 (approximately 2 months past their expiration). RN D reported that pharmacy checks for expired medications, as well as floor staff. Review of the facility's policy titled Medication Use, Medication Storage, (no revised date/updated date was included on the policy) documented in part Medications will be stored in a manner that maintains the integrity of the product ensures the safety of the residents and is in accordance with Department of health guidelines .all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel .Medications will be stored in an orderly, organized manner in a clean area .Medications will be stored in the original, labeled containers received from the pharmacy .Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy . 49083 R32, R46 A clinical record review revealed R32 was admitted on [DATE] for skilled nursing and rehabilitation related to a fall at home and required left femoral hip surgery. Medical history included a stroke resulting in right sided weakness, hypertension, and COPD (Chronic Obstructive Pulmonary Disease). The Brief Interview of Mental Status (BIMS) score assessed on 10/2/24 was 5/10 indicating R32 had moderate cognitive impairment. On 10/21/24 at 10:13 AM, during initial introduction, R32 was observed lying in bed with their bedside tray table across their front. A Ventolin Inhaler (a medication that relaxes airway muscles for COPD) was identified in reach of the resident. On 10/21/24 at 10:40 AM, the family of R32 was visiting with the resident and interviewed. While conversing with the resident, the Ventolin medication remained at the bedside. On 10/21/24 at 11:01 AM, during initial introductions, R46 was observed in their bed watching television, and a red and white colored inhaler (medication not identified) on their right side bedstand table. Record review revealed there were no orders for an inhaler. On 10/22/24 at 09:25 AM, R46 was observed up the chair. The inhaler that was previously observed was no longer in sight. R46 acknowledged they take vitamin supplments and a green bottlle labled Spirulina (an antioxidant from algae) was on the table in front of them. Record review revealed there was an order to self administer, however there were no orders written specific for an inhaler. On 10/22/24 at 9:31 AM, R32 was observed asleep and the Ventolin medication was observed on the counter under the residents television. A white round pill was observed lying on the floor next to the residents left side. On 10/22/24 at 10:12 AM, R32's assigned Registered Nurse (RN) F was in the room and questioned about the Ventolin inhaler. RN K confirmed they did not administer the inhaler, was unclear why it was at the bedside and that R32 did not have orders to self-administer. RN K was going to leave the medication in the room after commenting it was out of reach of the resident, then immediately stated . I better take it . and then was observed removing the medication from the counter. RN K was questioned about the white round pill, picked it up off the floor with their bare hand and commented there was no identifiers on it. RN K remarked that she observed all medications were administered that morning and the pill must have been given by another Nurse. On 10/23/24 at10:20 AM, The Director of Nursing (DON) acknowledged medications should not be left at the bedside and residents must have an order and assessment to self-admiinter medications.

Based on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment, affecting multiple residents throughout the facility. Findings include: On 10/21/24 at 11:00 AM, 3:00 PM and 10/22/24 at 8:45 AM and 1:30 PM, the 200 hallway was observed to have multiple areas of live spiders and webs on and around the hallway love seat, and there were multiple live sewer flies observed on the walls, baseboards and more heavily at the base of a door that was locked and marked for employees only. There were multiple (eight) dead sewer flies observed on the window ledge in the hallway across from room [ROOM NUMBER]. On 10/22/24 at 2:30 PM, an interview was conducted with the Maintenance Director (Staff 'A') who reported they began to work at the facility on 4/24/24. They also reported they had recently taken over as the Housekeeping Manager in August. When asked about their housekeeping staff, Staff 'A' reported they were short three housekeepers and have a few starting in the next week but they also needed to go through several weeks of orientation before they started work on the floor. They also indicated the housekeeping staff worked between both the facility's long term and assisted living. During an observation of the 100, 200, and 300 hallways with Staff 'A' the same observations of the live spiders, and sewer flies were confirmed. When asked how those items were not identified despite observing housekeeping in the hallways on both 10/21/24 and 10/22/24, Staff 'A' reported they had no explanation for that. Upon observation of the 300 hall, Staff 'A' confirmed the loveseat was heavily soiled with darker colored stains and debris and they reported that should've been taken care of. The walls and baseboards were also observed to have several areas soiled with what appeared to be dried food and liquid debris. On 10/22/24 at 4:13 PM, an interview was conducted with the Administrator who reported he began working at the facility about three weeks ago. When asked about the concerns with the environment, they reported they were aware of the concerns observed with Staff 'A' and would be addressed.

Based on interview and record review, the facility failed to complete an annual OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation for one resident (R27) of one resident reviewed for PASARR (Preadmission Screen and Resident Review). Findings include: Clinical record review revealed R27 was admitted to the facility on [DATE] with heart disease, hypertension, and stroke. Psychiatric history included anxiety, depression and bipolar disorder. A Brief Interview for Mental Status (BIMS) evaluated on 8/17/24 score totaled 15/15 indicating R27 was cognitively intact. On 10/21/24 at 1:13 PM, a record review of the available PASSAR dated 11/11/23 revealed R27 was a Thirty Day-Hospital Exemption Discharge. There was no evidence a Level II evaluation was completed (given the resident's recent mental status exam which indicated intact cognition) R27 would likely require a Level II evaluation for a psychiatric history anxiety, depression and bipolar disorder. On 10/22/24 at 3:15 PM, an Interview with the Facility Transition Care Coordinator A acknowledged a Level II was not completed for R27. Facility Transition Care Coordinator A revealed the OBRA Coordinator was scheduled to assess R27 on Monday 10/28/24 but now that the State Agency (SA) was on site, the evaluation was expedited, and the Facility was in the process of collecting the required documentation for the evaluation. Review of the facilities Policy title; PASARR Policy No: 5011 Dated 5.2024, documented: .If the resident needs nursing care beyond the thirty (30) days permitted by a Hospital Exempted Discharge ([NAME]), the nursing facility must notify the local Community Mental Health Services Program (CMHSP) .

Based on observation, interview and record review, the facility failed to obtain physician orders for one resident (R32) of one reviewed for oxygen use, and not monitoring oxygen delivery equipment for proper fit, resulting in the potential for respiratory distress, and undetected respiratory status changes. Findings include: A clinical record review revealed R32 was admitted on [DATE] for skilled nursing and rehabilitation related to a fall at home and required left femoral hip surgery. Diagnoses included a stroke resulting in right sided weakness, hypertension, and COPD (Chronic Obstructive Pulmonary Disease). The Brief Interview of Mental Status (BIMS) score assessment on 10/2/24 was 5/10 indicating R32 had moderate cognitive impairment. On 10/21/24 at 10:13 AM, during initial introduction, R32 was observed lying in bed wearing a nasal cannula (medical device that delivers oxygen into the nostrils) incorrectly, observed only right nares receiving oxygen dispensing two liters of oxygen. On 10/21/24 at 10:40 AM, R32 was visiting with family and the nasal cannula remained only administering oxygen to the right nares. On 10/22/24 at 9:31 AM, R32 was observed asleep with the nasal cannula incorrectly placed into the nose. A clinical record review revealed there were no orders for R32 to receive oxygen. Further record review revealed no documentation in the Careplan for oxygen administration or monitoring. On 10/22/24 at 10:12 AM, R32's assigned Registered Nurse (RN) F was in the room and confirmed the nasal cannula was not placed correctly on R32 and then observed replacing the tubing so both nares were receiving oxygen and informing R32 the placement was incorrect. RN F was questioned if there were orders for R32 to be provided oxygen. RN F reviewed the electronic medical record and confirmed there were no orders from the Physician and indicated they would contact the Physician to obtain orders. On 10/22/24 at 10:54 AM, a telephone interview with Respiratory Therapist H confirmed orders should be written for R32 to receive oxygen. Therapist H commented recommendations are made to the Physician after their assessment and R32 should have orders for oxygen. On 10/23/24 at 10:20 AM, the Director of Nursing (DON) acknowledged orders from the physician were not obtained for oxygen administration and requires an order.

This citation pertains to intakes: MI00144321 and MI00144496. Based on interview and record review, the facility failed to notify the Licensed Practitioner and Resident Representative regarding an unwitnessed fall for one (R903) of two residents reviewed for accidents. Findings include: Review of complaints reported to the State Agency alleged R903 was found on the floor in the resident's room on 4/23/24 at 5:45 PM and the resident's representative was not informed of the fall, change in condition, and the need for additional pain medication related to right hip pain until 4/25/24 at 10:30 PM as the facility was preparing the resident for transfer to the emergency department. According to the facility's policy titled, Falls Management dated 3/2024: .If a fall occurs the following actions will be taken .RN/LPN (Registered Nurse/Licensed Practical Nurse) at time of fall occurrence .Notify the Licensed Practitioner and the Resident's Representative . Review of the clinical record revealed R903 was admitted into the facility on [DATE] with diagnoses that included pancreatic cancer and was receiving hospice services. According to the Minimum Data Set (MDS) assessment dated [DATE], R903 had moderate cognitive impairment (scored 11/15 on the Brief Interview for Mental Status exam (BIMS); had a history of falls and required partial to moderate assistance with transfers. Further review of the clinical record revealed there was no documentation following the resident's fall on 4/23/24 at 5:45 PM that the physician, resident representative, or nurse manager had been notified of the fall or complaint of hip pain at a level of 10 (with 10 being the highest pain) and need for administration of morphine. On 5/21/24 at 12:57 PM, a phone interview was conducted with Certified Nurse Assistant (CNA D). When asked to recall the events regarding R903's fall, CNA D reported on 5/23/24 around 5:45 PM, while performing last rounds, they entered R903's room and did not immediately see the resident and they thought R903 was out of the room. CNA D reported they found R903 on the floor between the bed and the wall and then notified Register Nurse (RN B). On 5/21/24 at 12:40 PM, an interview was conducted with RN B who confirmed while performing last rounds prior to shift change on 4/23/24, R903 was found lying on the floor. R903 was transferred back to bed with assistance from CNA D using a blanket. When asked who was notified after R903 was found lying on the floor, RN B confirmed no nurse manager, no physician, no family representative was made aware of the incident. Furthermore, RN B reported the oncoming shift nurse (RN E) was not informed of R903 being found on the floor just prior to shift change. When asked why not, RN B reported they were handling two admissions and reported to the other nurse on those residents. RN B stated when a resident is found on the ground and there is no obvious injury, and vitals are stable, it did not warrant an escalation of notification. On 5/21/24 at 1:40 PM, An interview was conducted with the Director of Nursing (DON). When asked when they were notified R903 was found on the floor, the DON reported they were not notified until 4/26/24 via a text message from the afternoon Unit Manager. The DON acknowledged and reported RN B should have notified the nurse manager, physician, and residents' representative.

This citation pertains to intakes: MI00144321 and MI00144496 Based on interview and record review, the facility failed to ensure timely and adequate assessment and investigation into an unwitnessed fall for one resident (R903)of two residents reviewed for falls, resulting in a delay of post-fall policy practices which included increased monitoring, initiate an investigation which delayed identification of an acute hip fracture resulting in transfer to the hospital for further evaluation and escalation of care, and increased pain. Findings include: Review of the complaints reported to the State Agency (SA) alleged R903 was found on the floor in the resident's room on 4/23/24 at 5:45 PM and the resident's representative was not informed of the fall, change in condition, and the need for additional pain medication related to right hip pain until 4/25/24 at 10:30 PM as the facility was preparing for to transfer the resident to the emergency department. Review of the clinical record revealed R903 was admitted into the facility on [DATE] with diagnoses that included pancreatic cancer and was receiving hospice services. According to the Minimum Data Set (MDS) assessment dated [DATE], R903 had moderate cognitive impairment (scored 11/15 on the Brief Interview for Mental Status exam (BIMS); had a history of falls and required partial to moderate assistance with transfers. An interview with Registered Nurse (RN B) acknowledged that on 4/23/24 at 5:45, R903 was found on the floor in the resident's room. RN B denied initiating an incident report and confirmed the fall was not reported to the physician, nurse manger, personal representative or the assigned RN (RN C) for the next shift. On 5/21/24 at 12:45 PM, a telephone interview with RN C confirmed Nurse B did not report R903 was found on the floor prior to start of the next shift. The Medication Administration Record (MAR) revealed R903 was medicated with morphine on 4/23/24 at 7:49 PM for severe hip pain, not relieved by relaxation. R903 rated the pain at 10 out of 10 (10 being the highest pain score). When inquired if severe pain in the hip rated 10/10 indicated a change in condition and should the physician have been notified, RN C confirmed R903 previous pain assessment was not reviewed. RN C replied the physician was not contacted, and medicated with the morphine because there was an order already in place. The physician and family representative were not informed. Review of the facilities policy title; Pain Management dated 5/2024 documented: .Licensed Nursing may notify the Health Care Provider of any new development of pain, change in pain, change in condition that could potentially cause pain . On 4/24/24 at 12:47 documentation revealed R903 .was having some right hip pain with movement, thisam <sic> . On 4/25/24 at 8:02 AM, RN A administered morphine for moderate/severe pain, c/o (complained of) right hip pain. Further clinical record review revealed RN A on 4/25/24 at 12:08, documented R903 was having moderate/severe pain, moaning, guarding with movement, Dr (Doctor) made aware. A STAT X-ray was ordered. On 4/25/24 at 10:46 PM, an x-ray revealed right hip femoral fracture. The facility transferred R903 to the hospital for further evaluation and escalation of care. On 5/21/24 at 1:40 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed the Post Fall IDT (Interdisciplinary Team) was not conducted until 4/29/24. A record review of R903's Care Plan initiated on 3/5/24 was not amended reflecting the fall and did not establish new Goals or Interventions. The care plan was not revised until 4/29/24, Reason: Discharge. The DON further revealed that the responsible party was not notified R903 was found on the floor until 4/26/24 via a text message from the afternoon Unit Manager. The DON acknowledged a fall investigation should've been initiated and the care plan should've been updated on 4/23/24 when R903 was found on the floor. The DON acknowledged RN B should have notified the nurse manager, physician, and residents' representative. Review of the facility's policy titled; Falls Management dated 3/2024 documented: .If a fall occurs the following actions will be taken .RN/LPN at time of fall occurrence .Evaluate the resident including initial neurological check, pain, ROM (range of motion), skin, joints, extremities vital signs .Evaluate the resident each shift for 72 hours .Notify the Licensed Practitioner and the Resident's Representative .Complete an incident report in risk management. This report includes the circumstances surrounding the fall, devices in use, full body observation for injury, pain, range of motion, and neuro checks as needed .The nurse at the time of fall with [sic] review and update the resident's fall plan of care with a new intervention .

This citation pertains to intake # MI000142466. Based on record review and interviews, the facility failed to identify and monitor a change in condition for one resident (R610) resulting in a delay in a transfer to the hospital for unresponsiveness. Findings include: On 3/11/24 a record review revealed that R610 had been admitted to the facility on [DATE] with the diagnosis of muscle weakness, pneumonia and a dislocation of internal left hip. R610 was admitted to the facility to receive therapy because the resident had fallen and had a broken hip. According to progress notes dated for 11/10/23 at 1:54 AM Nurse went in to give guest scheduled pain pill and guest was unresponsive even to sternal rub. Guest VS (vital signs) were taken BP (blood pressure) was 124/74. Guest was having constricting movements in the bed such as curling toes and fingers but would not respond to verbal cues. Nurse was unable to obtain pulse ox reading on 25L (liters) o2 (oxygen) after 20 minutes guest breathing appeared shallow. EMS (Emergency Medical Services) was called . On 3/11/24 at 10:00AM the Assistant director of nursing(ADON) was interviewed and asked what was the facilities policy on change in condition, ADON replied, the floor nurse will notify the Nurse Practitioner or the Physicians Assistant. The ADON was asked what would be the steps for someone placed on 25L of oxygen and what is the time frame that you are waiting in order to send them out, the ADON replied, I would call 911 immediately and get them sent out, then notify the family and medical doctor of the transfer. ADON was then asked what caused the delay in care for R610, ADON stated she would have to gather information to see if she could find out why he was not sent out immediately. There was no additional information provided by the exit of the survey.

This citation pertains to Intake #MI00141671 Based on observation, interview and record review the facility failed to ensure continuous nursing professional standards were practiced for signing documents and for one (R704) of two resident reviewed for dignity/respect. Finding include: Complaints were filed with the State Agency (SA) that alleged the Director of Nursing (DON) was forging nursing signatures on the controlled substance forms and that nursing staff were not treating residents in a dignified manner. On 1/29/24 at approximately 1:20 PM, an observation of the narcotic sign-off sheet located on the medication cart (100/200 hall) was conducted. Nurse M was in charge of the cart. Nurse M reported that they had worked at the facility for approximately a year and a half. They indicated that they generally worked the day shift. During the interview, Nurse M was asked if anyone, including the DON, had ever forged their signature. Nurse M reported yes and explained that the DON signed their name on the narcotic sheet and noted that they were not the only nurse involved. On 1/29/24 at approximately 1:35 PM, the DON was interviewed and asked whether they had every signed for another nurse on the narcotic sheets. The DON reported that they had. They stated that following a Survey that took place in November 2023 they helped develop a plan of correction to ensure that all medication carts were cleaned, medication was labeled and dated as well as proper storage for insulin. The DON explained that nurses on each shift complete a sheet titled, Controlled Substance Shift Inventory. The sheet had nurses signing the total number of controlled substance prescription at the start and end of each shift. The DON reported that they decided to create a new form that had a section on the Controlled Substance Inventory form that read no unlabeled meds? Unopened Insulins in fridge? Cart is clean. The DON then reviewed the original forms signed by nursing staff and in lieu of having the nurses resign the new sheet, they (the DON) signed the names of each nurse without notice or approval. The DON reported that they signed other nurse's names for approximately 3-4 days (12/11/23-12/14/23), until it was identified that they should not be signing another nurse's signature on any documents. On 1/29/24 at approximately 2:12 PM an interview was conducted with the Administrator. When asked if they were aware that the DON was signing other nurse's signatures on the new Controlled Substance Shift Sheet, the Administrator reported that they were aware and noted that the DON should never had signed another nurse's name and received training on nursing ethics. R704 On 1/29/24 at approximately 1:00 PM, R704 was observed lying in bed. The resident had family visiting. R704 was alert and able to answer all questions asked. When asked about care provided in the facility, both the resident and a family member reported they had been having some concerns with the care provided. The resident noted that when they were first admitted to the facility, following a fall with injury, they were not initially provided with a wheelchair, walker and gate belt. They noted that their biggest concern was when an aide was trying to transfer them, they pulled them up by holding their pants/underpants and it gave them a wedgie that really hurt. R704's family member reported that R704's concerns were reported to the facility. A review of R704's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: fracture of right tibia, difficulty walking and diabetic neuropathy. A review of the resident's Minimum Data Set (MDS) noted the resident was cognitively intact. The resident's careplan noted: Focus: I need help with my ADLs (activities of daily living) .Interventions: .Transfers I need assistance of 1/2 .because limited mobility that for transfers gait belt may assist with my transfers (1/14/24) . The facility was asked to provide any grievances pertaining to R704. A document titled, Administrative Statement Investigation Analysis (1/19/24) was provided and documented, in part: .R704 .made a statement of the following complaints .No equipment to assist her to get around upon admission .staff did not have proper equipment and were pulling on waist of pants to assist with transfer .Investigation: Staff did not have proper equipment and were pulling on waist of pants to assist with transfer .Staff interviews were completed and noted the lack of gait belt use for this transfer. Education was provided to all nursing staff members .Analysis: It was found that some staff did not know where gait belts were stored .Plan of Action: .the facility has initiated an in-service for all staff using gait belts for all assisted transfers . The document was signed by the DON, Administrator and the Director of Customer Experience (Staff N). *It should be noted that there was no specific staff member(s) identified in the document. On 1/29/24 at approximately 3:20 PM, an interview was conducted with the Administrator regarding R704 concerns. The Administrator reported that they were aware that R704 reported concerns about improper transfers and noted that Staff N was responsible for the investigation. On 1/29/24 at approximately 3:50 PM an interview was conducted with Staff N. Staff N was asked about the concerns reported by R704 and reported that they found that that staff were not using a gait belt when transferring the resident. They were not able to provide the names of the staff that did not use a gait belt and lifted the resident by their pants/underpants. Staff N stated that just re-educated all staff on utilizing proper/professional transfer techniques.

Based on interview and record review, the facility failed to report bilateral (B/L) facial bruising and right lower extremity (RLE) pain to the State Agency (SA) for one (R701) of one resident reviewed for injuries of unknown origin. Findings include: A complaint was filed with the SA on 1/22/24 that alleged in part, .On the morning of 1/11/24 . it was noted substantial amount of bruising on left side of face, large knot on top of (R701's) head, bruising on right side starting as well . Resident also complained of severe right leg pain along with new onset chest pain . nothing was reported regarding incident that happened sometime between the evening of the 10th and the 11th . Review of the closed record revealed R701 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: chronic obstructive pulmonary disease, atrial fibrillation and heart failure. According to the Minimum Data Set (MDS) assessment dated [DATE], R701 had moderately impaired cognition, and was dependent on staff for activities of daily living (ADL's). On 1/29/24 at 8:53 AM, the Administrator was interviewed and asked if there was a Facility Reported Incident (FRI) for R701. The Administrator explained she had not reported anything regarding R701 to the SA. The Administrator was asked about R701's facial bruising and RLE pain on 1/11/24. The Administrator explained they had done an investigation, but had not reported the incident to the SA. Review of the provided investigation revealed an Administrative Statement Investigative Analysis that read in part, .On the morning of 1/11/24 . (R701) had bruising to the L (left) temple and R (right) temple with unknown origin . (R701) was asked if she is having pain. She stated that she was experiencing headache and had pain all over but mainly to the right side of her body at that time . All x-rays (R knee, R tib/fib {tibia/fibula - lower leg}, R pelvis, and chest) were negative . Review of a Wound Assessment Details Report dated 1/11/24 at 11:48 AM by Registered Nurse (RN) H, who was the Wound Care Nurse, revealed, .Wound: L scalp/temple . Type: Trauma . Classification: Bruise (not DTI)(deep tissue injury) . Size (cm)(centimeters): 4.00 x 3.00 x 0.00 (L x W x D)(length x width x depth) . new bruise noted to L temple . c/o (complaining of) 'bad' HA (headache) 8/10 to surrounding bruised area, across forehead and to posterior scalp . Review of an additional Wound Assessment Details Report dated 1/11/24 at 11:51 AM by RN H revealed, .Wound R scalp/temple . Type: Trauma . Classification: Bruise (not DTI) . Size (cm): 3.00 x 2.00 x 0.00 (L x W x D) . new bruise noted to R temple . On 1/29/24 at approximately 4:00 PM, the Administrator was asked why R701's bruising to the B/L temple, that was documented on by the Wound Care Nurse, and pain to the RLE, that x-rays were ordered on, was not reported to the SA. The Administrator agreed suspicious injuries of unknown origin should be reported to the SA. Review of a facility policy titled, Reporting of Incidents, Investigations and Facility Response to Investigations revised 7/2017 read in part, .Reasonable suspicions of a crime against a guest, possible incidents of abuse, neglect, misappropriation, exploitation, or injuries of unknown sources are reported to the individual's supervisor timely. a) Allegations involving alleged abuse must be reported immediately but not more than 2 hours after the allegations is made . A suspicious injury of unknown origin is one that is not observed by any person or explained by the guest AND: 1) Because of the extent or location of the injury . the injury is suspicious OR 2) Because of the number of injuries observed at one particular point in time or the incident of injuries over time, the injury is suspicious .

This citation pertains to intake(s): MI 315. Based on observation, interview and record review, the facility failed to prevent a cognitively impaired resident identified as an elopement risk from exiting the facility unsupervised for one (R703) of two residents reviewed for elopement, resulting in an Immediate Jeopardy when R703 exited the facility through an alarmed door that was deactivated by staff. This staff and another staff member both visualized R703 outside and failed to identify and initiate the facility's elopement protocol. The resident was found near a local gas station approximately half a mile from the facility, near a busy four lane street approximately 14 minutes after the alarm was deactivated by staff. Additional environmental risks included surrounding ponds and a railroad. Due to the deficient practice, R703 and additional residents at risk for elopement had the increased likelihood for serious harm, serious injury, and/or death. Findings include: The Immediate Jeopardy started on 6/24/20. The Immediate Jeopardy was identified on 1/13/21. The Administrator was notified of the Immediate Jeopardy on 1/13/21 at 12:25 PM, and a plan to remove the immediacy was requested. Although the immediacy was removed on 7/1/20, the facility remained out of compliance at the scope of isolated and a severity of potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has been verified by the State Agency on 1/14/21. Review of a facility policy titled, Risk for Actual Missing Person/Elopement dated Revised: 6/2020 documented, in part, .It is the policy of this facility that it provides an environment that reduces the likelihood of elopement of a guest .If the missing guest policy had <sic> been activated in response to an emergency door alarm, the first staff member to respond will not shut off the alarm and will immediately search on the outside of the facility and the perimeter of the building will begin at the point of exit . Review of the closed clinical record revealed R703 was admitted into the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R703 had moderately impaired cognition and required supervision with ambulation. Review of the admission documentation provided to the facility upon R703's admission from the facility R703 transferred from included a physician ordered elopement securement device that had been used for R703 while at their facility since 9/19/19. Review of R703's elopement risk assessments included an initial assessment on 6/5/20 which identified a score of 4 which indicated moderate risk. A second assessment on 6/24/20 (following this elopement incident) identified a score of 7 which indicated high risk. Review of the social service assessment dated [DATE] revealed no identification of previous elopement/wandering risk. Review of a care plan initiated 6/12/20 and revised 6/27/20 documented, in part, I am an elopement risk/wanderer AEB (As Evidenced By) exit seeking and verbalizing desire to leave the facility. I scored high on the elopement risk assessment 6/24/2020. Review of a facility reported incident (FRI) which was dated as having occurred 6/24/20 at approximately 1:07 PM, and a facility investigation report completed 7/1/20 documented, in part: .As part of the admission process an elopement risk assessment was completed which (R703) scored a 4, indicating a moderate risk of attempting to leave the facility without staff oversight .On the day of 06/24/2020 housekeeper (Staff 'O') heard the alarm go off on the emergency exit door outside of (room # redacted) at approximately 1:08 PM. Housekeeper (Staff 'O') stated she deactivated the alarm, walked out the door and saw a man walking with a suitcase towards the parking lot. (Staff 'O') stated she thought it was the husband of the discharge in (room # redacted) carrying his wife's suitcase to the car. On the day of 6/24/2020, Maintenance personnel (Staff 'P') reports seeing a well dressed man pulling a suitcase and walking towards the parking lot at approximately 1:09 PM. (Staff 'P') reports he thought it was the husband of the woman in (room # redacted) that was discharging. (Staff 'P') reports asking the man if he needed help with his luggage but did not receive a response. On the day of 6/24/2020 Nurse 'T' reports she was notified at approximately 1:00 pm that the resident was not in his room. Nurse 'T' reports searching the resident's room, interviewing the roommate, paging Dr Gone overhead and on walkie talkies and notifying (Director of Nursing/DON). Nurse 'T' reports she was notified that the resident had been found but was unsure of how much time had elapsed. On the day of 6/24/2020 Housekeeping Supervisor (Staff 'J') reported hearing the page for Dr. Gone while she was at the nursing station. Staff 'J' reports giving directions to her staff to start searching hallways. Staff 'J' reports upon giving direction to her staff, Staff 'O' the housekeeper, reported seeing a man a short time earlier with suitcases, whom she thought was (room # redacted) husband, walking towards the parking lot. Staff 'J' reports then heading to the receiving area to search the nearby property. On the day of 6/24/2020 medical records (Staff 'R') reported that she and (Staff 'S') in HR (Human Resources) were instructed to take a vehicle to search for resident (R703). Staff 'R' reported that she and Staff 'S' saw R703 walking on the sidewalk near the (name of local grocery store) gas station, approximately 350 yards from the facility. Staff 'R' reported R703 was not cooperating and did not want to return to the facility. Staff 'R' reports calling (name of DON) to report resident had been located. Staff 'R' reports crossing the street safely with R703 to wait for help .Staff 'R' reports that that the guardian and local police arrived and assisted R703 safely back to the building. (Using an online map application's distance measuring tool, this distance was over 350 yards.) On the day of 6/24/2020 (name of DON) reports she was notified by nurse (Nurse 'T') that Dr. Gone had been initiated and R703 is believed to have left the building. (DON) instructed staff to start outside search in the apartment complex and out towards (name of busy four lane street). (DON) notified General Manager (Staff 'U'). (DON) circled the building searching for R703. (DON) was contacted by Staff 'R' and reported R703 had been located and she was with R703 near the (name of local grocery store) gas station. (DON) reports at approximately 1:25 PM the staff was informed that the resident R703 was located and Dr Gone had been canceled. (DON) reports Staff 'R' reported R703 appeared agitated and did not wish to return to the facility. (DON) informed Staff 'R' that she would call the local police to assist in helping to return resident R703 to the facility. New elopement assessment was completed, and the guest's plan of care was updated to reflect immediate implementation of one-on-one supervision . The temperature outside was approximately 79 degrees, sunny, with no precipitation. Resident was wearing a dark coat, khakis, and shoes at the time he exited the facility. R703 was assessed for injury, upon return, including a skin assessment and vital signs, no injury was observed .R703 was placed on one-to-one observation immediately until further notice. ANALYSIS .R703 did exit the facility through the 300-hall emergency exit door without authorization. The guest was unsupervised for approximately 14 minutes after he exited the building. R703 exited the building at approximately 1:08 PM, was last seen by staff at 1:09 PM and was located by staff at 1:23 PM . CONCLUSION .Given the investigation and response to this incident, an opportunity for improvement in our procedure was identified and our policy was updated. Update to the policy includes questioning of any person seen outside the facility regarding what door they exited from and the purpose of their visit. All staff have been educated on the updated elopement policy and procedure .PLAN OF ACTION: 1. (R703) was immediately placed on one-to-one supervision and his plan of care was updated. 2. Elopement risk information books were added in Housekeeping and Maintenance Departments. 3. Intermittent Elopement drills completed on 6/25/2020 and 6/26/2020 and will continue weekly until the QAPI committee determines compliance. 4. All staff educated on the updated elopement policy and procedure. 5. Maintenance check of all exit doors to ensure alarms are in working order. 6. Emergency Exit only, Alarm Will Sound signs posted at exits. 7. Weekly audits performed to ensure appropriate plan of care in place on all guests scoring moderate or high risk on elopement risk assessments. On 1/12/21 at 10:41 AM, Staff 'O' was attempted to be contacted for interview. A message was left but a response was not received by the end of the survey. On 1/12/21 at 12:30 PM, the DON was queried about R703's elopement incident on 6/24/20 and reported similar details as to the documentation in the facility's investigation. The DON was queried about whether the facility had any additional elopement alarm systems in place such as the one identified at the facility R703 had transferred from and indicated that they did not, but that all of the exit doors were alarmed. On 1/12/21 at 1:35 PM, the Administrator was queried about R703's elopement incident and reported she was not working at the facility at the time of the elopement incident. When asked about the ability to review video surveillance as multiple video cameras were observed throughout the facility, the Administrator reported the facility's server was currently down and there was no way to access any previous video footage for review. The Administrator was queried to see if possibly the previous Administrator may have kept any additional video files, however there was no further information provided by the end of the survey. On 1/12/21 at 2:05 PM, an interview was conducted with the Transitional Care Coordinator (Staff 'K') who reported was not a licensed social worker. When queried about R703's elopement risk upon admission and lack of identification on the social service assessment completed by Staff 'K' on 6/8/20, Staff 'K' was unable to offer an explanation as to why that had not been identified as part of the resident's behavioral assessment. When asked who was responsible for elopement risk assessment, Staff 'K' reported that was completed by the nursing staff. On 1/13/21 at 2:22 PM, Staff 'J' was queried about the incident with R703 on 6/24/20 and reported one of her housekeepers (Staff 'O') had turned off the door alarm that had been activated and further reported there had been a lot of discharges that day, and that Staff 'O' had thought he was a visitor. Staff 'J' was queried about Staff 'P's' observation and lack of identification of R703 as an elopement risk and reported Staff 'P' no longer worked at the facility. Staff 'J' was requested to observe the facility's exit doors which included the door R703 exited from. Observation of the area R703 exited from revealed the exit door led to a small courtyard which had a sidewalk that went to one of the parking lots surrounding the facility, which then led to a long driveway which led directly to the busy four lane street. The facility submitted the following accepted plan of removal dated 1/13/21: 1. R703 returned to the facility without evidence of injury or harm and was provided one on one supervision. A new elopement assessment for R703 was performed which increased R703's risk level from moderate risk to high risk. R703 care plan was updated on June 24, 2020. R703 no longer resides in the facility. 2. The facility policy and procedure was updated on June 24, 2020 to contain specific instructions to stop all individuals outside the facility to offer assistance even if believed to be a visitor. 3. A duplicate book was prepared for the housekeeping and maintenance department reference. Maintenance checks were conducted of all exit doors to ensure alarms are in working order which all alarms were functional. 4. Staff were educated on the updated Elopement Policy and Procedure starting June 24, 2020. 5. Facility alleges immediacy removal on July 1, 2020 and asserts the likelihood that serious harm to any resident no longer exists. The facility provided documentation that showed they corrected the deficient practice and showed sustained compliance since July 1, 2020.

This citation includes intake MI 948. Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 (Resident #25) and properly transfer 1 (Resident #225) of 3 reviewed for falls and transfers, from a total of 20, resulting in Resident #25 sustaining a fall with fracture and Resident #225 being improperly transferred and the potential for injury. Findings include: Resident #25 Review of the Admission Record and Minimum Data Set ((MDS) dated [DATE], revealed Resident #25 was an [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #25 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), transferred with extensive assistance of 2 staff members, and walked with limited assistance of 1 staff member. The MDS revealed Resident #25 had a history of [REDACTED]. Review of the Fall Risk Evaluation dated 11/8/17, revealed Resident #25 scored 28, indicating she was a high risk for falls. Review of Resident #25's Fall Risk care plan, initiated 11/10/17, revealed an update on 11/25/17 that included: 1) encourage to seek assistance with all mobility and transfers. Give me opportunities to be visible by staff to reduce fall risk, for example helping me to get involved in activities, therapy, etc, and offer opportunities to toilet throughout the day. I sometimes forget to ask for help; 2) provide diversion activities; 3) provide encouragement to participate in activities. The Fall Risk care plan included the following interventions implemented on 11/2717: 1) encourage to participate in activities in common areas, where staff can watch guest more closely; 2) encourage me to be in common areas and to attend activities when my caregiver is not present visiting; 3) I don't always put my call light on when I need to go to the bathroom, please toilet me before and after meals and offer me toileting every 2 hours in between; 4) make sure I have my non-slip grip in my wheelchair; and 5) please educate my visitors to let the staff know when they are leaving and I am in my room. Review of Resident #25's Progress Notes revealed she slid out of bed on 11/14/17. Review of the Health Status Note dated 11/25/17 at 9:27 AM, revealed Guest observed sitting in front of wheelchair with right leg petal broken off. Guest tore left side of pants on the thigh, scraped, abrasion to left thigh with minimal bleeding. Guest stated she was just trying to readjust and pushed too hard against the foot petal and slid down the chair . Review of the Health Status Note dated 11/25/17 at 3:43 PM (late entry) revealed Guest was found on ground in room , with no pants on, face down on right side. Guest has abrasion on left forehead. Guest left on floor d/t (due to) excruciating pain with movement. Guest stated she hit her head and shows increased pain with movement, guest also stated she was coming out of the bathroom and tripped. VS (vital signs) taken, neck and spine precautions maintained . Review of a second Health Status Note dated 11/25/17 at 3:43 PM, revealed Guest was self-ambulating in room, stating she was coming out of the bathroom and tripped. Guest stated she hit her head and shows increased pain with movement. Guest was found on ground in room , with no pants on, face down on right side. Guest has abrasion on left forehead. Guest left on floor d/t (due to) excruciating pain with movement . Review of the Health Status Note dated 11/25/17 at 8:45 PM, revealed Resident #25 returned form the hospital with a new [DIAGNOSES REDACTED]. Review of the Physician's Progress Note dated 11/2817, revealed .was sent out s/p (status [REDACTED].shortly after family left, guest was self-ambulating to the bathroom and tripped and fell , per guest statement. Guest was sent to ER r/t (related to) extreme back pain, noted to have a T2 fracture . Review of the facility's Administrative Statement Investigative Analysis, dated 12/1/17, revealed After first fall (from (wheelchair)): in response to this incident, staff implemented interventions to keep the guest (Resident #25) within reasonable observation by having her engaged in activities and being placed in common areas, rather than in areas where she would be unobserved. Although these interventions were developed, they were not immediately put to writing. During the morning hours, the newly implemented intervention of having the guest in a supervised area was accomplished as the guest participated in therapy, and an activity, lunch and a family visit. Shift change occurred at approximately 2 PM. The family left the facility at approximately 235 PM. The PM CNA (Certified Nursing Assistant S) did enter the guest's room at approximately 247 PM and obtained information regarding (Resident #25's name) meal preferences for the upcoming meals. She was unaware that the guest had a new care plan intervention of having the guest in a supervised area and left the guest alone in her room. (Resident #25) was comfortably seated and watching TV at this time. At approximately 317 PM, CNA (CNA S). walked past (Resident #25's) room and noted the door to be shut. She opened the door and noted her to be laying on the ground, and she immediately got the nurse for help. Nurses (Registered Nurse (RN) T and RN J) went in and immediately assessed the guest. The guest had informed them she was walking back from the (bathroom) and tripped .unfortunately, the staff failed to document this change of the plan of care in writing at the time and verbally instructed staff to keep the guest in supervised areas. Thus, although the services were provided for by the facility staff, the communication between the two shifts resulted in the guest being left in her room for the short 30-minute time interval that provided the opportunity for the incident to occur. On 1/30/18 at 08:19 AM, the surveyor attempted to contact CNA S via telephone, but the phone number was out of service. Director of Nursing (DON) B reported CNA S no longer worked at the facility and the facility did not have another phone number for her. In an interview on 1/20/18 at 8:38 AM, RN J reported he worked 7:00 AM to 7:00 PM on 11/25/17, when Resident #25 fell twice. RN J stated I just remember she fell on ce in the morning by sliding out of her wheelchair like she always does. She had so many falls that we made her sign a form. No matter what we did, she would fall. She always tried to get up herself and try to use the wheelchair footrest to try to get up .It's just I heard in report that she falls all the time so we have to keep an eye on her. We tried to keep her in the common areas and high traffic areas where we could keep an eye on her, even in front of the nurses station. There is only so much we can do . When asked what intervention was put into place after the first fall, RN J stated we just tried to keep her in the common areas more. When asked about Resident #25's second fall on 11/25/17, RN J reported Resident #25 fell coming out of the bathroom and stated she always tried to do it herself . When asked if anything could have prevented Resident #25's second fall, RN J stated if someone was with her 24/7, but reported the facility did not provide one on one supervision. RN J reported the facility could have provided Resident #25 with more activities to do and staff could have rounded more. When asked if Resident #25 was in a lot of pain after her second fall on 11/25/17, RN J stated yeah we couldn't get her off the floor. In an interview on 1/30/18 at 8:57 am, when asked about Resident #25, RN T stated we just always had to watch her .she was constantly trying to get up. RN T stated Resident #25's second fall on 11/25/17 was different .she was in pain. You couldn't even touch her to do an assessment .just everything about her was in pain .you couldn't even touch her to put a blood pressure cuff around her arm. When asked what could have been done to prevent Resident #25's second fall on 11/25/17, RN T stated there's just not enough staff to do one on one care . In an interview on 1/30/18 at 9:24 AM, Director of Nursing (DON) B reported on 11/25/17, Resident #25 fell the first time after sliding out of her wheelchair because she was kicking at her leg rest. DON B reported the immediate intervention was to keep Resident #25 engaged in activities to observe her more, but the intervention was not updated on Resident #25's care plan. DON B reported CNA S was not aware of the new intervention when she started her shift at 2:00 PM that day. DON B reported Resident #25's family came in to visit for most of the day until about an hour after lunch. DON B reported an aide (CNA S) checked on Resident #25 to get her dinner order and about 10 minutes later, CNA S went back into Resident #25's room and noticed her on the floor in excruciating pain. When asked where Resident #25 was prior to the second fall, DON B stated sitting in her wheelchair, watching TV. When asked what should have happened between shifts, DON B: stated if it (the new intervention) would have been put in writing, the aides would have seen it, or verbally passed on in report . Resident #225 Resident #225's Admission Record dated 1/26/18, revealed she was [AGE] years old and had the [DIAGNOSES REDACTED]. Resident #225's Admission assessment dated [DATE] at 12:53 PM revealed she was alert and orientated to person only. On 1/24/18 at 4:15 PM, Resident #225 was observed wearing regular crew socks, without gripper material, during a transfer from her wheelchair to her bed with the assistance or Registered Nurse (RN) G and Certified Nursing Assistant (CNA) M. RN G and CNA M transferred Resident #225 by placing her wheelchair directly facing the middle of the bed, RN G placed her arm under Resident #225's left arm and grasped the back of Resident #225's knit-type legging pants; CNA M placed her arm under Resident #225's right arm and grasped the opposite side of Resident #225's pants. Resident #225 did not bear weight when lifted into a standing position and her feet were in the way of pivoting. The transfer was stopped and Resident #225 was placed back into her wheelchair. RN G and CNA M attempted to transfer Resident #225 in the exact same manner as described previously, without using a gait belt, and pivoted Resident #225 to the right and sat her onto the bed. Resident #225 was unable to maintain sitting balance on the bed and collapsed backwards on the bed onto her back. During an interview following the transfer on 1/24/18 at approximately 4:30 PM, CNA M stated the facility did use gait (transfer) belts for transfers, but explained she had not worked with Resident #225 in a long time and did not know how to transfer her. According to Perry and Potter, Clinical Nursing Skills and Techniques, 7th edition, 2010; a transfer belt allowed the nurse to maintain stability during a transfer and reduced risk for falling. In review of Resident #225's Activities of Daily Living (ADL) care plan, dated 1/11/18, she had weakness on her right side, impaired balance, limited mobility, and a history of left knee pain and weakness prior to her stroke. The same care plan indicated that she required a hoyer lift for transfers and was a risk for joint injury and falls. On 1/25/18 at 3:52 PM, Assistant Director of Nursing (ADON) I stated Resident #225's transfer status was a hoyer lift (total lift). In review of Resident #225 progress notes, dated 1/25/18 at 6:09 PM, therapy attempted to transfer Resident #225 from the bed to the wheelchair with a two person assist; due to Resident #225's extensor tone (pushing to her affected side) in standing, as well and her right sided [MEDICAL CONDITION] (weakness) it was still recommended that she remain a hoyer lift with floor staff.

This citation includes intake MI 948. Based on interview and record review, the facility failed to develop and revise care plans for 3 (Resident #2, #8, #25) of 20 reviewed for care plans, from a total sample of 20, resulting in Resident #2 not having an anti-psychotic medication care plan in place, Resident #8 not having a restorative program care plan, updated Foley catheter care plan, or a constipation care plan in place, and Resident #25's care plan not being updated after a fall resulting in Resident #25 sustaining a fall with fracture. Findings Include: Resident #2 According to the Electronic Medical Record (EMR) on 01/30/18 at 11:57 AM Resident (R) #2 was admitted to the facility on [DATE] related to [MEDICAL CONDITION] femur neck, with diagnoses that included: fracture of neck of right femur, dementia without behavioral disturbance, [MEDICAL CONDITION], anxiety disorder, brief [MEDICAL CONDITION], fall, major [MEDICAL CONDITION], and gastro-[MEDICAL CONDITION] reflux disease. R2's Five day Minimum Data Set (MDS: Resident assessment tool) dated 10/20/17 reflected R2 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 (severely cognitive impairment). R2 required extensive assistance of one to two people for transfers, toileting, hygiene, dressing and bathing. During an interview with R2's family member on 01/26/18 at 10:34 AM it was revealed that over the last 2 months R2 had been tired a lot, would cry but could not explain herself. R2 was observed on 01/26/18 10:49 AM in her room asleep, her bed was low to the ground, her baby doll was next to her, her TV was on, and her call light was in reach. While interviewing Certified Nursing Assistant (CNA Q) on 01/26/18 at 10:51 AM, it was revealed that R2 seemed somewhat groggy on that day. Normally R2 would be awake calling out for her momma and papa, CNA Q would stay up and do activities/interact with her, that R2 could not used the call light but she would often check on her. Also, that R2 would cry doing transfer, with gentleness and patience, moves on her own at will, and was not able to obey commands. At approximately 8:48 AM on 1/30/18 Registered Nurse (RN U) was asked about R2's mannerisms. RN U replied, She's almost like pseudo bulbar, she cries a lot, but lately she has been pretty good, happy. She does not recognized her husband. When she first got here she cried. She would say, Daddy don't do that that hurts. Doesn't recognize husband. She gets up real early and takes a nap after breakfast .She is very demented. Wikipedia (YEAR) online reference defined pseudo bulbar affect as: Pseudobulbar affect (PBA), or emotional incontinence, is a type of emotional disturbance characterized by uncontrollable episodes of crying and/or laughing, or other emotional displays. PBA occurs secondary to a neurologic disorder or [MEDICAL CONDITION]. At the facility R2 was currently being followed by psychological/behavioral service, and was taking [MEDICATION NAME] for anxiety, [MEDICATION NAME] for [MEDICAL CONDITION], and [MEDICATION NAME] for brief [MEDICAL CONDITION]. Yet, there was no plan of care to address the plan of care related to the anti-psychotics, including monitoring for adverse side effects, or non-pharmacological interventions. The Social Worker (SW F) was interviewed on 1/30/18 at 2:05 PM, and was queried about the absence of an anti-psychotic care plan including adverse side effects to monitor, and non-pharmacological interventions for R2. SW F revealed, She should have an anti-psychotic care plan, that was before my time. On 1/30/18 at 2:11 PM the Director Of Nursing (DON B) was interviewed. She was informed of R2 psych related diagnoses and medications. When asked if residents on anti-psychotics should have a care plan, DON B nodded Yes. All of the current care plans for R2 were read off to the DON, which were without any related to anti-psychotics. DON B was also informed that there was no documentation to support that non-pharmacological interventions were implemented , prior to starting the anti-psychotic [MEDICATION NAME] after [MEDICATION NAME] was discontinued, nor could monitoring of side effects related to anti-psychotic could be found. Later on 1/30/18 at 2:44 PM SW F provided a copy of an anti-psychotic medication care plan that had been initiated then discontinued/resolved on 11/7/17, but was not currently in place. Resident #25 Review of the Admission Record and Minimum Data Set ((MDS) dated [DATE], revealed Resident #25 was an [AGE] year old female, admitted to the facility on [DATE], with diagnoses that included compression fractures T9-12 vertebra, history of falls, and [MEDICAL CONDITION]. The MDS revealed Resident #25 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), transferred with extensive assistance of 2 staff members, and walked with limited assistance of 1 staff member. The MDS revealed Resident #25 had a history of [REDACTED]. Review of the Fall Risk Evaluation dated 11/8/17, revealed Resident #25 scored 28, indicating she was a high risk for falls. Review of Resident #25's Fall Risk care plan, initiated 11/10/17, revealed an update on 11/25/17 that included: 1) encourage to seek assistance with all mobility and transfers. Give me opportunities to be visible by staff to reduce fall risk, for example helping me to get involved in activities, therapy, etc, and offer opportunities to toilet throughout the day. I sometimes forget to ask for help; 2) provide diversion activities; 3) provide encouragement to participate in activities. The Fall Risk care plan included the following interventions implemented on 11/2717: 1) encourage to participate in activities in common areas, where staff can watch guest more closely; 2) encourage me to be in common areas and to attend activities when my caregiver is not present visiting; 3) I don't always put my call light on when I need to go to the bathroom, please toilet me before and after meals and offer me toileting every 2 hours in between; 4) make sure I have my non-slip grip in my wheelchair; and 5) please educate my visitors to let the staff know when they are leaving and I am in my room. Review of Resident #25's Progress Notes revealed she slid out of bed on 11/14/17. Review of the Health Status Note dated 11/25/17 at 9:27 AM, revealed Guest observed sitting in front of wheelchair with right leg petal broken off. Guest tore left side of pants on the thigh, scraped, abrasion to left thigh with minimal bleeding. Guest stated she was just trying to readjust and pushed too hard against the foot petal and slid down the chair . Review of the Health Status Note dated 11/25/17 at 3:43 PM (late entry) revealed Guest was found on ground in room , with no pants on, face down on right side. Guest has abrasion on left forehead. Guest left on floor d/t (due to) excruciating pain with movement. Guest stated she hit her head and shows increased pain with movement, guest also stated she was coming out of the bathroom and tripped. VS (vital signs) taken, neck and spine precautions maintained . Review of a second Health Status Note dated 11/25/17 at 3:43 PM, revealed Guest was self-ambulating in room, stating she was coming out of the bathroom and tripped. Guest stated she hit her head and shows increased pain with movement. Guest was found on ground in room , with no pants on, face down on right side. Guest has abrasion on left forehead. Guest left on floor d/t (due to) excruciating pain with movement . Review of the Health Status Note dated 11/25/17 at 8:45 PM, revealed Resident #25 returned form the hospital with a new [DIAGNOSES REDACTED]. Review of the Physician's Progress Note dated 11/28/17, revealed .was sent out s/p (status [REDACTED].shortly after family left, guest was self-ambulating to the bathroom and tripped and fell , per guest statement. Guest was sent to ER r/t (related to) extreme back pain, noted to have a T2 fracture . Review of the facility's Administrative Statement Investigative Analysis, dated 12/1/17, revealed After first fall (from (wheelchair)): in response to this incident, staff implemented interventions to keep the guest (Resident #25) within reasonable observation by having her engaged in activities and being placed in common areas, rather than in areas where she would be unobserved. Although these interventions were developed, they were not immediately put to writing. During the morning hours, the newly implemented intervention of having the guest in a supervised area was accomplished as the guest participated in therapy, and an activity, lunch and a family visit. Shift change occurred at approximately 2 PM. The family left the facility at approximately 235 PM. The PM CNA (Certified Nursing Assistant S) did enter the guest's room at approximately 247 PM and obtained information regarding (Resident #25's name) meal preferences for the upcoming meals. She was unaware that the guest had a new care plan intervention of having the guest in a supervised area and left the guest alone in her room. (Resident #25) was comfortably seated and watching TV at this time. At approximately 317 PM, CNA (CNA S). walked past (Resident #25's) room and noted the door to be shut. She opened the door and noted her to be laying on the ground, and she immediately got the nurse for help. Nurses (Registered Nurse (RN) T and RN J) went in and immediately assessed the guest. The guest had informed them she was walking back from the (bathroom) and tripped .unfortunately, the staff failed to document this change of the plan of care in writing at the time and verbally instructed staff to keep the guest in supervised areas. Thus, although the services were provided for by the facility staff, the communication between the two shifts resulted in the guest being left in her room for the short 30-minute time interval that provided the opportunity for the incident to occur. On 1/30/18 at 08:19 AM, the surveyor attempted to contact CNA S via telephone, but the phone number was out of service. Director of Nursing (DON) B reported CNA S no longer worked at the facility and the facility did not have another phone number for her. In an interview on 1/20/18 at 8:38 AM, RN J reported he worked 7:00 AM to 7:00 PM on 11/25/17, when Resident #25 fell twice. RN J stated I just remember she fell on ce in the morning by sliding out of her wheelchair like she always does. She had so many falls that we made her sign a form. No matter what we did, she would fall. She always tried to get up herself and try to use the wheelchair footrest to try to get up .It's just I heard in report that she falls all the time so we have to keep an eye on her. We tried to keep her in the common areas and high traffic areas where we could keep an eye on her, even in front of the nurses station. There is only so much we can do . When asked what intervention was put into place after the first fall, RN J stated we just tried to keep her in the common areas more. When asked about Resident #25's second fall on 11/25/17, RN J reported Resident #25 fell coming out of the bathroom and stated she always tried to do it herself . When asked if anything could have prevented Resident #25's second fall, RN J stated if someone was with her 24/7, but reported the facility did not provide one on one supervision. RN J reported the facility could have provided Resident #25 with more activities to do and staff could have rounded more. When asked if Resident #25 was in a lot of pain after her second fall on 11/25/17, RN J stated yeah we couldn't get her off the floor. In an interview on 1/30/18 at 8:57 am, when asked about Resident #25, RN T stated we just always had to watch her .she was constantly trying to get up. RN T stated Resident #25's second fall on 11/25/17 was different .she was in pain. You couldn't even touch her to do an assessment .just everything about her was in pain .you couldn't even touch her to put a blood pressure cuff around her arm. When asked what could have been done to prevent Resident #25's second fall on 11/25/17, RN T stated there's just not enough staff to do one on one care . In an interview on 1/30/18 at 9:24 AM, Director of Nursing (DON) B reported on 11/25/17, Resident #25 fell the first time after sliding out of her wheelchair because she was kicking at her leg rest. DON B reported the immediate intervention was to keep Resident #25 engaged in activities to observe her more, but the intervention was not updated on Resident #25's care plan. DON B reported CNA S was not aware of the new intervention when she started her shift at 2:00 PM that day. DON B reported Resident #25's family came in to visit for most of the day until about an hour after lunch. DON B reported an aide (CNA S) checked on Resident #25 to get her dinner order and about 10 minutes later, CNA S went back into Resident #25's room and noticed her on the floor in excruciating pain. When asked where Resident #25 was prior to the second fall, DON B stated sitting in her wheelchair, watching TV. When asked what should have happened between shifts, DON B: stated if it (the new intervention) would have been put in writing, the aides would have seen it, or verbally passed on in report . Resident #8 Review of the Admission Record and the Minimum Data Set ((MDS) dated [DATE], revealed Resident # 8 was a [AGE] year old female, admitted to the facility 11/17/17 and readmitted [DATE] with diagnoses that included [MEDICAL CONDITIONS] disorder, dementia, and major [MEDICAL CONDITION]. There was no [DIAGNOSES REDACTED]. The MDS revealed Resident #8 scored 1 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and had an indwelling urinary catheter. An observation on 1/30/18 at 1:45 PM and 3:54 PM, revealed Resident #8 was asleep in bed with a catheter bag hanging from the bed. Review of the Urinary Catheter care plan initiated 1/15/18, revealed no mention of the size of Resident #8's indwelling catheter. In an interview on 1/30/18 at 1:48 PM, Assistant Director of Nursing (ADON) I agreed Resident #8's care plans did not address the size of her indwelling catheter. In an interview on 1/30/18 at 3:32 PM, MDS Coordinator N reported that catheter size was usually indicated on the catheter care plan, but agreed Resident #8's catheter care plan did not address the size of her indwelling catheter. Review of the Occupational Therapy (OT) and Physical Therapy (PT) discharge summaries, dated 12/29/17, revealed Resident #8 was discharged for m PT and OT. In an interview on 1/30/18 at 1:25 PM, Rehab Program Manager O reported Resident #8 was no longer appropriate for therapy and is now on a restorative program for passive range of motion as tolerated. Review of Resident #8's care plans, revealed there was no care plan in place for a restorative program. Review of Resident #8's physician's orders [REDACTED]. 1/13/18 for [MEDICATION NAME] 100 mg every 12 hours as needed for constipation 1/13/18 [MEDICATION NAME] 17 grams once a day for constipation 1/22/18 Milk of Magnesia 30 cc one time only for constipation Review of Resident #8's bowel records revealed she was incontinent of bowel on 1/24/18, 1/25/18, and 1/26/18. There were no other bowel movements recorded for Resident #8 Review of Resident #8's Medication Administration Record, [REDACTED] In an interview on 1/30/18 at 3:32 PM Minimum Data Set (MDS) Coordinator N reported the facility only care planned current action problems. MDS Coordinator N reported Resident #8's constipation was a current problem since she received Milk of Magnesia on 1/22/18. MDS Coordinator N reported Resident #8 should have a constipation care plan in place.

This citation refers to Intake MI 686 and MI 779. Based on observations, interviews and record review, the facility failed to meet professional standards in the administration of medications in one of five (Resident #105) sampled residents who experienced a significant medication error resulting in Immediate Jeopardy for Resident #105 who suffered severe [DIAGNOSES REDACTED] (low blood sugar) and irreversible (permanent) hypoglycemic-induced (low blood sugar caused by diabetic medication) [MEDICAL CONDITION] and died on [DATE]. Findings include: Resident #105 was admitted on [DATE] to the facility for rehabilitation following a fall with a fractured left arm. On [DATE] at 1:00 PM, a medical record review of Resident #105's clinical chart indicated that Resident #105 had the following Diagnoses: [REDACTED]. Please note that Resident #105 was not diagnosed with [REDACTED]. She was considered alert and oriented according to the Medicare daily nurse's notes from admission on [DATE] through [DATE]. A record review of the physician orders [REDACTED]. According to the "American Society of Consultant Pharmacists", nurses who administer medications must adhere to the five rights: right patient, right medication, right dose, right route and right time. On [DATE] at 1:00 PM, a record review of Resident #105's clinical chart indicated that Resident #105 had a Minimum Data Set (MDS) form completed on [DATE] that indicated that she was alert and oriented, could communicate and was understood by others, and had no forms of [MEDICAL CONDITION] or hallucinations. On [DATE] at 1:00 PM, a record review of Resident #105's care plan indicated that Resident #105 had a [DIAGNOSES REDACTED]. On [DATE] at 1:00 PM, a record review of the hospital medical records for Resident #105 showed that, on [DATE], on admission to the hospital, a blood sample from Resident #105 was sent to an out of State specialty clinic for a hypoglycemic agent (diabetic medicine) screening. The laboratory result was positive for [MEDICATION NAME], which was a medication used to treat Diabetes Mellitus. On [DATE] at 1:00 PM, a record review of physician's orders [REDACTED].#105 was not prescribed any diabetic medications. However, on [DATE] at 1:00 PM, a record review of Resident #104's physician's orders [REDACTED]. Resident #104 was the roommate of Resident #105. On [DATE] at 1:00 PM, a record review of the discharge summary from the hospital showed that a "serum hypoglycemic screen was drawn on admission and was found to be positive for [MEDICATION NAME]." According to the discharge summary from the hospital dated [DATE], Resident #105 had "irreversible hypoglycemic-induced (low blood sugar due to medication) [MEDICAL CONDITION]". On [DATE] at 3:00 PM, the surveyor was given a copy of the investigation that the facility performed. According to the documentation in the investigation report, on [DATE], the Risk Manager at the hospital informed the facility that there was a medication error involving Resident #105 because a laboratory screening for diabetic medications indicated that Resident #105 received [MEDICATION NAME], although Resident #105 was not a diabetic and had no physician's order [REDACTED]. Therefore, the facility did not complete an accident and incident report and did not report this occurrence to the State agency. On [DATE] at 9:50 AM, the surveillance tapes from [DATE] at 3:40 PM through [DATE], 8:00 AM, were observed with the Director of Compliance and Guest Relations. On the tape dated [DATE] at 3:42 PM, LPN #9, who was on orientation and was assigned to care for Resident #105, was observed preparing medications for room [ROOM NUMBER]. The surveillance camera was aimed from the ceiling downward and there was a clear observation of the medication cart and the top drawer containing medications for the resident in room [ROOM NUMBER] (a private room), including rooms 210 A and 210 B over the left shoulder of LPN #9. The drawers of the medication cart were divided into four (4) sections. Each section had a label on the front of the drawer with the resident's name and room number. Each labeled section contained medications for that particular resident. The top drawer of the medication cart had one section identified for the resident in room [ROOM NUMBER], two sections identified for the resident in room [ROOM NUMBER] A (the bed closest to the door) and the final section identified for the resident in room [ROOM NUMBER] B (the bed closest to the window). On [DATE] at 9:50 AM, while observing the surveillance tapes of medication administration that occurred on [DATE] at 3:42 PM, LPN #9 was observed preparing medications from the second and third sections of the drawer, which contained medications assigned to Resident #104. LPN #9 withdrew several white packets containing medication, opened them and placed the medications into a plastic cup for administration. LPN #9 prepared a cup of water and then entered room [ROOM NUMBER]. LPN #9 was then seen returning to the medication cart to chart the medications she administered. After she turned the pages of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s picture, reviewed the medication list and then flipped the MAR indicated [REDACTED]. LPN #9 was clearly seen removing packets of medications from the same two sections of the top drawer of the medication cart that she had just accessed for Resident #104. LPN #9 was seen taking those medications into room [ROOM NUMBER]. It was clear from the observation of the security tapes that LPN #9 prepared and administered medication for two residents from a single resident's drawer. LPN #9 did not follow the "five rights" because she did not identify the right resident when she administered medication. On [DATE] at 9:40 AM, in an interview with the Medical Director of the facility, he stated "perhaps" Resident #105 also "received [MEDICATION NAME] extended release". Resident #104 had an order for [REDACTED].#104 was receiving [MEDICATION NAME] 1,000 mg orally twice a day at the facility. On [DATE] at 10:00 AM, the Geriatric Dosage Handbook, 11th Edition, was referenced to check the two medications: [MEDICATION NAME] and [MEDICATION NAME]. The section for [MEDICATION NAME] had a warning which stated that [MEDICATION NAME] should be "used with caution in patients with renal and hepatic impairment" (a decrease in the function of a body organ). The recommended dosage for [MEDICATION NAME] was 1.25 mg to 2.5 mg per day with an increase by 1.25 mg to 2.5 mg increments every one to three weeks. Resident #105 received 10 mg. In the section titled "Special Geriatric Considerations", it was noted that giving [MEDICATION NAME] could result in "rapid and prolonged [DIAGNOSES REDACTED] (low blood sugar) despite administration of hypertonic glucose (a concentrated form of sugar) injections. [MEDICATION NAME] is a diabetic medication used in non-insulin dependent diabetes mellitus. According to the Geriatric Dosage Handbook, 11th Edition, it is "not to be used in residents greater than or equal to [AGE] years of age unless creatinine clearance" (test to evaluate kidney function) " verifies normal renal" (kidney) "function" because the majority of the drug is excreted (released) from the body via the kidneys. Resident #104 had a doctor's order for [MEDICATION NAME] extended release 1,000 mg to be given by mouth twice a day. On [DATE], a faxed copy of the re-investigation performed by the facility was received by the state surveyor at 11:39 AM. The facility noted that Resident #105 was to receive two inhailed medications which are administered through a small cylinder. LPN #9 did not remove any cylinders from the drawers of the medication cart when she prepared medications for room [ROOM NUMBER]. As a result of receiving additional information, the survey exit date was changed to [DATE]. The Facility Administrator was notified on [DATE] at 1:00 PM of the Immediate Jeopardy that began on [DATE] when LPN #9 gave Resident #105 medications that belonged to Resident #104 causing Resident #105 to experience severe [DIAGNOSES REDACTED], irreversible brain damage and who died on [DATE]. The surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1. Between [DATE] and [DATE], a medication pass audit was done to verify that staff were following policy and procedures appropriately. 2. Camera footage of medication administration to room [ROOM NUMBER] from [DATE] through [DATE] was reviewed a second time on [DATE]. 3. LPN #9 was suspended on [DATE] and terminated on [DATE]. While the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at an isolated scope and severity of no actual harm but potential for more than minimal harm but no Immediate Jeopardy due to the fact that all staff had not received in-service education regarding medication administration policy and procedures and sustained compliance had not been verified by the state agency.

This citation refers to Intake MI 686 and MI 779. Based on observations, interviews and records review, the facility failed to protect one of five sampled residents (#105) from a significant medication error resulting in immediate jeopardy for Resident #105 who suffered severe [DIAGNOSES REDACTED] (low blood sugar) and irreversible (permanent) hypoglycemic-induced (low blood sugar caused by diabetic medication) [MEDICAL CONDITION] and died on [DATE]. Findings include: Resident #105 was admitted on [DATE] to the facility for rehabilitation following a fall with a fractured left arm. On [DATE] at 1:00 PM, a medical record review of Resident #105's clinical chart indicated that Resident #105 had the following Diagnoses: [REDACTED]. Please note that Resident #105 was not diagnosed with [REDACTED]. She was considered alert and oriented according to the Medicare daily nurse's notes from admission on [DATE] through [DATE]. A record review of the physician orders [REDACTED]. According to the "American Society of Consultant Pharmacists", nurses who administer medications must adhere to the five rights: right patient, right medication, right dose, right route and right time. On [DATE] at 1:00 PM, a record review of Resident #105's clinical chart indicated that Resident #105 had a Minimum Data Set (MDS) form completed on [DATE] that indicated that she was alert and oriented, could communicate and was understood by others, and had no forms of [MEDICAL CONDITION] or hallucinations. On [DATE] at 1:00 PM, a record review of Resident #105's care plan indicated that Resident #105 had a [DIAGNOSES REDACTED]. On [DATE] at 1:00 PM, a record review of the nurse's notes showed that on [DATE] at 8:00 AM, RN #9, the day shift nurse assigned to care for Resident #105, was notified that something was wrong with Resident #105. Resident #105 was lying in bed with her eyes open and her lips pursed (contracting one's lips into a rounded shape). She did not respond to questions. Vital signs (pulse, blood pressure and respirations) were taken and were stable. Nurse Practitioner #11 (NP) was in the facility, was contacted by RN #9 and no new orders were received. Resident #105 was taken to breakfast in a wheelchair to a supervised dining room and was fed by a Certified Nurse Aid (CNA). Resident #105 became more responsive as she ate her meal and, finally, Resident #105 began to feed herself. On [DATE] at 1:00 PM, a record review of the nurse's notes for Resident #105 showed that on [DATE] at 3:45 PM, Resident #105 was found unresponsive by RN #10, the afternoon shift nurse assigned to care for Resident #105. Vital signs were stable. Resident #105's blood sugar registered on the glucometer (an instrument used to measure blood sugar) as "low" (unable to determine). Normal blood sugar levels are between 70 to 100 mg. Resident #105 received multiple doses of [MEDICATION NAME] (medication used to raise blood sugar levels) intramuscularly (into the muscle). At 5:10 PM, Resident #105 was, according to documentation in the nurse ' s notes "awake, alert and responsive". Resident #105 was able to take her medications and eat her supper. On [DATE] at 1:00 PM, a record review of the nurse's notes documented that, on [DATE] at 4:00 AM, Resident #105 was found unconscious and only responding to pain. Blood sugar at 4:00 AM was 33. [MEDICATION NAME] was given intramuscularly. Resident #105's blood sugar was measured at 4:15 AM and registered at 41. Multiple doses of [MEDICATION NAME] were administered and an intravenous line was inserted. Resident #105 was sent to the hospital at 6:00 AM. On [DATE] at 1:00 PM, a record review of the hospital medical records for Resident #105 showed that, on [DATE], on admission to the hospital, a blood sample from Resident #105 was sent to an out of State specialty clinic for a hypoglycemic agent (diabetic medicine) screening. The laboratory result was positive for [MEDICATION NAME], which was a medication used to treat Diabetes Mellitus. On [DATE] at 1:00 PM, a record review of physician's orders [REDACTED].#105 was not prescribed any diabetic medications. However, on [DATE] at 1:00 PM, a record review of Resident #104's physician's orders [REDACTED]. Resident #104 was the roommate of Resident #105. On [DATE] at 1:00 PM, a record review of the discharge summary from the hospital showed that a "serum hypoglycemic screen was drawn on admission and was found to be positive for [MEDICATION NAME]." According to the discharge summary from the hospital dated [DATE], Resident #105 had "irreversible hypoglycemic-induced (low blood sugar due to medication) [MEDICAL CONDITION]". On [DATE] at 3:00 PM, the surveyor was given a copy of the investigation that the facility performed. According to the documentation in the investigation report, on [DATE], the Risk Manager at the hospital informed the facility that there was a medication error involving Resident #105 because a laboratory screening for diabetic medications indicated that Resident #105 received [MEDICATION NAME], although Resident #105 was not a diabetic and had no physician's order [REDACTED]. Therefore, the facility did not complete an accident and incident report and did not report this occurrence to the State agency. On [DATE] at 9:50 AM, the surveillance tapes from [DATE] at 3:40 PM through [DATE], 8:00 AM, were observed with the Director of Compliance and Guest Relations. On the tape dated [DATE] at 3:42 PM, LPN #9, who was on orientation and was assigned to care for Resident #105, was observed preparing medications for room [ROOM NUMBER]. The surveillance camera was aimed from the ceiling downward and there was a clear observation of the medication cart and the top drawer containing medications for the resident in room [ROOM NUMBER] (a private room), including rooms 210 A and 210 B over the left shoulder of LPN #9. The drawers of the medication cart were divided into four (4) sections. Each section had a label on the front of the drawer with the resident's name and room number. Each labeled section contained medications for that particular resident. The top drawer of the medication cart had one section identified for the resident in room [ROOM NUMBER], two sections identified for the resident in room [ROOM NUMBER] A (the bed closest to the door) and the final section identified for the resident in room [ROOM NUMBER] B (the bed closest to the window). On [DATE] at 9:50 AM, while observing the surveillance tapes of medication administration that occurred on [DATE] at 3:42 PM, LPN #9 was observed preparing medications from the second and third sections of the drawer, which contained medications assigned to Resident #104. LPN #9 withdrew several white packets containing medication, opened them and placed the medications into a plastic cup for administration. LPN #9 prepared a cup of water and then entered room [ROOM NUMBER]. LPN #9 was then seen returning to the medication cart to chart the medications she administered. After she turned the pages of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s picture, reviewed the medication list and then flipped the MAR indicated [REDACTED]. LPN #9 was clearly seen removing packets of medications from the same two sections of the top drawer of the medication cart that she had just accessed for Resident #104. LPN #9 was seen taking those medications into room [ROOM NUMBER]. It was clear from the observation of the security tapes that LPN #9 prepared and administered medication for two residents from a single resident's drawer. LPN #9 did not follow the "five rights" because she did not identify the right resident when she administered medication. On [DATE] at 9:40 AM, in an interview with the Medical Director of the facility, he stated "perhaps" Resident #105 also "received [MEDICATION NAME] extended release". Resident #104 had an order for [REDACTED].#104 was receiving [MEDICATION NAME] 1,000 mg orally twice a day at the facility. On [DATE] at 10:00 AM, the Geriatric Dosage Handbook, 11th Edition, was referenced to check the two medications: [MEDICATION NAME] and [MEDICATION NAME]. The section for [MEDICATION NAME] had a warning which stated that [MEDICATION NAME] should be "used with caution in patients with renal and hepatic impairment" (a decrease in the function of a body organ). The recommended dosage for [MEDICATION NAME] was 1.25 mg to 2.5 mg per day with an increase by 1.25 mg to 2.5 mg increments every one to three weeks. Resident #105 received 10 mg. In the section titled "Special Geriatric Considerations", it was noted that giving [MEDICATION NAME] could result in "rapid and prolonged [DIAGNOSES REDACTED] (low blood sugar) despite administration of hypertonic glucose (a concentrated form of sugar) injections. [MEDICATION NAME] is a diabetic medication used in non-insulin dependent diabetes mellitus. According to the Geriatric Dosage Handbook, 11th Edition, it is "not to be used in residents greater than or equal to [AGE] years of age unless creatinine clearance" (test to evaluate kidney function) " verifies normal renal" (kidney) "function" because the majority of the drug is excreted (released) from the body via the kidneys. Resident #104 had a doctor's order for [MEDICATION NAME] extended release 1,000 mg to be given by mouth twice a day. On [DATE], a faxed copy of the re-investigation performed by the facility was received by the state surveyor at 11:39 AM. No additional information was included in the re-investigation but the survey exit date was changed to [DATE]. The Facility Administrator was notified on [DATE] at 1:00 PM of the Immediate Jeopardy that began on [DATE] when LPN #9 gave Resident #105 medications that belonged to Resident #104 causing Resident #105 to experience severe [DIAGNOSES REDACTED], irreversible brain damage and who died on [DATE]. The surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1. Between [DATE] and [DATE], a medication pass audit was done to verify that staff were following policy and procedures appropriately. 2. The investigation into the drug error involving Resident #105 was re-opened on [DATE]. 3. Camera footage of medication administration to room [ROOM NUMBER] from [DATE] through [DATE] was reviewed a second time on [DATE]. 5. In-services for nursing staff were held beginning on [DATE], [DATE] and [DATE] outlining specific medication administration techniques to re-enforce policies and procedures. As of [DATE], twenty of thirty nurses had been in-serviced. 6. Additional in-services were scheduled to encompass the entire nursing staff. 7. Nurses unable to attend scheduled in-services will need to attend the mandatory training before administering any medications. 8. Newly employed nursing staff are trained upon hire regarding medication policies and procedures beginning [DATE]. 9. The Director of Health Service or designee will perform weekly medication administration audits and report the results to the Quality Assurance Committee. 10. LPN #9 was suspended on [DATE] and terminated on [DATE]. While the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at an isolated scope and severity of no actual harm but potential for more than minimal harm but no Immediate Jeopardy due to the fact that all staff had not received in-service education regarding medication administration policy and procedures and sustained compliance had not been verified by the state agency.