Every finding on record at Caretel Inns of Linden

This citation pertains to intake Number 2970791.Based on observation, interview and record review, the facility 1) Failed to ensure that residents were monitored per orders for weight change. 2)Failed to ensure that a change of condition assessment was documented when a significant weight loss was identified, and. 3) Failed to update and revise a resident-centered care plan; resulting in delayed care contributing to a 9.23% weight loss in 7 weeks for one resident (Resident #1) of three residents reviewed for quality of care with weight loss. Findings include: Resident #1 (R1):A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R! was admitted to the facility on [DATE] with diagnoses: history of weakness, diabetes mellitus type 2, protein-calorie malnutrition, gastro-esophageal reflux disease (GERD), bipolar disorder, dementia and hypertension. The MDS assessment dated [DATE] indicated the resident had impaired cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 10/15 and needed assistance with care.A record review of the intakes 2970791 and 2978921 was completed regarding concerns involving R1. A record review of R1's chart revealed weight documentation of: October 23rd, 2025, at 10:41am, weight #141.0 November 2025, no weight recorded. December 30th, 2025, at 16:55PM (4:55PM), weight 132.8 That indicated a weight loss of 5.82% between October -December. January 2026, no weight recorded. February 4th, 2026, at 16:54Pm (4:45PM), weight 143.0 March 24th, 2026, at 09:48AM, weight 129.8 That indicated a weight loss of 9.23% between February - March. April 8th, 2026, at 09:48AM, weight 129.8 On 04/14/2026 at 9:38AM, Resident was observed resting in bed with eyes closed and under blankets wearing a gown, there was a full cup of water with lid and straw on her bedside table. CNA B was in the room with R1's roommate, CNA B was asked if R1 had breakfast and CNA B said that R1 required feeding with meals and that she had not fed R1 that morning another CNA had and she was unsure of what or how much R1 had eaten. On 04/14/2026 at 9:40AM, during resident observation, Nurse A was asked about the resident baseline she said that R1 is often sleepy after her morning medications and breakfast. When asked how much of her breakfast R1 had eaten, Nurse A said she was unsure that the CNA A had fed her. On 04/14/2026 at 11:48AM, during an observation of R1 in the dining room in a Geri chair, she was fed lunch by CNA C 100% of meal, she had a divided plate and cup with straw during meal service. ~100% of meal was consumed. On 04/14/2026 at 12:20PM, during an interview with CNA C he was asked about R1's diet and need for assistance. CNA C said R1 had been eating better since her diet changed to pureed about a week ago, that it was easier for her to eat. CNA C said R1 had been on a streak for about 3 days eating 100% of her meals and reported that R1 could not feed herself.A record review of R1's (bedside care plan) revealed: Eating/Nutrition: Eating: I need limited assistance with self-feeding with divided plate, 2 handle cup with Hot Liquids for safety, encouragement to complete, Encourage adequate fluid intake.A record review of R1's Nursing care plan revealed: Focus: ADL: Self-care deficit, require assist with ADLS .; interventions: Eating: I need limited assistance with self-feeding with divided plate, 2 handle cup with Hot Liquids for safety, encouragement to complete, revision on: 02/25/2026.On 04/14/2026 at 12:25PM, during an interview with Nurse A was observed administering medications to R1. R1 was unable to coordinate holding the cup to drink fluids offered and was a total assist. When Nurse A was asked about R1's need for extensive assistance she said that R1 had some improvement a couple months ago when she had therapy but had required complete assistance with eating and drinking since that ended. When Nurse A was asked why R1 was no longer in therapy she said, 'she thought it was because of insurance'. Nurse A was asked about restorative therapy, she said I don't think so. On 04/14/2026 at 12:45PM, during an interview with R1 she said she eats enough most of the time, when asked to clarify most of the time she said that she liked some foods more than others and eats more at those times. When R1 was asked if she was able to eat better since they changed her diet to pureed, she nodded yes. A record review of physician assistant (PA) progress notes revealed: Date of service: 03/09/2026: History of Present Illness: Resident is a debilitated female seen today in regards to worsening ability to perform ADLs and generalized decline. She is resting in bed in no acute distress. Nursing staff relay resident is again a total feed and are concerned about her level of weakness. Plan: Weakness/debility. Order resident to be weighed, check labs and reassess upon completion for further recommendations. According to records, resident is eating approximately 50% of meals with assistance. Date of service: 03/18/2026: History of Present Illness: Resident is a female seen today in regards to debility and decreased oral intake per nursing staff request. She is resting in bed appearing quite weak. Resident has been consuming approximately 25-50% of meals as of late which is concerning. Last documented weight noted on 2/4/2026 at 143 pounds. Resident refusing to get. Plan: Anorexia (loss of appetite) Resident to be weighed, further evaluation to follow. Date of service: 03/26/2026: History of Present Illness: Resident is a female seen today in regards to weight loss.Last documented weight noted on 3/24/2026 at 129.8 pounds as compared to a previous weight of 143 pounds on 2/4/2026. It is noted that resident is eating approximately 25-50% of meals and sometimes 0% as of late. Plan: Weight loss Discussed with resident option of adding Remeron (antidepressant with side effect of improved appetite) which she agrees. Start Remeron 15 mg daily and monitor for efficacy. Registered dietitian to follow to increase caloric intake, continue 2 cal.A record review of Dietary progress notes revealed: no notes after October 25th, 2025, to February 25th; and no notes after February 25th, 2026, until April 1st, 2026. '4/1/2026 15:03 Dietary Progress Note. WEIGHT WARNING: Value: 129.8 Vital Date: 2026-03-24 . -7.5% change [ 9.2%, 13.2 ]. LCS (low concentrated sugar) puree, thin liquids, res downgraded to puree for pocketing and SLP (speech language therapist) picked up. PA reviewed on 3/26 Remeron added for weight loss and possible to help with appetite.' '4/8/2026 11:10 Dietary Progress Note. WEIGHT WARNING: Value: 129.8.-7.5% change [ 9.2% , 13.2 ] Weight loss x 2 months noted, and stable x 2 weeks at this time. RD did review PA at this time and will increase Remeron.'A record review of Dietary review notes revealed the most recent note dated 02/13/2025: 2/13/2026 09:33; Dietary Review: This dietary review has been completed due to Monthly. Resident is eating 51-100% of LCS, Mechanical soft diet. Weight hx (history): 2/4 - 143#, 12/30 - 132.8#. Receives Mech Soft/2 calorie supplement 2x day. Resident receiving supplement to encourage weight gain.Continue 2 cal BID.RDN will monitor po intake, weight, and labs.On 04/14/2026 at 3:30PM, during an interview with registered dietician (RD) F was asked about R1's weight history and missing months of November 2025 and January 2026, she said it was a standard of practice that residents are weighed monthly unless otherwise needed/ordered. RD F' sad that she only worked at the facility on Wednesdays. She said that she was unsure of why R1 had no recorded weights for November 2025 and January 2025 and stated, I was on maternity leave and clarified her leave was from November until the end of February. RD F said she was not aware of R1's weight loss in December, it would have been addressed by another RD. RD F said that she talked to the PAG about R1's weight loss in March and that the PA G ordered Remeron 15mg once a day for R1 on 03/27/2026 for major depression and appetite. RD F said that on 04/01/2026 that she increased R1's 2 cal supplement for 2 times a day to 3 times a day and ordered that R1 had weekly weights. RD F said that on 04/08/2026 she downgraded R1's diet to pureed and changed it to a liberated diet. When asked what a liberated diet meant she explained it was a regular diet and no longer was an LCS diet. RD F said that on 04/08/2026 PA G increased R1's Remeron to 30 mg daily. RD F said 'we are monitoring R1's weights for stability now'.A record review of R1's Diet and supplement orders revealed: Revision date 04/01/2026: 2 calorie per ml Supplement; directions: three times a day 4oz. and Revision 01/12/2026: LOW CONCENTRATED SWEETS diet, Mechanical Soft texture, Thin consistency Revision 03/27/2026: LOW CONCENTRATED SWEETS diet, PUREED texture, Thin consistency Revision date 04/14/2026: Standard Diet., PUREED texture, Thin consistency; directions: total assistA record review of medication orders revealed: start date 03/28/2026: Remeron Oral Tablet 15 MG (Mirtazapine) daily and start date 04/09/2026: Remeron Oral Tablet 30 MG (Mirtazapine) dailyA record review of R1's orders for weights revealed: revision 10/7/2024: Weigh weekly and record x4 weeks. There were no additional orders for weight in the current medical record. A record review of the facilities guideline weight revealed: GUIDELINE:1. All residents will be weighed on admission, readmission, weekly for the first 4 weeks and then at least monthly. 2. Weekly weights will also be done with a significant change of condition, food intake decline that has persisted for more than one week, or with a physician order. The facility may weigh residents using the same scale, at the same time of day and in the same way each time they are weighed .A record review of the facilities guideline weight change investigation revealed: GUIDELINE:1. The weight change investigation will be initiated with the following: a. A significant weight change of 5% or more in one month, 7.5 % or more in 3 months and/or 10% or more in 6 months. b. An insidious weight change of 5 pounds or more in 2 consecutive months. The weight change investigation will occur each month until the weight has stabilized .A record review of R1's orders for dietician revealed: revision 12/31/2025: Dietitian to assess weight loss and poor nourishment.A record review of R1's orders for speech therapy (ST) revealed: revision date 12/31/2025. ST to evaluate dysphagia and pocketing. revision 04/01/2026: ST evaluation and ST to treat 3x/wk for 90 days to address. Dysphagia, oropharyngeal phase (involves tongue and pharyngeal muscles to propel food)A record review of R1's dietary care plan created on: 10/09/2024 with revision on: 01/19/2026 revealed: Focus: (R1) is at risk for malnutrition MNA=10. significant weight loss x 1mo, decreased mobility with interventions: Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia),muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date Initiated: 10/09/2024; Obtain and monitor weight report for any significant change. Date Initiated: 10/09/2024; RD to evaluate and make diet change recommendations PRN. Date Initiated: 10/09/2024; Weigh at same time of day and record: monthly or as needed. Date Initiated: 10/09/2024. There were no revisions in R1's care plan Department: Dietary when evaluated and documented as revised on 01/19/2026. Care plan also revealed diet/supplements and medication related to appetite in care plan as revealed in the dietary care plan interventions: Administer medications as ordered. Monitor/Document for side effects and effectiveness. Date Initiated: 10/09/2024; Provide and serve diet as ordered. Date Initiated: 10/09/2024.A record review of the facilities guideline Nutritional Assessment revealed: GENERAL: To determine which residents the dietician will see; RESPONSIBLE PARTY: RN, LPN Dietician, Diet Tech; GUIDELINE: 1. Nutritional assessments are completed on residents and include body mass index, usual body weight, height, weight, ideal body weight, and diagnosis . 3. Medical conditions include but are not limited to: Significant Weight Changes.A record review of R1's Nursing progress notes and SBAR (situation, background, assessment, recommendation) assessments (completed for a change in condition) revealed: There were no SBAR or change in condition documentation related to R1's significant weight loss. There were no nursing notes assessments documented about the residents' weight loss.On 04/14/2026 at 3:41PM, During an interview with the DON, she was asked about R1's weight history and missing months of November 2025 and January 2026, she said she I can not account for them and said she was new to her DON position since January 2026. DON was asked about if weight change such as R1's was considered a significant change and she said, yes. The DON was asked if there should be a change of condition (CoC) assessment and she said, yes. DON was asked to review chart for the assessment by the nursing staff, she agreed it was not in the medical chart. The DON was asked if a nursing note could cover the CoC assessment, she said yes it included the same documentation as the SBAR assessment, DON was asked to review R1's medical record for nursing notes related to SBAR assessment, she agreed there was not one in the medical record.When asked, the DON said that the SBAR assessment was the way nurses document the situation at the time of the change of condition of a resident and that communication of the change of condition was written in the doctor's book to see the resident. The DON said they have a medical doctor in facility on Monday through Thursdays; a PA in facility Monday through Friday; and a Nurse Practitioner (NP) on weekends either Saturday or Sunday and sometimes both days. The DON was asked about R1's weight obtained on Tuesday 3/24/2026 and there was a provider in facility weekdays how come R1 was not seen until Saturday 03/28/206 for the resident to be seen by the weekend provider, to which she had no answer. The DON was asked to review the care plan of R1's for revisions related to the update in dietary care, she agreed the dietary care plan had no revisions done since January 19th, 2026, and that no dietary interventions had been undated since October 9th, 2024. When she was asked if the care plan should have been updated to reflect the residents plan, she said yes. The DON said was asked to review R1's care plan for ADL's and eating, she said she was unaware that R1 was no longer limited and was now extensive/total feed and the DON agreed the care plan should but does not reflect that.The DON was asked to review the orders for R1 for weight orders, she said there would not be one because it is a standard of care to weigh residents Monthly. When asked about the weekly weights ordered recently by RD or the requested weights by provider, she was unable to find any. The DON was asked if there was any additional documentation she had to share, and she said she had nothing else to offer for documentation.A record review of the facilities guideline Change in residents condition revealed: GENERAL: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP and resident's responsible party of a change in condition; RESPONSBILE PARTY: RN, LPN, Social Services; POLICY: 1. Nursing will notify the resident's physician or nurse practitioner when: b. There is a significant change in the resident's physical, mental or emotional status. 2. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication. 4. The communication with the resident and their responsible party as well as the physician/NP will be documented in the resident's medical record or other appropriate documents. 5. The Care Plan for the resident will be updated as indicated.

This citation pertains to Intake Numbers 2741938 and 2745566.Based on observation, interview and record review the facility failed to prevent significant medication errors for one resident (Resident #101) of 7 residents reviewed for medication errors. Findings include:Medication Error #1 Cyclobenzaprine:During the Med Pass (Medication Administration) observation conducted on 3/3/26 at 1:00 PM, Nurse G told the surveyor that R101 did not have her muscle relaxer available at 1:00 PM. Nurse G stated that R101's medication is available except for her pain medication called Cyclobenzaprine or Flexeril. Nurse G revealed that she received a report from the nightshift nurse this morning, who told her it was not available for R101's 5:00 AM dose. The medication was not available in the emergency back-up box either. Nurse G continued to explain that she learned about it from the night shift nurse during morning report, that R101's last dose was given on 3/2/26, and that it was signed out as administered at 2100 (9:00 PM). The night nurse called the pharmacy last night but was told it was too early to fill, and the next delivery for R101's Flexeril is not until 3/11/26. The night nurse hung up with the pharmacy and reported to the day shift nurse that Flexeril was unavailable. Missed doses were 2: 1 at 05:00 AM and 1 at 1300. The surveyor asked whether the physician on call was notified, whether the DON was aware, and when. Nurse G said she notified the DON at 12:20 PM on 3/3/26 after learning that the surveyor had scheduled a Med Pass observation with her today. Nurse G informed the DON, and the DON called the Pharmacy at 12:20 PM.The order was: Cyclobenzaprine HCL oral tablet 10 mg. Give 1 tablet by mouth every 6 hours for a muscle relaxer related to Hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Scheduled times were: 0500 (5:00 AM), 1300 (1:00 PM and 2100 (9:00 PM).Resident #101 (R101):R101 was admitted to the facility on [DATE], with the diagnosis of pain, anxiety disorder, hemiplegia, and hemiparesis following cerebral infarction affecting the left non-dominant side and depression in addition to other diagnoses. R101 has an opioid pain management care plan related to hemiparesis and hemiplegia following a cerebral infarction, as well as suprapubic urinary catheter care. According to the most recent MDS Assessment, R101 was wheelchair bound for all mobility and required a Hoyer lift for transfers.Nurse G stated that Resident was not administered her Flexeril at the 5:00 AM and 1:00 PM doses on 3/3/26. The pharmacy will be in for delivery tonight.Nurses noted on 3/3/26 at 2:39 AM that the nurse notified the DON that the medication was not available but did not call the physician.According to the physician (MDH H), during a phone call on 3/4/26 at 2:37 PM, no one had informed him or his associates regarding R101's Flexeril. It is considered a medication error if R101 missed a pain reliever, especially if scheduled around the clock, and the physician was not aware of it otherwise. We could have given an alternative order if the medication was not available for refill. MD H continued, and stated, Med errors must be in the logbook so we can address them immediately and assess the resident. MD H confirmed that he did not receive a call regarding R101's Flexeril. A missed muscle relaxer should have been called to the on-call associate to check the pain level and provide a backup if Flexeril was not available. We could have Baclofen as a temporary substitute.Medication Error #2 Fentanyl patch: R101 did not have a current physician's order:On 3/3/26 at 1:30 PM, it was observed that Nurse G was asked what the patch on R101's chest was. R101 requested that it be removed because it had been there for weeks. Nurse G consulted with the DON, and they confirmed that it was a Fentanyl patch with a date of 2/10. When asked why it was on R101 when R101 did not have an order for a Fentanyl Patch. The DON stated that she was unaware that R101 's Fentanyl patch was discontinued on 2/16/26, and it was discovered on 3/3/26 at 1:30 PM, still on R101's chest.The Director of Nursing (DON) was interviewed on 3/3/26 at 2:10 PM, re: the findings during the Med Administration:The DON stated that the night-shift nurse verbally told her that R101 was out of Flexeril but that it was too early to refill.The DON stated no. Unfortunately, a call was not made to the physician to let them know that Flexeril was unavailable and to request any further orders or instructions.The DON explained the reordering process, but it was too early to refill. They could not deliver. The DON was asked to explain what too soon means. The DON replied, My guess is they may have wasted some of the Flexeril, so they ran out. The surveyor asked: How many tablets are we talking about ? The DON counted 9 days were missing, and it is 3 tablets every eight (8) hours per day, which means 3 tablets X 9 days is equal to 27 tablets that were missing. The DON indicated that they immediately called the pharmacy at 12:20 PM on (3/3/26), and it is now scheduled to arrive tonight.The DON confirmed that the Flexeril tablet was not available for the R101, and 2 doses were missed on 3/3/26. One at 5:00 AM and another at 1:00 PM.A phone interview was conducted with the Midnight Nurse I on 3/3/26 at 2:55 PM. The DON and the surveyor were present during the call. Nurse I admitted she did not call or notify any provider regarding the Flexeril. She only called the pharmacy, and they told her, It is not due until March 11th. They have delivered 90 tablets for a 30-day supply.R101 Medication Administration Record (MAR) indicated a missed (blank) dose of Flexeril at 0500 AM on 2/23/26. R101 Pain level was recorded to be at 8/10. The facility provided the Pharmacy consultant's number on 3/4/26 at 9:24 AM, when it was requested on 3/3/26. The Pharmacist stated that:1. Re: R101's Fentanyl patch found on her body. There was no active order for the Fentanyl Patch; the patch should have been discontinued, as it could have a reaction with other current medications.2. The surveyor asked the pharmacist what happens if the Fentanyl Patch has been on the resident since it was discontinued on 2/16/26.Reply: The pharmacist stated that after 48 hours, the ingredients are not as potent as the actual dosage.3. The pharmacist explained why Flexeril is not available:The surveyor asked, Why is Flexeril not in the pharmacy back-up list?The pharmacist replied: The facility will let us know what they want in their backup box. If they didn't ask for Flexeril to be there, we don't put it there.Explain what too early to fill means? What happened with R101's Flexeril? Too early to fill- (approx., 10 days missing (q 8 hours). According to the pharmacy record, the pharmacy dispensed a 30-day supply on [DATE]; therefore, there should be enough Flexeril to take 3x a day until March 11th. Insurance will not cover the medications that are too early. Our policy is for the facility to authorize an early fill, such as the DON.Is missing 2 doses of Flexeril 10 mg a medication error? Yes, if it is a doctor's order as scheduled pain relief/ pain management medication.What should the facility do when the scheduled medication runs out? Is there a Policy? Policy is to inform the Pharmacy and authorize a drop ship based on the number of days until the refill. Informing the Pharmacy of errors like this can help track any discrepancies or diversion.What time was the Flexeril delivered at the facility on 3/3/26 for R101? The pharmacist stated it was not delivered until 6:42 AM on 3/4/26.Policies were reviewed on 3/3/26 at 4:30 PM:The Pharmaceutical Policy entitled: Organizational Aspects: IA1: Provider Pharmacy Requirements (dated November 2020)Policy: Regular and reliable pharmaceutical services are available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies. A written agreement with a provider pharmacy stipulates financial agreements and the terms of the services provided. If the provider pharmacy also provides consultant pharmacist services and/or infusion therapy products, Separate contracts/ agreements are maintained for each service Procedures: . D. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to:11. Implement procedures for when medication delivery is delayed or medications are not available.12. Providing, maintaining. and replenishing an emergency medication supply in a sealed and properly labeled container in a timely manner.Policy: Preparation and General GuidelinesIIA2: Medication Administration-General Guidelines:Policy Medication is administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system, to ensure safe administration without unnecessary interruptions.Procedures:A. Preparation: .4. 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 .B, Administration .2. Medications are administered in accordance with written orders of the prescriber

This citation pertains to Intake Number 2792791.Based on observation, interviews and record review, the facility failed to protect the resident's right to be free from physical abuse for one resident (Resident #102) by another resident (Resident #103), who attacked the resident at the dining room of nine (9) residents reviewed for abuse, resulting in a skin tear to R102's right hand and possible infection of the open wound. Findings include:According to the facility's incident report dated 2/14/26 at 2:30 PM, a female resident (R102) from 100 Hall was seated in her wheelchair in the dining room. Resident #103 (R103) approached and began to push the resident's wheelchair. The resident (R102) extended her right hand and asked R103 to stop. At that time, R103 reached toward the resident's (R102) right hand and grasped the top of her hand, resulting in a skin tear to the dorsal (top) right hand. During the same timeframe, R103 was observed grabbing and shaking other residents' wheelchairs in the dining room area. No additional injuries were noted.Seven (7) staff members statements were obtained by the facility, and all 7 indicated that the event was unwitnessed.Nurse D stated during the facility investigation that the phone call statement was written on 2/16/26: I did not see the incident between R103 and R102, CNA C came to get me and said R102 was bleeding. When she approached R102, R103was in his room. I assessed R102's bleeding hand.Nursing Assistant C (CNAC) during the facility phone call statement dated 2/16/26, was reviewed. CNA C statement revealed, I did not see the incident happen. Shortly before dinner, R102 was in the Dining Room and called for help. I went to go help. I saw R103 in his wheelchair next to R102. She had a skin tear on her hand. I redirected R103 back to his room and notified the nurse (Nurse E).Nursing assistant F (CNA F) during the facility phone call statement, dated 2/16/26, revealed I didn't witness or hear the incident. I saw R102's hand bleeding and held a wet washcloth on it until the nurse arrived.An interview with R102 was conducted on 3/2/26 at 1:15 PM. R102 had told the surveyor the story when she was attacked recently by a person who lives in the building. When she was asked what happened to her hand? She immediately stated, That the man stabbed me, and caused a skin tear on her right hand. R102 showed her right hand with a dressing dated 3/1/26. R102 described the details of the encounter, which she said was unexpected. When R102 was asked how the man stabbed him? She yelled, He dug his fingers between my thumb and index finger, and it hurts. R102 expressed that she does not feel safe, and the facility is not doing anything because the man continues to live here and can hurt me again or others. That's why she is staying in her room, because it is where she feels safe. R103 denied feeling safe in the facility after the incident. She is afraid it will happen again, and if it does, she will fight back.Resident #102 (R102):According to the Electronic Medical Record (EMR), R102 was admitted to the facility on [DATE], with the diagnoses of muscle weakness (generalized), need for assistance with personal care and difficulty walking, major depressive disorder, and type 2 diabetes mellitus with unspecified complications in addition to other diagnoses. According to the BIMS assessment dated [DATE], R102's Brief Interview for Mental Status (BIMS) score was 11/15. A BIMS score of 11 indicates moderate cognitive impairment. The Minimum Data Set (MDS) dated [DATE] revealed that R102 is independent with eating, requiring setup for personal hygiene and supervision during transfers. R102 is frequently incontinent with bladder elimination pattern and occasionally incontinent with bowel movement.An interview with R103 on 3/2/26 at 3:53 PM. R103 denied recalling any incidents with another resident. When R103 was asked if he felt safe in the facility, R103 asked the question back and said, Do you?Resident #103 (R103):According to the Electronic Medical Record (EMR), R103 was admitted to the facility on [DATE] with the diagnosis of Type 2 diabetes mellitus, dementia, psychotic disorder with delusions, mood disorders, and generalized anxiety disorder. R103's care plan specific for behavior revealed that R103 can be combative at times, wandering at other residents' rooms.hitting out at other residents. The care plan initiation date was 10/21/2025, and although the revision date was noted on 2/18/26, it did not include a specific action to manage his combativeness and protect other residents from harm or injury. Care plan continued as, Goal: The resident will have no evidence of behavior problems by review date. The date the goal was initiated was 10/21/25. Revision date was 11/24/25. Interventions were: 1. Caregivers to provide an opportunity for positive interaction with him/her as passing by. Date initiated: 10/21/25. Created on 10/21/2025.R103's behavior care plan was not updated following the resident-to-resident altercation on 2/14/2026. The goal and intervention remained unchanged despite an actual incident with another resident. No intervention added.An interview with the wound nurse on 3/3/26 at 10:55 AM confirmed that she saw the wound during wound rounds on 2/16/26. See assessments belowWound assessment#1 dated 2/16/26, (no time specified). First assessed as a new wound: Right Hand skin tearOnset date: 2/14/26Presence of pain: YESMeasurement:Length: 1.9 cmWidth: 2.31 cmArea: 2.94 cmLight Sanguinous drainage Wound Assessment #2 dated 2/25/26 (no time specified) most recent assessment showedLength: 1.79 cmWidth: 1.71 cmArea: 2.13 cmLight, Serosanguinous drainageWound observation was conducted with the wound nurse on 3/3/26 at 10:45 am. R102 stated the wound still hurts. When the wound dressing was removed, a moderate amount of serosanguinous drainage was noted on the old dressing. The wound nurse cleansed the wound, applied treatment, and covered the wound with the dry dressing as ordered.During the Social Worker A interview on 3/3/26 at 11:45 AM, SW A denied that R102 expressed fear or felt unsafe during her visits with her. However, when we both entered R102's room at approximately 11:50 AM on 3/3/26, R102 expressed that she was angry that the man was still roaming the facility and worried that it could happen to her again. R102 stated that she feels unsafe outside her room, and if the man (R103) comes near, she has a plan to fight back. R102 also mentioned only one staff member, whom she trusted and felt would protect her, but the nursing assistant was off that day.The Director of Nursing DON was interviewed on 3/2/26 at 3:00 PM. The DON admitted that there were no witnesses to the incident; however, everything was captured in the camera until the two residents were separated. That was how they were able to account the date and time it happened and what actually happened. Staff responded to the commotion and R102 screaming. We informed their guardian/POA immediately and treated R102's wound.Administrator interviewed on 3/2/26 and stated that the Resident-to-Resident Altercation between R102 and R103 was reported to the state, and we have concluded that in our 5- day report that the Physical altercation was substantiated.Abuse Policy was reviewed on 3/3/26 at 4:00 PM.According to the facility policy entitled: Abuse Prevention and Reporting Abuse (undated) Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. This includes corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms.The facility's Residents Rights Policy (undated) was reviewed on 3/3/26 at 4:30 PM.The policy indicated: It is the facility policy to implement procedures to protect resident rights.Resident Rights specifies: What are my rights in a nursing home?Be Free from Abuse and Neglect: You have the right to be free from verbal, sexual, physical, and mental abuse. Nursing homes can't keep you apart from everyone else against your will. If you feel you have been mistreated (abused) or the nursing home isn't meeting your needs (neglect), report this to the nursing home, your family, your local Long-Term Care Ombudsman, or State Survey Agency. The nursing home must investigate and report all suspected violations and any injuries of unknown origin within 5 working days of the incident to the proper authorities.

Based on observation, interview, and record review, the facility failed to 1) Have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the residents in the facility; 2) Complete routine resident and staff Infection Surveillance, including audits/environmental rounds, analyze data for trends and report findings and 3) Ensure the appropriate use of Personal Protective equipment, per Standards of Practice, which could lead to an outbreak of infectious organisms, and illness. Facility Infection Control On 9/09/2025 at 10:48 AM during an interview with IP/Infection Preventionist “H”, she said she was new to the role. She started in December 2024 and completed the CDC/Center for Disease Control and Preventions Certificate training course for Long Term Care/LTC on 4/6/2025. When asked to review the Infection Surveillance data for the prior year, September 2024 through September 2025, The IP “H” said she began collecting Infection Surveillance in April 2025, and surveillance prior to that was completed by someone else. During the interview with IP “H” on 9/9/2025 at 10:48 AM, it was noted that the Infection Surveillance for July 2025 with line listings, analysis and reporting, (to track resident infections, review data for trends and report findings to aid in preventing the development and spread of infection) was completed, but there was no additional monthly Infection Surveillance for the year with line listings, analysis and reporting per the following: October 2024, November 2024 and December 2024 was identified to have some Infection surveillance line listings, but no summary/analysis. January 2025, February 2025, March 2025, April 2025, May 2025, June 2025, did not have line listings, analysis or reports. Some months had individual Infection worksheets for some residents and some months had nothing. August 2025, no September 2025 surveillance data, no line listing, some resident surveillance, no summary report, no antibiotic stewardship reporting for months without Infection surveillance. There was limited staff surveillance for infections, beginning May 2025. On 9/9/2025 at 11:30 AM, the Infection Preventionist “H” was interviewed about the months with no Infection Surveillance data over the past year and she said that is how it was when she started in the role, and she was trying to learn, and July 2025 was the month she had the most up to date information. She said she was working on audits, but the audits were not in writing. She said she began Hand hygiene, PPE use, pericare education in August 2025. She said she began attending the QAPI/Quality Assurance Process Improvement meetings in June 2025 and started reporting at QAPI. During the interview with the IP “H” on 9/9/2025 at 11:45 AM, identified issues with environmental cleanliness during the survey was discussed, including cleanliness issues from a lack of cleaning found in resident rooms and in the building. The IP “H” said she wasn't performing environmental rounds but planned to start. She said she was not aware of the residents', families and visitors' complaints of uncleanliness in the building, including the 100 Hallway. Also, during the interview, IP “H” was asked what she had identified as an issue based on her Infection Surveillance, and she said “UTI's” (urinary tract infections). She said she had 2 residents with the same Multi-drug-Resistant Organism/MDRO of ESBL E.coli. Both residents resided on the same hall/100 and both residents had concerns with their bathroom and rooms not being routinely cleaned or disinfected. The IP “H” referenced Resident #22 as having ongoing UTI's. When asked about Infection Surveillance, she said she only had the July 2025 information. IP “H” also said Resident #3 was identified to have the ESBL E. coli in her urine identified in July 2025, there had not been monthly Infection Surveillance prior to this. A review of the July 2025 Infection Surveillance data revealed Resident #67 was transferred to the hospital on 6/30/2025 and readmitted on [DATE] with diagnoses UTI (7/1/2025) and sepsis (systemic infection response). Resident #67 was initially admitted to the facility on [DATE] prior to the discharge to the hospital with a change of condition. IP “H” confirmed the facility had not been continuously monitoring Infection Surveillance during Resident #67's stay at the facility. Resident #67 also resided on the 100 hall. A review of the facility policy titled, “Infection Surveillance,” dated 10/2014 and reviewed 12/21 provided, “Guideline: Surveillance of infection swill be completed to calculate baseline rates, detect outbreaks, track progress and determine trend to assist in preventing the development or spread of infections. The goal is to minimize the number of infections and to identify behaviors or environmental factors that may warrant further evaluation… Infection prevention will review the Infection Surveillance data to identify trends and outbreaks at least monthly. IP will conduct surveillance at least once per week. Monthly environmental rounds and review of physician orders for antibiotics and laboratory results should be included…” On 09/03/2025 at 7:11AM during the initial kitchen tour, observed dead end plumbing near the coffee machine. The dead-end plumbing was a water line with an attached backflow preventer for beverage machines. On 09/03/2025 at 8:36 AM record review of the facility's Water Management Plan is missing the following: a description of the building water system with both a text and flow diagram. The last Legionella meeting inside the Water Management Plan binder is dated 2/21/18. On 09/03/2025 at 8:51AM-9:25AM conducted interview with the Director of Maintenance F on chlorine residual testing, and he stated that chlorine residual is completed on site on a weekly basis. On 09/03/2025 at 8:51AM-9:25AM record review of the chlorine residual and water temperature log provided by the Maintenance Director F, there are several empty lines in the chlorine residual and the water temperature columns for Van Gogh room [ROOM NUMBER], [NAME] room [ROOM NUMBER], and [NAME] room [ROOM NUMBER]. Several of the chlorine residual are recorded to be very high at 116.2 111.2 and 77ppm. Conducted interview with the Maintenance Director F on the extremely high chlorine residual results and he stated that the water temperatures and chlorine residual must have been switched around. According to the Centers for Disease Control and Prevention, Controlling Legionella in the Potable Water System dated January 3rd, 2025, Ensure disinfectant residual is detectable throughout the potable water system. and Eliminate dead legs, which are sections of no- or low-water flow. Resident #70 R70 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include dysphagia, heart failure, cerebral infarction and hemiplegia and hemiparesis. On 09/05/2025 at 9:56AM, it was observed that R70 is in enhanced barrier precautions related to their enteral tube. Licensed Practical Nurse (LPN) A was performing medication administration for R70. LPN A was observed not applying the proper personal protective equipment (PPE) for the clinical situation. LPN A applied gloves only. LPN A performed medication administration for R70 and exited the room upon completion. Upon exiting the room LPN A was asked if they should have applied PPE prior to administering medication for this resident? LPN A stated, yes, I should have applied a gown in addition to my gloves, prior to administration of the medication. LPN A' was asked why they didn't apply the proper PPE. LPN A stated, I just forgot, it was an oversight. On 09/05/2025 at 10:30AM, record review revealed a physician's order that read, Maintain enhanced barrier precautions to prevent infections r/t enteral feeding tube/history of klebsiella pneumoniae and ecoli, dated 09/02/2025.

Based on observation and record review, the facility failed to ensure that the appropriate backflow prevention was installed on cross connections. This deficient practice increases the likelihood of contamination of the water supply due to a backflow event, potentially affecting all residents, staff, and visitors who consume water at the facility.Findings include: On 09/03/2025 at approximately 7:25 AM, observed a hose attached to a spigot without a hose bib vacuum breaker located in the [NAME] sub kitchen. On 09/03/2025 at approximately 9:15 AM, observed a chemical dispenser attached to a utility sink downstream of an atmospheric vacuum breaker (AVB) without a wasting tee, located in the janitor's closet in 300, 200, and 100 hallways. According to the 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).According to the 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.

Based on observation, interview, and record review, the facility failed to properly dispose of waste and maintain dumpster area to mitigate the presence of insects and rodents, potentially affecting all residents, staff, and visitors in the facility.Findings include:On 09/03/2025 at approximately 8:51 AM -9:25 AM, during the environmental tour with the Maintenance Director F, observed a McDonald's wrapper, multiple dirty gloves, the cement surrounding the dumpster visibly soiled with dark waste, and the lid was open on one of two dumpsters. On 09/03/2025 at approximately 8:51-9:25AM conducted interview with Maintenance Director F on the cleaning schedule for the dumpsters, and he stated that because of the holiday weekend, they've been falling behind, but the dumpster area is usually cleaned every other day. According to the 2022 Food Code, 5-501.115 Maintaining Refuse Areas and Enclosures A storage area and enclosure for refuse, recyclables, or returnables shall be maintained free of unnecessary items.

Based on observation and interview, the facility failed to ensure that medications and supplements were labeled, stored and disposed of properly, resulting in expired supplements in the medication room, expired over the counter medication and loose and unlabeled medications in the medication carts.Findings include:On 09/05/2025 at 11:15AM, observation of the main hall medication storage room revealed the following expired item: - Three expired bottles of Jevity 1.5, the information on the bottle read, use before 9/1/25. These findings were verified with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) B. The DON disposed of the expired items. On 09/05/2025 at 12:23PM, observation of the 200 hall medication cart revealed the following expired item:- One bottle of Vitamin B-12, expired on 08/2025. This finding was verified with LPN C, LPN C stated they would dispose of the expired over the counter medication immediately. On 09/05/2025 at 12:30PM, observation of the 100 Hall Med Cart revealed the following findings:- Two medications (Hydroxyzine and Sertraline) sitting in the top drawer, they had no resident name on them.- One loose pill.These finding were verified with Registered Nurse (RN) C. RN C was asked about the unlabeled medications located in the cart medication cart. RN C stated, they were medications that were left over from last night. They belong to R21, but we no longer have a need for them since the medications came in from pharmacy. RN B was asked about the loose pill that was in the cart. RN B stated, That pill is a baby aspirin, I usually keep this cart pretty clean, I am not sure how it got there. RN B was observed disposing of the medications immediately. Review of the policy titled, Medication Storage in the Facility, revealed: Policy:Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures:C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label.H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedure for medication disposal and reordered from the pharmacy if a current order exists. Expiration Dating:G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner.

This Citation Pertains to Intake Number 2586675. Based on observation, interview and record review the facility failed to review and revise Care Plans to ensure a resident-centered comprehensive care plan for four residents (#21, #22, #60 and #67) of 40 residents reviewed, resulting in the residents (#21, #22, #60 and #67) lacking a Care Plan with resident specific interventions. Resident #21 Accidents Falls A record review of the Face sheet and electronic medical record indicated Resident #21 was admitted to the facility on [DATE] with diagnoses Dementia mood disturbance with anxiety, and weakness. Per the progress notes, Resident #21 was receiving Hospice services.On 9/03/2025 at 10:03 AM, Resident #21 was observed in the hallway with her legs hanging over the side of a broda chair. She was leaning forward and trying to move the chair. Nurse Aide M approached the resident and was asked if the resident was trying to get up out of the chair and she stated, Yes. She said the resident repeatedly tried to stand and they would try to lay her down and she would not stay in bed. A record review of the progress notes identified the resident had 2 recent falls on 8/29/2025 and 8/23/2025. Further review of the progress notes identified the following: 8/22/2025 at 22:58 PM, a Behavior note Resident is restless, unable to relax, sit still or sleep. Keeps trying to walk. 8/23/2025 at 12:20 PM, a Health status/Progress note, Resident was observed on floor of her bathroom on her left lateral thigh and hip, left hand was on the floor. She yelled help . It appears she was attempting to pull her pants up. Frequently incontinent, although will go on toilet if prompted. 8/25/2025 at 5:33 PM, a Behavior note, Resident found out of her w/c (wheelchair) without assistance @ around 1030. Was assisted back into her chair by writer. Resident also had to be redirected multiple times during shift to not get out of w/c without assistance (she was stopped multiple times by various staff as she was sliding forward in w/c seat. 8/29/2025 at 3:59 PM, a Health Status/progress note, Resident observed on floor in bathroom crying out for help. Resident was in bed prior to incident. Resident self-transferring without assistance. A review of the Incident and Accident Reports for Resident #21 revealed the times of her falls were: 8/23/2025 at 11:00 AM and 8/29/2025 at 9:45 AM. A review of the Care Plans for Resident #21 identified the following: The resident has a behavior problem r/t (related to) calling out at night, attempting to self-transfer, yelling at staff, resistive to care at times, date created and initiated 7/31/2025 and revised 8/26/2025 with one Intervention dated 7/31/2025, Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her (did not specify this was a her) as passing by. There were no additional interventions related to the resident wanting to stand, walk and go into the bathroom. Potential for falls, Resident at risk for injury from falls. Weakness, Unsteady Gait, Poor safety awareness/impulsiveness, date created, initiated and revised 7/29/2025 with new Interventions: Hospice to complete med review to address increased restlessness, date created and initiated 8/26/2025 and Offer toileting after breakfast, date created and initiated 9/2/2025. The ADL, Care Plan said, Toileting or check and change every 2 hours and (as needed). The progress notes indicated Resident #21 was attempting to toilet herself on several occasions. There was no specific plan for toileting until 9/2/2025 and the resident had fallen twice. A review of the physician orders indicated Resident #21 began receiving Ativan 0.5 mg tab two times a day as needed on 8/12/2025 for anxiety. This was not mentioned on the Fall Care Plan, Behavior Care Plan or other Care Plan. The resident continued receiving the medication through 8/28/2025. On 8/27/2025 the Controlled Substance Proof of Use document indicated the resident received the medication 3 times in the same day: 7:00 AM, 3:00 PM and 9:00 PM. This was more than was ordered. On 9/5/2025 at 9:20 AM Resident #21 was observed in hallway in the Broda chair, smiling, alert. The CNA said the resident was doing good today, had a bad day yesterday, yelling, trying to stand from chair, would not lay down in bed. Resident #22 Urinary Catheter or UTI A record review of the Face sheet and electronic medical record/emr indicated Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Multiple sclerosis, gait abnormality/stiffness, neuromuscular bladder dysfunction, history of urinary tract infections, glaucoma, and anxiety. The resident had a Brief Interview for Mental Status/BIMS score of 15/15 indicating full cognitive abilities. The resident needed some assistance with care. On 9/03/2025 at 10:20 AM, Resident #22 was observed lying in bed, she said she was taking an antibiotic for a urinary tract infection/UTI. She said she used a straight catheter by herself, as she could not urinate otherwise. A review of the physician orders revealed the following: Patient completes self-catheterization, Skilled nurse to educate and monitor patient ability and hygienic efforts, every shift, dated 8/18/2025. Skilled nurse to encourage and offer patient iodine swabs or antiseptic wipes for self-catheterization, document compliance and (acceptance), every shift, dated 8/18/2025. Maintain enhanced barrier precautions to prevent infections r/t history CDC targeted MDRO (multi-drug-resistant organism) ESBL (extended spectrum beta-lactamase producing)/E.coli, every shift, dated 8/19/2025.In addition, the physician orders identified the resident was currently being treated for a urinary tract infection/UTI and had a history of repeated UTI's. A review of the Care Plans for Resident #22 identified the following: I have potential for infection, complications r/t my dx (diagnosis) of urinary retention, Neurogenic bladder, I require SC (straight catheterization). I have MS, date created and initiated 11/28/2018 and revised 5/15/2019 with Interventions including: Intermittent catheterizations completed by guest, dated initiated and created 11/28/2018 and revised 6/18/2020; Remind resident to clean area prior to catheterization, date created and initiated 3/2/2023. Resident completes self-catheterization r/t neurogenic bladder, date created and initiated 7/14/2025 and revised 9/4/2025 with Interventions all dated 9/4/2025. I require enhanced barrier precautions r/t CDC targeted MDRO ESBL E.coli and Self catheterization, date created and initiated 5/31/2024 and revised 8/19/2025. Resident has: UTI/E.coli requiring Contact Precautions until antibiotics are completed on 9/11/25; 24 hours after d/c (discontinue) isolation, Resume enhanced barrier precautions after Contact is completed, date created and initiated 8/18/2025 and revised 9/9/2025 with no interventions. (Resident #22) is prescribed antibiotics for a UTI, dated created and initiated 6/18/2024 and revised 9/2/2025. The Care Plans did not mention the size, or any specifics of the Straight catheter Resident #22 was to use. There was no mention of how many times the catheter could be used to prevent the spread of infection, as the resident had ongoing UTI's with Multi-drug-resistant organisms. There was mention of cleansing the area but did not mention exactly what area. There was no mention of hand hygiene to prevent the spread of infection for Resident #22. The Care Plans did not provide resident specific interventions to aid in preventing further UTI's. Resident #60 Accidents Falls A record review of the Face sheet and electronic medical record/emr revealed Resident #60 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Dementia, anxiety, hypothyroidism, chronic kidney disease, and heart disease. The resident had severe cognitive loss and needed assistance with all care. A record review of the progress notes indicated Resident #60 had a fall beside her bed on 8/9/2025 at approximately 2:05 AM. The resident sustained an abrasion on her left elbow. A review of an Incident and Accident Report dated 6/22/2025 at 11:45 PM the resident was observed on the floor by her bed. She sustained redness to her left forehead, and right knee and a skin tear on her left hand. A review of the Care Plans for Resident #60 identified the following: At risk for falls r/t confusion, gait/balance problems, incontinence, poor communication/comprehension, unaware of safety needs, history of falls, cognitively impaired, medication side effects, pain, date created and initiated 4/14/2022 and revised 5/17/2024. The Care Plan was last updated 6/23/2025 Ensure resident has stuffed comfort animal within reach to prevent restlessness. The Care Plans were not reviewed or revised after the resident fell on 8/9/2025. Potential for falls, Resident at risk for injury from falls, dated created 12/21/2022, and initiated and updated 6/11/2024 with Interventions last updated 6/11/2024. Resident #67 Pressure Ulcer/Injury A record review of the Face sheet, Minimum Data Set/MDS assessment and electronic medical record/emr indicated Resident #67 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Diabetes, history of a stroke, dementia, pulmonary embolism, history of deep vein thrombosis, Parkinson's, heart failure, hypertension, Gout, depression, restless leg syndrome and pneumonia. The MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status/BIMS score of 9/15 indicating moderate cognitive decline. The resident also needed assistance with care. The resident discharged to the hospital on 8/8/2025 and did not return to the facility.The MDS section M for Skin Conditions dated 7/13/2025 revealed the resident did not have a pressure ulcer: Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device- No, was checked. The question Is this resident at risk of developing pressure ulcers/injuries? was checked Yes.On 9/09/2025 at 8:45 AM, during an interview with Confidential Person J she said Resident #67 developed 3 pressure ulcers at the facility: 1 left ear, sacrum/coccyx and left elbow. A review of the progress notes identified the following: 8/7/2025 at 3:27 PM, a Health status/progress note Left lateral elbow open area, 2cm x 1.5 cm, round/irregular shape, full thickness, with 100% firmly adherent yellow slough (dead tissue) covering wound bed, wound bed not observed. Moderate serous drainage. x2 open areas on sacrum observed, along spine: superior: 1.8cm x 1cm, thickness at least 0.1 cm, full thickness open area, oval configuration, 100% firm adherent yellow slough attached to wound bed. Inferior: 1.6cm x 0.8cm, oval configuration, thickness at least 0.1cm, full thickness open area with wound bed 50% non-granulated/adherent yellow slough. A note dated 8/3/2025 identified the resident had an open area on the left ear. A review of the Care Plans for Resident #67 identified the following: Skin: Potential for alteration of skin integrity, dated created and initiated 10/10/2024 with all interventions dated 10/10/2024, including: Check skin daily, Pressure redistribution mattress, Remind/Assist resident to reposition frequently. ADL (activities of daily living): Self-care deficit, require assist with ADL's r/t (related to) limited mobility, debility, and impaired balance, date created and initiated 10/10/2024 and revised 1/7/2025 with Interventions including: Bed Mobility: I need extensive assist of 2 to help me, dated initiated and created 10/10/2024. Potential/At Risk for alteration in skin integrity due to risk factors associated with Cognitive impairment, Immobility, date initiated 8/8/2025. The day of discharge. Alteration in skin integrity-Resident has Pressure Injury. Site: Sacrum/Left elbow, Factor that may inhibit wound healing: Immobility, Incontinence, dated created, initiated and revised 8/8/2025. The date 8/8/2025 was the day the resident was transferred to the hospital and did not return. There was no mention of the area on the resident's left ear. Per a Dietary review dated 4/23/2025 at 2:32 PM, Resident #67 had Weight loss of 10% x 5 weeks & x 5 months. A review of the Weight Summary indicated the resident had a gradual weight loss from 4/22/2025 to 8/1/2025 (10 lbs.), but had lost 70 lbs. from 10/11/2025 to 8/1/2025. The resident returned from the hospital on 7/10/2025 with a feeding tube. The resident's Care Plans were not updated to note her increased risk of skin breakdown, with her weight loss and declining condition.

This Citation Pertains to Intake Numbers 2586675 and 2594091.Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that resident rooms, bathrooms and common areas were clean, for residents on the 100 hall and for a Confidential Group of Residents on the 100, 200 and 300 halls, resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness, and Infection Control practices. Environment During a tour of the building on 9/3/2025 at 7:45 AM, there were multiple observations of unclean resident rooms on the 100 hall. Several rooms were noted to have a strong, foul odor including room [ROOM NUMBER] and #114. Many rooms were cluttered with items, including items on the floor, windowsills and other surfaces. Several Resident rooms were noted to have wastebaskets overflowing onto the floor. Resident bathrooms were noted to have large rust stains coated in the sink and toilets. Some of the toilets were also soiled with brown/gray stains and feces. Several resident rooms had uncovered toothbrushes stored on the sink and in some of the rooms 2 residents shared the same bathroom. The following resident rooms had cleanliness issues: Rooms: 101- rusty sink and toilet; 104- urine smell in room, soiled clothes on the floor, bathroom soiled rust coated sink and toilet, toothbrush bare on the sink counter; room [ROOM NUMBER]- cluttered and soiled surfaces in room and bathroom, wastebasket in bathroom overflowing; room [ROOM NUMBER]- bathroom with soiled toilet and sink, wastebasket overflowing onto floor; room [ROOM NUMBER]- soiled toilet and sink; room [ROOM NUMBER]- bathroom toilet and sink soiled. On 9/03/2025 at 9:31 AM, during an interview with a Confidential Resident, they said their room was not cleaned, very often, It's pretty good except for the commode, they don't clean it. On 9/03/2025 at 9:48 AM, a Confidential Resident was interviewed and stated, They cleaned last Wednesday or Thursday, almost a week ago. They are supposed to do it twice a week, but recently it was 2 weeks before it was cleaned. The resident said their toilet was very soiled, trash overflowing, the sink was stained dark orange from rust. Another Confidential Resident said their room was last cleaned over one week ago on Monday (in August). On 9/3/2025 at 10:14 AM, Housekeeper I and Housekeeping Supervisor F were interviewed about cleaning the residents' rooms. Housekeeper I stated, We try to take care of it the best we can. Asked about the rust soiled sinks and toilets. Housekeeper I showed the product used to clean the bathroom and it said Disinfectant, asked if it was also able to remove the stains because the bathrooms were very soiled. Housekeeping Supervisor F said he would check into it. He also said the facility had hired a 3rd housekeeper who was in day one of orientation on 9/3/2025. He said there was a total of 3 housekeepers, We do the best we can. Reviewed the observations of waste baskets not emptied, and multiple resident complaints of trash overflowing on the floors in their rooms and no trash bag in the garbage can. Also on 9/3/2025 at 8:15 AM, soiled gloves with a pink stain were observed sitting on a counter in the small dining/day room and remained for several hours; toothbrushes noted in multiple rooms laying on the bare sink surfaces uncovered and several rooms with foul odors including a strong urine smell with soiled toilet bowls. Housekeeping Supervisor F said they were going to try to fix the issues. Copies of the Housekeeping cleaning schedule was requested. On 9/4/2025 at 8:45 AM, during an interview with Confidential Person J, she said she had visited the facility to see a family member on multiple occasions and the resident's room did not appear to be cleaned very often. She said the windowsills had someone's food on them, the floors were not cleaned, and the bathroom was soiled. She said she had spoken to someone about it and the uncleanliness did not change. A review of the facility cleaning schedule titled, Housekeeping Hall schedule undated had a list for Monday-Sunday. On it there was listed halls 100, 200, 300, 500 and 700. The facility only had halls 100, 200 and 300; 500, 700 and 800 were in the Assisted Living. Per the cleaning schedule Hall 100 was to be cleaned on Monday, Wednesday, Friday and Sunday. Hall 200 was to be cleaned on Monday, Tuesday, Thursday, Friday, and Saturday. Hall 300 was to be cleaned every day. In addition, the common areas were cleaned Monday, Wednesday, Friday and Sunday. The residents' rooms were not cleaned daily and per the residents they were not always cleaned on their scheduled days. The cleaning schedule also said the housekeepers would handle the laundry on the weekends between room cleaning. There was also a list of items to be cleaned for the 200 hall (that was to be cleaned almost daily), but there was no list for the 100 Hall.

Based on observation, interview and record review, the facility failed to ensure that a wound was assessed with appropriate treatment for one resident (R6) and hospice orders were in place for two residents (R60 and R65) of three residents reviewed for quality of care, resulting in missing treatments for a wound and the absence of hospice treatment orders.Findings include: Resident #6 Skin Conditions A record review of the Face sheet and electronic medical record indicated Resident #6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Diabetes, dementia, chronic pain, arthritis, depression, and anxiety. The resident had moderate cognitive decline and needed some assistance with care. On [DATE] at 11:21 AM, Resident #6 was observed sitting on the side of the bed. She had a red, scabbed area on the tip of her nose, and a red, raw area under her lip. The resident said she rubbed them and began rubbing them. On [DATE] at 9:32 AM, Resident #6 was observed resting in bed. She was awake and a larger red raw partially scabbed area was observed on the tip of her nose approximately 0.5 cm x 0.5 cm and under her lip approximately 0.3 cm x 0.3 cm. The resident was asked if she was receiving treatment to the areas and she said she was not sure what was being done about them. A record review of the physician orders revealed an order for the resident's nose Cleanse chronic nonhealing picking wound to nose with iodine, Pat dry with gauze, apply triple antibiotic ointment and cover with a Bandaid, dated [DATE]. There was no order for the wound under the resident's lip. A review of the Medication Administration Record/MAR and Treatment Administration Records/TAR for [DATE] and [DATE] revealed a treatment was identified as completed from [DATE], to [DATE]. The [DATE] TAR had documentation on days the wound care was completed [DATE], to [DATE]. On [DATE] at 9:50 AM, Nurse D entered Resident #6's room. He said he was caring for the resident. He was asked about the resident's wounds on her face, and he said there was a treatment to her nose, and he said he had already completed the treatment that morning. There was no evidence of an ointment or Bandaid on the resident's nose. He said she probably removed it. The resident said she had not had a Bandaid that day. Nurse D was asked if there was an assessment or treatment for the area under the resident's lip and he said he did not think so. Discussed with Nurse E the wound was also present on [DATE]. He said he would request a treatment to the wound, as the resident continued to pick at the wound. A review of the progress notes indicated there was no mention of a wound beneath the resident's lip. Resident #60 A record review of the Face sheet and electronic medical record/emr revealed Resident #60 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Dementia, anxiety, hypothyroidism, chronic kidney disease, and heart disease. The resident had severe cognitive loss and needed assistance with all care. The resident was receiving Hospice services. A review of a Hospice document titled, Plan of Care Update indicated the resident was to receive Hospice services from [DATE] to [DATE] A review of the Care Plans for Resident #60 revealed there was no mention that the resident was receiving Hospice services. On [DATE] at 2:40 PM during an interview with Social Services Manager E she said Resident #60 was receiving Hospice services. Reviewed the Care Plans did not mention this and there was no order for Hospice. Social Services E said the resident had received Hospice services off and on during her stay but currently received the Hospice care. Resident #65 R65 is [AGE] years old and admitted to the facility on [DATE] on hospice care. R65 had diagnoses that included major depressive disorder, degenerative disease of the nervous system, hemiplegia and hemiparesis following cerebral infarction and aphasia following cerebral infarction. R65 expired on [DATE] in the facility while on hospice care. On [DATE] at 11:58AM, record review revealed there was no order for hospice care to evaluate and treat R65. On [DATE] at 1:11PM, an interview was conducted with the Transitional Care Coordinator (TCC) E. TCC E was asked if there should've been a physician's order for hospice to treat R65. TCC E stated, yes there should be an order for hospice to evaluate and treat R65. TCC E was asked who is responsible for entering the order. TCC E replied, I can put the order in, providers can too or the floor staff can put the order in. TCC E was asked why they thought there wasn't an order entered. TCC E replied, I believe there is a miscommunication about who is putting it (the order) in. The floor nurses can do it, I can enter it and so can providers. Then in the end it just doesn't get done.

Based on interview, and record review the facility failed to ensure residents were 1) Consistently assessed for Influenza and Pneumococcal vaccinations on admission, per Standards of Practice, 2) Provided an educational vaccination information statement for each vaccination, and 3) Documented vaccination information in the residents' medical record, which could potentially affect all residents, including Residents #27, #30, #68 and #70, reviewed for infections, resulting in the potential for exposure to Influenza and Pneumococcal disease, and severe illness. Findings include:FacilityInfection Control On 9/09/2025 at 11:25 AM, during an interview with Infection Preventionist/IP H, she was asked about resident vaccinations for Influenza/FLU and Pneumonia. She said she was currently working with a local pharmacy to implement a vaccination clinic in October 2025 to provide FLU, Pneumonia and Covid vaccinations for the residents. She said resident vaccinations were assessed on admission by the Admissions Coordinator N. The IP H said she thought the residents' received education about the vaccinations via a Vaccine Information Statement/VIS for each specific vaccination, but she wasn't sure because a different staff member Admissions Coordinator N talked to the residents on admission.The IP nurse said the residents' vaccination information was supposed to be placed in the electronic medical record, but she was unable to access the MCIR/Michigan Vaccination Portal to gather past vaccination history. She said she had recently talked to someone about getting access, but she did not have it yet. A review of the vaccination information from the electronic medical record for each resident identified the following information about vaccinations for Resident #27, #30, #68 and #70: Resident #27: there was no vaccination information for FLU, Pneumonia or Covid.Resident #30: there was no Covid vaccination information.Resident #68: there was no vaccination information for FLU, Pneumonia or Covid.Resident #70: there was no vaccination information for FLU, Pneumonia or Covid. On 9/09/2025 at 2:39 PM, Admissions Coordinator N was interviewed about resident vaccinations, and she said she informed the residents that vaccinations were offered at the facility, including Flu during flu season, shingles, Covid, Pneumonia, and RSV. When the admission Coordinator said the residents would then sign a form that they consented or declined the vaccinations. Admissions Coordinator N was asked if the residents were provided educations about each vaccination so they could make an informed decision of whether to accept or decline and she said she was not a nurse and did not provide that information. The admission Coordinator was asked if a current Vaccine Information Statement was provided for them to look over and review, she stated, I am not familiar with that (VIS). The Admissions Coordinator was asked if she had received training to talk to the residents about vaccinations and she said she had not. A review of the facility policy titled, Influenza and Vaccination, date revised 12/16/2022 revealed the policy had outdated information in it from the 2021-2022 Influenza season and did not mention providing the mandatory Vaccine Information Statement. The policy stated the consent would serve as education and once the consent was obtained a new consent was not needed every year: this contradicts professional Standards of Practice.

Based on interview and record review the facility failed to ensure resistance patterns of organisms were identified and reviewed in the antibiotic stewardship meeting, resulting in the potential exposure of infection and ineffective antibiotic use for all 52 residents in the facility. Facility Infection Control On 9/09/2025 at 10:48 AM during an interview with IP/Infection Preventionist H, she said she was new to the role. She started in December 2024 and completed the CDC/Center for Disease Control and Preventions Certificate training course for Long Term Care/LTC on 4/6/2025. When asked to review the Infection Surveillance data for the prior year, September 2024 through September 2025, The IP H said she began collecting Infection Surveillance in April 2025, and surveillance prior to that was completed by someone else. During the interview with IP H on 9/9/2025 at 10:48 AM, there was identified Infection Surveillance for July 2025 with line listings, analysis and reporting completed. There was no additional monthly Infection Surveillance for the year with line listings, analysis and reporting per the following: October 2024, November 2024 and December 2024 was identified to have some Infection surveillance line listings, but no summary/analysis for trends. January 2025, February 2025, March 2025, April 2025, May 2025, June 2025, did not have line listings, analysis or reports. Some months had individual Infection worksheets for some residents and some months had nothing. August 2025, no September 2025 surveillance data, no line listing, some resident surveillance, no summary report, no antibiotic stewardship reporting for months without Infection surveillance. On 9/9/2025 at 11:30 AM, the Infection Preventionist H was interviewed about the months with no Infection Surveillance data over the past year and she said that was how it was when she started in the role. The IP H was asked how she could track antibiotic resistance if there was no Infection Surveillance data that included infectious organisms, and infections and she said she couldn't. She said she could report antibiotic use, but there was no additional data related to what organisms or infections they were treating, if there were resistant organisms such as Multi-drug-resistant-organisms/MDRO's, if the antibiotics were appropriate or if there were any trends related to the infections.A review of the facility policy titled, Antibiotic Stewardship, dated 8/2018, revised 8/2021 and reviewed 8/2025 provided, Policy: It is the policy of (the facility) to maintain an Antibiotic Stewardship Program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use.

Based on interview and record review, the facility failed to ensure Code Status was accurately documented and accessible in the medical record Care Plan for one resident (#21) of 1 reviewed for Advance Directives, resulting in the potential for miscommunication of code status which could lead to a lack of appropriate interventions for care.Resident #21 Advance Directives NotesA record review of the Face sheet and electronic medical record indicated Resident #21 was admitted to the facility on [DATE] with diagnoses Dementia mood disturbance with anxiety, and weakness. Per the progress notes, Resident #21 was receiving Hospice services.A review of the Face sheet for Resident #21 identified, Code Status: (Advance Directives)- Code Status: DNR. A review of the Documents section of the electronic medical record identified an assessment form titled, Code Status Form for Resident #21. Do-Not-Resuscitate was checked and further provided, Patient Advocate Consent/Guardian Consent: I authorize that in the event the declarant/resident's heart and/or breathing should stop; no person shall attempt to resuscitate the declarant/resident. signed by the resident's Responsible Party on 7/31/2025. The physician signed the document on 8/7/2025. A record review of the physician orders for Resident #21 identified, Code Status: DNR (do not resuscitate) . dated 8/6/2025. A review of the Care Plans for Resident #21 identified the following: I am a Full Code, date initiated and created 7/31/2025. The Care Plan contradicted the resident's wishes to not receive resuscitation. On 9/04/2025 at 11:07 AM, Social Services Manager E was interviewed about the Code Status for Resident #21 identifying an assessment for DNR, the Face Sheet said DNR, the physician orders dated 8/6/2025 said DNR and the Care Plan for Resident #21 said Full Code. The Social Services Manager said the resident's Care plan was updated to DNR on this day 9/4/2025; almost 1 month after her Code status was ordered and over 1 month since her responsible party signed the DNR assessment form. The Social Services Manager said the Care plan was wrong and had been missed. A review of the facility policy titled, Advance Directives Policy, dated 6/2005 and reviewed 8/25 provided, General: When a resident is admitted to the facility, a discussion of advance directives will take place between the resident or family/resident representative, if the resident is incompetent, and the facility staff. This enable the staff to readily and clearly ascertain how to treat the resident in advance of an emergency.

Based on observation, interview, and record review, the facility failed to provide appropriate supervision and revise the care plan to prevent falls for one resident (Resident #7) of three residents reviewed for falls and accidents. Findings include:Resident #7 (R7)According to the review of Resident #7's clinical record, on 9/3/2023 at 1:30 PM, R7 was [AGE] years old, admitted to the facility on [DATE], with the primary diagnosis of generalized muscle weakness and difficulty walking, dementia with obsessive compulsive disorders, mixed anxiety disorders, in addition to other diagnoses. and major depressions in addition to other diagnoses.Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 05/15. A score of zero to 07 means that the person has severe cognitive impairment. R7's Section GG of the same assessment date, 7/24/2025, indicated that R7 was dependent on all ADLs (hygiene, showers, and dressing) except for eating. R7 required supervision or touching assistance with eating. R7 is dependent on staff for all transfers and mobility, utilizing a wheelchair for mobility/ambulation. R7 was not assessed for standing nor attempted walking with or without staff assistance on July 24, 2025. The MDS dated [DATE], revealed she was always incontinent for both bowel and bladder elimination patterns.R7's Care plan reviewed on 9/9/25 at 12:01 PM, revealed: 1. Activities of Daily Living (ADL) Care plan was created on 9/19/22 related to Impaired balance. Interventions:Toilet Use- R7 required extensive assistanceTransfers: requires one person, extensive assistanceBed Mobility: requires one person or extensive assistance to help with bed mobilityAmbulation in therapy only, and R7 is working with Occupational Therapy OT to increase independence ( No specific ADL task was noted)2. R7's Incontinence care plan was noted to remain coded as occasionally incontinent. It was not updated or revised since April 3, 2025, when Section H of the MDS specified that R7 was always incontinent for both bowel and bladder elimination patterns as of the June 24, 2025, assessment date.R7 was noted in the incident report to be found incontinent after she fell on 8/24/25. 3. R7's Potential for Fall's Care plan initiated on 5/07/2025 revealed, Potential for falls, Resident at risk for injury from falls was initiated on 9/19/2022 and last revised on 5/7/2025. The goal is to reduce the likelihood of residents experiencing a fall by the next review. There were no revisions or updates despite R7's fall on 8/24/25, noted. The Care plan remained Potential for Fall even if R7 had an actual fall with a minor physical injury.4. R7's Impaired Cognitive function related to dementia Care Plan Interventions/Actions was not updated according to R7's BIMS Score was five as of 7/15/2025 MDS assessment.On 09/03/3035 at 8:09 AM, the surveyor approached R7 in the dining room, sitting alone by the table. R7 was talking to herself and was not coherent with the questions asked by the surveyor. The surveyor observed bruising with dark brown, black, and purple in color found on the right forehead, around the right eye, and some on her cheek and face (right sided). Unit Manager Nurse B at the dining room area, when asked about the incident, revealed that R7 had recently fallen and was sent to the hospital. R7 did not appear in pain nor was in any signs of distress.A review of the facility Incident Report dated 8/24/25 at 14:10 (2:10 PM) revealed, Nursing Description: Patient was observed on the floor lying next to the bed. Patient was transported to the hospital by EMS (ambulance), and has a hematoma on the right forehead. Predisposing Physiological Factors: Confused and incontinent. Other information: The resident was seen within 2 hours before the fall. She was wheeled back to her room after lunch and requested to go back to bed. Call light within reach.The facility incident report provided no indication or mention of R7 being toileted from lunch in the dining room to being put into bed by her aide.According to the Incident Staff (written) Statement dated 8/24/25 at 2:20 PM. Type of Incident: Fall. Staff G wrote: I did not witness the incident. Observe the resident on the floor next to her bed. Had a lump on her forehead. Called the nurse for help. Last saw resident (R7) was when I assisted the resident back to her room and placed her in bed per her request. Placed call light within reach at about 1:30 PM.Staff G written statement did not indicate that she had toileted R7 between the time she was at the Dining room for lunch and the time she was placed in bed. Staff G had mentioned in writing that R7 went to the hospital immediately.During the interview with Nurse H on 9/9/25 at 10:25 PM, she explained that R7 fell a couple of weeks ago, which caused her to have a bruise on her head. R7's fall was unwitnessed and was confused (BIMS was 5/15). R7 was transferred to the hospital because she sustained a hematoma on her right forehead and was unable to give an accurate account of what happened. When Nurse H was asked where the call light was for R7, she was sitting out in a hallway. Nurse (-) stated that R7 does not use the call light, so we keep an eye on her and anticipate all her needs. R7 does not have a pressure sore or ulcer currently. The facility's Hospital Transfer Record dated 8/24/24 at 14:10 (2:10 PM) revealed: Patient was observed on the floor, lying next to the bed. Patient has a hematoma on the right forehead. Vitals were obtained, Blood Pressure (BP) =133/81, Pulse (P) =61, Patient c/o (complained of) headache pain.Services that will be provided at the new facility: Further treatment for hematoma on the patient's right forehead related to (r/t) Patient being observed on the floor.A review of the Hospital record dated 8/24/25, R7 was diagnosed and treated for a head injury. A CT scan of the Brain without contrast was performed at the hospital on August 24, 2025. The results revealed, Clinical History: Trauma, [NAME]: Intact. Additional Findings: Large Right Frontal Scalp Hematoma seen. The Emergency Department (ED) Patient Discharge summary dated [DATE] was reviewed. Discharge instructions were given for Adult Head Injury.Fall Management Policy was reviewed on 9/9/25 at 12:20 PM. Policy: This facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.Fall Prevention Guidelines: 3. The care plan will be reviewed following each fall, quarterly, annually, and when a resident is triggered for a significant change in MDS.

Based on interview, and record review the facility failed to ensure that residents were 1) Consistently assessed for Covid-19, per Standards of Practice, 2) Provided an educational vaccination information sheet for each vaccination, and 3) Documented vaccination information in the residents' medical record, which could potentially effecting all residents, including Residents #27, #30, #68 and #70, reviewed for vaccinations, resulting in the potential for exposure to Covid-19 and severe illness. FacilityInfection Control On 9/09/2025 at 11:25 AM, during an interview with Infection Preventionist/IP H, she was asked about resident vaccinations for Influenza/FLU and Pneumonia. She said she was currently working with a local pharmacy to implement a vaccination clinic in October 2025 to provide FLU, Pneumonia and Covid vaccinations for the residents. She said resident vaccinations were assessed on admission by the Admissions Coordinator N. The IP H said she thought the residents' received education about the vaccinations via a Vaccine Information Statement/VIS for each specific vaccination, but she wasn't sure because a different staff member Admissions Coordinator N talked to the residents on admission.The IP nurse said the residents' vaccination information was supposed to be placed in the electronic medical record, but she was unable to access the MCIR/Michigan Vaccination Portal to gather past vaccination history. She said she had recently talked to someone about getting access, but she did not have it yet. A review of the vaccination information from the electronic medical record for each resident identified the following information about vaccinations for Resident #27, #30, #68 and #70: Resident #27: there was no vaccination information for Covid.Resident #30: there was no Covid vaccination information.Resident #68: there was no vaccination information for Covid.Resident #70: there was no vaccination information for Covid. On 9/09/2025 at 2:39 PM, Admissions Coordinator N was interviewed about resident vaccinations, and she said she informed the residents that vaccinations were offered at the facility, including Flu during flu season, shingles, Covid, Pneumonia, and RSV. When the admission Coordinator said the residents would then sign a form that they consented or declined the vaccinations. Admissions Coordinator N was asked if the residents were provided educations about each vaccination so they could make an informed decision of whether to accept or decline and she said she was not a nurse and did not provide that information. The admission Coordinator was asked if a current Vaccine Information Statement was provided for them to look over and review, she stated, I am not familiar with that (VIS). The Admissions Coordinator was asked if she had received training to talk to the residents about benefits and risks of vaccinations and she said she had not.

Based on interview and record review, the facility failed to ensure PASARR assessments were completed yearly and posted into the residents' clinical record for two residents (R#7 and R#10) of 3 residents reviewed for coordination of PASSAR and Assessments.Findings Include:On 9/4/25 at 2:30 PM, a review of R7's Pre-admission Screening and Resident Review (PASARR) was conducted. It revealed that R7 did not have one on file for 2025. The last PASARR in R7's File was dated7/3/2024. No other PASSAR Forms were found in R7's Electronic Medical Record. On 09/04/2025 2:58 PM, R10's PASARR was reviewed. An outdated Level I PASARR was found dated 12/20/2021. Another outdated PASSAR Level I and Level II dated August 16, 2024, was found. There was no assessment dated 2025 posted. The social worker (SW) was interviewed on 09/04/25 at 3:00 PM and stated that, according to the facility's policy, the PASARR Assessment must be done within 25 days from admission and then annually. She admitted that she did not have the PASARR Forms uploaded into their electronic medical records (EMR). The SW revealed that the policy stated Annual reviews must be done, submitted, and posted into the resident's record. SW admitted she did not have them posted in the EMR. Shen, the SW, was asked who was responsible for ensuring it is accurately done yearly and posted. The SW revealed that it was her responsibility since she is the Social Services Director.Resident #7 (R7)According to the review of Resident #7's clinical record, on 9/3/2023 at 1:30 PM, R7 was [AGE] years old, admitted to the facility on [DATE], with the primary diagnosis of generalized muscle weakness and difficulty walking, dementia with obsessive compulsive disorders, depression, psychotic disorder with delusions, delirium, and mixed anxiety disorders, in addition to other diagnoses.Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 05/15. A score of zero to 07 means that the person has severe cognitive impairment. R7's Section GG of the same assessment date, 7/24/2025, indicated that R7 was dependent on all ADLs (hygiene, showers, and dressing) except for eating. R7 required supervision or touching assistance with eating. R7 is dependent on staff for all transfers and mobility, utilizing a wheelchair for mobility/ambulation. R7 physician's orders for Risperidone .5 mg/ml solution by mouth one time a day (0900) for delirium, Risperidone 1 mL by mouth one time a day for delirium (2100), Alprazolam oral tablet 0.25 mg, give one tablet by mouth every 8 hours as needed for General Anxiety Disorder (GAD).Resident #10 (R10)A review of R10's Electronic Medical Record revealed R10 was [AGE] years old, admitted to the facility originally on 12/20/2021. Her most recent readmission was 4/10/2025 with the diagnosis of difficulty walking, Dementia, Bipolar Disorder, Depression, and Anxiety Disorder in addition to other diagnoses. Medications for these diagnoses were Risperdal oral tablet 0.5 mg twice a day, Trazodone HCL oral 100 mg tablet at bedtime, and Lorazepam 1 mg oral tablet.According to R10 PASARR Level II dated 8/16/24, R10 was prescribed Cymbalta, Seroquel, and Aricept for Bipolar disorder, which was not in the list of the doctor's orders reviewed on 9/4/25 at 1210 AM.The facility's Pre-admission Screening and Annual Resident Review PASSR Policy was requested and further reviewed on 9/5/25 at 12:00 PM. A review of the facility's Pre-admission Screening and Annual Resident Review PASSR Policy ( with a revised date of May 2024) revealed: Goal: PASARR will be used on admission as required by the federal government to identify individuals with mental illness or intellectuals with mental illness or intellectual disability or related conditions who are requesting admission to a nursing facility . 2. Social Services/Transition Coordinator (SS/TC) will review the DCH 3877/3878 following admission to ensure accuracy . 3. The SS/TC is responsible for monitoring DCH3877/3878 and ensuring that the information complies with state requirements .The 3877/3878 will be completed annually by the SS/TC .PASARR Level II Recommendations will be incorporated into the resident's Plan of Care .

Based on interview and record review the facility failed to ensure consents were signed and behavior monitoring was provided for psychotropic medications for two residents (R13, R60) of two residents sampled for psychotropic medications, resulting in the lack of consents and behavior monitoring.Findings include: Resident #13 R13 is [AGE] years old and admitted the facility most recently on 08/23/2025, with diagnoses that include schizophrenia, major depressive disorder, anxiety disorder and dementia. On 09/05/2025 at 02:35PM, record review revealed that R13 has physician's orders for Fluoxetine 20mg (anti-depressant) and Risperdal 1mg (anti-psychotic). On 09/05/2025 at 02:40PM, record review revealed there was no physician's order for behavior monitoring. Record review also revealed a task (area where the Certified Nursing Assistants chart) titled Behavior Monitoring and Interventions. There were two entries noted, one on 8/18/25 and 8/24/25. No other entries had been made for R13. On 09/05/2025 at 2:42PM, an interview was conducted with Transitional Care Coordinator (TCC) E. TCC E was asked about the lack of behavior monitoring for R13. TCC E stated, we are working on a process where it (behavior monitoring) triggers a progress note when a medication is given. TCC E acknowledges there is an issue with behavior monitoring, but says the facility is working on it and working to improve the process. Review of the policy titled, Psychotropic Medications revealed: Initiating the use of Psychotropic Medications: 1. Prior to using any new psychotropic medication, the staff will document the behaviors and alternative interventions used and the outcomes of those interventions. For residents admitted to the facility on psychotropic medications, the behaviors and need for such a medication will be pulled from the referral information and listed in the EMR. 9. If an order is obtained for psychotropic medication, the resident/responsible part must be informed of the risks and benefits of the medication. The facility must obtain informed consent. If the resident/responsible part cannot sign the consent, phone consent will be taken with two nurses verifying the consent. This documentation will be placed in the medical record in the designated area. Resident #60 A record review of the Face sheet and electronic medical record/emr revealed Resident #60 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Dementia, anxiety, hypothyroidism, chronic kidney disease, and heart disease. The resident had severe cognitive loss and needed assistance with all care. A record review of the progress notes indicated Resident #60 had a fall beside her bed on 8/9/2025 at approximately 2:05 AM. The resident sustained an abrasion on her left elbow. A review of an Incident and Accident Report dated 6/22/2025 at 11:45 PM the resident was observed on the floor by her bed. She sustained redness to her left forehead, and right knee and a skin tear on her left hand. A review of the physician orders indicted Resident #60 was receiving several psychotropic medications including antipsychotic and anti-anxiety medications: ABH Gel/Ativan 1mg, Benadryl 2.5 mg, Haldol 0.5 mg date started 8/25/2025; Risperdal 1 mg started 6/6/2024 and revised 7/7/2025; Xanax tablet 0.5 mg started 6/9/2025; Quetiapine 50 mg start date 6/1/2024. A review of the Documents tab in the electronic medical record in the Consents tab revealed there was no consent for the ABH gel that included Ativan (an anti-anxiety medication), Benadryl (a medication that can be sedating) and Haldol (an antipsychotic medication). A review of the Medication Administration Records for June, July, August and September 2025 indicated there was no behavior monitoring documented to indicate the medication was necessary or effective. There was documentation for adverse effects, but not the need for use. A review of the Tasks documentation tab in the electronic medical record/emr identified an entry titled, Behavior Monitoring & Interventions. A review of the past 30 days from 8/5/2025 to 9/4/2025 revealed there was no documentation of behavior monitoring. A review of the progress notes identified an entry on 8/25/2025 that Resident #60 scratched a staff member during care. There was no additional explanation if it was intentional or identification of interventions used to minimize or prevent the behavior. On 9/04/2025 at 2:38 PM, Social Services Manager E was interviewed about Resident #60 receiving psychotropic medications and said it had taken the resident a long time to get stable. She said the resident had been yelling, hitting, and scratching at people. She said the behaviors had improved, but still had some behaviors at times. The resident's medication was reviewed with the Social Services Manager and it was identified that on 8/25/2025 the ABH gel/Ativan/Benadryl/Haldol combination had an increased frequency to be administered, from every 6 hours to every 4 hours. Reviewed with the Social Services Manager that there was no consent in the medical record located for the ABH gel. During the interview with the Social Services Manager E on 9/4/2025 at 2:38 PM, she reviewed the medical record and identified there was no consent for the ABH gel. The behavior charting in the tasks section was discussed and confirmed there was no behavior charting in the Tasks section of the emr or on the Medication Administration Records. The progress notes had an entry on 8/25/2025 that the resident scratched a staff member, but no additional behavior charting was identified. The ABH gel was increased that day. The Social Services Manager asked if the resident was often sleepy because of the sedating effects of the psychotropic medications she was receiving, as she was noted to be sleeping until approximately 11:00 AM on 9/3/2025 and the resident had several falls. She said the resident usually got up later in the morning. A review of the Care Plans for Resident #60 identified the following: The resident displays behavioral symptoms related to: Dementia, (Resident #60) has behaviors of hitting, pinching, pulling, and scratching at staff; spitting out medication, biting staff, scratching at residents, attempting to stab staff with cutlery, date created and initiated 6/26/2024 and revised 7/8/2025 with Interventions including: Give psychoactive medications as ordered. Record behavioral symptoms and side effects, date created, initiated and revised 6/26/2024. (Resident #60) uses antipsychotic medication, date created and initiated 9/10/2024 and revised 7/14/2025 with Interventions including: Monitor/record occurrence of target behavior symptoms, pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol, date created, initiated and revised 9/10/2024. On 9/04/2025 at 3:31 PM, the Director of Nursing/DON was interviewed about the antipsychotic medications including the ABH gel with Haldol that Resident #60 was taking. She said the resident had behaviors at times in the past; reviewed there was no documentation supporting this except for one progress note. She said there should be documentation. Also reviewed there was no consent for the ABH gel, and the dose was increased on 8/25/2025. She said they were looking at that.

Based on observation, interview and record review, the facility failed to ensure residents were treated in a respectful and dignified manner for 2 Residents (#22 and #59) from a facility census of 52 residents, resulting in missing items not being replaced in a timely manner for Resident #22 and some confidential group of residents were unable to reenter the building nor reach the facility by phone for reentry after hours or after outside visitation with family and friends. Findings include: Facility Resident Council On 09/04/2025 at 10:30 AM, seven (7) confidential group of residents and a family member (who wished to remain anonymous) attended the Resident Council (RC) Meeting. The council has invited a Family Member#8 (FM8) during the Resident Council Meeting to attend on 09/04/2025 at 10:53 AM. The FM8 expressed that the resident's prescription glasses had been missing for almost a year, and there has been no follow-up in finding the glasses, nor have there been any resolution or efforts made to replace the missing glasses. The resident was described by FM8 as unable to express or speak for himself but still able to see, watch TV, and wear his glasses. FM8 revealed that she had expressed this frustration to staff, but nothing has been done regarding his prescription glasses. FM8 and other confidential group of residents had expressed their frustration about the difficulty they experience when staff does not answer the facility phone. One resident reported, when the office is closed, and receptionist is gone, no one answers the phone. There are too many prompts on the answering machine, so you have to leave a message on the voicemail. They don't call back after 5:00 PM. Confidential Resident #2 expressed frustration during the Resident Council meeting about the visitation hours rules. Resident #2 recalled going out with her friend, who visited her from out of town, and returned after 5:00 PM. It took her over an hour to get her friend inside the building. Her visitor waited for her to get into the building and did not want to leave her outside. It was getting dark for her visitor to drive back home, and she was worried about her visitor's safety driving alone in the dark. She indicated that they had called the facility over and over, tried every prompt, and left messages, but no one replied until one of the staff members coming from outside let her in. Confidential Resident #6 during the RC meeting .09/04/2025, 11:21 AM, revealed that he was unable to return to the building after he rang and rang the doorbell and called the after-hours facility phone number posted outside the locked back door for half an hour. The front door closes automatically after office hours. Residents are expected to use the back door after office hours. Confidential Resident #6 revealed that a couple of weeks ago, he visited his brother's house, and his brother signed him out. Resident #6 explained, It was around 10:30 PM. We were told we could stay out as long as we returned before midnight, so we made it back at 10:30 PM since my brother lives over an hour away. I had to go back to his house and come back the next day. I did not have my medications that night and morning. I did not return to the facility until the afternoon the following day because that's the only time his family was available to give him a ride. No one had called my brother to find out where I was or what had happened. The Social Services Director was interviewed on 09/04 2025 at 12:04 PM, confirmed that the resident had a court-appointed guardian and must have a preapproval to visit his brother and his family from his guardian. She stated that, 'no one is at the front desk after five. The doors are closed. After-hours Phone lines are supposed to be picked up by staff, and different units have prompts. Staff are supposed to answer them. The Administrator admitted to the surveyor on 9/4/25 at 12:30 PM, revealed the ongoing phone issue since he started as the facility administrator in January 2025, and they are working on it from the corporate level. The Administrator explained that the front door is locked from the outside after 5 PM, and no receptionist is scheduled to be by the front door after 5 PM. There is also no one to hear the backdoor buzzer (doorbell) because it only goes to the receptionist, and there's no one after 5 PM. The after-hours phone does not appear to be working effectively. They don't get answered. Facility policies were reviewed on 9/9/25 at 2:00 PM. It revealed: Resident Rights Policy (Last revised on 9/2018, Approved on 9/2018) Policy: It is the facility policy to implement procedures to protect residents' rights. GOAL: To ensure residents rights are protected. To ensure that all employees know and understand the resident's rights. To ensure each resident of the facility is provided a copy of his/her rights in writing upon admission… Spend time with Visitors; you have the following rights: to spend private time with visitors. To have visitors at any time, as long as you wish to see them, as long as the visit does not interfere with the provision of care and privacy rights of other residents… 2. The Visitation Hours Policy submitted by the facility (undated) revealed: Residents receive visitors when they wish to. Personal Property A record review of the Face sheet and electronic medical record/emr indicated Resident #22 was admitted to the facility on [DATE] ad readmitted on [DATE] with diagnoses: Multiple sclerosis, gait abnormality/stiffness, neuromuscular bladder dysfunction, history of urinary tract infections, glaucoma, and anxiety. The resident had a Brief Interview for Mental Status/BIMS score of 15/15 indicating full cognitive abilities. On 9/03/2025 at 12:05 PM, interviewed Ombudsman “K”, she said she was at the facility to talk to Resident #22” who said she was missing clothes amounting to $22.00. Ombudsman “K” said she had spoken to the Administrator several times about this. The Ombudsman was asked if she spoke with the Administrator on this day and she said she had not; She then met with him and came back and said nothing had been done about the resident's missing items. On 9/03/2025 at 12:27 PM, the Administrator was interviewed, and he was asked about Resident #22's missing items. He said she had missing clothes and forgot that he replaced them already. The Administrator was asked if he had a receipt that indicated he had replaced the resident's missing clothes or some form of documentation that he replaced them; He said he didn't have any but thought he might have an Amazon receipt. He was asked to see it. On 9/04/2025 at 9:30 AM, interviewed the Administrator and he said he did not have any documentation that he replaced the resident's items or what the items were. He could not say when they were replaced. On 9/05/2025 at 9:23 AM, Resident #22 was interviewed in her room. She was up in her wheelchair, alert and oriented x4. She said that she had a missing purple outfit from amazon- purple leggings and a purple sweatshirt that go together. She said she had spoken with the Administrator several times and he said he had already sent her an outfit, and she must not have received it; she said she did not receive a new outfit. She believed she was not being told the truth. On 9/05/2025 at 11:30 AM, Activities Director “L” was interviewed. She said she handled missing items for the residents. She said there was a Grievance form for missing items. The Activities Director said once an item was reported missing the information was placed on a Grievance form and she and her staff would look for the item in the resident's room, search their closet, laundry room, etc. and the item would be replaced if not located. During the interview with the Activities Director on 9/5/2025 at 11:30 AM, she said Resident #22, reported missing clothes a few months ago. She said the Administrator was aware that they could not locate it. She said she would look for a Grievance form for the missing clothes. On 9/05/2025 at 12:04 PM, the Administrator said he met with the resident and gave her $23.00 to replace her purple outfit. He said he did not have a receipt, Grievance form or proof that she received that. He said he would obtain a receipt. On 9/5/2025 at 1:30 PM, spoke with Resident #22, she said she received $23.00 for her purple outfit from the Administrator, and she said she would buy a new outfit. A review of the facility policy titled, “Resident's [NAME] of Rights,” date reviewed 1/25 provided, “Policy: It is the facility policy to implement procedures to protect resident rights… You have the right to be treated with dignity and respect… Make Complaints: You have the right to make a complaint to the staff of the nursing home… The nursing home must address the issue promptly…”

This Citation Pertains to Intake Numbers MI00149339 and MI00149518. Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment by failing to ensure that residents' rooms were clean, for two resident's (#1 and #5) and there was enough linen to accommodate residents' needs, resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness and linen. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: Dementia, Schizophrenia, diabetes, COPD, Cognitive communication deficit, Depression, and a history of falls. Hospice care began 12/16/2024. The MDS assessment dated [DATE] indicated Resident #1 had full cognitive abilities with a Brief Interview for Mental Status score of 14/15 and needed assistance with all care. During a tour of the facility on 1/22/2025 at 9:40 AM, Resident #1 was observed lying in bed, awake and alert. There were 4 large clear bags of clothes and towels in the room: 3 were in a metal cart and one was on the floor. The resident was asked why the bags were sitting there and she said she thought Hospice had brought them in. There were colored/patterned towels in one bag. Resident #1 was asked about it, and she said she wasn't sure why she had the towels. Upon observation of Resident #1's bathroom on 1/22/2025 at 9:45 AM, the resident's toilet bowl was unclean with a ring stained orange-brown at the edge of the water and orange brown stains around the upper area of the bowl. The floor beneath the sink had bright yellow stains in an approximately 1-foot x 1-foot area surrounding the sink pipe. The waste basket was full and there was something scattered on the floor. On 1/22/2025 at 10:00 AM, during a tour of the laundry room with the Director of Nursing/DON it was noted there were no clean towels or wash clothes stored in the Clean laundry area. The DON said they could be in the wash. The 100 hall, 200 hall and 300 hall were toured with the DON beginning at approximately 10:04 AM. The DON said each hall had a clean linen storage closet. Between the 3 resident hallways, there was 1 clean towel and 1 clean wash cloth, available for resident use. On 1/22/2025 at 10:10 AM, during an observation of Resident #1's room with the Director of Nursing/DON, Nurse Aide E was observed sorting one of the large plastic bags of clothes. She was sorting each item and asking the resident if it was hers. The DON was asked about the large bags of clothes and towels. She said the resident had moved into a private room when she was diagnosed with Covid-19 in December 2024 and they hadn't been put away in the resident's room. The DON was asked why the resident had the colored towels and she said she didn't know but thought they came from her home. Reviewed the resident said Hospice brought them and she stated, I don't think so. During the observation, on 1/22/2025 at 10:10 AM, Resident #1's bathroom was viewed with the DON. The toilet bowl was still soiled with orange-brown stains, there was debris on the floor and the floor underneath the sink was still soiled with a yellow substance. The DON said the bathroom wasn't used often and someone would be in to clean it. On 1/22/2025 at 11:34 AM, the Administrator was interviewed about the lack of clean towels and washcloths for resident use. He provided a copy of an order form for new towels and wash cloths dated 1/22/2025 at 9:57 AM. Reviewed with the Administrator that Resident #1's bathroom was very soiled and had not been cleaned in some time, but the resident had resided in the room for several weeks. He said they had staff turnover in the Housekeeping and Maintenance departments and had recently hired new staff. Requested a copy of the Housekeeping schedules, assigned duties and Housekeeping policy and Linen policy at this time. Resident #5: A record review of the Face sheet and MDS assessment indicated Resident #5 was admitted to the facility on [DATE] with diagnoses: Dementia, kidney disease, history of falls, heart disease, anxiety, and hypothyroidism. The MDS assessment dated [DATE] revealed the resident had severe cognitive deficits with a BIMS score of 0/15 and the resident needed assistance with all care. On 1/23/2025 at 12:35 PM, Resident #5's bathroom was observed to have a large dark orange stain in the sink. It covered approximately 1/2 of the sink basin. The toilet was also observed to have dark orange stains and the floor in the bathroom was soiled, with yellow stains underneath the sink. An unlabeled bed pan was sitting on a commode chair in the bathroom. A policy for Housekeeping/Cleaning for daily cleaning was requested and not received. A policy for Terminal cleaning on discharge was received. A policy for Linens was requested and not received.

This Citation pertains to Intake Number MI00148245. Based on observation, interview, and record review, the facility failed to ensure that the bladder scanner for the entire facility was in good repair to clinically assess residents diagnosed with urinary retention for one resident (Resident #500) of 3 residents reviewed with indwelling catheters, resulting in urinary retention, severe abdominal pain and the likelihood of further complications and delayed urinary care needs. Findings include: Resident #500 (R500): According to the clinical record review on 12/3/24 at 1:30 PM. R500 was discharged to home on 12/1/24. R500 was [AGE] years old and admitted to the Administrator on 11/11/24, with the diagnosis of Urinary Retention, Elevated Prostate Specific Antigen (PSA), Chronic Kidney Disease Stage 3, and Chronic Respiratory Failure (CRF) in addition to other diagnoses. Further clinical record review conducted on 12/3/24 at 1:30 PM revealed the following: On 11/16/24 at 1:24 AM, according to the eMar-(electronic Medication Administration Record) Note, an order was written for a trial void written as Remove Foley Catheter. Bladder scan q6h (every 6 hours) or post-void, which comes first, for 24h. If >350cc, straight cath. If >1 straight cath, replace Foley and notify the provider in the book. Nursing noted a comment: every 6 hours for urinary retention for 1 day. Scanner unavailable. 1 1/16/24 at 3:01 AM revealed an eMAR-Medication Administration Note: Trial void. Remove Foley Catheter. Bladder scan q6h (every 6 hours) or post-void, which comes first, for 24h. If >350cc, straight cath. If >1straight cath, replace Foley and notify the provider in the book. Nursing noted a comment: every 6 hours for urinary retention for 1 day. Scanner inoperable. Nurses' Notes on 11/16/24 at 16:24 (4:24 PM) revealed: Sent to the ER to have the catheter placed after the writer attempted to reinsert per NP (Nurse Practitioner's name mentioned). On 11/16/24 at 1625 (4:25 PM), the Situation, Background, Assessment, and Recommendation (SBAR) Notes revealed: REASON FOR REPORT: unable to place Foley NEW ORDERS: sent for placement. On 11/16/2024 at 22:45 (10:25 PM), the nurse's notes revealed that R500 returned from the hospital with a 14 French 10cc Balloon Foley secured to the right thigh with a stat lock. Foley bag placed dependently on side of the bed, and it is draining blood-tinged yellow urine. Resident denies pain at this time . On 12/3/24 at 3:01 PM, an interview with Nurse A was conducted by phone. Nurse A indicated R500 had a history of prostate cancer and urinary retention. Nurse A was working on the floor that weekend when R500 complained of abdominal pain. R500 was on a Trial Void. Staff on a previous shift took his Foley catheter out and was on a trial void order. R500 could void in the toilet, but could not measure the amount, and we could not determine if there was retention because the bladder scanner machine was broken. Nobody knew when and what was wrong. It was not charging. Nobody reported nor notified us that the bladder scanner was broken. It was the first time I knew it was not in good repair. I notified the Nurse Practitioner (NP B) by phone that the bladder scanner was broken. The NP B told me to reinsert the catheter if the abdominal pain persisted. Nurse A revealed that she attempted to insert the 16 French Foley, but there was resistance. Blood clots were observed coming out when they tried to insert the catheter. Nurse A continued to say that she notified the NP and sent R500 to the emergency room for reinsertion because it was unsuccessful. Nurse A admitted that she observed a heavy amount of blood clots during the attempt to reinsert the indwelling catheter. Nurse Practitioner (NP B) interview was conducted by phone on 12/3/24 at 3:15 PM. NP B revealed that R500 had a history of urinary retention and Prostate Cancer. He was complaining of abdominal discomfort, and apparently, there was bleeding during the attempt to reinsert the Foley catheter after a trial void. We attempted to reinsert the Foley because the bladder scanner was not working. Because the staff had difficulty reinserting, we sent R500 to the emergency room . NP B commented that there must have been blood accumulation that caused the occlusion. On 12/3/24 at 1:15 PM, an interview was conducted with the Director of Nursing (DON). She reported that R500 went home on 12/1/24. R500 is receiving 24-hour home care. The DON explained what happened on 11/16/24. The DON admitted that she did not know the bladder scanner was broken. She stated, I only knew it was not working that day. R500 was sent to the ER for reinsertion at around 4 PM and returned at around 11 PM. R500 was his person and had a BIMS (Brief Interview of Mental Status) score of 15/15. Nurse A (mentioned name) was on duty and called me about the Broken equipment and the blood clots. Nurse A was not successful in reinserting the Foley catheter. He had a history of urinary retention, and the DON recalled that he did have the same problem on his previous admission. Nurse C was interviewed on 12/3/24 at 2:20 PM. Nurse C recalled that the previous shift nurse removed R500's catheter and was on trial void but encountered pain. Staff had problems reinserting, and the bladder scanner was broken. Several attempts were made to reinsert them, but it was challenging, so they had to send him out. There are trial void orders, but it varies per individual post void what the bladder scan results are. The Administrator was interviewed on 12/3/24 at 3:57 PM. He revealed that the bladder scanner was determined broken on 11/16/24. The Administrator was made aware on 11/26/24. When asked about: What has been done since? Answer: We put it away out of service. Was there an attempt to have them in repair? Answer: No Was there a replacement request, or have you ordered a replacement? Answer: No According to the Administrator, the equipment was broken before he started working at the facility, but he was made aware of this on 11/26/24. The Administrator admitted that he has not called for repair, nor has he asked for a replacement or loaner. He confirmed he listed four residents currently with indwelling catheters. Policies were requested from the Administrator and the DON on 12/3/24 at 5:00 PM: I. Guest Care Equipment Policy dated 9/2009 was reviewed. Purpose: It is the policy of this facility that guest care equipment will be inspected to ensure that it is maintained to promote a safe environment for guests. Procedure: . Repairs: 9. Equipment identified to need repair will immediately be removed from use until the repair can be performed. 10. All repairs are prioritized and performed in a timely manner. To ensure the continuation of guest care in the event of equipment failure (facility owned and guest owned), the equipment will be removed, and backup devices may be provided . II. Bladder Scanner Guideline dated 5/2014 reviewed and revised on 5/2021. Purpose: To provide a guideline for the use of a bladder scanner. Guideline: 1. The bladder scanner will be used to determine residual urine in the bladder. 2. The bladder scan can be completed by a nurse or physician; there is no need for an order to use the bladder scanner. 3. Appropriate infection control should be maintained. 4. Usage of the bladder scanner is based on the manufacturer's guidelines. 5. If the bladder scanner does not work correctly, the facility will call for repairs. III. Trial Void Policy - According to the DON on 12/3/24 at 5:10 PM, she explained that they can not locate a Trial Void Policy and had reached out to corporate.

This Citation pertains to Intake Number MI00133932. Based on observation, interview and record review the facility failed to implement and carry out interventions to prevent the development of pressure ulcers for one resident (Resident #39) of three residents reviewed for pressure ulcers resulting in the development of four facility-acquired pressure ulcers (1-Stage 3 and 3-Unstageable). Findings include: Resident #39 (R39): Resident #39 is [AGE] years old and most recently admitted to the facility on [DATE] with diagnoses that include dysphagia, cerebral infarction, traumatic brain injury and pressure ulcers. R39 has a brief interview for mental status score (BIMS) of 6, indicating severe cognitive impairment and R39 is currently receiving hospice services. On 08/19/24 at 11:43 AM, R39 was observed in bed, appropriately dressed, well groomed, free of odors, laying supine, R39 was non-verbal, but did nod at a few yes/no questions. On 08/19/24 at 03:28 PM, record review revealed that R39 has multiple pressure ulcers, some of which were facility acquired. The pressure ulcers located on both elbows and the left and right iliac crest are facility acquired as of 8/7/24 and the coccyx. pressure ulcer was present on admission. -Left Elbow measures 0.50Lx1.00W and classified as unstageable, identified 8/7/24. -Right Elbow measures 1.5Lx1.5W and classified as unstageable, identified 8/7/24. -Left Iliac Crest measures 3.5Lx1.5W and classified as a Stage 3, identified 8/7/24. -Right Iliac Crest measures 2.5Lx3.0W and classified as unstageable, identified 8/7/24. On 08/19/24 at 3:45 PM, record review revealed a care plan titled, alteration in skin integrity, interventions included an air mattress, wedge for positioning, and a heels up to help with offloading weight, specialty air mattress to bed, pressure redistribution cushion when up in a chair/wheelchair, off load heels, reposition/shift weight at frequent intervals to resident's comfort. On 08/20/24 at 09:04 AM, R39 was observed in bed, well dressed, groomed and positioned on their back. No wedge cushion noted for positioning, air mattress was in place, heels were elevated on pillows. On 08/20/24 at 12:57 PM, an interview was conducted with LPN 'B'. LPN 'B' was asked about the pressure ulcers R39 has. LPN 'B' stated the coccyx wound was present on admission and classified as unstageable, it is now a Stage 4 since the wound bed can be visualized. LPN 'B' stated the pressure ulcers on his elbows and the iliac crests are new as of 8/7/24. LPN 'B' stated these occurred after R39 had a change in tube feed rate. LPN 'B' believes his wounds are improving. LPN 'B' was asked what interventions were in place prior to the pressure ulcers developing on the elbows and iliac crests LPN 'B' stated that R39 had elbow guards in place, was turned every two hours and has an air mattress in place. LPN 'B' was asked if they thought every intervention was in place, but the pressure ulcers still developed. LPN 'B' stated yes, they believed so. LPN 'B' was asked if they completed an unavoidable skin condition form for R39. LPN 'B' stated that yes, they use the form and that it was completed in the electronic medical record (EMR). LPN 'B' looked at the EMR for R39 but was unable to locate the completed form. LPN 'B' was asked why R39 was positioned on their back during most of the survey. LPN 'B' stated that the nursing assistants are supposed to be turning R39 intermittently to offload pressure. LPN 'B' stated they would enter an order for the nursing staff to be reminded to turn R39 more often. On 08/20/24 at 01:47 PM, record review revealed an Unavoidable Skin Condition Form is now present in the EMR, dated 8/20/24. On 08/20/24 at 01:54 PM, record review revealed the alteration in skin care plan had been edited on 08/20/24 to now include elbow protectors. On 08/20/24 at 02:58 PM, R39 was observed on their back in bed, the right elbow has an elbow protector in place, but the left elbow does not and no wedge cushion noted On 08/21/24 at 10:30 AM, R39 was observed on their back in bed, right elbow pad in place and a pillow under the right arm, the left elbow had a dressing on it and a pillow providing pressure relief under it. On 08/22/24 at 03:36 PM, record review revealed R39 has a Braden Score of 14, indicating that they are at moderate risk for pressure ulcer development. Record review of the policy titled Skin Management, approved 7/19 revealed: 7. An initial plan of care is developed upon admission if the resident is at risk or has a current 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. Hydration Nutrition Preventative devices, including support surfaces for bed and chairs Preventative skin care Pain Physical activity Positioning requirements Proper body alignment Education, when appropriate Pressure Injury Evaluation of Avoidability 1. The Director of Nursing or designee is responsible for ensuring that the Evaluation of Pressure Injury form is completed accurately and timely if applicable to the resident's condition. Significant changes in condition Decline in overall health status Hospice, Palliative and/or Comfort care is initiated Anticipated development of pressure injury Facility acquired pressure injury Worsening condition of a pressure injury 2. The completed form will be scanned into the guest's EMR under documents. 3. The Evaluation of Pressure Injury form should be completed annually for any unavoidable pressure related injury.

Based on interview and record review, the facility failed to prevent and refer two residents (Resident #29, Resident #50) to infectious disease for recurrent Urinary Tract Infections (UTI), resulting in the likelihood for bladder/kidney injury and/or antibiotic multi drug resistant organisms (MDROs). Findings include: Record review of the facility 'Infection Surveillance 'policy dated 12/2021, revealed surveillance of infections will be completed to calculate baseline rates, detect outbreaks, track progress, and determine trends to assist in preventing the development or spread of infections. The goal is to minimize the number of infections and to identify behaviors or environmental factors that may warrant further evaluation. frequent indicators of infection in the elderly: Urinary tract infection- new burning on urination, flank or supra pubic tenderness, frequency, or urgency, change in the character of urine (cloudy, dark, foul-smelling). Resident #29: In an interview on 06/21/22 at 12:32 PM, Resident #29 revealed a recent hospitalization with stents removed last week and the hospital removed his urinary catheter. Record review of Resident #29's medical record on 06/27/22 at 10:14 AM showed recurrent Urinary Tract Infection's (UTI) with no colonization report. Record review on 06/27/22 at 10:15 AM Resident #29's urinalyses and Medication Administration Records revealed that the resident received an antibiotic in for urinary tract infection in October 2021. March 2022, April 2022 for the Proteus Mirabilis organism. An interview and electronic medical record review on 06/27/22 at 10:16 AM with the Director of Nursing/Infection Preventionist related to Resident #29's recurrent Urinary Tract Infection's (UTI) revealed that the resident had Urinary stents placed and kidney disease. Director of Nursing/Infection Preventionist revealed the Resident #29 needed to have a colonization of urine done and an infectious disease referral. Continuously giving antibiotics can lead to C-diff and super bugs/MDROs' Resident #50: An interview on 06/21/22 at 10:47 AM with Resident #50 revealed that she had a urinary tract infection (UTI) which went into her blood stream and that she was septic. The hospital told her it was not treated properly. Resident #50 stated that she had a urinary tract infection six weeks ago, and now was having one again. Resident #50 stated that she got a Peripherally Inserted Central Catheter (PICC) line and it fell out onto the floor here at the facility. Now she gets pill antibiotics. Record review on 06/21/22 of Resident #50's Electronic medical record revealed urinalysis reports for January, March, April, May and again in June 2022. The record review showed recurrent UTI's with hospitalization s and antibiotic usage. Staff education on peri care? appropriate antibiotic use? Infections disease physician? An interview on 06/22/22 at 1:20 PM with Resident #50 revealed that she has had a lot of Urinary infections. Resident #50 revealed that she had one in January, March, April, May, and she has one now. Resident #50 revealed that she ended up at the hospital. She had Intravenous (IV) antibiotics. The infection went to her bladder and then her blood stream and she was septic. Resident #50 revealed that her PICC line fell out here in her room, and now she gets pills that hurt her stomach. Resident #50 wanted to know why do I get so many Urinary Tract Infection's? Can't they give me the right antibiotic? Record review of Resident #50's April 2022 Medication Administration Record (MAR) revealed the resident was started on Flagyl antibiotic, then Vancomycin antibiotic for clostridium difficile (C-diff). On April 18, 2022, resident is observed restless, lethargic, and diaphoretic. Resident was noted unable to open her eyes or communicate verbally. Resident #50 was sent to the hospital from 4/18/2022 through 4/29/2022. On April 29, 2022, Resident was ordered Merrem intravenous (IV) antibiotic. Record review of Resident #50's hospital progress note dated April 25, 2022, revealed problem 1: sepsis secondary to bacteremia, urinary tract infection. Problem 2: Urinary Tract Infection, urine culture grew ESBL (Extended Spectrum [NAME] Lactamase), Enteral Coli, proteus mirabilis, blood culture growing E. Coli. Record review of Resident #50's May 12, 2022, urinalysis/urine culture revealed greater than 100,000 proteus mirabilis, ESBL (Extended Spectrum [NAME] Lactamase) organism. Record review of Resident #50's May 2022 Medication Administration Record (MAR) revealed the resident was started on Bactrim DS for urinary tract infection. Record review of Resident #50's May 31, 2022, urinalysis/urine culture revealed greater than 100,000 Enterococcus Avium organisms. Record review of Resident #50's June 2022 Medication Administration Record (MAR) revealed the resident was started on ciprofloxacin (Cipro) oral for urinary tract infection on 6/1/2022. Record review of Resident #50's June 2022 Medication Administration Record (MAR) revealed on 6/15/2022 Resident #50 was ordered ceftriaxone (Rocephin) 1 gram intravenous (IV) for infection and malaise. Record review of Resident #50's June 2022 Medication Administration Record (MAR) revealed Registered Nurse D administered the ceftriaxone (Rocephin) 1 gram intramuscularly (IM) in top right buttocks dorsogluteal. On 6/16/2022 Resident #50 was given ceftriaxone (Rocephin) 1 gram intravenous (IV) for infection and malaise. Record review of Resident #50's June 2022 Medication Administration Record (MAR) revealed on 6/17/2022 the resident was started on Bactrim DS oral antibiotic. Record review of Resident #50's urinalysis/urine culture revealed greater than 100,000 Escherichia coli and ESBL (Extended Spectrum [NAME] Lactamase) organism. An interview and records review on 06/27/22 at 09:15 AM with the Registered Nurse/Director of Nursing/Infection Preventionist regarding the recurrent infections revealed the timeline for Resident #50's urinary tract infections (UTI) electronic medical records timeline: -On January 7,2022 urinalysis report results with greater than 100,000 mixed culture (3) or more organisms isolated. Record review of January nursing progress notes revealed there were no notes related urinalysis results, treatment, signs, and symptoms to monitor. -On March 24, 2022, Resident #50 started with loose stools, positive lab results for C-diff, started on Flaygl oral antibiotic on 3/28/2022 and then went to Vancomycin 125 mg oral antibiotic on 4/1/2022. Was cleared with 2 formed stools on 4/13/22. -On April 18, 2022, Resident #50 became lethargic, restless, and diaphoretic, was sent to the hospital. diagnosed with Sepsis and Urinary Tract Infection (UTI). We did not know she had a UTI. Surveyor asked about sign and symptoms or treatment. We just didn't know is what the DON stated. -On 4/29/2022 Resident #50 came back from the hospital with Intravenous (IV) Merrem and positive for COVID and was placed in isolation. Had ESBL (Extended Spectrum [NAME] Lactamase) -On 5/12/2022 record reviewed of UA positive for Proteus mirabilis organism. Bactrim DS -On 5/31/2022 UA reviewed with Enterococcus Avium greater than 100,000, review of medication orders there was no treatment. DON stated yes, she would treat that organism. -On 6/1/2022 Ciprofloxacin was given for UTI. -On 6/15/22 UA with E. Coli with ESBL greater than 100,00 treated with Rocephin 1 gram, and Bactrim DS for 10 days. During the interview and record review on 6/27/2022 at 09:15 AM with the Registered Nurse/Director of Nursing/Infection Preventionist, the state surveyor inquired about Infectious disease referral or colonization lab. the RN/DON/IP stated No, none was done. to be honest. The state surveyor questioned MDRO (Multi Drug Resistant Organisms). The RN/DON/IP stated possible, yes, we need to refer to infectious disease and get a colonization lab. To be honest nobody was performing the infection preventionist role here. Facility had an Infection Preventionist, and she was doing it remote form home. The last time she was in the building was in January 2022. The former DON stepped down from DON position on May 9th and became the Infection control preventionist. She stopped showing up and quit on May 27th, 2022. We had missing paperwork and no forms filled out. I was off for a month of May 2022, and I came back on June 10th. The RN/DON/IP stated she would recommend infectious disease referral for recurrent UTI's with ESBL, with possible MDRO's that we may not be seeing on regular labs. Resident #50 may need a prophylactic antibiotic or a stronger antibiotic for a long duration of treatment. Superbugs are going to get worse if we don't stop treat them right/correctly. The state surveyor inquired about Resident #29 who also has recurrent UTI's with Proteus Mirabilis organism, and there is no colonization report or infectious disease referral. The RN/DON/IP stated he (Resident #29) does go to a urologist for ureter stents and kidney disease. Resident #17 also is another resident with recurrent UTI's. The RN/DON/IP stated that yes, too many antibiotics can cause C-diff and other health concerns. In an interview and record review on 06/27/22 at 10:00 AM, the Registered Nurse/Director of Nursing/Infection Preventionist was asked about Resident #29's recurrent urinary tract infections and if the organism of Proteus Mirabilis is recurrent. The RN/DON/IP revealed that she does not know if Resident #29 was colonized and it's chronic. The DON stated that if the facility had a colonization of organism lab, then they wouldn't need to keep giving antibiotics to him.

Based on observation, interview and record review, the facility failed to operationalize policies and procedures for fall investigation and prevention, and ensure safe storage of sharp implements for four residents (Resident #4, Resident #5, Resident #32, and Resident #34) of seven residents reviewed for accidents, resulting in a lack of comprehensive investigation and inconsistent documentation related to falls, lack of implementation of interventions to prevent falls, sharp knives being accessible to cognitively impaired residents, and Resident #34 experiencing a fall with fracture, delayed treatment, ongoing limitation in Range of Motion (ROM), unnecessary pain, and the likelihood for decline in overall quality of life. Findings include: Resident #5: On 6/23/21 at 11:45 AM, Resident #5 was observed sitting in a chair in their room. An interview was completed at this time. When queried if they had fallen in the facility, Resident #5 revealed they had and had to go for x-rays. With further inquiry, Resident #5 revealed they fell when a staff member was pushing them to fast in the wheelchair. The Resident indicated their foot got caught on the floor when the staff was pushing them. When asked if they had any other falls or concerns pertaining to falls, Resident #5 stated, The right break on my wheelchair does not work. It will move when I push it. Resident #5 proceeded to demonstrate that the wheelchair moved backwards, with the brakes engaged, when they sat down. Resident #5 then stated, I requested new wheels or a new chair, but they (facility staff) said they couldn't do it because of the State. I don't see why they can't. When queried if the facility had attempted to repair the wheelchair, Resident #5 revealed the facility had not completed a repair. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, chronic pain, and obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to limited assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident had two or more falls without injury and two or more falls with injury. Review of Resident #5's care plans revealed a care plan entitled, My Fall risk assessment scores me at Moderate risk for falls r/t (related to) Gait/balance problems, weakness, RLS (Restless Leg Syndrome), [CONDITION(S)] and hx (history) fall, potential for medication side effects . (Initiated: 7/10/19; Revised: 3/31/21). The care plan included the following interventions: - Ensure that guest is wearing appropriate footwear (shoes, bedroom slippers, nonskid socks) when ambulating or up in the wheelchair (Initiated: 5/12/20) - Foot pedals to be placed on wheelchair when transporting guest (Initiated: 7/27/20) - Guest educated on the need to lock brakes on wheelchair prior to standing up (Initiated: 12/19/20) - Medical review from physicians' group due to recent falls (Initiated: 2/4/21) - Non-Slip grip to wheelchair (Initiated: 7/24/20) - Provide nonslip pad under chair to prevent sliding of chair (Initiated: 2/4/21) - Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes (Initiated: 9/10/20) - Stand by assist to the toilet and transfers (Initiated: 1/31/21) Review of Resident #5's fall Incident and Accident reports for the previous year revealed the Resident fell seven times on 7/24/20, 9/10/20, 12/19/20, 12/31/20, 1/10/21, 1/31/21, and 2/4/21. The Incident and Accident reports detailed the following: -7/24/20 at 10:30 AM: Incident Location: Hallway . Incident Description . CNA (Certified Nursing Assistant) reported to this nurse that the guest caught their left foot on the floor and fell out of their wheelchair on the floor when the CNA was taking the guest back to their room. Resident Description: 'I caught my foot on the floor and fell out of my chair .' No injuries observed at time of incident . Predisposing Environmental Factors . Rugs/Carpeting . An investigation nor any staff/witness statements were provided with the Incident and Accident report. -9/10/20 at 3:56 PM: Incident Location: Resident Room . Incident Description: Guest observed sitting on their bottom in front of recliner chair and was found by aide . Resident Description: 'My foot got caught up in my blanket, and I slid out of my recliner chair onto my bottom.' Immediate Action Taken . Guest assessed for injuries . Achy left arm . No Injuries observed at time of incident . Level of pain: 5 (scale of zero to 10 with 10 being the highest level) . Predisposing Environmental Factors . Clutter . Predisposing Situation Factors . Improper Footwear . -12/19/21 at 4:11 PM: Incident Location: Resident's Room . Nursing Description: Nurse assistant heard thud then guest yell for help. When nurse assistant reached room, guest was observed on floor. Resident Description: Guest stated . 'stood up too fast' and fell backward. Immediate Action Taken: Guest vitals taken and assessed for injuries. Guest then assisted off floor. Guest instructed to use call light for assistance, and also lock wheels to wheelchair whenever standing. (Guest had not locked wheelchair when stood). Skin tear to left elbow cleaned and dressed . No Injuries observed at time of incident . Level of pain: 6 . Injuries Report Post Incident: Abrasion: Right iliac crest (rear) . Skin Tear: Left elbow . - 12/31/21 at 2:51 PM: Incident Location: Resident's Room . Nursing Description: Observed on knees lying over the bed. Resident Description: Resident states, 'I was reaching for something' . Immediate Action Taken: Four staff transferred resident into wheelchair. No c/o (complains of) pain . Level of pain: 2 . - 1/10/21 at 3:57 PM: Incident Location: Resident's Bathroom .Resident reported fall. Resident Description: Resident stated, 'Was in wheelchair in bathroom and fell on to one knee.' Resident was not able to recall which knee but thinks 'Left' . Immediate Action Taken: Resident was on toilet when staff answered call light to assist and reported to CNA fall . - 1/31/21 at 4:06 AM: Incident Location: Resident's Room . Nursing Description: Resident was found on the bathroom floor faced on their side next to the toilet. Bleeding was noted from right arm. Resident Description: Resident stated they were trying to walk to the bathroom with walker and one of their slippers slipped on the carpeting . Immediate Action Taken: Resident was assessed . skin tears noted . one to right hand and the right elbow. Resident stated they hit their head . Resident was slurring their words . Mechanical lift with 4 people to assist Resident back to recliner . Dr. ordered Resident to be sent out (to hospital) . Predisposing Environmental Factors . Rugs/carpeting . Equipment . Predisposing Situation Factors . Improper Footwear . - 2/4/21 at 2:00 AM: Incident Location: Resident's Room . Nursing Description: Guest was observed on the floor on left side with left arm under head next to bed side table. Resident Description: Guest stated was standing up using the urinal when finished went to sit down and the chair moved away . causing them to fall . Guest was assess noted abrasion on the left side of the abd (abdomen), breast and under fold . Injury . Abrasion Left Flank . No Injuries Observed Post Incident . Review of documentation in Resident #5's Electronic Medical Record (EMR) revealed the following: - 7/24/20: Incident Note . Guest caught left foot on the carpet of the hall as was taken back to room in wheelchair and fell to the floor . Intervention to Prevent Reoccurrence: Refer guest to therapy for assessment for foot pedals . - 7/27/20: Health Status/Progress Note . IDT note for guest's recent fall. Guest sustained fall during transport. Guest is alert and oriented, usually ambulates per self. Guest was being pushed in wheelchair when sustaining fall. Staff to make sure guest has foot pedals placed on wheelchair for transportation. Care plan reviewed and updated . - 8/17/20: Order Note .[MEDICATION(S)] Gel (topical prescription pain medication) .left foot pain . Note: There was no progress note documentation of Resident #5 having pain in their left foot prior to the fall on 7/24/20. - 9/11/20: Health Status Note . IDT met today to discuss guest's recent fall and plan of care. Guest stated foot got caught up in blanket, and that had slid out of recliner chair onto bottom. Therapy to screen guest and provide dycem to his chair if appropriate. Guest is to use grippy socks when available. Plan of care discussed; care plan updated. - 9/16/20: Status/Progress Note . Guest refused chest x-ray ordered today 9/16/20 to r/o (rule out) fractured ribs post fall. Physician aware and confirmed . -12/19/20: Health Status/Progress Note . Guest observed on floor after nurse assistant heard loud thud and guest yell out for help. Guest stated they had stood too fast and fell backward. When asked, guest stated they had not locked their wheelchair. Guest checked for orthostatic BP (Blood Pressure- blood pressure measurements when laying, sitting, and standing, a drop in blood pressure is considered position orthostatic). Guest does not lay down . All vitals WNL (Within Normal Limits). Guest assessed for injuries. Guest has L elbow skin tear approximately the size of a nickel. Guest also had an abrasion/bruising on left lower back . pain at a pain of 6 . - 12/23/20: Skilled Look Back Late Entry . Also pain in right side of ribs from a recent fall . - 12/31/20: Health Status/Progress Note . New order for 3 view left foot x-ray. Requisition completed . - 1/31/21: Incident Note . Description: unwitnessed fall, resident bleeding, resident stated hit head on the floor. Resident slurring words. Assessment: Resident slurring words, Alert x 2 (previously Alert X 4) . unsteady standing, and very dizzy. Resident still slurring words slightly. Injuries Noted: skin tears to right hand and right elbow. Intervention to Prevent Reoccurrence: Different footwear needed . Review of scanned documentation in Resident #5's EMR revealed hospital emergency room discharge documentation dated 1/31/21 (Admit 5:28 AM and Discharge 6:36 AM) detailed the Resident was discharged with diagnoses of a head injury and elbow contusion. An interview and review of the fall Incident and Accident Reports for Resident #5 occurred with the Director of Nursing (DON) on 6/29/21 at 11:56 AM. When queried regarding what occurred when the Resident fell on [DATE], the DON reviewed the documentation and stated, I assume they were being pushed in the wheelchair without foot pedals (footrests) and their foot got caught on the floor. The DON was then asked if the facility completed an investigation into the fall and indicated they would look but revealed they had not previously seen an investigation. When queried if an investigation should have been completed, the DON indicated they would have expected something including staff education. The DON was then queried if Residents should be pushed in a wheelchair without footrests and replied, No. When queried what interventions were implemented following Resident #5's fall on 9/10/20, the DON revealed the documentation and interventions and indicated the care plan intervention, Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes was initiated following the fall. When asked how that intervention addressed the cause of the fall to prevent further falls the DON stated, It would not. The DON was then queried regarding the fall on 12/19/20 and stated, (Resident #5) didn't lock their wheelchair. The DON was then asked how Resident #5 is able to lock their wheelchair when the brakes are not functioning properly and do not prevent the chair from moving when engaged. The DON stated, It's broke? The DON was then told about observation of Resident #5's wheelchair moving, with the brakes engaged, when they sat down as well as Coordinator Staff C being aware and revealed they would have maintenance look at the wheelchair. Resident #34: On 6/23/21 at 11:35 AM, an interview was completed with Resident #34. The Resident was in their room, sitting in their wheelchair. Resident #34 responded slowly in a soft tone when asked questions. When queried if they had fell in the facility, Resident #34 shook their head to indicate yes and said, Had to go for x-ray. When asked if they were injured, Resident #34 shook their head to indicate yes and gestured toward their left arm. Record review revealed Resident #34 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which include cerebral infarction (stroke) with subsequent dysarthria and anarthria (speech impairment with inability to articulate words) and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) assessment should be completed but cognitive assessment was not assessed. The MDS did reveal the Resident required limited to extensive, one-person assistance to perform all Activities of Daily Living (ADLs) and had impaired ROM in one upper extremity. On 6/24/21 at 3:34 PM, Resident #34 was observed in the central dining room of the facility at a table with three other Residents. Resident #34 had spilled their beverage on the floor and another Resident was observed attempting to dry the area with a paper towel. No staff were present in the central dining area. The spilled beverage was under the Resident's wheelchair and their feet. The wheelchair did not have anti-rollback safety devices in place. Review of Resident #34's care plans revealed a care plan entitled, My Fall risk assessment scores me at Moderate risk for falls r/t Gait/balance problems, difficulty walking, weakness, medication side effects, risk for incontinence. I have had a recent CVA (Cerebral Vascular Accident -stroke) (Initiated: 3/13/20; Revised: 3/19/21). The care plan included the following active interventions: - Ensure that guest is wearing appropriate footwear (shoes, bedroom slippers, nonskid socks) when ambulating or up in the wheelchair (Initiated: 3/13/20; Revised: 6/18/20). - Be sure call light is within easy reach (Initiated: 3/13/20; Revised: 6/18/20). - Guest continues to self-direct care by refusing to sleep in bed and to sleep in a chair. Maintenance to provide guest with recliner chair in room to facilitate positioning for sleep for fall prevention (Initiated: 5/3/21) - Teach guest proper use of assistive devices (walker, W/C, handrails, grips in bathroom) (Initiated: 6/18/20) - Therapy to assess use of anti-roll back device (Initiated: 5/3/21) - When guest is sitting in her recliner chair, encourage proper positioning to prevent guest from sitting on edge of chair, for fall prevention (Initiated: 2/10/21) Resident #34 also had a care plan entitled, I need help with my ADL's because Impaired balance, Limited Mobility, HX (History) CVA, generalized weakness, malaise . (Initiated: 3/13/20, Revised: 3/19/21). The care plan included the following active and resolved interventions: - I use a Wheelchair to maneuver throughout environment/in hallways. I require anti-tippers and extensions on the brake handles . (Initiated: 10/15/20) - RESOLVED: THERAPEUTIC AMBULATION PROGRAM: I can walk with limited assistance of 1 to bathroom and to dining room using my 4ww (wheeled walker) (Initiated: 5/28/20; Revised: 12/4/20) An interview was completed with the Director of Nursing (DON) on 6/24/21 at 4:26 PM. When queried regarding Resident #34's limitation in ROM, the DON stated, (Resident #34) had a fall here with a fractured wrist. (The Resident) has not regained all their mobility. Review of Resident #34's fall documentation revealed the revealed the Resident fell seven times in the facility from June 2020 to June 2021 on 6/11/20, 6/14/20, 6/18/20, 8/25/20, 11/27/20, 2/10/21, 5/3/21 at 4:34 PM, and 5/3/21 at 9:50 PM. Review of the Incident and Accident report for Resident #34's fall on 11/27/21 revealed, Incident Location: Nursing Station . Description: Nursing notified author they heard a thumb at the nurses station and observed guest on floor . Immediate Action Taken: VS (Vital Signs), neurochecks, and ROM WNL . Injury: Hematoma Left Eye . Level of Pain: 3 (scale of zero to 10 with 10 being the worst pain) . No Injuries Observed Post Incident . Predisposing Physiological Factors . Gait Imbalance . Predisposing Physiological Factors . Attempt to Perform ADL . Predisposing Situational Factors . Using Walker . Review of Resident #34's progress note documentation in the Electronic Medical Record (EMR) revealed the following: - 6/18/20 at 10:00 PM: Hospital Transfer . guest had a fall and hit head. guest is on blood thinners . - 6/25/20 at 4:33 PM: Health Status/Progress Note . IDT note for guest's most recent fall. Guest was sent out to ER for evaluation . Plan of care reviewed, Guest assessed at ER and returned same day . - 8/31/20 at 1:03 PM: Health Status/Progress Note . IDT met to discuss guest's fall . Order obtained to have PT and OT screen . plan of care discussed and care plan updated . -11/27/20 at 5:10 PM: SBAR . REASON FOR REPORT: recent fall. NEW ORDERS: STAT x-ray to L (Left) periorbital eye . - 11/27/20 at 7:05 PM: Incident Note . Nursing notified author that they heard a thump at the nurses' station and observed guest on the floor. Author observed guest laying in front of nursing station. No s/s (signs/symptoms) of distress noted. Guest states (they were) walking with walker and tripped . Injuries Noted: L eye (periorbital) hematoma . Treatment Administered: Ice pack to L (Left) eye, STAT Xray to L periorbital hematoma. Intervention to Prevent Reoccurrence: Educated guest to ask for assistance when needing help . - 11/28/20 at 10:41 PM Follow Up/Monitoring . Has the resident reported changes in their experience of pain? Pain with movement to left arm Has the resident reported changed in their ability to perform ADL tasks or mobility? Resident unable to perform any activity that requires use of left arm . Have any new orders been received this shift that are related to this event? Order to get x-ray of left shoulder and arm given today during day shift . - 11/29/20 at 8:14 AM: Health Status Note . Nurse received in report that guest was in pain and not moving left arm. Guest also crying in pain at touch to or any move of left arm. X-ray order was obtained yesterday, and x-ray had still not been completed this am, and passed on in report. On call Dr informed. Orders obtained to make x-ray STAT and called in . Will continue to monitor guest . - 11/29/20 at 8:42 AM: SBAR Note Text: REASON FOR REPORT: Guest only responding to painful stimuli and is lethargic . -11/29/20 at 9:13 AM: Health Status Note . Guest has had a decline in response and increased lethargy. On call physician notified of change of condition. Orders obtained to send guest to the hospital for evaluation and treatment . - 11/29/20 at 9:25 AM: Discharge Narrative Note: Guest left facility via ambulance stretcher with 2 attendants to be transported to (Hospital) for evaluation and treatment . - 11/29/20 at 9:53 AM: Alert Note . Resident was responding to painful stimuli at the beginning of the shift. PRN (As Needed) pain medication administered. Left arm Xray has not been completed. New call into mobile (X-ray company) for STAT. Resident neuros were to be obtained next at noon as reported by previous shift. This nurse preformed neuro check and resident has had a significant decline from previous day. On call provider notified of change and new order to send to ER for evaluation . -11/29/20 at 2:18 PM: Health Status Note . Received call from hospital RN. Resident has a left humeral head fracture . - 11/30/20 at 11:02 AM: MDS Note: Guest remains in observation at (Hospital) . - 12/9/20 at 8:14 AM: PM&R (Physical Medicine and Rehabilitation) Note . (Hospital) x-ray and CAT scan L shoulder revealed two-part L proximal humerus fracture. The injury was managed non-operatively in a sling. Patient is NWB (Non-Weight Bearing) LUE (Left Upper Extremity) . - 2/10/21: SBAR . REASON FOR REPORT: fall. NEW ORDERS: neuros per facility protocol and follow up with facility provider . - 5/3/21 at 5:20 PM: Health Status/Progress Note . Guest observed on floor sitting on bottom with call light within reach. Guest wheelchair locks were not in use (wheelchair unlocked). Guest states . transferring from easy chair to wheelchair . does not have any c/o (complaints of) pain or distress. No injuries noted . (Family member) was extremely unhappy when writer called . started speaking of concerns that were from days that writer was not here . Care plan updated to have therapy assess for use of anti-rollback device. Therapy aware. Writer will continue to monitor . - 5/3/21 at 10:38 PM: Health Status Note . Notified per CNA (Certified Nursing Assistant) around 9:5 that guest was observed laying on the floor in guest's room, in front of winged back chair in a side lying position on right side. Guest was repositioned to a sitting position on the floor, assessed for injury, and then Guest was transferred with 2-assist back into her chair. No injury or pain noted at this time . Review of the facility provided fall Incident and Accident reports revealed the following: An interview was conducted with Physical Therapist (PT) M on 6/29/21 at 12:15 PM. When queried regarding Resident #34's LUE ROM following the fall with fracture in the facility, PT M revealed they would need to review the Resident's documentation. PT M revealed the Resident experienced a reduction in LUE ROM following the fracture. Review of Resident #35's MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired, required one-person limited assistance with transferring and ambulation and did not have any limitations in ROM. An interview and review of Resident #34's Incident/Accident report and medical record documentation was conducted with the DON on 6/29/21 at 12:25 PM. When queried regarding the X-ray ordered following the fall on 11/27/20, the DON reviewed the documentation and indicated the x-ray was not completed at the facility prior to the Resident being transferred to the hospital. When asked why the x-ray was not completed, the DON was unable to provide an explanation. The DON was then asked when the change in the Resident's pain level and ROM began, the DON referred to the nurses' note dated 11/28/20 at 10:41 PM which revealed the x-ray order was obtained during the day shift and indicated the change may have occurred then. When queried how they knew the Resident did not have reduced ROM, increased pain, and/or other symptoms when there was no documentation of the change and/or the reason x-ray order was obtained, the DON revealed they were unable to determine the information from the medical record. When queried what is included when ROM is assessed following a fall, the DON revealed staff assess based upon the fall and the incident. The DON was then asked why a ROM assessment was not documented in the medical record, the DON revealed the assessment should have completed and documented. When queried what the Resident's level of assistance required and interventions in place at the of the fall, the DON reviewed the care plan and indicated the Resident was supposed to have one person assistance when ambulating. When asked why the Resident did not have assistance, the DON did not provide a response. When queried regarding the likelihood of the Resident falling and breaking their humorous in two places if they would have had one- person assistance, the DON revealed they were able to see concerns. The DON was queried regarding their concerns regarding Resident #34's fall and replied, Initial assessment, timely follow-up of abnormal assessment findings, follow up for x-rays, and pain assessments. Resident #32: According to the facility policy for Accident/Incident Report and Reporting, Including Falls, dated 11/2020, after each incident, the facility was to investigate to determine issues that could be addressed for enhancement or improvement through management and planning to manage the risk of situations. The Charge nurse was to initiate interventions to help prevent a recurrence of the incident. According to the Admission Record, printed on 6/25/2021, Resident #32 was a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses that included delusional disorders, adjustment disorder, arthritis, [CONDITION(S)], anxiety, depression, falls, cognitive communication deficit, high blood pressure, and dementia. On 06/25/21 at 10:17 AM the falls, with the investigations, for the last six months were requested for Resident #32. Seven reports were delivered. The dates of the occurrences were: 1/7/2021 at 10:16 AM, in her room; 2/5/2021 at 8:10 PM, in her room; 2/18/2021 at 10:50 PM, in the dining room; 3/6/2021 at 9:45 PM, in the dining room; 4/22/2021 at 3:58 PM, in her room; 5/10/2021 at 5:31 PM in the hallway; and 5/10/2021 at 8:28 PM, in the dining room. The incident for Resident #32 that had occurred on 1/7/2021 at 10:16 AM, had happened in her bedroom. She had been found on the floor, on her side next to her bed. There had been no injuries observed at that time. Her mental status was identified as oriented to person only. The level of pain had not been assessed and the second section for a mental status evaluation had not been completed. The predisposing environmental factors checked had been, Bed in Lowest Position, Seen in last 2 hours? (document in, and Call Light in Reach. The predisposing physiological factors checked were: Recent change in Medications/New, Confused, and Impaired Memory. the second section for predisposing physiological factors checked were: Incontinent, Noncompliant with Safety Guidance, and Weakness/Fainted. The predisposing situation factors checked included Recent Room Change, Leaning, Wanderer. The Other info added was, Guest seen by nurse at 9:15 AM during med pass. The form identified that there were no witnesses and the physician, family and nurse management were notified. There was no documentation of any potential cause of the fall, or any interventions to prevent a future fall. The incident for Resident #32 that had occurred on 2/5/2021 at 8:10 PM, had happened in her bedroom. She had been found on the floor, in the hall (now it was not in her room) on her side next to her wheel chair. There had been no injuries observed at that time. Her mental status was identified as oriented to person only. The resident was described as drowsy, and the care plan was updated for her to be placed in bed after her meds were given at night. The level of pain had not been assessed and the second section for a mental status evaluation had not been completed. The predisposing environmental factors checked had been, Seen in last 2 hours? (document in. The predisposing physiological factors checked were: Gait imbalance and Impaired Memory, the box for recent change in Medications/New had not been checked. The second section for predisposing physiological factors checked were blank. The predisposing situation factors were none checked. The Other info added was, had recent increase psych meds which makes her drowsey [sic]. The form identified that there were no witnesses and the physician, family and nurse management were notified. There was no documentation of any potential cause of the fall, or any interventions to prevent a future fall. The incident for Resident #32 that had occurred on 2/5/2021 at 10:50 PM, had happened in the dining room. She had been found on the floor next to her wheel chair. She did not call out. She had her brief checked within last 30 minutes. She had suffered a skin tear to the back of her right hand. Her mental status was identified as oriented to person,place, and situation. The level of pain had not been assessed and the second section for a mental status evaluation had not been completed. The predisposing environmental factors checked had been, Guest toileted in Last 2 hours? (document . The predisposing physiological factors checked were: Confused. The second section for predisposing physiological Factors had been checked was Incontinent. The predisposing situation factors was Using a Wheelchair. The Other info added was blank. The form identified that there were no witnesses and the physician and nurse management were notified. There was no documentation of any potential cause of the fall, or any interventions to prevent a future fall. The incident for Resident #32 that had occurred on 3/6/2021 at 11:45 PM, had happened in the dining room. She had been found on the floor next to her wheel chair. She did not call out. She had her brief checked within last hour. Her mental status was identified as oriented to person and situation. The level of pain had not been assessed and the second section for a mental status evaluation had not been completed. The predisposing environmental factors checked had been, Seen in the last 2 hours? (document in, Guest toileted in Last 2 hours? (document . The predisposing physiological factors checked were: Confused. The second section for predisposing physiological Factors had been checked was Incontinent. The predisposing situation factors was Using a Wheelchair and Reaching for Item. The Other info added was blank. The form identified that there were no witnesses and the physician and nurse management were notified. There was no documentation of any potential cause of the fall, or any interventions to prevent a future fall. The incident for Resident #32 that had occurred on 4/22/2021 at 3:58 PM, had happened in the resident's room. She had been found on the floor next to her reclining chair. She had an open area to the right side of her temple and a forehead abrasion. Her mental status was identified as not oriented. The level of pain had not been assessed and the second section for a mental status evaluation had not been completed. There was a second box for Mental Status that was checked as Not Oriented. The predisposing environmental factors checked had been, Seen in the last 2 hours? (document in, Guest toileted in Last 2 hours? (document . The predisposing physiological factors checked were: Gait Imbalance, Impaired Memory, and Confused. The second section for predisposing physiological Factors had been checked was Incontinent, Noncompliant with Safety Guidance and Poor Trunk Control. The predisposing situation factors was Using a Wheelchair. The Other info added was blank. The form identified that there were no witnesses and the physician, family, and nurse management were notified. There was no documentation of any potential cause of the fall, or any interventions to prevent a future fall. The incident for Resident #32 that had occurred on 5/10/2021 at 6:31 PM, had happened in the hallway. She had been found on the floor in hallway slid out of wheel chair. Her mental status was identified as unable to Determine. The level of pain had not been assessed and the second section for a mental status evaluation had not been completed. There was a second box for Mental Status that was not checked. The predisposing environmental factors had not been checked. The predisposing physiological facto [TRUNCATED]

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to prevent worsening and development of pressure ulcers (wound caused by pressure) for one resident (Resident #26) of two residents reviewed for pressure injuries resulting in lack of implementation and monitoring of interventions, lack of correct hand hygiene procedures during wound care, and Resident #26 experiencing a worsening pressure ulcer, having one pressure developing two Stage IV pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle, and often include slough, eschar, undermining, or tunneling), unnecessary pain, and the likelihood for the decline in overall health status. Findings include: Resident #26: Record review revealed Resident #26 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required extensive, two-person assistance with bed mobility, transfers, and locomotion, and limited two-person assistance with dressing and personal hygiene. The MDS also revealed the Resident had three stage four facility acquired pressure ulcers. On 6/23/21 at 11:54 AM, a staff member was observed exiting Resident #26's room and closing the door. When queried if the Resident was available, the staff member revealed staff were assisting the Resident to get dressed and go then go to see their spouse. On 6/24/21 at 3:49 PM, Resident #26 was not in their room and an observation of their room occurred. An alternating air mattress was present on the Resident's bed. The mattress was on and set at 200 pounds, alternating air every 20 minutes. An interview was completed with the Administrator and Director of Nursing (DON) on 6/25/21 at 7:20 AM. When queried regarding Resident #26's having three stage four pressure ulcers and if they were facility acquired, the DON stated, Yes, they were facility acquired. One was from a failed surgical flap (surgical intervention to heal wounds) I think. With further inquiry regarding the origin dates of the pressure ulcers, the DON revealed they would need to review the Resident's medical record documentation. Review of Resident #26's care plans revealed a care plan entitled, I have pressure ulcer AEB (As Evidenced By) current wounds to sacrum, b/l (bilateral) ischium r/t (related to) comorbidities, compromised skin integrity secondary to failed surgical flap, hx (history) of pressure ulcer on my right heel. Decreased mobility due to s/p surgery, pain, muscle weakness, fatigue (Initiated and Revised: 3/23/21). The care plan included the interventions: - Guest was educated not to sit for long periods to assist in wound healing, verbalized understanding (Initiated: 4/23/21) - Low Air Loss Mattress to bed (Initiated: 3/25/21) - Nutritional supplements to promote wound healing (Initiated: 3/23/21; Revised: 6/23/21) - Use Pillows or Wedges to Position Guests off bony prominences (Initiated: 3/25/21) A wound care observation for Resident #26 was completed on 6/25/21 at 10:28 AM with Registered Nurse (RN) G and Certified Nursing Assistant (CNA) O. Upon entering the room, Resident #26 was observed in bed positioned on their back with their heels directly on the mattress. The alternating air mattress remained in place with the same settings in place. When queried regarding their wounds, Resident #26 stated, Two years ago this month, I had surgery on my back and in went into a coma for 4 months. The Resident revealed they have been struggling to regain their health since that surgery. When asked if the wounds they currently had were from that surgery, Resident #26 disclosed the wounds were from laying in bed on their back. When asked if the pressure ulcers developed at the facility, Resident #26 replied, Yes. At this time, RN G brought wound care supplies in the room and CNA O began positioning the Resident. When queried regarding the Residents wounds, RN G stated Resident #26 had pressure ulcers on their left ischium, coccyx, and right ischium. RN G began by completing the dressing change on the Resident's left ischium. RN G donned gloves, removed the dressing, doffed their gloves, and applied hand sanitizer. RN G rubbed their hands together for nine seconds, shook the wet sanitizer off their hands, and donned gloves. The wound opened was triangular shaped and approximately the size of a dime with visible depth and noted tunneling. The wound bed was unable to be accurately visualized due to depth. The wound edges were noted to be unattached and white in color. When asked if they would measure the wound and the tunneling, RN G revealed they do not measure the wounds. RN G proceeded to cleanse the wound in a circular, around and over the wound bed with Normal Saline (NS) and gauze. RN G then used a Sure Prep (skin protectant) wipe around the wound opening, placed Maxsorb (absorbent, antibacterial) dressing inside the wound bed, and covered with a dry Optiform dressing. RN G doffed their gloves, applied hand sanitizer for approximately nine seconds. RN G donned gloves when their hands were still visibly wet and removed the dressing covering their coccyx pressure ulcer. The removed dressing was noted to have a small amount of light brown colored, serosanguinous drainage. The wound was circular and irregularly shaped, approximately the size of a dime. The wound bed was unable to be visualized due to notable depth and the edges were unattached. RN G applied a new dressing and proceeded to remove their gloves, sanitize their hands for approximately nine seconds, and don gloves while their hands were still visibly wet. RN G struggled get the gloves on over their visibly wet hands and indicated it was difficult to put gloves on with wet hands. After repositioning the Resident, RN G removed the dressing in place over Resident #26's left ischium pressure ulcer. The wound was circular and irregularly shaped with visible depth and tunneling. The edges of the wound bed were white in color, unattached, with a section of loose white colored tissue present. RN G washed the wound with NS and gauze in a circular motion while crossing over the open wound bed. After cleaning the wound area, RN G doffed their gloves, applied hand sanitizer, rubbed their hands together for eight to nine seconds, and donned gloves. When queried regarding the depth and area of the tunneling, RN G used the Q-tip they were using to pack the wound bed, inserted it into one area of the wound but did not move the Q-tip in the wound to determine the area of greatest depth. The depth of the wound where RN G placed the Q-tip was approximately one inch deep. RN G was asked if they agreed the depth where they inserted the Q-tip was approximately one inch and replied, Yes. RN G proceeded to pack the wound bed with Maxsorb dressing and covered with a dry Optiform dressing. After the dressing change, Resident #26 was repositioned in bed with their heels directly on the bed. After the dressing change, CNA O and RN G were queried regarding the settings on the Residents alternating air mattress. Both RN G and CNA O revealed they were unaware of what the mattress setting were supposed to be set at. RN G indicated facility maintenance brings the mattresses into the rooms and sets them up. CNA O revealed they only check to make sure the mattress is on. When queried who checks the mattresses to ensure they are functioning properly and that the settings have not been modified to ensure appropriate pressure reduction, CNA O stated, I don't know. We (CNAs) don't. RN G concurred with CNA O and revealed nursing staff does not check the mattresses either. The alternating air mattress settings were reviewed with the staff at this time. The mattress remained set at 200 pounds. When queried regarding Resident #26's weight, Resident #26 stated, I weighed 143 (pounds) this morning. When asked why the mattress was set at 200 pounds when the Resident weights 143 pounds and if the mattress was providing the appropriate pressure reduction, neither RN G nor CNA O were able to provide an explanation. At this time, Resident #26 verbalized they also check the mattress to make sure it is on but had not been informed of the correct settings and had concerns related to lack of staff monitoring. Upon request to view Resident #26's heels, CNA O removed the Resident's socks. Both of the Resident's heels were reddened. When asked if the skin on the heels blanched, RN G pressed on various areas of the Resident's heels. On both heels, one area was noted to have minimal to no blanching (indicating impaired blood flow and potential pressure ulcer formation). When queried regarding the Resident's heels being reddened and observation of minimal to no blanching, RN G stated, Will order skin prep. RN G then obtained a skin prep wipe and wiped both of the Resident's heels. When queried regarding the Resident's heels being directly on the bed, Resident #26 revealed they recently received pressure reduction boots which they wear at night. Resident #26 was asked if staff elevate their heels off the bed to reduce pressure when they are in bed other than at night and revealed they do not. When queried, Resident #26 indicated they require assistance to move themselves in bed. Resident #26 was then asked how long they are in their wheelchair during the day. The Resident explained their spouse resides in the Assisted Living section of the facility and they spend the majority of their day in their wheelchair with them without returning to their room. When asked if staff assist them to reposition in their wheelchair, Resident #26 revealed they do not but stated, I use my arms to lift myself up for a second. The Resident was then asked if they are able to shift their weight in the chair and/or if they have devices for positioning, Resident #26 revealed they are supposed to be getting a different pad for their wheelchair but did not have any other pressure reduction devices. When queried if regarding their heel placement when in the wheelchair, Resident #26 revealed they have a reclining (high back wheelchair noted in room with regular, elevated leg rests) wheelchair and their feet are just on the rests. Record review revealed Resident #26 weighted 146.2 pounds on 6/24/21. An interview was conducted with the facility Administrator and Director of Nursing (DON) on 6/25/21 at 12:45 PM. When queried if Resident #26 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator and DON were informed of the observation of Resident #26's heels and asked why the Resident did not have interventions in place to prevent pressure ulcer development. Both the Administrator and DON were unable to provide an explanation. When queried if the Resident was at risk of pressure ulcer development on their heels, the DON indicated they were and revealed Resident #26 had already developed a facility acquired pressure on their heel which had healed. When asked if the Resident should have interventions in place for pressure prevention, both the DON and Administrator stated, Yes. Resident #26's wound dates of origination as well as progression were requested again at this time. Review of Resident #26's medical record revealed the following skin/wound progress notes and assessment documentation: -7/17/19: Skin/Wound . wounds measured today and tx (treatment) completed. Guest has a pressure area on coccyx that measures 6.5 cm (centimeters) x 9 cm. Areas of slough and eschar present at this time. Prevention measures in place . -8/7/19: Skin/Wound . Skin assessed today per weekly skin log. Coccyx measures 4.5 cm x 4.5 cm with areas of slough present. Odorous and minimal drainage that is purulent. New area on right heel that measures 2.5 cm x 3 cm that is unstageable blister . -8/14/19: Skin/Wound . Wound Assessment completed. Unstageable wound to coccyx remains mostly slough covered, malodorous, with light purulent drainage from wound . Wound Measures 7.5 (cm) x 6.5 (cm) with unknown depth due to slough. Will refer to physician for further treatment options. The unstageable wound to Guest's Right Heel was also assessed. Wound contains 30% eschar and 70% bright, beefy red tissue . Wound Measures 3.5 (cm) x 4.0 (cm) . -8/27/19: Skin/Wound . Unstageable wound continues to be present to coccyx. Wound was debrided while guest was the hospital. Wound continues to have necrotic tissue present. Wound measures 9.0 x 6.5 outside. Depth unable to determine at this time. Tunneling is present at 6 o clock and measures 4.0. Foul odor present. Edges of wound are rolled . Guest has 2 stage 2 wounds present below coccyx wound on left buttock. Treatment initiated with barrier cream . The upper wound is measuring 2.0 (cm) x 1.0 (cm), and the lower measures 1.5 (cm) x 1.0 (cm) . continues to have an unstageable wound to right heel present on admit. Area measures 4.5 (cm) x 3.0 (cm). Area composed of a necrotic cap . - 10/11/19: Skin/Wound . Sacral . Area measures 7.0 x 3.5 cm. Bright, beefy base currently . right heel measuring 1.0 x 0.4 cm . - 12/5/19: Skin/Wound . Wound to coccyx measures 5.5 (cm) L (long) x 4 (cm) W (wide) x 1.2 (cm) D (depth) with undermining at 1 cm all around wound with 2 cm noted at 6 o'clock. Wound beefy red with serosanguinous drainage noted . Right heel wound healed . Two healing skin tears noted to left hip measuring 1.5 (cm) x 3.5 (cm) x 0 (cm) and 1.4 (cm) x 1.6 (cm) x 0 (cm). Healing skin tear to left upper buttock measuring 2.6 (cm) x 1 (cm) x 0 (cm) . - 3/2/20: Skin/Wound . Stage IV sacral wound measuring 9 cm long by 5 cm wide with depth of 1.2 cm. Previous eschar at 8 o'clock position resolved. Slough observed from 10:00 to 12 o'clock position . Large amount of serosanguineous drainage . Undermining from 3 o'clock to 11 o'clock position with a depth increased from 8 to 9 o'clock position to 3.2 cm. Guest with area of blanchable redness noted to left ischium . Right ischium noted to have unstageable ulcer surrounded by area of DTI (Deep Tissue Injury) Measurement of both of these areas are 5 x 5 cm with a depth unable to determine. Left ischium does have area of blanchable redness. Very high risk for progression to open wound. Apply Skin-Prep to this area. Sacral ulcer has extended in size however this is thought to originate from previous area of eschar which is now resolved . RD (Registered Dietician) following . - 4/6/20: Skin/Wound . Stage IV sacral wound measuring 8.5 x 5 x 1.5 cm . Undermining noted from 3 o'clock to 11 o'clock position measuring 3.5 cm. Large amount of serosanguineous drainage noted to dressing . Unstageable wound to left ischium measuring 4.0 x 5 cm by unable to determine. Wound is filled with 50% eschar and 50% granulation. Unstageable wound to right ischium noted to have unstageable ulcer measuring 4 (cm) x 9 (cm) x unable to determine . - 6/12/20: Skin/Wound . Stage IV sacral wound measuring 6.5 x 5 x 1.5 cm. Undermining noted from 12 to 8 o'clock position measuring 4.0 cm . Large amount of serosanguineous drainage . Left ischium is an unstageable ulcer measuring 3.5 x 2.5 by UTD . Right ischium is a stage IV ulcer measuring 6 x 8.5 x 2.8 cm deep with tunneling at 5 o'clock position 4.5 cm deep. Muscle is exposed . - 8/13/20: Skin/Wound . Sacral stage IV wound: 6.5 x 4.7 x 1.5 cm; undermining between 4 and 6 o'clock position: 2.0. cm. Moderate amount of serous drainage . L ischium stage IV ulcer: 1.5 (cm) x 1.8 (cm)x 2.4 (cm); tunneling noted at 7 o'clock position of wound bed to 4.8 cm, filled with granulation tissue. R ischium Stage IV ulcer: 2.9 x 4.3 x 2 cm; no tunneling . Open wound to R thigh area, previously blistered: 2 x 3.5 x 0.1 cm. Scant amount of serous drainage noted. blister no longer intact . - 1/14/21: Skin/Wound . sacral wound, stage IV. Measurement of 2.5 x 2.5 x 0.5 cm. There is 1.0 cm undermining noted at 12:00 o'clock position . Left ischium is a stage IV ulcer measuring 0.5 x 0.5 x 1 cm. Right ischium is a stage IV ulcer. Area is 0.6 x 1.1 x 0.5 cm . - 2/25/21: Skin/Wound . Guest continues with stage 4 pressure ulcers on her coccyx and bilateral ischium . ensure plus to aide in healing . has an indwelling catheter . Guest often goes to visit (spouse) at the (assisted living) for hours at a time . has a pressure reducing pad on chair . - 6/24/21: Wound Assessment . Sacral . Pressure Injury Stage 4 . Full Thickness . Measurements: Length 1 (cm), Width 1 (cm), Depth 0.6 (cm) . Exudate/Drainage Amount: Moderate . Serous . - 6/24/21: Wound Assessment . Facility Acquired: Yes . Left Ischium . Pressure Injury Stage 4 . Measurements: Length 0.8 (cm), Width 1 (cm), Depth 1.5 (cm) . Exudate/Drainage Amount: Heavy . Comments . Guest has 3 wounds. Interventions include foam cushion for wheelchair, Ensure drinks three times daily, every 2-hour checks for toileting needs . - 6/24/21: Wound Assessment . Facility Acquired: Yes . Date: 3/2/20 . Right Ischium . Pressure Injury Stage 4 . Full thickness . Measurements: Length 1 (cm), Width 1.5 (cm), Depth 1.2 (cm) . Tunneling 12:00 (o'clock), 2.1 cm . Exudate/Drainage Amount: Heavy . Serous . Additional review of Resident #26's care plans revealed a care plan entitled, I am at risk for pressure ulcers due to decreased mobility, bowel incontinence and loss of feeling (Initiated: 12/19/19; Revised: 3/23/21). The care plan included the interventions: - Ensure TID (three times a day) (Initiated: 12/19/19; Revised: 3/22/21) - Roho cushion in wheelchair . (Initiated: 1/5/21). - The intervention, I wear soft boots every night for prevention was added to the care plan on 6/28/21 during the survey. Review of Resident #26's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR also revealed Resident #26's wound care treatment was not completed on 6/6/21, 6/10/21 and 6/16/21 night shift. There was no explanation in the nurses' notes related to the treatments not being completed. An interview was completed with the DON on 6/29/21 at 11:30 AM. When queried regarding Resident #26's pressure ulcers including dates, the DON stated, They were admitted with the coccyx in July 2019 and revealed the other pressure ulcers developed at the facility. The Resident's care plan and MAR/TAR were revealed with the DON at this time. When queried how frequently Resident #26 is supposed to receive Ensure, the DON replied, I would assume TID. When asked why they were only receiving twice a day, the DON was unable to provide an explanation. When queried regarding the missing wound treatments and lack of documentation, the DON did not provide an explanation. The DON was then asked if Resident #26 should be repositioned minimally every two hours for pressure reduction and indicated they should. When queried why the Resident did not have an intervention in place in their care plan related to turning and repositioning, the DON indicated there were definitely areas which needed improvement. The DON was then asked how the settings are determined for air mattresses, and indicated the settings are individualized based upon the Resident. When what Resident #26's air mattress settings should be, the DON reviewed the medical record and indicated they were unable to find the settings. When asked if the mattress should be set at 200 pounds when the Resident weighs between 140 to 150 pounds, the DON replied, No. When queried if the mattress would provide optimal pressure reduction when not set at the correct weight, the DON revealed it would not. The DON was then asked what interventions were in place upon Resident #26's admission to the facility and prior to them developing facility acquired pressure ulcers. The DON reviewed the Resident's active and discontinued care plan and revealed the Resident did not have an alternating air or pressure reduction mattress, scheduled repositioning, and/or and intervention to offload pressure on their heels. When asked why the Resident did not have interventions in place, due to risk and being admitted with a pressure ulcer, the DON was unable to provide an explanation. Review of facility policy/procedure entitled, Skin Management (Approved 7/19) revealed, It is the policy of the facility that a guest does not develop pressure injury . 4. Guests admitted with skin impairments will have . Appropriate interventions implemented to promote healing .

Based on observation, interview and record review the facility failed to assess and monitor weight changes for two residents (#6 and 8) of five residents reviewed for weight changes and nutrition, resulting in Residents #'s 6 and 8 both gaining undesired weight with increased [MEDICAL CONDITION] (swelling from fluid retention) that contributed to [MEDICAL CONDITION] (skin inflammation) and discomfort for Resident #6 and fluid overload with respiratory distress and hospitalization for Resident #8. Findings Include: Resident #6: On 04/16/19 at 1:44 PM, Resident #6 was observed to have [MEDICAL CONDITION] (swelling of body tissue due to fluid accumulation) with scaling and bright redness to both lower legs and feet. The left foot was very red with +4 [MEDICAL CONDITION] (the skin indented when pushed on and didn't rebound within 20 seconds). The resident stated, My lower legs are very swollen. Resident #6 said he had heart failure, was having more difficulty breathing and needed oxygen therapy since readmission to the facility. A review of the Face Sheet and Minimum Data Set (MDS) assessment, dated 3/8/19, indicated the resident had been admitted to and discharged from the facility multiple times since (MONTH) (YEAR) with Diagnoses: [REDACTED]. The resident had full cognitive abilities and needed 1-2-person assistance with all care except for eating and was able to feed self. A review of the Weights and Vitals, revealed Resident #6 weighed 238.4 pounds on 4/10/19, 4/14/19 244.6 pounds, 4/15/19 252.6 pounds, 4/16/19 259.4 pounds and 4/18/19 weighed 257.6 pounds. From 4/10/19-4/15/19 the resident gained 14.3 pounds-5.96% weight gain. A review of the medical record indicated there was no communication about the resident's weight with the physician regarding weight gain until 4/17/19, during the survey. A progress note dated 4/17/19 at 9:08 AM, Physician contacted regarding weight gain . and 4/17/19 at 10:52 AM, Physician added 40 mg more of [MEDICATION NAME] (diuretic medication) for today and five days following for fluid retention . A review of the assessments and progress notes indicated there was no nutritional note from the Dietitian or Dietary Manager related to weight gain until 4/17/19 and it mentioned a 3.6% weight gain in 30 days, however the resident was newly readmitted to the facility on [DATE] after being discharged to home on 3/15/19 and was not a resident in the facility for ½ of the 30 days- .Guest continues on 1500 cc fluid restriction as ordered. Guest maintains a good appetite and continues to consume 76-100% of most meals per (food acceptance record) . A review of the physician orders [REDACTED]. A review of the Care Plans for Resident #6 revealed: [MEDICAL CONDITION] . date initiated and revised 4/10/19, with Interventions: Assess/record/report to MD as needed: .weight gain .fluid overload .[MEDICAL CONDITION] . date initiated/revised 4/10/19, and Provide diet as ordered .dated 4/10/19. Two care plans addressed the Fluid Restriction, but there was a discrepancy, the Renal Care Plan said 1200 cc/day and the Fluid Restriction Care Plan said 1500 cc/day. The Nutritional Problem Care Plan did not mention what type of diet the resident had but included the intervention RD (Registered Dietitian) to evaluate and make diet change recommendations as needed, dated 4/10/19. On 4/18/18 at 1:30 PM, during an interview with the Dietitian (who was not a Registered Dietitian ) and Administrator, they were asked about Resident #6's weight gain and the Dietitian stated, I look in the chart every day. When asked if the staff had notified the Dietitian about the resident's sudden weight gain, increased [MEDICAL CONDITION] in the lower legs and shortness of breath, she said no. The Dietitian was queried about the resident's Heart Healthy Diet and she reviewed the facility's diet titled, Regular/NAS (no added salt)/Consistent CHO (carbohydrate), and said this was the diet they used for Heart Healthy Diet. The Dietitian was further queried about the sodium (salt) content of the diet and said, It has 3,498 milligrams (mg) a day. It's too much, especially for [MEDICAL CONDITION]. It should be about 1500 mg a day. The Dietitian and Administrator were asked if that could be a contributing factor to Resident #6's weight gain and worsening condition and stated, We are working on a plan, because we know our diet needs to be worked on. The Dietitian was further queried about Resident #6's fluid restriction of 1500 cc/day, as the Care Plans listed 1200 cc and 1500 cc and the Dietitian said she was responsible for updating the Nutrition Care Plans and was not aware of the discrepancy. A review of the facility policies titled, Liberalized Diets, revised 2/18 provided, Physicians may order a restricted diet for guests needing to manage a disease . and Nutrition Assessment, dated revised 2/18 revealed, CDM (certified dietary manager) will evaluate diet order to determine if appropriate and communicate with the kitchen .CDM will evaluate [DIAGNOSES REDACTED]. and Communication of Weight Concerns, revised 5/16 Identified concerns with a change in weight will be recorded and reported in accordance with this policy .In the event of a 5% weight loss or weight gain, the guest will be reweighed on the same scale to verify the weight change .If the re-weight verifies a 5% weight loss or 5% weight gain, the nurse will notify the physician and the RD/CDM who will evaluate the guest .After evaluating, the RD/CDM will initiate the appropriate interventions and update the care plan . Resident #8: According to the Resident Face Sheet, printed on 04/18/2019, Resident #8 was a [AGE] year-old male re-admitted to the facility on [DATE] (initial admission date of [DATE]) with a [DIAGNOSES REDACTED]. Record review of Resident #8's documented weights revealed that Resident #8 weighed 257.2 pounds upon admission 03/12/19. One month later (04/12/19) Resident #8 weighed 215.2 pounds (42 pound/16.33 percent loss over one month). It was also noted that Resident #8 had a significant weight gain of 10 pounds over three days. Resident #8 weighed 238 pounds on 03/18/2019 and weighed 248 pounds on 03/21/2019. Resident #8 was sent to the hospital on [DATE] from a cardiac doctor appointment. On 03/27/2019 Resident #8 weighed 249 pounds. Upon return from the hospital on [DATE] Resident #8 weighed 212.6 pounds (36.4 pound/13.41 percent weight loss in twelve days). Resident #8 was not weighed on 03/19/19, 03/20/2019, days prior to his hospitalization . It is a standard of practice to obtain weights daily for residents with a [DIAGNOSES REDACTED]. Weights were documented daily for all other days during residents stay. Record Review of Resident #8's hospital discharge orders dated 03/12/19 and 04/9/19 revealed Low Fat, Low Cholesterol, Low Sodium, American Diabetes Assoc (association) Diet. Review of hospital discharge summary (04/08/2019) read, . comes into the hospital with complaints of difficulty in breathing . Patient was found to be in acute exacerbation of [MEDICAL CONDITION]. Patient's hospital stay was complicated with his [MEDICAL CONDITION] and worsening renal function. Patient had significant volume overload. He required several days of IV (intravenous) diuretics. Record Review of Resident #8's orders revealed a controlled carbohydrate diet and diuretics ordered daily. Record Review of resident #8's baseline care plan (dated 3/13/19) revealed that a care plan was not developed related to Resident #8's [DIAGNOSES REDACTED]. Record Review of Nutritional assessment dated [DATE], revealed nutritional risk factors that included diabetic, diuretic medication use, and fluid restrictions (1800 milliliter). Review of Nutritional assessment dated [DATE], revealed nutritional risk factors that included recent weight loss, diabetic, diuretic medication use, and fluid restrictions (1500 milliliter). There was no mention of weight gain in the past 30 days on the 04/09/19 assessment. Record Review of Resident #8's progress notes revealed a Food and Nutrition Services note on 03/27/19 (date of re-hospitalization ) regarding weight increase. It reads, Weight increase, monitored by MD (doctor). Noted diuretic adjusted per 3/22/19 note. Weight (3/26/19) 247.0 lbs (pounds), 249.0 lbs (3/27/19). Will discuss weight with MD. Will continue to monitor. Further review of progress notes (3/18/19-3/27/19) did not reveal documentation regarding weight gain or signs or symptoms of fluid overload. Review of facility policy titled, Liberalized Diets (revised 2/18), read, 4. Physicians may order a restricted diet for guests needing to manage a disease or condition . Review of facility policy titled, Nutrition Assessment (revised 2/18), read, Guests shall be assessed . To determine nutritional status, diet order, weights, labs . CDM (certified dietary manager) will evaluate diet order to determine if appropriate . CDM will evaluate [DIAGNOSES REDACTED]. Review of facility policy titled, Communication of Weight Concerns (revised 5/16), read, .If the re-weight verifies a 5% weight loss or a 5% weight gain, the nurse will notify the physician and the RD (registered dietician/CDM who will evaluate the guest . Possible recommendations include Investigation into potential causes for the weight loss .It was noted during survey that Staff F was not a RD or CDM and had not consulted with one for Resident #8. During an interview on 04/18/19 at 09:45 AM with the Dietary Manager (Staff F) and Nursing Home Administrator (NHA), Resident #8's weight gain and weight loss for the time period of 3/12/19-present was discussed and reviewed. Staff F acknowledged that Resident #8 had lost a significant amount of weight in one month and had also experienced weight gain related to [MEDICAL CONDITION]/swelling in which he was re-hospitalized on [REDACTED]. When asked to describe Resident #8's diet during his stay at the facility, Staff F explained that Resident #8 is on a carbohydrate-controlled diet with a 1500 milliliter per day fluid restriction and that diets are determined based on hospital discharge recommendations and dietary assessments. Staff F, stated, We have orders for fluid that nursing gives him each day and the fluid dietary gives him each day, but strict (exact) fluid intake is not documented here. When asked if Resident #8 was ordered a low sodium diet, Staff F answered, No. After reviewing resident #8's diet orders recommended upon discharge from the hospital on [DATE] and 4/8/2019, Staff F then explained, The carbohydrate-controlled diet includes low sodium per the American Diabetes Association (ADA). During the interview the NHA, stated Our menu is based on 2400 grams of sodium per day which is the daily recommended amount .I would consider over 4 grams of sodium excessive. When asked if Resident #8 was compliant with his diet and restrictions or if family brings in food items high in sodium, Staff F stated that Resident #8's wife does a really good job watching his food and fluid intake. Staff F continued to explain that Resident #8 does not generally order ala cart and that there have not been any non-compliance issues. During a follow up interview on 04/18/2019 with Staff F and NHA a sample Detailed Menu Cycle Nutritional Analysis reports (printed 04/17/2019) were reviewed. Day 24's daily sodium total was 3520 milligrams (a 1120 milligram deviation from the facilities daily sodium goal of 2400 milligrams per day). A trend of high sodium menus was discussed. The NHA admitted that the survey had drawn their attention to this area of concern and that it had not been an area of recognized concern by the facility until now. Increased intake of sodium can lead to high blood pressure and thickening of arteries in the body. According to the AHA (American Heart Association) low sodium is defined as 140 milligrams per serving and recommends that adults consume no more than 2300 milligrams a day. However, the AHA says that the ideal amount of sodium for an adult per day is 1500 milligrams or less. The AHA infographic titled The Effects of Excessive Sodium on your Health and Appearance dated (2014), reveals that excess sodium puts people at risk for health conditions that include stroke, heart failure, kidney disease and enlarged heart. The infographic also notes that excess sodium can cause puffiness ([MEDICAL CONDITION]) and weight gain. On 04/18/19 at 10:03 AM Nurse Practitioner L was interviewed and informed of the high sodium content of the facility provided menu. Nurse Practitioner L said, I don't know what to say to the surveyor, but I am concerned.

Based on observation, interview and record review the facility failed to prevent a fall for one resident (#20) of three residents reviewed for falls resulting in significant facial bruising. Findings include: According to the Resident Face Sheet, printed on 04/18/2019, Resident #20 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #20's most recent cognitive assessment, her cognition is moderately impaired. On 04/16/19 at 11:39 AM, Resident #20 was observed to have significant black and purple bruising and swelling covering 50% of her face (the left side). The bruising extended from her hair line to neckline vertically and from ear to nose horizontally. Resident #20's eye was swollen and blood shot. Resident #20 stated, I fell here. I was going to the bathroom and I scooted over wiping myself. I hit face on floor when I landed. Resident #20 stated bruising had improved a little since the fall. Upon review of facility matrix, dated 4/16/19, Resident #20 was noted to have had a fall with injury within the past 30 days. Incident & Accident Report (I&A report) dated revised 4/10/19 noted that Resident #20 was found sitting in her restroom on the seat of her walker after she put on her call light and reported to staff that she had fallen. The I & A report noted a hematoma to the forehead, and a bruise to the left eye. The I & A report also noted Resident #20 was marked for recent illness and gait imbalance. Progress noted on 4/10/19 notes resident was on the commode wiping and leaned to one side was unable to recover and fell to the left side. Upon review of physician's progress note (dated 4/16/19), skin is described as swollen rounded oval on left forehead deeply purple with left periorbital (surrounding the eye) bruising- slightly reduced in size. According to a Fall Risk assessment dated [DATE], Resident #20 was noted to have a history of multiple falls within the last six months and last 30 days. She was also noted to have had a fall with fracture within the last six months. Resident #20 was noted to be on two medications that increase risk of falls, incontinence of bowl and bladder. Resident #20 was also noted to be unable to independently come to a standing position. According to Resident #20's care plan, she is at moderate risk for falls (related to) deconditioning (initiated on 03/29/2019, last revised 03/29/2019). One intervention noted on Resident #20's care plan is to complete a fall risk assessment as needed. Review of Resident #20's record did not reveal an as needed care plan related to her physical decline and weakness noted in her progress notes. Another intervention read instruct resident to seek assistance with all mobility and transfers (initiated 03/29/19, revised 4/10/2019). Another care planned area for Resident #20 noted impaired thought processes (related to) .(initiated 04/04/19). Another care planned area reads, I need help with my ADL's (activities of daily living) because impaired balance (initiated 03/29/19, last revised 03/29/19). Resident #20's interventions for the task of toilet use was extensive assistance with one person and stated, do not leave me unattended on the toilet. (initiated 03/30/2019, resolved 04/02/19). From 4/3/19-4/17/19 Resident #20's toilet use intervention said, I am MI for toileting. There is no noted change in care plan intervention the correlates to the stated ADL decline noted in the progress note on 4/15/19 or the I & A report dated 04/10/2019. Upon review of Resident #20's Kardex (bedside care report) (printed 4/17/19), resident #20 is MI for toileting. Review of progress notes revealed a note written on 4/15/19 that read, Guest has had a decline in functional mobility this week. She is requiring increased assist for transfers, bed mobility and ambulation. She is no longer MI in her room secondary to decreased cognition and decreased strength. Therapy extending guest to 4/23. During an interview with the Director of Nursing (DON) 4/17/19 at 2:28PM, DON stated Resident #20 has had a new pneumonia so she has become weaker. During an interview on 04/18/19 at 03:00 PM with Certified Nursing Assistant (CNA) Staff M he stated that Resident #20 was sitting on her roller walker when he answered her call light on the day of the fall. Staff M stated, I think she was almost independent in her room. She had a yellow sticker on her walker. Once therapy gives them a green sticker they can move about on their own. Staff M also explained, When they have a yellow sticker and I know that they have been extensive recently I still try to keep an eye on them especially right after they have been upgraded. Therapy maybe pushes the residents a little bit further then they should, and I don't think the yellow sticker is explained well to the residents or if they have dementia, I'm not sure if they even recall what therapy taught them. When asked what MI means for Resident #20's toilet use intervention, Staff M explained, I think MI means totally independent for toileting. I'm not sure what the modified independent means. We never really get the info from therapy. During an interview on 04/18/19 at 03:39 PM with CNA Staff N she revealed she was assigned to care for Resident #20 on the evening of the fall. Staff N stated, They have been changing her transfer status often. I don't recall if resident was a red yellow or green sticker that night. When asked what MI means for Resident #20's toilet use intervention, Staff N explained, MI means minimal assistance. that means she can move around in her room .we were not educated on that term. I had to ask the nurse what it meant.

This citation has two deficient practices. Deficient practice #1: Based on observation, interview, and record review, the facility failed to provide timely pain management for one (#408) of three sampled residents reviewed for pain from a total sample of 13, resulting in extended, severe post-operative pain from an extensive surgical procedure, crying, and mental/physical anguish. Findings include: On 5/29/14 at 8:25 AM, resident #408 was observed being assisted by staff in transferring from bed to wheelchair. The resident winced in pain and kept her left leg straight with limited weight bearing while pivoting to the wheelchair. The nurse gave the resident [MEDICATION NAME] (narcotic). The resident was alert and fully oriented, and stated that her pain level was "5" on a scale from 0 (no pain) thru 10 (intense pain) and that the pain was "incisional." On 5/29/14 at 10:45 AM, resident #408 was observed resting in bed. When asked about her stay so far at the facility, the resident stated that the only problem occurred when she first arrived at the facility on 5/25/14 and gave the following account: "I got here last Sunday (5/25/14) around 11 (AM) and didn't get any pain medication until late that night. I got something at the hospital right before I got here. They (staff) told me that the pain medication had to come from out of state. They told me that there was a glitch with the (back-up medication dispensing) machine and when they put in (entered) the order (for the pain medication) the medication wouldn't come out. They said that the machine was new and they were getting use to it and that you had to use your thumbprint (to gain access)." Resident #408 said, "They said that there were no more (pain) pills the next day (5/26/14). I called my daughter crying and told her to bring me something for pain. I didn't know she was at work. There was nothing she could do. She was so upset. My son called a few hours later and said he was coming, but by that time they had giving me something, so I told him not to come. I have 63 staples in my (left) hip. It was very extensive and they (surgeons) had to go in from the back (a different angle) because they had to remove the old parts first (from a previous hip replacement) before they could put in the new parts." On 5/29/14 at 12:30 PM, resident #408 was observed laying in bed with her left leg elevated on a pillow. The leg was very swollen, shiny, and hard in appearance. Nurse Practitioner (NP) 'I' entered the room to examine her leg. Therapy staff entered the room and asked the resident if she wanted to go to the dining room for lunch, but the resident declined stating that she wanted to keep her leg elevated due to the [MEDICAL CONDITION] and said, "It feels better when I don't move it." On 5/30/14 at 10 AM, resident #408's clinical record was reviewed with Nurse Unit Manager 'J'. The resident was admitted on [DATE] at 2:06 PM with [DIAGNOSES REDACTED]. Nurses notes dated 5/28/14 documented that the resident had 63 staples to the left hip that was covered with a dressing that was "completely saturated and leaking." There were no documented nurses notes between 5/25/14 at 2:06 PM when resident #408 arrived, and 5/26/14 at 1:06 AM and 1:12 AM when it was noted: the resident received [MEDICATION NAME] 7.5-325 milligrams (mg) for "complaint of pain in left hip" and that [MEDICATION NAME] was "given upon arrival from pharmacy." A review of the resident's "Controlled Drug Administration Record" revealed that [MEDICATION NAME] was first given on 5/26/14 at 1 AM (11 hours after the resident arrived) and the next dose was not given until almost 12 hours later, at 11:50 AM. The controlled drug record noted that these two doses of [MEDICATION NAME] came from the emergency drug back-up supply kit. On 5/25/14, resident #408 was prescribed [MEDICATION NAME] every six hours PRN (as needed). When queried regarding why there was a delay in resident #408 receiving pain medication, UM 'J' shrugged her shoulders and did not respond, but did say, "We have two back-up supplies," "Narcotics are (located) in one of the supplies," and "Narcotics are not (located) in the machine." Per review of a 24-hour physician's log with UM 'J', on 5/27/14, staff noted: "Per (the resident's) request, change [MEDICATION NAME] order (to) one every four hours (from every six hours)." UM 'J' stated that the resident asked to receive [MEDICATION NAME] more frequently. On 5/30/14 at 11:45 AM, resident #408's Primary Care Physician (PCP) was queried regarding the delay is the resident receiving pain medication. The PCP said, "She (the resident) told me she didn't get her pain medication. I don't know what happened. I was not on call. I think (NP 'I') was on call." At 11:50 AM, when NP 'I' was queried, he did not respond why pain medication was not promptly given, deferred back to the PCP and said, "I will find out." At 12:15 PM, when the Director of Nursing (DON) was queried and the controlled drug record was reviewed, the DON said, "She didn't get her med until 1 AM (on 5/26/14). I don't know why. It was available in the back-up supply. She should have gotten it." Further review of the controlled drug record with the DON revealed that after the dose of [MEDICATION NAME] on 5/26/14 at 11:50 AM, staff still had to give resident #408 eight more doses from the emergency drug back-up supply until 5/28/14 dose at 5:32 PM, indicating that the resident's prescription had not been delivered from the pharmacy. The DON did not respond why. On 5/30/14 at 2 PM, the facility's policies on "Guest's Bill of Rights (undated)," "Pain Assessment and Management" dated 7/2011, and "Stat (immediate drug) Delivery" dated 12/2013, were reviewed and noted: - "A guest (resident) is entitled to adequate and appropriate pain and symptom management as a basic and essential element of his or her medical treatment." - "Pain will be managed for guests. Guests will be....comfortable." - "Stat deliveries will not be made for any medications that are available in the emergency drug (supply) kits....A stat delivery may be delivered from (the pharmacy) directly, or by a local backup pharmacy." ( ) Deficient practice #2. Based on observation, interview and record review, the facility failed to coordinate care with hospice services and failed to ensure hospice plan of care was available for two (Resident #403 and #410) of two hospice residents reviewed, from a total sample of 13, resulting in the potential for unmet care needs. Finding include: On 5/28/14 at 9:35 a.m., during the initial tour of the facility with Unit Manager "J" Resident #403 was observed sitting in his wheel chair in his room. The resident was able to answer simple questions appropriately. Unit Manager "J" stated, "He is on hospice." On 5/28/14 at 12:30 p.m., Resident #403's medical record was reviewed and revealed that the resident was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's minimum data set assessment (MDS), dated [DATE] revealed that the resident's cognition was severely impaired and required extensive assistance for most activities of daily living. The MDS also indicated that the resident was receiving hospice services. Review of Resident #403's medical record revealed no documented plan of care from the hospice group. The record was further reviewed and revealed no documentation of Certified Nursing Assistant (CNA) visits between 4/18/14 and 5/1/14. Review of Resident #403's facility care plan titled, "Guest was admitted to hospice," dated 9/9/13, revealed "SNF (skilled nursing facility) and hospice staff will collaborate to provide optimal support and care at end of life." On 5/29/14 at 12:00 p.m., Resident #403's Hospice Nurse, Nurse "H" was queried regarding Resident #403's Hospice plan of care and regular CNA visits. Nurse "H" stated, "(Resident #403) gets seen twice a week by a CNA. They document what care and services they provided for the resident on a green visit log and go over the plan of care with one of the facility CNA's and document the name on that sheet." When queried as to where the Hospice services care plan was, Nurse "H" reviewed Resident #403's medical record and stated, "I will have to have them fax one over. There should be one in there but I don't see it." When queried regarding the lack of CNA visit documentation on the log between 4/18/14 and 5/1/14, Nurse "H" stated, "I don't know what to tell you. He has a regular care giver. I will double check and see what happened." On 5/30/14 at 9:55 a.m., the Director of Nurses (DON) provided documentation that Hospice CNA, CNA "F" had seen Resident #403 on 4/23, 4/24 and 4/29/14. On 5/30/14 at 10:05 a.m., CNA "F" was queried as to where the documentation was for her visits with Resident #403 and stated, "I just filled it out and gave it to the DON. I called the office and they let me know when I was out here. She had it in the computer." When queried as to how the facility was to know what type of care and services were provided to the resident when there was no documentation of the visit on the residents medical record, CNA "F" stated, "I understand. I don't know what happened to it. Some times the charts are not available." On 5/28/14 at 9:35 a.m., during the initial tour of the facility with Unit Manager "J," Resident #410 was observed sitting in his wheel chair in his room. The resident was well groomed and able to answer questions appropriately. Unit Manager "J" stated, "He also receives hospice services." On 5/30/14 at 9:50 a.m., Resident #410's medical record was reviewed and revealed that the resident was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's minimum data set assessment (MDS), dated [DATE], revealed that the resident's cognition was intact and required extensive assistance for most activities of daily living. The MDS also indicated that the resident received hospice services. Review of Resident #410's medical record revealed no documented plan of care from the hospice group. The record was further reviewed and revealed no documentation of CNA visits after 5/1/14. Review of Resident #410's facility care plan titled, "Guest has a terminal prognosis related to cardiopulmonary disease," revised 12/10/13, revealed "Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met." On 5/30/14 at 9:55 a.m., the DON was queried as to where Resident #410's Hospice services plan of care was and the documentation of CNA visits after 5/1/14. The DON stated, "I will have to contact the company." On 5/30/14 at 10:05 a.m., Hospice CNA, CNA "F" was queried regarding CNA visits for Resident #410 and stated, "(Resident #410), I see him twice a week. I don't see them (notes). I will have to call the office. I will ask for a plan of care too." On 5/30/14 at 10:30 a.m., CNA "F" stated, "They faxed it over." CNA "F" provided a copy of Resident #410's plan of care as well as provided a green visit log. When queried regarding the log, CNA "F" stated, "I just filled it out. I was out and seen the resident on 5/6, 5/7, 5/13, 5/16, 5/19, 5/27 and 5/28/14. I don't know what happened to the sheet." On 5/30/14 at 1:05 p.m., the facility Administrator was queried regarding knowledge of the lack of Hospice plan of care in the medical record and lack of CNA documentation of visits and stated, "I wasn't aware it was an issue." On 5/30/14 at approximately 2:30 p.m., the facility's policy titled, "Hospice Care in the Skilled Nursing Home," revised 4/2006, was reviewed and revealed no information in regards to how the facility and a hospice company will coordinate and document care and services for the resident. On 5/30/14 at approximately 2:35 p.m., the facility's "Hospice General Contract," signed 3/8/13, was reviewed and revealed "In accordance with applicable federal and state laws and regulations, Facility shall coordinate with Hospice in developing a Plan of Care for each Hospice patient. Each clinical record shall completely, promptly and accurately document all services provided to... each hospice patient. Each record shall document that the specified services are furnished in accordance with the Agreement and shall be readily accessible and systematically organized to facilitate retrieval by either party." ( )

This citation pertains to intake #M 2708, M 2881, and M 2882. Based on observation, interview, and record review the facility failed to identify and analyze individual resident risk of an accident including implementing interventions, modifying interventions as necessary and training staff on interventions in 1 (Resident #101) of 3 sampled residents from a total sample of 47 residents resulting in a spiral tibial fracture and a displaced (out of alignment) spiral fibula fracture. Findings include: On 10/8/13, an unannounced investigation was conducted. According to the medical record and the Minimum Data Set ((MDS) dated [DATE], Resident #101 was a [AGE] year old female admitted to the facility 9/17/13, with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) (a measure of cognitive function) was not assessed or scored on the MDS 5 day report. The medical record indicated that Resident #101 was able to make her needs known but did exhibit periods of confusion. Resident #101 left the facility 9/22/13. Review of the Physical Therapy Evaluation and Plan of Treatment dated 9/18/13, revealed that Resident #101 had displayed "minimal movement LLE (left lower extremity)". The report indicated that Resident #101 was "at risk for falls", "further decline in function"' and "decrease in level of mobility". Review of the "Guest Transfer Status" form for Resident #101 dated 9/18/13, revealed "Transfer Status Recommendations" included weight bearing assistance of "2 person". The form indicated that Resident #101 was "WBAT" (weight bear as tolerated) on the right and left lower extremities, and left upper extremity. Review of the bottom of the form revealed handwritten instructions for resident transfer as follows, "T/F (transfer) pt (patient) to right and block left knee during T/F. Remove L (left) armrest from w/c (wheelchair) during transfer and replace once pt sitting in w/c". Review of the facility Incident/Accident Form dated 9/19/13, at 8:15 AM, revealed that Resident #101 was observed on the floor of the hallway in front of her wheelchair. Review of the report revealed that the Doctor (Dr.) and the family of the Resident had been notified. The report indicated that Resident #101 was transferred by ambulance to the hospital for evaluation. Review of the hospital emergency room report dated 9/19/13, at 9:15 AM revealed that Resident #101 was evaluated for upper extremity pain. The report indicated that X-rays of the arms and shoulders did not show a fracture. The report indicated that Resident #101 returned to the facility. Review of the facility Incident Accident Report dated 9/19/13, at 8:50 PM, revealed that Resident #101 had been found on the floor of her room. The report did not identify any injury following an assessment. The report revealed that the Dr. and the family of Resident #101 had been notified and that the Care Plan had been updated. In an interview conducted 10/9/13, at 1:47 PM, Certified Nurse Aide (CNA) "N" stated she had provided care for Resident #101 on 9/18/13, and 9/19/13. CNA "N" stated Resident #101 had no movement of the left leg. CNA "N" stated that she knew that the transfer instructions for Resident #101 were written as a 2 person transfer but to move the Resident by the instructions "was not safe". CNA "N" stated that during the time that she had provided care for Resident #101 she had transferred the Resident by using a Hoyer lift (a mechanical lift). CNA "N" stated that the transfers using the Hoyer lift had been completed without incident. In an interview conducted 10/9/13, at 2:12 PM, CNA "M" stated that she had provided care for Resident #101 on 9/19/13, and 9/20/13. CNA "M" stated that she had assisted with the transfer of Resident #101 by using the Hoyer lift and not by the instructions written on the Guest Status Transfer form . In an interview conducted 10/10/13, CNA "P" stated that she had assisted with the transfer of Resident #101 on 9/20/13. CNA "P" stated the Resident #101 had been transferred out of, and back to bed by use of the Hoyer lift. CNA "P" stated that prior to the second time Resident #101 was transferred out of bed that it was noted that Resident #101 was a 2 person transfer. CNA "P" stated that the transfer was completed without incident but was not able to describe how the transfer was completed. CNA "P" stated that Resident #101 was up in the wheelchair the rest of her shift. CNA "P" stated that Resident #101 was wearing Capri style pants. CNA "P" denied seeing a bruise on the left lower leg of Resident #101. CNA "P" stated that any injury that Resident #101 had sustained had to happened between the end of her shift on 9/21/13, at 2:00 PM, and 9/22/13, at 6:00 AM, when she returned to work. In a telephone interview conducted 10/8/13, at 10:33 AM, Family Member (FM) "V" stated that on Saturday, 9/21/13, at about 4:30 PM, she was visiting Resident #101 in the Resident's room at the facility. FM stated that she had noted a bruise with a laceration in the middle of it on the left lower leg of Resident #101. FM "V" stated that 2 "workers" had come into the room and used a mechanical lift to transfer Resident #101 from the bed to the wheelchair. FM "V" stated that she did not ask the "workers" about the bruise. FM "V" stated that she had pushed Resident #101 in the wheelchair to a dining area for dinner. FM "V" stated that at about 5:15 PM, a nurse had come in to check the blood sugar of Resident #101. FM "V" stated that she asked the nurse about the bruise and laceration on the left lower leg of Resident #101. FM "V" stated that the nurse told her she did not know anything about the bruise and would have to check the chart of Resident #101 and "get back with you". FM "V" stated that the nurse did not get back with her. FM"V" stated that Resident #101 was unable to finish her meal because of pain in the left lower leg. FM "V" stated that 2 girls came into the dining area and took Resident #101 back to her room. FM "V" stated that she had left the facility at that point. In an interview conducted 10/10/13, at 12:19 PM, Licensed Practical Nurse (LPN) "H" stated that she was assigned to the care of Resident #101 on 9/21/13, beginning about 3:30 PM. LPN "H" stated that at the start of her shift she had spoken to Resident #101. LPN "H" stated that Resident #101 had denied any pain . LPN "H" stated that Resident #101 was with family in the dining room for dinner. LPN "H" stated that she did not specifically recall obtaining the blood sugar but conceded that she had documented the blood sugar result in the medical record. LPN "H" stated that she did not remember talking to the family member. LPN "H" stated that the family member nor any CNA had reported to her any bruise or injury of Resident #101. In an interview conducted 10/10/13, at 3:30 PM, LPN "I" stated that she had assumed care of Resident #101 from LPN "H" for the night shift starting 9/21/13, through the morning of 9/22/12. LNP "I" stated that she had completed a physical assessment of Resident #101 by night light. LPN "I" stated that Resident #101 was able to move her lower extremities and had not complained of pain. LPN "I" stated that she she did not see a bruise on the left lower extremity of Resident #101 and nothing seemed "out of the ordinary". LPN "I" stated that Resident #101 had "a weird transfer order", but had remained in the bed throughout the night. In an interview conducted 10/10/13, at 11:56 AM, CNA "Q" stated that she had cared for Resident #101 from 9/21/13, at 10:00 PM, until 9/22/13 at 6:00 AM. CNA "Q" stated that she knew that Resident #101 had a history of [REDACTED]. CNA "Q" stated that Resident #101 had a bed alarm in place and that the alarm "kept making noise" during the night. CNA "Q" stated that she had readjusted the alarm and had changed the battery pack. CNA "Q" stated that Resident #101 remained in bed throughout her shift. CNA "Q" stated that she did not "check or change" Resident #101 during the night. CNA "Q" stated that she did not roll or move Resident #101 as the Resident had slept the entire night. In an interview conducted 10/9/13, at 2:12 PM CNA "M" stated that on the morning of 9/22/13, she had gone in to prepare Resident #101 to get up out of bed by use of the Hoyer lift. CNA "M" stated that when she pulled back the blankets Resident #101 "stiffened" and complained of pain in the left leg. CNA "M" stated that she had informed the nurse. Review of the Dr's Progress Note for 9/22/13, revealed that the Dr. had evaluated Resident #101 after being notified that the Resident had a swollen leg. The entry indicated that an Xray of the leg would be obtained. Review of the Xray report dated 9/22/13, revealed that an Xray of the left lower leg of Resident #101 had been taken. The "impression" indicated a"spiral fracture" of the left tibia bone. Review of the Dr's Orders for 9/22/13, revealed an order for [REDACTED]. Review of the Patient Transfer Form dated 9/22/13, revealed Resident #101 was transferred by ambulance to the hospital. Review of the hospital record Consultation Report page 1 of 2 dated 9/22/13, at 7:06 PM, revealed that Resident #101 had been evaluated in the emergency roiagnom on [DATE], for shoulder pain following a fall at the facility. The report indicated that no lower extremity fracture was discovered at that time. The report revealed that Resident #101 "had another fall between now and then, however, the family cannot determine when the injury might have occurred". Page 2 of the Consultation Report indicated that the hospital Xray revealed a, "spiral type fracture of the tibia which is noncomminuted (not out of alignment), along with a fibular neck fracture which is also an oblique spiral type fracture"...""with approximately 25% displacement laterally of the fracture". The report indicated that a course of treatment was established and follow up was arranged. Review of the facility 5 day investigation report revealed that, "(Resident #101) had fallen twice on 9/19/13"... "therapist did report discomfort of the left lower extremity when placed the (Resident's) foot upon a foot pedal on 9/20/13"..."there was no obvious deformity or change in the appearance of the extremity". Review of the Nurses Notes for 9/20/13, did not reveal a report that Resident #101 had been assessed for left lower extremity discomfort Review of the Dr's Progress Notes for 9/20/13, revealed that Resident #101 was evaluated for follow up shoulder pain after returning from the hospital for evaluation for the fall of 9/19/13. The entry indicated that the left shoulder was evaluated. The documentation of the encounter did not reveal an evaluation of the left lower extremity. Review of the facility 5 day investigation revealed that, ..."it was identified that the transfer instructions themselves were inherently confusing and difficult to read". The facility report indicated that "the transfer form itself ...failed to highlight the specific requirements for (Resident#101)".

THIS CITATION HAS THREE DEFICIENT PRACTICES. DEFICIENT PRACTICE #1. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ADDRESS A 21.6 POUNDS/16.8 PERCENT SEVERE WEIGHT GAIN IN LESS THAN ONE MONTH FOR ONE (#409) OF ONE HIGH RISK [MEDICAL TREATMENT] RESIDENT REVIEWED FOR [MEDICAL TREATMENT] FROM A TOTAL SAMPLE OF 15, RESULTING IN AN INCREASE IN BLOOD PRESSURE REQUIRING CLINICAL INTERVENTIONS AND hospitalization . FINDINGS INCLUDE: ON 5/14/13 AT 9:45 A.M., DURING THE INITIAL TOUR OF THE FACILITY RESIDENT #409 WAS OBSERVED SITTING IN A WHEELCHAIR IN HER ROOM. THE RESIDENT INDICATED THAT SHE HAD BEEN TRANSFERRED TO THE FACILITY AFTER A STROKE FOR THERAPY. THE RESIDENT ALSO INDICATED THAT SHE WENT TO [MEDICAL TREATMENT] THREE TIMES A WEEK AND WAS NEW TO [MEDICAL TREATMENT]. WHEN QUERIED AS TO IF SHE HAD ANY DIET RESTRICTIONS, RESIDENT #409 STATED, "I DON'T THINK SO." ON 5/14/13 AT 12:20 P.M., RESIDENT #409'S ROOM WAS OBSERVED. THERE WAS APPROXIMATELY 8 OUNCES OF WATER IN A GLASS AT HER BEDSIDE AND A 4 OUNCE CONTAINER OF YOGURT ON THE TABLE. ON 5/14/13 AT 12:25 P.M., RESIDENT #409 WAS OBSERVED SITTING AT A DINING ROOM EATING WITHOUT ASSISTANCE. THE RESIDENT HAD FOUR OUNCES OF MILK, 8 OUNCES OF TEA, MASHED POTATO, CORN CHOWDER SOUP, DICED HAM, GREEN BEANS, AND A ROLL WITH MARGARINE. THE RESIDENT LATER RECEIVED A PIECE OF CHOCOLATE CAKE. RESIDENT #409 CONSUMED 100 PERCENT OF HER MEAL. REVIEW OF RESIDENT #409'S MEDICAL RECORD REVEALED A FACE SHEET INDICATING AN ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENTS MINIMUM DATA SET ASSESSMENT, DATED 4/30/13 REVEALED THAT THE RESIDENT WAS COGNITIVELY INTACT AND REQUIRED EXTENSIVE ASSISTANCE FOR ACTIVITIES OF DAILY LIVING. THE RESIDENT ALSO RECEIVED [MEDICAL TREATMENT] SERVICES. REVIEW OF RESIDENT #409'S PHYSICIAN ORDERS, DATED 5/1/13, REVEALED THE FOLLOWING: "ANCILLARY ORDERS: [MEDICAL TREATMENT] MON, WED, FRI. DIET ORDERS: RENAL NAS (NO ADDED SALT) SOFT DIET WITH GROUND MEAT AND VEGGIES. SUPPLEMENTS: 120 CC (CUBIC CENTIMETERS) H20 OR JUICE QID (FOUR TIMES A DAY). MEDICATION: [MEDICATION NAME] ([MEDICATION NAME]/BLOOD PRESSURE MEDICATION) 2.5 MG (MILLIGRAM) 1 TAB PO (ORAL ROUTE) DAILY." REVIEW OF RESIDENT #409'S WEEKLY FACILITY WEIGHT RECORD AND BLOOD PRESSURE READINGS REVEALED THE FOLLOWING: 4/18/13: WEIGHT 128.8 POUNDS 4/20/13 BLOOD PRESSURE WAS 142/51 4/21/13 BLOOD PRESSURE WAS 137/51 4/22/13 WEIGHT 135.2 POUNDS 4/24/13 BLOOD PRESSURE WAS 169/59 4/29/13 WEIGHT 140 POUNDS 4/30/13 BLOOD PRESSURE WAS 163/55 5/1/13 WEIGHT 142 POUNDS, BLOOD PRESSURE WAS 190/60 5/3/13 BLOOD PRESSURE WAS 184/52 5/4/13 BLOOD PRESSURE WAS 180/60 5/5/13 BLOOD PRESSURE WAS 176/66 5/6/13 BLOOD PRESSURE WAS 189/59, WEIGHT WAS 145.2 RESIDENT #409'S PHYSICIAN ORDER [REDACTED]. 5/13/13 WEIGHT 150.4 POUNDS THE RESIDENT'S WEIGHT RECORD INDICATED THAT RESIDENT #409 HAD A 21.6 POUND/16.8 PERCENT WEIGHT GAIN IN LESS THAN ONE MONTH. REVIEW OF RESIDENT #409'S PATIENT TRANSFER FORM DATED 5/15/13 REVEALED A TRANSFER TO THE HOSPITAL DUE TO DIFFICULTY IN BREATHING AND A PULSE OXIMETRY (SPO2/OXYGEN LEVEL IN THE BLOOD) OF 73 PERCENT (NORMAL RANGE BEING BETWEEN 95-98 PERCENT). RESIDENT #409'S INTERDISCIPLINARY PROGRESS NOTES, DATED 5/15/13 AT 4:30 A.M., REVEALED THE FOLLOWING: "GUEST TRANSFER TO (HOSPITAL) emergency room FOR EVALUATION AND TREATMENT. AT APPROXIMATELY 3 AM GUEST STARTED REPEATEDLY PUSHING CALL LIGHT BUTTON FOR VARIOUS REASONS, ONE TIME GUEST STATED SHE NEEDED TO VOMIT AND THEN PROCEEDED TO SPIT SMALL AMOUNTS OF WHITE FOAMY SUBSTANCE... AT 330 GUEST PULLED CALL LIGHT CORD OUT OF WALL AND STATED SHE WAS "BREATHING FUNNY." SPO2 73 PERCENT. GUEST IS HAVING RETRACTIONS AND ABDOMINAL BREATHING. PLACED ON OXYGEN PER MASK, SPO2 INCREASED TO 80 PERCENT ONLY. GUEST VERY DIAPHORETIC...NOTIFIED DOCTOR, ORDER TO TRANSFER RECEIVED..." RESIDENT #409'S NUTRITION ASSESSMENT AND PROGRESS NOTES WERE REVIEWED. THE PROGRESS NOTE DATED 5/1/13 REVEALED "GUEST RECEIVES GROUND DIET WITH FAIR APPETITE. CURRENT BODY WEIGHT (CBW) 141.2, REWEIGHT 140 POUNDS. WILL FOLLOW." THERE WAS NO DOCUMENTATION NOTING THE 11.2 POUND WEIGHT GAIN SINCE ADMISSION, LESS THAN 2 WEEKS PRIOR. RESIDENT #409'S HISTORY AND PHYSICAL, DATED 4/24/13 REVEALED "PLAN: 2) NUTRITION SUPPORT." RESIDENT #409'S physician progress notes [REDACTED]. THERE WAS NO DOCUMENTATION NOTED IN RESIDENT #409'S physician progress notes [REDACTED]. ON 5/15/13 AT 9:35 A.M., RESIDENT #409'S PHYSICIAN, DR "C" WAS QUERIED REGARDING RESIDENT #409'S DIET ORDER AND HISTORY OF [MEDICAL CONDITION], DM, [MEDICAL CONDITION], AND [MEDICAL CONDITION]. DR "C" STATED, "I DON'T KNOW VERY WELL ABOUT THE DIET. THE ORDER IS WRITTEN FOR RENAL DIET SO WE WOULD EXPECT THAT SHE WAS RECEIVING IT. WE LOOK AT THE PATIENT AS A WHOLE." WHEN QUERIED IF SHE WAS AWARE THAT RESIDENT #409 HAD GAINED 21.6 POUNDS IN LESS THAN A MONTH, DR "C" STATED, "FRANKLY, NO. THEY (THE FACILITY) DID NOT MAKE ME AWARE. THAT IS A SIGNIFICANT CONCERN, (THE WEIGHT GAIN) FOR SOMEONE WHO HAS END STAGE [MEDICAL CONDITION] AND [MEDICAL CONDITION]." WHEN QUERIED AS TO IF THE INCREASE IN WEIGHT COULD HAVE CONTRIBUTED TO RESIDENT #409'S NEED FOR AN INCREASE IN HER BLOOD PRESSURE MEDICATION, DR "C" STATED, "I CAN'T SAY THAT IT DID NOT." ON 5/15/13 AT 10 AM, THE [MEDICAL TREATMENT] REGISTERED DIETITIAN, RD "E" WAS CONTACTED VIA PHONE AND QUERIED REGARDING RESIDENT #409'S DIET. RD "E" STATED, "SHE SHOULD BE ON A RENAL DIET WHICH WOULD INCLUDE A POTASSIUM RESTRICTION AND A FLUID RESTRICTION OF 1250 ML PER DAY." WHEN QUERIED AS TO IF THE FACILITY'S RD HAD BEEN IN CONTACT WITH HER REGARDING THE SIGNIFICANT WEIGHT GAIN AND RESIDENT #409 NOT RECEIVING A RENAL DIET, RD "E" STATED, "NO, I WAS NOT AWARE." ON 5/15/13 AT 10:15 A.M., THE FACILITY RD, RD "F" WAS QUERIED REGARDING RESIDENT #409. RD "F" STATED, "SHE'S GAINED A LOT OF WEIGHT HASN'T SHE! (RESIDENT #409) IS NOT ON A RENAL DIET, SHE IS JUST RECEIVING A GROUND MEAT AND VEGETABLE DIET." RESIDENT #409'S PHYSICIAN ORDERS [REDACTED]." RD "F" STATED "I WAS NOT AWARE. SHE WAS NEVER ON A RENAL DIET." WHEN QUERIED ABOUT COORDINATION OF CARE WITH THE [MEDICAL TREATMENT] CENTER RD "F" STATED, "WE USE THE COMMUNICATION SHEETS OR THE [MEDICAL TREATMENT] RD WILL CALL." ON 5/15/13 AT 12:05 P.M., RD "F" WAS FURTHER QUERIED REGARDING RESIDENT #409'S HISTORY WITH [MEDICAL TREATMENT] AND IF THE RESIDENT HAD RECEIVED ANY DIET EDUCATION. RD "F" STATED, "SHE HAS BEEN ON [MEDICAL TREATMENT], I AM NOT SURE HOW LONG. I DIDN'T PROVIDE ANY FORMAL EDUCATION (IN REGARDS TO DIET AND [MEDICAL TREATMENT])." WHEN QUERIED AS TO IF SHE HAD CONTACTED THE [MEDICAL TREATMENT] CENTER AND DISCUSSED RESIDENT #409'S DIET AND SIGNIFICANT WEIGHT GAIN WITH RD "E", RD "F" STATED "NO." WHEN QUERIED ABOUT THE SIGNIFICANT WEIGHT GAIN, RD "F" STATED, "I DID NOT ADDRESS THE WEIGHT." WHEN QUERIED AS TO IF THE SIGNIFICANT WEIGHT GAIN WAS DISCUSSED WITH NURSING OR THE PHYSICIAN, RD "F" MADE NO COMMENT. RESIDENT #409'S CARE PLAN TITLED, "DIETARY CARE PLAN," DATED 4/26/13, REVEALED "PROBLEM-[MEDICAL TREATMENT], WEIGHT FLUCTUATIONS EXPECTED. GOALS: GUEST WILL MAINTAIN LIFELONG BODY WEIGHT =/- 5 POUNDS." RESIDENT #409'S CARE PLAN TITLED, "POTENTIAL FOR COMPLICATIONS ASSOCIATED WITH [DIAGNOSES REDACTED]. NOTIFY MD, RD OF SIGNIFICANT WEIGHT CHANGES." THE FACILITY'S POLICY TITLED, "COMMUNICATION OF WEIGHT CONCERNS," REVISED 12/2009, REVEALED THE FOLLOWING: "IDENTIFIED CONCERNS WITH A CHANGE IN WEIGHT WILL BE RECORDED AND REPORTED IN ACCORDANCE WITH THIS POLICY. GOAL: TO ENSURE THAT WEIGHT CHANGES ARE PROPERLY REPORTED TO THE APPROPRIATE STAFF. IN AN EVENT OF ... A 5 POUND WEIGHT GAIN, THE GUEST WILL BE REWEIGHED ON THE SAME SCALE TO VERIFY THE WEIGHT CHANGE. IF A RE-WEIGHT VERIFIES ...A 5 POUND WEIGHT GAIN, THE WEIGHT CONCERN SHEET IS FILLED OUT BY THE CHARGE NURSE. ...THE CHARGE NURSE PLACES A COPY OF THE WEIGHT CONCERN FORM IN THE PHYSICIANS COMMUNICATION BOOK..." THE FACILITY POLICY TITLED "[MEDICAL TREATMENT]," DATED 8/2011, REVEALED "GOAL: FACILITY AND [MEDICAL TREATMENT] CENTER WILL COMMUNICATE WITH EACH OTHER ON THE GUESTS STATUS. PROCEDURE: SEND [MEDICAL TREATMENT] COMMUNICATION SHEET FORM TO [MEDICAL TREATMENT] CENTER WITH EACH VISIT. REVIEW COMMUNICATION FORM UPON RETURN TO THE FACILITY. GIVE COMMUNICATION FORM TO PHYSICIAN OR PHYSICIAN EXTENDER TO REVIEW." ( ) DEFICIENT PRACTICE #2. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROPERLY ASSESS AND MANAGE PAIN FOR ONE (#408) OF ONE RESIDENT REVIEWED FOR PAIN FROM A TOTAL SAMPLE OF 15, RESULTING IN UNTREATED EXTREME BREAKTHROUGH PAIN. FINDINGS INCLUDE: ON 5/14/13 AT 9:45 A.M., DURING THE INITIAL TOUR OF THE FACILITY RESIDENT #408 WAS OBSERVED LYING IN BED ON HER BACK. THE RESIDENT WAS RUBBING HER RIGHT KNEE. WHEN QUERIED AS TO IF SHE WAS IN PAIN THE RESIDENT STATED, "YES, MY PAIN IS POORLY CONTROLLED." WHEN FURTHER QUERIED AS TO IF THE FACILITY WAS MAKING ADJUSTMENTS FOR PAIN MANAGEMENT THE RESIDENT STATED, "THEY ARE BARELY WORKING ON IT." ON 5/14/13 AT 12:30 P.M., RESIDENT #408 WAS OBSERVED EATING LUNCH IN HER ROOM. WHEN QUERIED ABOUT HER PAIN THE RESIDENT STATED, "I GOT A PAIN PILL IN THE MORNING, BUT MY PAIN IS A 10 (ON A SCALE OF 1-10 WITH 1 BEING NO PAIN AND 10 BEING EXTREME PAIN)." I DON'T GET PAIN MEDICATION BEFORE THERAPY. I WAS TAKING PAIN MEDICATION AT HOME AND WAS SEEING A PAIN SPECIALIST. I AM ON LESS PAIN MEDICATION NOW AFTER SURGERY THAN I WAS TAKING BEFORE." ON 5/15/13 AT 12:30 P.M., RESIDENT #408 WAS OBSERVED LYING IN HER BED WRAPPED IN BLANKETS. WHEN QUERIED ABOUT HER PAIN, THE RESIDENT STATED "MY PAIN IS A 10; IT' S ALWAYS A 10 LATELY. I HAVE CHILLS AND MY PAIN IS JUST HORRIBLE TODAY." WHEN QUERIED AS TO IF THE NURSES ASK ABOUT HER LEVEL OF PAIN BEFORE ADMINISTRATION OF PAIN MEDS THEN FOLLOW UP TO ASSESS HER PAIN THE RESIDENT STATED, "THEY DON'T ALWAYS ASK." RESIDENT #408'S MEDICAL RECORD WAS REVIEWED AND REVEALED A FACE SHEET INDICATING AN ADMISSION INto the facility on [DATE]. THE RESIDENT'S HISTORY AND PHYSICAL, DATED 5/8/13, REVEALED THAT THE resident underwent [REDACTED]. THE ASSESSMENT REVEALED "C/O (COMPLAINTS OF) PAIN, SWELLING OF RIGHT KNEE. MEDICAL [DIAGNOSES REDACTED]. REVIEW OF SYSTEMS: RIGHT KNEE PAIN-SWELLING." RESIDENT #408'S MEDICARE DAILY NURSING NOTES WERE REVIEWED AND REVEALED THAT THE RESIDENT WAS ALERT AND ORIENTED TIMES THREE AND REQUIRED EXTENSIVE ASSISTANCE FOR MOST ACTIVITIES OF DAILY LIVING. RESIDENT #408'S physician progress notes [REDACTED]. 5/9/13: "CHIEF COMPLAINT: WORSENING PAIN/SWELLING OF THE RIGHT KNEE BOTHERS HER MUCH. 1) RIGHT KNEE status [REDACTED]. ICE PACK. CONTINUE PHYSICAL THERAPY/OCCUPATIONAL THERAPY, ELEVATE LEG WHEN SITTING DOWN, PAIN BARELY CONTROLLED. DOPPLER TO RULE OUT DEEP VEIN [MEDICAL CONDITIONS]." 5/10/13: "CHIEF COMPLAINT: REQUESTING [MEDICATION NAME] 10/325 (PAIN MEDICATION) AROUND THE CLOCK-SHE TOOK IT THAT WAY AT HOME BEFORE SURGERY AND A SECOND [MEDICATION NAME] EVERY FOUR HOURS AS NEEDED FOR INCREASED PAIN. ALSO ON [MEDICATION NAME] PATCH 25 MILLIGRAM PATCH-STILL NEEDS [MEDICATION NAME] TO CONTROL PAIN. RIGHT LOWER EXTREMITY-NO [MEDICAL CONDITION]. PLAN: UNCONTROLLED RIGHT LOWER EXTREMITY PAIN S/P (status [REDACTED]. CONTINUE [MEDICATION NAME]." 5/13/13: "CHIEF COMPLAINT: RIGHT KNEE PAIN/SWELLING/WARM. NOT IMPROVED. COMPLAINTS OF RIGHT KNEE STILL HURT. FELT WARMER THAN OTHER SIDE. PLAN: RIGHT KNEE [MEDICAL CONDITION]-[MEDICATION NAME] (ANTIBIOTIC). 2) RIGHT KNEE [MEDICAL CONDITION] JOINT DISEASE status [REDACTED]. CONTINUE CURRENT PAIN MEDS." 5/15/13: "CHIEF COMPLAINT: COMPLAINTS OF INCREASE IN HER CHRONIC LOWER BACK PAIN-FEELS SHE HAS TROUBLE POSITIONING IN BED COMFORTABLY FOR BOTH HER KNEE AND BACK. USED [MEDICATION NAME] 25 MCG PATCH EVERY TWO DAYS AT HOME PER HER PAIN DOCTOR. HISTORY OF EVERY TWO DAYS BEING EFFECTIVE. PLAN: BACK PAIN-CHRONIC-CHANGE [MEDICATION NAME] TO 25 MCG (MICROGRAMS) EVERY 48 HOURS." 5/16/13: "CHIEF COMPLAINT: CHRONIC PAIN, MIGRAINES S/P RIGHT KNEE TKA. PLAN: PAIN CONTROL-[MEDICATION NAME] AND [MEDICATION NAME] ([MEDICATION NAME] FROM PAIN DOCTOR CHRONIC LOWER BACK PAIN." RESIDENT #408'S PT (PHYSICAL THERAPY) EVALUATION AND PLAN OF TREATMENT, DATED 5/7/13 REVEALED THE FOLLOWING: "BACKGROUND ASSESSMENT: PRECAUTIONS: POOR PAIN CONTROL MANAGEMENT DURING hospitalization (PER FAMILY). MAKE SURE PAIN MEDS PRIOR TO TREATMENT. PAIN AT REST: INTENSITY 9/10; FREQUENCY/DURATION=CONSTANT; LOCATION: R KNEE; PAIN DESCRIPTION/TYPE: DISCOMFORTING. PAIN WITH MOVEMENT: INTENSITY-10/10; FREQUENCY/DURATION=INTERMITTENT; LOCATION: RIGHT KNEE; PAIN DESCRIPTION/TYPE: DISTRESSING. PAIN ASSESSMENT: DOES PAIN LIMIT PATIENT ' S FUNCTIONAL ACTIVITIES: =YES." RESIDENT #408 ' S ADMITTING PHYSICIAN ORDERS, DATED 5/7/13, REVEALED: [MEDICATION NAME] 25 MCG/HR (HOUR) PLACE ONE PATCH ONTO TRUSKIN EVERY THIRD DAY FOR 30 DAYS-PAIN. [MEDICATION NAME] 10/325 MG (MILLIGRAMS) ONE TABLET PO EVERY 4 HOURS PRN (PRO RE NATA/AS NEEDED) FOR MILD TO MODERATE PAIN. [MEDICATION NAME] 10/325 MG TWO TABLET EVERY 4 HOURS PRN FOR MODERATE TO SEVERE PAIN. ADDITIONAL ORDERS: 5/10/13: [MEDICATION NAME] 10/325 TABLET ONE TABLET PO Q 4 HOURS ROUTINE. CONTINUE [MEDICATION NAME] 10/325 ONE TABLET PO Q 4 HOURS PRN FOR BREAKTHROUGH PAIN. DISCONTINUE [MEDICATION NAME] 10/325 2 TABS PRN. 5/15/13: CHANGE [MEDICATION NAME] 25 MCG PATCH TO ONE PATCH CHANGE EVERY 48 HOURS. 5/16/13: D/C [MEDICATION NAME] 10/325 EVERY 4 HOURS PRN. ON 5/15/13 AT 2:50 P.M., RESIDENT #408'S MEDICATION ADMINISTRATION RECORD (MAR) FOR MAY 2013 WAS REVIEWED WITH NURSE "T" AND REVEALED THE FOLLOWING: RESIDENT #408 RECEIVED 2 TABS OF [MEDICATION NAME] 10/325 MG ON THE FOLLOWING DATES AND TIMES: 5/8/13 AT 4:30 AM AND 7:30 PM. 5/9/13 AT 3 AM, 10:45 AM, 3 PM, 7 PM AND 11 PM. 5/10/13 AT 5:15 AM AND 11:45 AM RESIDENT #408'S PRN PAIN MANAGEMENT RECORD WAS REVIEWED AND REVEALED THE FOLLOWING: NO PRE OR POST PAIN ASSESSMENT FOR THE PRN PAIN MEDICATIONS GIVEN ON 5/8/13. THERE WAS ONE PRE AND POST PAIN ASSESSMENT FOR 5/9/13, NO TIME STAMP, THAT INDICATED LOCATION OF PAIN WAS THE RIGHT LEG, THE INTENSITY WAS A 9 ON A SCALE FROM 1-5 (1=SMILEY FACE AND 5=SAD FACE). THE POST SCALE HAD "NE" DOCUMENTED IN THE EFFECTIVENESS SECTION MEANING NOT EFFECTIVE AND THE LETTERS "RL (RIGHT LEG)" IN THE PAIN SCALE SECTION. THERE WAS ONLY ONE ASSESSMENT WITH UNKNOWN TIME OUT OF 5 DIFFERENT PRN PAIN MEDICATION ADMINISTRATIONS FOR THAT DAY. THERE WAS ONE PRE AND POST PAIN ASSESSMENT COMPLETED ON 5/10/13 AT 11:45 AM THAT INDICATED THAT THE LOCATION WAS THE RIGHT LEG. THE INTENSITY WAS A 9 ON A SCALE OF 1-5. THE POST PAIN ASSESSMENT REVEALED AN "E" MEANING EFFECTIVE IN THE EFFECTIVENESS SECTION AND A POST PAIN SCALE OF 5. THERE WAS NO PRE AND POST ASSESSMENT COMPLETED FOR THE 5:15 AM ADMINISTRATION OF PAIN MEDICATION. ON 5/10/13 RESIDENT #408'S [MEDICATION NAME] WAS CHANGED TO ONE TAB EVERY 4 HOURS ROUTINE. NURSE "T" WAS QUERIED AS TO WHERE RESIDENT #408'S PRE AND POST PAIN ASSESSMENTS WERE LOCATED FOR THE SCHEDULED [MEDICATION NAME] STARTING 5/10/13. NURSE "T" REVIEWED THE MAR AND STATED, "IT WASN'T DONE." RESIDENT #408'S PAIN ASSESSMENT INITIATED 5/7/13 FOR THE 3-11 SHIFT THROUGH 5/10/13 FOR THE 7-3 SHIFT REVEALED THE FOLLOWING: ON 5/8/13 THERE WAS NO PAIN ASSESSMENT FOR THE 11-7 SHIFT OR THE 3-11 SHIFT. ON 5/9/13 THERE WAS NO PAIN ASSESSMENT FOR THE 11-7 SHIFT OR THE 3-11 SHIFT. ON 5/10/13 THERE WAS NO PAIN ASSESSMENT FOR THE 11-7 SHIFT OR THE 7-3 SHIFT. NURSE "T" WAS QUERIED AND STATED, "THESE PAIN ASSESSMENTS ARE SUPPOSED TO BE DONE ON ALL RESIDENTS EACH SHIFT FOR THE FIRST THREE DAYS." NURSE "T" MADE NO COMMENT AS TO WHY ONLY THREE OF THE NINE PAIN ASSESSMENTS WERE COMPLETED. ON 5/15/13 AT 3:25 P.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING PRE AND POST PAIN ASSESSMENTS FOR PAIN MEDICATIONS. THE DON STATED, "ANY PAIN MEDICATION GIVEN SHOULD HAVE A PRE ASSESSMENT OF PAIN LEVEL AND A POST ASSESSMENT OF PAIN LEVEL." ON 5/16/13 AT 11:25 A.M., PHYSICAL THERAPY ASSISTANT, PTA "B" WAS QUERIED REGARDING RESIDENT #408'S PHYSICAL THERAPY. PTA "B" STATED "SHE HAS A LOT OF PAIN. SHE SAYS SHE HURTS TOO MUCH AND SHE CRIES DURING THERAPY." WHEN QUERIED REGARDING ICE PACKS, PTA "B" STATED, "SHE HAS PERSONAL ICE PACKS. I ICE HER KNEE BEFORE AND AFTER THERAPY. SHE SAYS IT WORKS (TO DECREASE THE PAIN)." WHEN QUERIED AS TO IF PTA "B" FELT HER PAIN WAS INHIBITING HER PROGRESS IN THERAPY, PTA "B" STATED, "OH, YES!" ON 5/16/13 AT 11:37 A.M., NURSE PRACTIONER, NP "D" WAS QUERIED REGARDING RESIDENT #408. NP "D" STATED, "I SEEN HER FOR THE FIRST TIME TODAY. SHE HAS A HISTORY OF CHRONIC PAIN AND SEE'S A PAIN SPECIALIST ON THE OUTSIDE. THE PRN [MEDICATION NAME] WAS DISCONTINUED TODAY. HER PAIN IS BETTER CONTROLLED AND SHE IS RECEIVING A PAIN PATCH. SHE STILL WILL GET THE SCHEDULED [MEDICATION NAME]. OVERALL I THINK SHE IS DOING BETTER (WITH PAIN CONTROL)." WHEN QUERIED REGARDING GOALS OF TREATMENT, NP "D" STATED "GOAL IS TO BE ABLE TO TOLERATE THERAPY." NP "D" WAS FURTHER QUERIED AS TO HOW RESIDENT #408 WAS DOING IN THERAPY AND STATED, "I HAVEN 'T TALKED WITH THERAPY ABOUT HER." NP "D" WAS QUERIED AS TO IF SHE WAS AWARE THAT RESIDENT #408 WAS CRYING DURING THERAPY AND THE THERAPIST INDICATED THAT HER PAIN WAS INHIBITING HER PROGRESS, NP "D" MADE NO COMMENT. BUT LATER STATED, "WE COULD PROBABLY SCHEDULE HER [MEDICATION NAME] SO IT IS MORE EFFECTIVE AROUND THERAPY." ON 5/16/13 AT 3:25 P.M., THE DON WAS QUERIED REGARDING RESIDENT #408'S PAIN CONTROL AND STATED, "I CAN SEE WE HAVE SOME AREAS WE NEED TO WORK ON." ON 5/17/13 AT 11:20 A.M., THE DON WAS QUERIED VIA PHONE REGARDING RESIDENT #408'S THERAPY SCHEDULE AND STATED, "THERE IS NO FORMAL SCHEDULE FOR THERAPY, THEY EITHER HAVE SPLIT TIME (BOTH AM/PM SCHEDULE) OR A MORNING OR AFTERNOON." THE DON WAS FURTHER QUERIED REGARDING THE ICE PACKS MENTIONED IN THE physician progress notes [REDACTED]." RESIDENT #408'S CARE PLAN TITLED "NEEDS PAIN MANAGEMENT AND MONITORING," INITIATED 5/10/13, REVEALED "GOAL WILL MAINTAIN ADEQUATE LEVEL OF COMFORT AS EVIDENCED BY NO S/SX (SIGNS/SYMPTOMS) OF UNRELIEVED PAIN OR DISTRESS, VERBALIZING SATISFACTION WITH LEVEL OF COMFORT. APPROACHES: MONITOR AND RECORD EFFECTIVENESS, SIDE EFFECTS PRN. ASSESS/RECORD/REPORT TO MD PRN S/SX OF DISTRESS OR PAIN UNRELIEVED BY ORDERED TREATMENTS/MEDS. PT/OT EVALUATE AND TREAT AS ORDERED. CONSIDER PREMEDICATING FOR PAIN PRN TO OPTIMIZE PARTICIPATION. " THE FACILITY'S POLICY TITLED "PAIN ASSESSMENT AND MANAGEMENT," DATED 7/2011, REVEALED "GUESTS WILL BE ASSESSED AND treated for [REDACTED]. GUESTS WILL BE COMFORTABLE. 1. A PAIN HISTORY AND ASSESSMENT WILL BE COMPLETED UPON ADMISSION AND WHEN A GUEST REPORTS OR OBSERVATION IS MADE OF NEW, INCREASED, OR UNUSUAL SYMPTOMS OF PAIN. 2 THE HISTORY AND ASSESSMENT WILL BE USED TO ASSIST IN DEVELOPING CARE PLAN GOALS AND OR APPROACHES RELATED TO PAIN MANAGEMENT. ASK THE GUEST TO RANK HIS/HER PAIN ON A SCALE OF 1 TO 10 ...IF A GUEST IS NOT HAVING RELIEF FROM PAIN WITHIN 24 HOURS THE PHYSICIAN MUST BE NOTIFIED TO REVIEW THE SITUATION TO PRESCRIBE OR MODIFY THE PLAN. EFFECTIVENESS OF PRN PAIN MEDICATIONS WILL BE DOCUMENTED ON THE MEDICATION ADMINISTRATION RECORD USING THE PAIN SCALE." ( ) DEFICIENT PRACTICE #3: BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROPERLY DOCUMENT ADMINISTRATION OF SCHEDULED MEDICATIONS FOR TWO (#403 AND #407) OF 13 SAMPLED RESIDENTS REVIEWED FOR MEDICATIONS FROM A TOTAL OF 15 AND FIVE (#'S 22, 28, 29, 33, AND 37) SUPPLEMENTAL SAMPLED RESIDENTS, RESULTING IN THE POTENTIAL FOR MEDICATION ERRORS LEADING TO COMPROMISE/DECLINE IN HEALTH STATUS. FINDINGS INCLUDE: ON 5/14/13 AT 12 NOON, MEDICATION ADMINISTRATION RECORDS (MARS) WERE REVIEWED WITH THE DIRECTOR OF NURSING (DON) AND MEDICATION NURSE 'U'. PER THE MARS, NURSE 'U' HAD INITIALED THAT SHE HAD ADMINISTERED THE FOLLOWING MEDICATIONS SCHEDULED FOR THE 2 PM MEDICATION PASS TO RESIDENTS #'S 403, 407, 22, 28, 29, 33, AND 37: RESIDENT #403-[MEDICATION NAME] (FOR ANXIETY). RESIDENT #407-[MEDICATION NAME] (FOR PAIN). RESIDENT #22-[MEDICATION NAME] (HYPERTENSION). RESIDENT #28-[MEDICATION NAME] (NERVE PAIN), [MEDICATION NAME] ([MEDICAL CONDITION]), AND [MEDICATION NAME] (IRRITABLE BOWEL). RESIDENT #29-[MEDICATION NAME]. RESIDENT #33-[MEDICATION NAME], AND [MEDICATION NAME] (ANTIBIOTIC). RESIDENT #37-[MEDICATION NAME]. WHEN SHOWN THE MAR FOR RESIDENT #22 AND ASKED WHY THE 2 PM MEDICATION WAS INITIALED (SIGNED OUT) AT 12 NOON, NURSE 'U' SAID, "THAT WAS A MISTAKE" AND STATED THAT THE 2 PM MEDICATIONS HAD NOT YET BEEN GIVEN. WHEN SHOWN THE MARS FOR THE OTHER SIX RESIDENTS AND ASKED TO PROVIDE AN EXPLANATION, NURSE 'U' DID NOT RESPOND. WHEN ASKED ABOUT THE PROCESS FOR DOCUMENTATION OF ADMINISTERED MEDICATIONS, THE DON SAID, "AFTER THE MEDICATION IS GIVEN, THE NURSE IS SUPPOSED TO COME BACK AND SIGN (INITIAL) IT OUT." AT 1:20 PM, NURSE 'U' AND THE DON DID NOT RESPOND WHEN TOLD THAT, IF NURSE 'T' HAD TO SUDDENLY LEAVE THE FACILITY BEFORE THE 2 PM MEDICATION PASS, MEDICATION ERRORS COULD OCCUR BY STAFF WHO TOOK OVER OVER HER ASSIGNMENT AND REVIEWED THE MARS. AT 1:30 PM, NURSE 'U' STATED, "I HAVE BEEN HERE A LONG TIME. I GUESS I JUST GOT A LITTLE TOO COMFORTABLE (IN SIGNING OUT MEDICATIONS BEFORE THEY WERE ADMINISTERED)." PER REVIEW OF ADMISSION FACE SHEETS, MARS, AND HISTORY AND PHYSICALS: RESIDENT #403 WAS admitted on WITH [DIAGNOSES REDACTED]. RESIDENT #407 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #22 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #28 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #29 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #33 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #37 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. PER REVIEW OF THE FACILITY'S "MEDICATION PASS" POLICY DATED 11/2011: "....ALL EFFORTS TO REDUCE MEDICATION ERRORS SHOULD BE TAKEN.." "THE LICENSE NURSE WILL WAIT UNTIL THE MEDICATIONS HAVE BEEN INGESTED" AND "THE LICENSED NURSE WILL RETURN THE EMPTY PILL CONTAINERS TO THE MED CART AND SIGN OUT THE MEDICATIONS GIVEN." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 963 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT PREVENTIVE INTERVENTIONS TO PREVENT FALLS FOR ONE RESIDENT (#501) WHO WAS IDENTIFIED AS A FALL RISK, OF THREE RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL OF SIX SAMPLED RESIDENTS RESULTING IN RESIDENT #501 SUSTAINING A FALL WITH RIB FRACTURES. FINDINGS INCLUDE: ON 9/27/12 AT 12:20 P.M., DURING A TOUR OF THE FACILITY, RESIDENT #501 WAS OBSERVED IN THE DINING ROOM SEATED IN A WHEELCHAIR, EATING LUNCH. RESIDENT #501 HAD PROTECTIVE SLEEVES TO HIS BILATERAL FOREARMS. A REVIEW OF THE FACILITY FACE SHEET REVEALED THAT RESIDENT #501 WAS A [AGE] year OLD MALE WHO WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted [DATE], WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT RESIDENT #501 REQUIRED EXTENSIVE ASSISTANCE FROM STAFF WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING, BED MOBILITY, TRANSFERS, LOCOMOTION ON AND OFF THE UNIT, DRESSING, EATING TOILETING AND PERSONAL HYGIENE. THE MDS FURTHER DOCUMENTED THAT RESIDENT #501 HAD IMPAIRMENT ON ONE SIDE OF HIS UPPER EXTREMITY, USED A WHEELCHAIR FOR MOBILITY AND WAS "...NOT STEADY, ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE..." WHEN MOVING FROM SEATED TO STANDING, MOVING ON AND OFF THE TOILET AND SURFACE TO SURFACE TRANSFERS. A REVIEW OF THE FACILITY'S "INCIDENT/ACCIDENT FORM" DATED 8/10/12 REVEALED THAT RESIDENT #501 WAS OBSERVED ON THE FLOOR AND SUSTAINED A SKIN TEAR. "...GUEST (#501) TRANSFERRED SELF FROM BED, UNABLE TO STATE WHY. SKIN TEAR TO LEFT UPPER EXTREMITY RESULTING FROM FALL. PAIN ASSESSMENT: COMPLAINED OF LEFT SIDE PAIN. PRN (AS NEEDED) VICODIN (NARCOTIC PAIN MEDICATION) GIVEN FOR COMPLAINTS OF PAIN, X-RAY TO LEFT SIDE ORDERED, SKIN TEAR TO LEFT UPPER EXTREMITY AND LEFT ELBOW CLEANSED WITH NORMAL SALINE, STERI-STRIPS (PAPER SUTURES) APPLIED AND COVERED. BED ALARM INITIATED..." THE FACILITY'S "INCIDENT/ACCIDENT FOLLOW-UP" DOCUMENT NOTED, "...DATE OF INCIDENT 8/10/12. TIME OF INCIDENT 4:30 A.M., ALERT AND ORIENTED TIMES ONE. IN BED APPROXIMATELY TWO (2) HOURS PRIOR. GUEST HAS FOLEY (INDWELLING URINARY CATHETER). WAS ALARM SOUNDING: NO, ONLY HAS CHAIR ALARM. ARE MEDICATIONS THAT CONTRIBUTE TO FALL RISK? NO. DOES THE GUEST HAVE DECREASED VISION? YES. WERE SPECIFIC ADLS BEING ATTEMPTED? YES; SELF TRANSFERRING. HAS GUEST HAD A RECENT (FALL)? YES..." THE "FACILITY INCIDENT REPORT-24 HOURS" DATED 8/11/12 DOCUMENTED THAT ON 8/10/12 AT 4:30 A.M., "...GUEST SELF TRANSFERRED HIMSELF FROM THE BED. GUEST WAS UNABLE TO TELL THE NURSE WHAT HE WAS DOING AND WHY HE GOT UP FROM BED. GUEST WAS NOTED ON THE FLOOR AND COMPLAINED OF PAIN IN HIS LEFT SIDE. AN X-RAY WAS ORDERED AND THE FRACTURE OF THE 8TH AND 9TH RIBS ON THE LEFT WAS IDENTIFIED..." A REVIEW OF A "RADIOLOGY REPORT" DATED 8/10/12 REVEALED, "...REASON: status [REDACTED]. THERE ARE MARKED DISPLACED RECENT FRACTURES EIGHTH AND NINTH RIBS ON LEFT..." A REVIEW OF #501'S "FALL RISK ASSESSMENT FORM" DATED 6/7/12 IDENTIFIED #501 AS A FALL RISK WITH A SCORE OF "40" WHICH INDICATED "MODERATE RISK FOR FALLS." THE FALL RISK ASSESSMENT FURTHER REVEALED, "...POOR SAFETY AWARENESS. GUEST IS NOT ABLE TO TRANSFER SELF WITHOUT ASSISTANCE..." A REVIEW OF RESIDENT #501'S "FALL" CARE PLAN DATED 5/21/12 REVEALED, "...AT RISK FOR FALLS RELATED TO DECREASED MOBILITY AND [DIAGNOSES REDACTED]. THE INTERVENTIONS TO BE IMPLEMENTED WERE AS FOLLOWS: "...SENSOR ALARM TO BE USED WHEN IN WHEELCHAIR AND LAZY BOY (RECLINER CHAIR)..." "...SENSOR ALARM TO BE USED WHILE IN BED..." "...MATS NEXT TO BED..." A physician's orders [REDACTED]. ON 10/1/12 AT 1:36 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) WAS QUERIED ABOUT THE DOCUMENTATION ON #501'S CARE PLAN WHICH INDICATED THE NEED FOR FLOOR MATS NEXT TO HIS BED. THE DON REPORTED, "...I DON'T SEE ANYTHING ABOUT A MAT. I WOULD HAVE TO LOOK INTO THAT..." ON 10/1/12 AT 2:36 P.M., DURING A SUBSEQUENT INTERVIEW, THE DON WAS QUERIED ABOUT #501'S MATS AND REPORTED, "...I CAN'T EXCUSE THE FACT THAT THE MATS WERE INDICATED ON HIS (#501) CARE PLAN AND I CAN'T EXPLAIN WHY THE NURSES WROTE FOR HIM TO HAVE MATS ON THE CARE PLAN, YET THEY WEREN'T IMPLEMENTED. IF HE HAD MATS AT THE TIME OF THE FALL, THE MATS WOULD HAVE CUSHIONED THE FALL..." WHEN ASKED IF #501'S FALL COULD HAVE BEEN AVOIDED, THE DON REPORTED, "...I DON'T KNOW. I CAN'T SAY. HE HAS A HISTORY OF ATTEMPTS TO TRANSFER TO THE BED..." WHEN ASKED WHAT INTERVENTIONS WERE IN PLACE PRIOR TO THE FALL, THE DON REPORTED, "...HE HAD AN ALARM TO HIS CHAIR AND LAZY BOY. AT ONE TIME, HE HAD A PERIMETER MATTRESS BECAUSE HE WAS FALLING OUT OF BED, BUT THAT WAS DISCONTINUED A WHILE BACK AND ON 8/13/12, WE DISCONTINUED HIS REMERON (MIRTAZAPINE/USED FOR THE treatment of [REDACTED]. COMMON SIDE EFFECTS INCLUDE DROWSINESS, DIZZINESS AND WEAKNESS), BECAUSE WE FELT THAT COULD HAVE BEEN A CONTRIBUTING FACTOR..." A REVIEW OF RESIDENT #501'S "MEDICATIONS ADMINISTRATION RECORDS" FOR THE MONTH OF AUGUST 2012 REVEALED THAT #501 HAD BEEN ADMINISTERED HIS PM DOSE OF REMERON ON THE EVENING OF 8/9/12. THE DON COULD NOT EXPLAIN WHY NURSING STAFF FAILED TO FOLLOW THE WRITTEN CARE PLAN WHICH REFLECTED THE NEED FOR MATS NEXT TO RESIDENT #501'S BED. A REVIEW OF THE FACILITY'S "IDENTIFYING FALL RISK" POLICY REVISED 7/2011 REVEALED: "...INTERVENTIONS WILL BE IMPLEMENTED BASED ON FALL RISK..." "...GUEST SAFETY WILL BE MAINTAINED..."

This citation pertains to intake #MI 591 Based on observation, interview, and record review the facility failed to provide a safe environment, free of accident hazards for 2 (#101 & #104) Residents of 4 sampled Residents of a total of 4 sampled Residents, resulting in 1 (#101) Resident falling in the shower and sustaining multiple abrasions and a neck fracture and 1 (#104) Resident feeling unsafe while in the shower. Findings include: Resident #101, was a [AGE] year old female admitted to the facility on [DATE]. According to her Minimum Data Set ((MDS) dated [DATE] she had the following Diagnoses: [REDACTED]. According to the Kardex (caregiver information sheet) she required assistance of 2 people for toilet use (toilet was equipped with a commode over the toilet, this increased the toilet height and provided arm rests), under transfers was listed 2 person physical assist with a sliding board (transfer equipment), transfer to the right side, left side paralysis (unable to move). Under bathing shower and bed bath were both marked and crossed out. According to her "Brief Interview for Mental Status (BIMS) dated 5-27-2011 she scored 14/15 (good mental status) and she was listed as her own responsible party on the face sheet. According to an Accident/Incident Report for Resident #101 dated 6-16-2011, it stated under description of the Incident and Causing Factors, "Guest getting showered by 2 aides, 1 aide went to lift feet and put towel under feet as doing so, Guest fell of the left side of shower chair onto bathroom floor hitting head." Under Cognitive Status, across from Neurochecks started, "yes" was circled. Under, Recommendation for prevention of re-occurrence, it stated, " re-evaluation by physical therapy. Under was Care Plan Started/updated, it stated, "yes". For Stated Intervention it stated, "Educated staff on safety measures of 2 person assist with showering guest." During an interview/observation on 7-12-2011, at 1:30 PM, CNA (certified nurses aide) #1 and #2 demonstrated how they performed the shower with Resident #101 on 6-16-2011. CNA #1 and #2 demonstrated the transfer using RN (registered nurse) #1 as Resident #101. CNA #1 and #2 put a transfer belt on RN #1 while she was in the wheelchair and transferred her to the shower chair, during the transfer they moved RN #1 to her left side. While RN #1 was in the shower CNA #1 and #2 were on RN #1 right side. The shower was a walk in style with three walls. RN #1's back was on the back rest of the shower chair an a few inches from a wall. RN #1 left side was several inches from a wall and RN #1 was facing the 3rd wall. CNA #1 and #2 could not recall if Resident #101 was undressed in her wheel chair or the shower chair. CNA #2 demonstrated lifting RN #1's feet a couple of inches off the floor while RN #1 was still in the position described above. CNA #2 said when she lifted Resident #101's feet she fell forward to the front and left. CNA #2 went to get a nurse. CNA #1 stayed with Resident #101 to comfort her. CNA #1 said Resident #101 was on her left side. Resident #101 had an abrasion and was bleeding on her right upper forehead and both of her knees had abrasions. During an interview with RN #2, on 7-13-2011, at 8:55 AM, RN #2 said she was the nurse that assessed Resident #101 when she fell in the shower on 6-16-2011. RN #2 said she assess Resident #101 vital signs (blood pressure, heart rate, respirations), neurological assessment was completed. She recalled Resident #101 was alert and oriented to person, place and time. Resident #101 had normal active range of motion of her right arm and both legs. RN #2 said the only complaint of pain Resident #101 had while on the shower floor was her left arm. RN#2, said Resident #101 was assisted on her back with the help of 2 people in a log roll form and than assisted to her wheel chair with a 3 person total lift. RN #2 said, Resident #101 complained of neck pain once she was back in bed and ice was applied. During an interview with PTA (physical therapy assistant) #1, on 7-12-2011, at 9:30 AM, PTA #1 said she worked with Resident #101 in therapy. PTA #1 was asked if the chair that Resident #101 was using in the shower was one she would choose (shower chair used had a back rest and no arm rests). PTA #1 said, "no, she would use a shower chair with arm rest and one that tilts the Resident back". PTA #1 reviewed the therapy discharge records and said that Resident #101 did not have normal sitting balance, she had fair balance and could recover some when off balance. PTA #1 said the nurses aides were provided education after this incident of shower safety, which included staying on the Residents weak side for support and use of a different shower chair. During and interview with a corporate RN #1 on 7-12-2011, at 2:40 PM, the corporate RN #1, provided an updated copy of the facility Shower Policy #1307, Approved 7/2011. Under Item #2 a statement was added that stated, "Prior to the first shower being administered, a therapist will evaluate the available bathing equipment. If changes to the equipment are recommended, the need for an alternative device with be communicated to nursing." According to a hospital note, titled "Hospital Course" for Resident #101, dated 6-21-201l, the note stated, "Apparently, the patient was getting a shower at the nursing home and she ended up falling, was having neck pain. She was brought over to the emergency room . She was found to be having C2 odontoid fracture. The patient was admitted by trauma team. Neurosurgery saw her and they recommended conservative management using a Miami J collar with reevaluation in three months, the same evaluation by the orthopedic surgery team. She apparently had some left-sided residual from a CVA (stoke) that she had in May." Resident #104, was a [AGE] year old female admitted to the facility on [DATE]. According to her Physician order [REDACTED]. According to her face sheet she was her own Responsible Party. According to her Brief Interview for Mental Status (BIMS) dated 7-13-2011, she scored 15/15 (normal mental status). According to her Kardex (care giver information sheet), she required assist of 2 person for transfers, toilet and bathing. Hand written next to bathing was Reclining shower chair for showers, reclining position. On 7-13-2011 at 9:15 AM Resident #104 was observed to have a shower chair in her bathroom that had arm rest and able to recline. During an interview with Resident #104 at this date and time the Resident was asked how she gets showered or bathed. Resident #104 said her daughter has provided 2 showers for her here and the facility has provided one shower. She said they had a different shower chair in the bathroom last night and for all of her showers. She said the shower chair did not have arm rest and she did not feel safe in it. She said last night when her daughter gave her the shower she felt like the shower chair was going to tip. Resident #104 was asked if staff helped her daughter she said, "no". When she was asked if two staff helped her when she had her shower she said, "no." During an interview with the Director of Nursing (DON), on 7-13-2011, at 10 AM, the DON was informed of Resident #104's report of her daughter providing showers for her without assistance, only one staff person providing assistance with showers when facility provided shower and last night 7-12-2011 daughter used a shower chair without arm rests or ability to tilt back. The DON said she would contact the daughter to let her know she needed training and said Resident #104 was given a new shower chair today.