Every finding on record at Caretel Inns of Tri-Cities

This Citation Pertains to Intake 3137291. Based on observation, interview and record review, the facility failed to ensure Activity of Daily Living (ADL) care, including bathing and oral care, were provided for six Residents (#6, #10, #17, #40, #46, & #70) of nine Residents reviewed for ADL care. Findings include: Resident #17 On 8/18/2026, at 1:04 PM, a record review of Resident #17's electronic medical record (EMR) revealed an admission on [DATE] with diagnoses that included muscle weakness, Alzheimer's disease and history of falling. Resident #13 had intact cognition and required assistance with Activities of Daily Living (ADL's). A review of the Focus ADLS r/t (related to) limited mobility, debility, and impaired balance. Date Initiated: 02/06/2025 . Goal mobility, transfers, eating, dressing, toilet use, and personal hygiene, through review date. Date Initiated: 02/06/2026 . Interventions . I prefer a shower twice a week. Date Initiated: 02/06/2026 . Personal hygiene: I need limited assist of 1 to help me. Date Initiated: 02/16/2026 . On 8/19/2026, at 10:29 AM, Resident #17 was sitting in their wheelchair in their bathroom in front of the sink with only a bra on. Resident #17 was asked if they activated their call light and the resident stated, I had it on but she said she had a shower to do and there's nobody for showers today. It gets worse and worse. There's not enough aides to help when you need help so there's no way she can help me. Resident #17 was asked when they had a shower last and Resident #17 stated, I don't get them regularly and I don't like reporting on the girls. They didn't give me a shower yesterday. It's supposed to be Tuesday and Friday. Resident #17 stood and began to clean their perineal area with a hand towel in an unsanitary manner. On 8/19/2026, at 10:47 AM, Unit Manager (UM) T entered the room and was alerted Resident #17 was in the bathroom alone. UM T offered to assist the resident with a shower. Resident #17 stated, oh no that's ok I know you're busy. UM T reassured the resident they had time. Resident #17 offered, the cleaning lady gave me a towel and I've already washed up. While standing outside the bathroom, UM T reassured they had enough time as the resident kept saying, I know they don't have enough help. While being assisted with their shower, Resident #17 stated, the other girl said she had 3 more showers to do and didn't have enough time. Resident #17 was asked if that was today or the day prior and Resident #17 stated, today. Resident #17 stated, oh that feels so good. This feels so much better. Thank you so much. Once the shower was completed, Resident #17 was asked if they felt clean and Resident #17 stated oh yes that feels so much better. On 8/19/2026, at 11:30 AM, a record review along with UM T of Resident #17's ADL/shower task list revealed the last shower the resident received was 8/11/2026 and had no documented shower their scheduled day of July, 31st. Resident #6 An interview was completed with Resident #6 on 8/18/26 at 9:25 AM. When asked regarding ADL care and assistance received at the facility, Resident #6 stated, My body is dirty. I need to be clean. When asked, Resident #6 verbalized they needed staff assistance for bathing and to take a shower. Resident #6 was asked the last time they had a shower and stated, It had been three weeks. When asked if they liked taking a shower, Resident #6 replied, Oh yes. They (staff) keep postponing it. Resident #6 became tearful and with tears visible in their eyes and on their cheeks, stated, I don't like to be dirty. When asked, Resident #6 revealed they have top dentures but not bottom dentures. When asked if the staff assisted with cleaning their dentures, Resident #6 stated, They (staff) don't help me clean them. Record review revealed Resident #6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes mellitus, dementia, and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required maximum assistance with showers/bathing and moderate assistance with transfers and ambulation. Review of Resident #6's Electronic Medical Record (EMR) revealed the Resident had a care plan entitled, ADL (Activity of Daily Living): Self-care deficit, require assist with ADLS r/t limited mobility, debility, and impaired balance (Initiated: 11/21/25). The care plan included the interventions: - Bathing: I need limited assist with 1 person to help me (Initiated: 11/21/25) - I prefer a bed bath twice a week (Initiated: 11/21/25) - Toileting: I need limited assist of 1 to help me (Initiated: 11/21/25) - Transfers: I need limited assist of 1 to help me (Initiated: 11/21/25) Review of Resident #6's Documentation Survey Report for August 2026 revealed the task, Shower on Tues and Fri nights. Review revealed the Resident received one shower on 8/4/26 and no bed baths. There was no documentation of a shower being offered on 8/7/26 and documentation on the report specified Resident #6 refused a shower on 8/11/26 and 8/14/26. The Documentation Survey Report for August 2026 included a section for Oral Hygiene. The documentation specified, The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment but did not include a section to denote if oral care was actually provided. There was no documentation on 8/1/26 AM, 8/7/26 PM, 8/17/26 AM, and 8/18/26 AM. An interview was completed with Resident #6 on 8/8/26 at 8:02 AM. When queried, Resident #6 stated, I finally got a shower last night and my body isn't dirty anymore. Resident #6 expressed how good they felt after having a shower. When queried if they recalled refusing a shower on 8/11/26 and 8/14/26, Resident #6 adamantly responded that they did not refuse a shower because they like to be clean. Resident #10 On 8/17/26 at 12:02 PM, Resident #10 was observed in their room. The Resident was in bed with their eyes closed. The Resident's appearance was disheveled, and their hair had a greasy and unclean appearance. On 8/19/26 at 8:28 AM, Resident #10 was observed in their room, sitting on the side of their bed. The Resident's hair was long with visible knots and a greasy and unkempt appearance. An interview was completed at this time. While speaking, visible build up and debris were observed on Resident #10's teeth. Resident #10 was asked the last time they brushed their teeth and indicated it had been a long time but did not know the specific date. Resident #10 then stated, I don't know where my toothbrush is. When asked regarding the level of assistance they require to get out of bed, Resident #10 stated, They (staff) use the Hoyer (mechanical lift with a sling used to transfer dependent individuals from one surface to another). When asked regarding bathing and showers, Resident #10 stated they are supposed to get showers on Mondays and Thursdays. When asked what they meant when they said they were supposed to, Resident #10 revealed they do not always get a shower. When asked why, Resident #10 stated, They don't got enough help. Resident #10 was asked when they last received a shower and replied, I didn't get a shower on Monday. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, dementia, schizoaffective disorder, and falls. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact, was dependent upon staff for bathing and required moderate assistance with oral hygiene. Review of Resident #6's Documentation Survey Report for August 2026 revealed the task, Shower on Tues and Fri nights. Review revealed the Resident received no showers, two partial bed baths on 8/4/26 and 8/18/26, and one complete bed bath on 8/11/26. There was no documentation of a shower being offered on 8/7/26 and documentation on the report specified Resident #6 refused a shower on 8/14/26. The Documentation Survey Report for August 2026 included a section for Oral Hygiene. The documentation specified, The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment but did not include a section to denote if oral care was actually provided. There was no documentation for Oral Hygiene on 8/1/26 AM, 8/7/26 PM, and 8/15/26 AM. Resident #70 Review of intake documentation revealed a concern that Resident #70 did not receive showers twice a week as they were supposed to due to lack of staff assistance. Record review revealed Resident #70 was admitted to the facility on [DATE] and discharged on 12/8/25 with diagnoses which included right hip replacement surgical aftercare, weakness, and difficulty walking. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required maximum assistance with showers/bathing. Review of Resident #70's Documentation Survey Report for December 2025 revealed the Resident did not receive showers as scheduled twice per week during their stay at the facility. An interview was completed with the Director of Nursing (DON) on 8/19/26 at 1:50 PM. When asked what blank areas indicate on documentation in Resident's EMRs, the DON responded, and stated it meant the task was not completed. The DON was then informed of observations and Resident statements pertaining to ADL care including oral care and not receiving showers. When asked regarding the lack of ADL care, the DON did not provide an explanation. Resident #40 On 08/19/2026 at 2:08 PM, record review revealed that R40 has only had one shower since admission on [DATE]. Showers are scheduled for Tuesdays and Saturdays on the night shift. Potential shower dates were 8/8/26, 8/11/26, 8/15/26 and 8/18/26. Not applicable is documented on 8/10/26 and a shower was given on 8/16/26. Resident #46 On 08/17/2026 at 10:08 AM, R46 was observed on the bedpan and stated it's been more than an hour. R46 stated they haven't felt clean since they were admitted to the facility. R46 was asked if they received showers or baths. R46 says the facility wasn't giving showers on time and indicated they hardly had any showers since admission. On 08/18/2026 at 3:46 PM, record review revealed R46 has had four showers since admission on [DATE], the dates are 7/28/26, 8/4/26, 8/11/26x2 (these were documented by the same staff less than an hour apart). R46 has potential shower dates of 7/27/26, 7/30/26, 8/3/26, 8/6/26, 8/10/26, 8/13/26 and 8/17/26. On 08/19/2026 at 9:37 AM, record review revealed R46 is scheduled to receive showers on Mondays and Thursdays on the second shift (1800-0600). There were no documented refusals in the EMR. On 08/19/2026 at 9:43 AM, record review of the care plan for R46 revealed they required extensive two person assist for washing their lower body while standing. The care plan also stated R46 preferred bed baths twice a week. Review of the policy titled, Activities of Daily Living revealed: Procedure: A. Hygiene f. Showers or baths will be scheduled per facility protocol while incorporating residents shower/bath preferences.

This Citation Pertains to Intake Number 3066377.Based on observation, interview, and record review, the facility failed to ensure that medications were stored under proper temperature/environmental controls in one of one medication rooms, resulting in the potential for all 54 facility residents to receive medications with altered efficacy and effectiveness including medications unsafe for administration. Findings include:On 7/21/26 at 1:30 PM, the ambient air temperature in the main hallway/corridor of the skilled facility was uncomfortably hot and humid and perspiration began immediately even without movement. Upon approaching the nurses' station, the ambient air temperature and perceptible humidity did not improve. Residents were observed sitting in the assisted and regular areas of the dining room across from the nurses' station and an interview was completed with Licensed Practical Nurse (LPN) A and LPN B. When queried regarding the air temperature in the building, LPN B stated, It gets so hot in here that people are getting sick. When queried regarding the residents and the temperature, LPN A stated, They (residents) complain but the AC has been broken out here. With further inquiry, LPN A and LPN B revealed the AC in individual resident rooms work. A tour of the medication room was completed with LPN A at this time. Upon entering the medication room, the ambient air temperature was even hotter and the perceptible humidity remained. A thermometer was present on the countertop displayed a temperature reading of 86.6 degrees Fahrenheit (F). When queried if it was always this hot in the medication room, LPN A stated, Yes. When queried regarding the safe temperature range for medication storage, LPN A did not provide a response. LPN A was then asked if maintenance and/or the Director of Nursing (DON)/facility Administrator were aware of elevated temperatures in the medication room and responded, Yes. With further inquiry, LPN A revealed the AC had been broken all summer. An interview was completed with Maintenance Director F on 7/21/26 at 2:30 PM. When queried if they were aware of elevated air temperatures in the building including the medication room, Director F responded that it was being fixed. When asked what was broken, Director F replied, They are replacing thermostats. When queried how long the thermostats had been broken, Director F responded they were unsure as they started working at the facility approximately one month ago. When asked if the AC had been broken since they started, Director F responded that it was not really broken. When asked if the thermostats have needed to be replaced or fixed since they started at the facility, Director F replied, Yes. Director F then revealed one thermostat had already been replaced. When queried why it took over a month to replace a wall thermostat, Director F responded that the contractor had to run wires. When asked why wires had to be run to replace a thermostat, Director F indicated it was not a household thermostat and stated, You would have to ask them (HVAC [Heating, Ventilation, and Air Conditioning]) contractor. Documentation of what was malfunctioning and what was being repaired including dates, purchase orders, and repair quotes was requested from Director F at this time. On 7/21/26 at 2:40 PM, an observation of Housekeeping/Maintenance Staff H obtaining air temperature readings with the facility air temperature gun was completed. Staff H was knowledgeable of and observed to be proficient with use of the air temperature gun. The temperature in the medication room, using the air temperature gun was 83.2 F and the thermometer on the countertop was observed to read 86.2 F. Additional temperatures obtained using the air temperature gun included:- Main Corridor/Hallway: 88 F- Assistive Dining Room: 79.2 F- Large Dining Room: 79.8 F- 200 Hallway: 80.2 F- 300 Hallway: 76.2 FWhen asked what thermostat had been repaired/replaced, Staff H responded that a thermostat had been placed on the 300 Hall. Upon request to see the thermostat, Staff H showed a new digital thermostat on the wall inside the Dirty Utility room on the 300 hallway. The thermostat was set at 70 F but indicated the current temperature was 73 F. Upon request, Staff H utilized the air temperature gun to check the temperature in the 300 Hall Dirty Utility room. Per the air temperature gun, the temperature was 74.4 F. When queried why the hallway and room temperature were higher than the set temperature on the thermostat, Staff H revealed the thermostat functions by monitoring and responding to the air temperature directly around the thermostat in the closed-door Dirty Utility room. Staff H was then asked if there had been a thermostat in the Utility Room previously and responded, No. Staff H then explained the facility did not have wall thermostats to control the roof mounted HVAC system prior to the malfunction. With further inquiry, Staff H stated, Roof (HVAC) units were controlled by a computer and that broke. When asked when the control system broke, Staff H revealed it was during the winter. An interview was completed with the Director of Nursing (DON) on 7/21/26 at 3:00 PM. When queried regarding the acceptable temperature in the medication room, the DON replied, 73 (F). The DON was then asked why the temperature in the medication room was 83 to 86 F currently, the DON stated, We knew there was a problem and the old Maintenance guy (Director) put in a new baffle (device placed on the end of a HVAC duct to distribute and spread air in the room). When queried regarding the thermometer sitting in the medication room, the DON stated, (Pharmacy Staff I) gave that to use to monitor the temperature when they were here last because they said it was too hot. On 7/21/26 at 3:47 PM, an interview was completed with Maintenance Director F. When queried regarding documentation requested related to the HVAC system, Director F did not provide any documentation and stated, I am waiting for (HVAC Contractor J) to email me. When asked to clarify if they were saying the thermostats were the problem, Director F stated, Yes. When asked to explain why the thermostats had not been repaired/replaced previously, Director F stated, It isn't that easy. When queried why it was not that easy, Director F stated, (Contractor) has to run wires. Director F was asked why the contractor had to run wires but did not provide an explanation. When asked how the HVAC system functions and how the temperature is adjusted, Director F did not answer the question and stated, It is working fine. When asked why the temperature in the medication room was between 83 to 86 F if the HVAC system was fine On 7/21/26 at 3:55 PM, a request for all work orders placed and/or completed related to the HVAC system was requested from the facility Administrator. An interview was completed with the facility Administrator on 7/21/26 at 4:30 PM. When queried regarding the elevated temperatures observed in the medication room and facility, the Administrator responded they began employment at the facility approximately one month prior, around the same time, as Maintenance Director F. The Administrator revealed they found the offices to be super-hot and instructed Director F to make it a priority to get it fixed. The Administrator asked about the status of information requests related to the HVAC system and verbalized the facility was waiting for the HVAC company to provide documentation and did not anticipate receiving a response today due to the time. The Administrator then stated that Maintenance Director F had obtained a lower temperature in the medication room than the temperature obtained by Staff H. When asked where in the medication room Maintenance Director F had utilized to obtain the lower temperature, the Administrator revealed Director F had pointed the temperature gun directly at the HVAC baffle on the ceiling. The Administrator was informed that Staff H had pointed the gun at various places in the medication room including areas where medications were stored. On 7/22/26 at 8:55 AM, the Administrator provided the documentation below and an interview was completed.- Printed screenshot of a Microsoft list of maintenance requests. The items visible in the screenshot included four requests related to Heating and Cooling from 4/13/26 to 6/10/26. Three of the concerns were related to individual resident rooms and the fourth request was dated 6/10/26 that the Med fridge needs defrosted. An interview was completed with the DON on 7/21/26 at 4:38 PM. When queried if the Over the Counter (OTC) and prescription medications in the medication room were safe for administration to residents due to the known elevated temperatures, the DON stated they would call their pharmacy consultant and ask. No further explanation was provided. An interview was completed with Contractor K on 7/22/26 at 9:40 AM. When queried regarding the work their company was completing at the facility, Contractor K replied, They called and we gave them a quote, but they waited months and now they only want to fix two (rooftop units) with thermostats. When queried if the installation of two thermostats fix the HVAC system in the facility, Contractor K revealed it would not. Contractor K then stated, Doesn't make sense because they are probably going to end up paying more than the original quote by the time they get done trying to do it piece by piece. The quote provided to the facility was requested at this time. On 7/22/26 at 12:25 PM, an interview was completed with Consultant Pharmacy Staff I. When asked when they were last at the facility, Staff I stated, June 10th (2026). When queried if there were concerns regarding the temperature in the medication room, Staff I stated, That was definitely one of our talking points the last time I was there. When asked, Staff I confirmed they left the thermostat on the counter in the facility medication room to monitor the room temperature. Staff I was then informed that the thermometer read 86.2 and the temperature with the facility air gun was 83.2 on 7/21/26. When asked what the maximum safe temperature for medication storage is, Staff I responded, Normally meds are good to 77 (F). When asked how the temperatures being that high will affect all the medications, including the OTC and meds in the stock medications in the dispense system, Staff I stated, Supposed to be below 77 (F) but I will have to check my supervisor for that. When queried if they maintain a list of all the OTC meds, Staff I revealed the pharmacy does not supply OTC meds to the facility and does not maintain a list of those medications. When queried if they discussed anything else with the facility, Staff I replied, Discussed a portable AC unit for the med room with the DON. A review of the facility Temperature Log documentation for July 2026 revealed the medication room temperatures for the room was greater than 77F every day. The medication room temperatures ranged from 79F (lowest) to 86.6F (highest). The log specified, US Pharmacopeia (USP) <659>' Packaging and Storage Requirements'. working environment of. 68 to 77F, Excursions (period of time allowed out of acceptable temperature range) between. 59 & 86F are experienced in pharmacies hospitals, warehouses & during shipping are allowed. Provided mean kinetic temp does not exceed 25 degrees Celsius (C) (77 F) . Further review of the medication room temperature logs revealed a different form entitled, Temperature Monitoring Log was utilized from April to June 2026. This log specified, Acceptable Med Room Temperature: Less that 77F. Detailed review revealed the following:- April 2026: Med room temperatures increased to greater than 77F on 4/13/26. From 4/13/26 the documented temperatures ranged from 78F to 82.4F- May 2026: Med room temperatures were less than 77F on 5/1/26, 5/2/26, and 5/3/26. From 5/4/26 until 5/31/26, the room temperatures ranged from 78F to 85.5F- June 2026: Med room temperatures was greater than 77F every day and ranged from 78F to 85.7F. An interview was completed with the Pharmacy Director of Clinical Services L on 7/22/26 at 2:28 PM. When queried if they were aware of the facility medication room having a temperature of greater than 86 F per the thermometer in the medication room, Pharmacy Director of Clinical Services L stated, When (Pharmacy Staff I) had came there on June 10th, they identified that the med room was warm and there were some increasing temperatures. When asked what the temperature was in the room when Pharmacy Staff I was at the facility, Pharmacy Director of Clinical Services L responded that Pharmacy Staff I didn't have a temperature. Pharmacy Director of Clinical Services L continued, I spoke to (Pharmacy Staff I) and they did leave them (the facility) a thermometer for the countertop and recommended they monitor temperatures. Pharmacy Director of Clinical Services L was then informed the recorded medication room temperatures from 4/13/26 to current had been greater than 77 F with the exception of the first three days in May. When asked what the facility should do when the temperature is greater than 77 F, Pharmacy Director of Clinical Services L did not provide a response and indicated they would need to speak to the facility staff. Pharmacy Director of Clinical Services L revealed they were unaware of the length of time the medications had been out of acceptable temperature range. When queried if the medications were safe for administration, Pharmacy Director of Clinical Services L responded a little bit of time out of that (temperature) range is okay. Pharmacy Director of Clinical Services L was then asked how long a little bit of time is and replied, Yeah, that's a good question. Pharmacy Director of Clinical Services L continued, We go by the USP standards and they do have excursions. When asked how long an excursion is, Pharmacy Director of Clinical Services L stated, They don't define a specific time period for that. With further inquiry, Pharmacy Director of Clinical Services L stated, Typically what we would do is if medications have been out of range for a period of time, we would go through the medication list to see what the manufacturer has published and if there's any doubt to the integrity of it, we would replace that medication. When queried regarding the pharmacy procedure when medication room temperatures are elevated, Pharmacy Director of Clinical Services L communicated that when a Health Care Facility (HCF) contacts them regarding an elevated temperature, they ask for a repeat temperature and attempt to identify why the temperature is elevated. Pharmacy Director of Clinical Services L verbalized they will have the medications moved to a different location to identify the cause if the temperature elevation is not temporary. Pharmacy Director of Clinical Services L was then informed the facility HVAC system originally malfunctioned in January and had not been fixed and stated, So it's been a prolonged issue, that's where my concern is. When told that the facility had removed the thermometer provided by the pharmacy because they did not feel it was accurate as well as the temperature readings obtained on 7/21/26 in the medication room, Pharmacy Director of Clinical Services L responded, Either temperature is too warm. Documentation of the prescription medications maintained and supplied by the pharmacy in the medication room and medication dispense system was requested at this time. At 2:52 PM on 7/22/26, an interview was completed with Maintenance Director F. When queried regarding the HVAC system and lack of cooling in the facility and medication room, Director F stated, I found out stuff that I had no idea about and that is on me. When asked what they found out, Director F stated, I didn't know that we have a tablet that using instead of the system controller. When asked to explain, Director F responded, We have to go on the roof to each unit and set it up for the season and change the temperatures for the other four (HVAC units) that do not have thermostats. When asked if the second thermostat had been installed, Director F confirmed it had not. When queried how they were controlling the thermostat to ensure appropriate temperatures in the Medication Room when the thermostat had not been installed for the HVAC unit which controls the temperature in that room/area, Director F verbalized the HVAC contractor would be installing the thermostat as soon as possible. No further explanation was provided. An interview was completed with the facility Administrator on 7/22/26 at 3:20 PM. The Administrator indicated they would like to measure the temperature in the medication room because Maintenance Director F had obtained a temperature of 79F yesterday when Staff H had obtained a higher temperature. An observation of the Administrator obtaining the temperature in the medication room was completed at this time. The temperature obtained by the Administrator was 82.2 F. When asked, the Administrator confirmed the temperature was outside of the acceptable range. On 7/22/26 at 4:42 PM, an interview was completed with the DON. When queried regarding the temperatures in the medication room and if they had received any information from the pharmacy, the DON indicated they had spoken to the pharmacy and stated, The temps were consistently above temp for the past 3 months. We are going to have to throw away thousands of dollars of medications. The DON then stated, I just wish it would have been identified sooner. When asked why it was not addressed when Pharmacy Staff I had brought it to their attention on 6/10/26, an explanation was not provided. The DON then provided a list of OTC medications which were stored in the medication room and indicated they removed the medications highlighted as strict temperature ranges were indicated on the packages. Review of the list revealed a list of 91 different OTC medications, with multiple quantities, stored in the medication room. Per the list, 29 of the 91 OTC medications had been removed. Of the 29 medications removed, the actual number of medications removed was 86 due to each medication of the 29 medications having different/multiple quantities. On 7/22/26 at 3:21 PM, a list of the current prescription medication inventory for the medications contained in the medication storage room medication dispense machine was received via email from Pharmacy Director of Clinical Services L. The email specified the consultant pharmacy team will be going through to review medications for temperatures above 77 degrees Fahrenheit. The list provided contained 226 different medications from all medication classifications including injection and intravenous (IV) medications. The total individual number of medications was 1987. When queried when the determination related to the safety of individual medications would be complete, Pharmacy Director of Clinical Services L responded via email on 7/22/26 at 5:03 PM that the pharmacy was going to replace the entire inventory of medications contained in the medication dispense system in the medication storage room.A list of the total number of medications administered and the total number removed from the medication dispense system was requested from Pharmacy Director of Clinical Services L via email on 7/22/26 at 5:11 PM and on 7/23/26 at 11:17 AM. Pharmacy Director of Clinical Services L responded via email on 7/23/26 at 12:33 PM and stated, I reached out to the (facility) team for some more information and what is needed. The information requested was not received by the conclusion of the survey. Review of facility policy/procedure entitled, Medication Storage in the Facility (Dated November 2021) revealed, Storage of Medications. All medications are maintained within the temperature ranges noted in the United States Pharmacopeia (USP) and the Centers for Disease Control (CDC). 1. Room Temperature 59F to 77F. 2. Controlled Room Temperature (the temperature maintained thermostatically) 68F to 77F. Temperature: A. Medications and biologicals are stored at their appropriate temperatures and humidity according to the USP guidelines for temperature ranges. B. Medications requiring storage at 'room temperature' are kept at temperatures ranging from 59F to 77F. E. The facility should maintain a temperature log in the storage are to record temperatures at least once a day.

This Citation Pertains to Intake Numbers 3066377 and 3063033. Based on observation, interview and record review, the facility failed to notify a resident's representative of a change in the resident's status and an alteration in treatment for one resident (Resident #701) of three residents reviewed. Findings include: Review of Intake documentation dated as received 7/1/26 revealed a concern the facility did not notify Resident #701's legal decision maker that their transfer status had been changed from a two person assist to a Hoyer (mechanical lift used to move a dependent individual from one surface to another). Per the intake, Resident #701's legal decision maker (Family N) received an unplanned call on Wednesday 7/1/26 for a quarterly care conference. During the care conference, the staff verbalized they did not have much to report and omitted the fact that multiple days prior, (Family N) discovered (Resident #701) sitting on a blue transfer (Hoyer lift). The intake specified Family N spoke to Certified Nursing Assistant (CNA) G who told them they Hoyer lift had been implemented yesterday. The intake documentation relayed Family N was not notified of the change in transfer status, nor the reason for the change in transfer status, until they directly asked the facility staff. An interview was completed with Family N on 7/20/26 at 8:41 AM. When queried regarding Resident #701's transfer status, Family N responded, I had concerns because they put (Resident #701) in a Hoyer lift which I didn't know they had. Family N stated, I thought when there was any change in (Resident #701's) care plan or anything they were supposed to let me know. It was just shocking to walk in to (the Resident) having to use a Hoyer lift. Resident #701:Record review revealed Resident #701 was admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit, dementia, Parkinson's disease, and stroke. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to moderate assistance to complete Activities of Daily Living (ADL). On 7/21/26 at 11:10 AM, Resident #701 was observed in their room. Certified Nursing Assistant (CNA) C and CNA A entered the Resident's room and were observed transferring the Resident to their bed using the Hoyer lift. When queried how long Resident #701 has been a Hoyer for transfers, CNA A responded, Not that long. When asked why the Resident was changed to a Hoyer, CNA C stated, (Resident #701) was a two assist but was getting harder to stand with two assist. Review of Resident #701's care plan revealed a care plan entitled, Potential for falls, Resident at risk for injury from falls (Initiated: 4/3/25). The care plan included the intervention, Staff educated on the need for 2-person assist with transfers & ambulation (Initiated: 4/29/26). A second care plan entitled, Skilled Therapy/ADL: Self-care deficit, require assist with ADLS r/t (related to) limited mobility, debility, and impaired balance (Initiated: 4/3/25) was present in Resident #701's Electronic Medical Record (EMR). This care plan included the intervention, Transfers: I need extensive assist of 2 to help me with the use of full mechanical (Hoyer) lift with large sling (Initiated: 4/3/25; Revised: 6/29/26). Review of progress note documentation in Resident #701's EMR revealed one Health Status/Progress note, dated 6/29/26 at 5:35 AM, which specified, Transferring resident getting increasingly more difficult. therapy needs to evaluate.There was no documentation noted in Resident #701's EMR of representative notification of change in transfer status.Note: This was the same date Resident #701's Skilled Therapy/ADL. care plan was changed from a two person assist to a full mechanical (Hoyer) lift. Review of Resident #701's EMR revealed the Resident had been deemed incompetent and Family N was their activated Durable Power of Attorney (DPOA) for medical decisions. An interview was completed with Therapy Manager Occupational Therapist (OT) O on 7/21/26 at 12:54 PM. When queried if Physical Therapy evaluated Resident #701's transfer status when they were changed to a Hoyer lift, OT O replied, No, I did because (the Resident) was getting harder to the staff to transfer and was becoming super hesitant with the start and stop phase and rigidity phase (Parkinson's associated progression symptoms). When queried if they contacted Family N related to downgrading the Resident's transfer status to a Hoyer lift from a two person assist, OT O replied, No. When asked why they did not, an explanation was not provided. An interview was completed with the Director of Nursing (DON) on 7/21/26 at 4:02 PM. When queried if Resident #701's representative should have been notified when their transfer status changed from a two assist to a Hoyer lift, the DON responded, Yes, they should. When asked where staff would document that the Representative was notified in the EMR, the DON stated, (OT O) already told on themselves that they did not notify the family and therefore there would be no documentation. When queried what the facility procedure is for notification of change to family/representative, the DON stated, Since (Resident #701) was on therapy - therapy would call. The DON added that if a resident was not on therapy, nursing would be responsible to call. When queried regarding the discrepancies in Resident #701's care plans related to transfer status, the DON reviewed the care plans and stated, I own that. The DON verbalized the care plan should have been updated and was not. No further explanation was provided. Review of facility policy/procedure entitled, Change in Resident's Condition (Reviewed: 6/21) revealed, It is the policy of the facility, except in a medical emergency, to alert the resident. and resident's responsible party of a change in condition. 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. e. It is deemed necessary or appropriate in the best interest of the resident. 2. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication. 3. Once the physician/NP has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and any physician orders. 4. The communication with the resident and their responsible party as well as the physician/NP will be documented in the residents' medical record or other appropriate documents. 5. The Care Plan for the resident will be updated as indicated.

This Citation Pertains to Intake 3066377.Based on observation, interview and record review, the facility failed to implement and operationalize procedures to ensure personal linens were transported and maintained in a sanitary manner for two residents (Resident #701 and Resident #703) of three residents reviewed. Findings include: Based on observation, interview and record review, the facility failed to implement and operationalize procedures to ensure personal linens were transported and maintained in sanitary manner for two (#'s 701 and 703) of three residents reviewed resulting in the potential for linen contamination and the spread of microorganisms to all 54 facility residents who have laundry completed at the facility. Findings include: Review of intake documentation dated as received on 7/1/26 revealed a concerns related to, Gross Cross-Contamination of Laundry and Clean Linens. Per the intake the facility staff were using the same laundry basket, with no barrier, to transport Resident #701's clean and dirty personal linen thereby completely cross contaminating clothing with residual bacteria and urine and were not covering linens in the hallways during transport. Resident #701Record review revealed Resident #701 was admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit, dementia, Parkinson's disease, and stroke. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to moderate assistance to complete Activities of Daily Living (ADLs). On 7/21/26 at 10:55 AM, Laundry Staff M was observed transporting uncovered laundry baskets through the hall. Staff M stopped outside a resident room and took the laundry basket in. Resident #703On 7/21/26 at 11:05 AM, a clothes basket with clothing was observed on the floor of the resident's room. There were clothes on the floor around the basket. Some of the clothing in the basket and on the floor surrounding the basket appeared visibly soiled. An interview was completed with Resident #703 at this time. When queried, Resident #703 stated the clothes in the basket and on the floor were dirty. On 7/21/26 at 11:50 AM, Laundry Staff M was observed in the hallway pushing a cart containing laundry baskets of different sizes and shapes. An interview was completed at this time. When asked, Staff F verbalized they were delivering resident's clean laundry. When queried regarding the laundry baskets, Staff M revealed each resident has their own basket. When asked the procedure for washing resident's personal laundry, Staff M stated, We just go around and pick up the baskets, take them to laundry, make sure they (clothes) are labeled, wash them and take them back. Staff F was observed delivering the clean linen to individual resident rooms. While distributing the clean laundry, Staff F removed a basket of clothes from the cart and placed it directly on hallway floor. Staff M located the clothes backet they were looking for and removed it from the cart. Staff M then placed the basket which they had set on the hallway floor directly on top of a different resident's basket of clean clothes. When queried why they did not cover resident's personal laundry basket while transporting them, Staff M replied, I don't know, was never told to. Staff M then stated, We cover the house laundry when we transport it. When asked what house laundry was, Staff M revealed it was any laundry such as bedding and towels that were not resident personal items and clothing. Record review revealed Resident #703 was admitted to the facility on [DATE] with diagnoses which included dementia, weakness, and Chronic Obstructive Pulmonary Disease (CODP). Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required moderate to total assistance to complete ADLS with the exception of eating and oral hygiene. An interview was completed with Housekeeping Manager H on 7/21/26 at 2:10 PM. When queried regarding the facility procedure for washing resident's personal laundry, Manager H stated, Go pick up and bring back (to laundry room). Make sure (clothing is) labeled, wash, dry, fold, put back in the backet and return to the resident's room. When queried regarding the personal linens being uncovered during transport, Manager H did not provide an explanation. When queried regarding residents clean clothing being placed in the same laundry basket which previously contained dirty/soiled laundry with no barrier, Manager H revealed the baskets are sprayed with a disinfectant cleaner prior to the clean clothes being placed in the basket. When queried why the soiled clothing are not placed in a bag or barrier in the laundry basket, Manager H stated, I wish I knew the answer to that. Manager H was informed of the observation of Staff M placing the laundry basket of clean clothing directly on the floor and then placing back in the cart, directly on top of a different resident's laundry. When queried if that was acceptable, Manager H responded, No and verbalized the clothing was contaminated. An interview was completed with the Director of Nursing (DON) on 7/21/26 at 3:00 PM. When queried why personal resident laundry was not covered during transport, the DON revealed they were unaware that personal resident laundry was not covered. When asked if it should be covered, the DON verbalized it should be. The DON was then informed of the observation of Staff M placing the laundry basket of clean clothing directly on the floor and then placing back in the cart, directly on top of a different resident's laundry. The DON stated, That is an infection control concern and that it would need to be addressed. When asked who the infection control nurse was, the DON stated they were not working today. When queried if dirty clothing should be on the floor in the Resident's room next to the laundry basket, the DON stated it should not. No further explanation was provided. On 7/22/26 at 8:00 AM, the clothes basket with dirty clothing directly on the floor was visible in Resident #703's room from the hallway of the facility. Review of facility policy/procedure entitled, Laundry and Linen Handling & Storage (Reviewed 4/26) revealed, Policy: The purpose of this procedure is to provide a process for safe and aseptic handling, washing, and storage of linen. 3. Consider all soiled linen to be potentially infectious. 4. All soiled linen must be placed directly into a plastic bag. 7. When removing soiled linen from hampers, hold plastic bags from the bottom with the opening over the washer, and empty the bags directly into the washer without handling the linens. Discard the empty bags into appropriate receptacles. In Resident rooms. 1. Do not allow linen, clean or soiled, to touch clothing or uniform. 2. Handle all soiled linen as though it is potentially infectious. Review of facility policy/procedure entitled, Linen (Revised 7/26) revealed, Policy: Residents will have clean linen available. Goals: Linen will be handled in a safe, clean manner. Procedure: 1. Linen transported from the laundry room will be placed in a clean plastic bag. 2. Linen transported from linen closet to resident's room will be carried away from staff uniform. 3. Handle all soiled linen as though it is potentially infectious. 8. All soiled linens will be placed in a bag and kept off the floor. 9. Dirty linens will be taken directly to the laundry.

This citation pertains to Intake Number 2999812.Based on interview and record review the facility failed to implement care plan interventions and provide appropriate supervision for feeding assistance for one resident (Resident #2) of three residents reviewed for feeding assistance, resulting in Resident #2 sustaining a burn on the abdominal area.Findings include: Resident #2 (R2):R2 is [AGE] years old and initially admitted to the facility on [DATE], with diagnoses that include muscle weakness, dementia, chronic pain and dysphagia. R2 has a brief interview for mental status (BIMS) score of 5, indicating severe cognitive impairment.On 5/7/26 at 12:27pm, R2 was observed in the dining room for the lunch meal, she is seated in the assisted area of the dining room. R2 is in a Broda chair, positioned upright and centered in the chair. Staff reports that R2 just returned from the wound care clinic. R2 was pleasant and open to conversation, however, R2 is not following the line of questioning and does not answer appropriately.On 5/7/26 at 12:32pm, the facility reported incident (FRI) investigation was reviewed for R2. It revealed that R2 sustained a burn from spilling hot liquids on herself while eating in bed during the breakfast meal. The investigation also revealed that R2's cup still had the top on it when it was found spilling hot liquid out of it and that R2 had a clothing protector in place and the care plan stated to assist resident with eating as allowed, the nutrition care plan said to assist as needed and the adl care plan stated to assist with feeding. As of 12/19/25, the care plan for eating stated, EATING: I require assistance with eating. Please get me up in Broda chair for meals as I will allow. The facility completed a hot liquid evaluation for all residents in the facility and provided education on the updated policy that outlines the hot water temperatures coming from the coffee machine. R2 had a hot liquid screen completed on 4/16/26 and is now a total assistance with eating.On 5/7/26 at 11:45am, record review of SW-Skin Issues revealed that R2 has an in-house acquired full thickness burn located on the left lower quadrant of the abdomen. Measurements obtained on 4/16/26 are Length 19.3cm and Width of 16.72cm. R2 is attending the wound care clinic at a local hospital, in addition to the wound care being performed in the facility.On 5/7/26 at 12:35pm, record review of the care plans for R2 were completed and revealed a care plan titled:I need help with my activities of daily living (ADL's) because of pain. I have limited range of motion (ROM in bilateral knees. As evidenced by (AEB): Self-imposed bed rest.Intervention/Tasks Include:-Covered mug with lid for all liquids every meal r/t risk of injury from hot liquids. Date initiated 11/20/2024-I will benefit from a clothing protector at meals and will wear as I allow. (POA approved wearing of clothing protector). Date initiated 02/01/2023-EATING: I require assistance with eating. Please get me up in Broda chair for meals as I will allow. Date revised 12/19/2025.On 5/7/26 at 12:45pm, record review of the Kardex (the portion of the medical record the aides use to provide care) from 4/14/26 revealed:Category:Eating/NutritionInterventions:-EATING: I require assistance with eating. Please get me up in the Broda chair for meals as I will allow.-Covered mug with lid for all liquids every meal.Category:Resident CareInterventions:-I will benefit from a clothing protector at meals and will wear as I allow. (POA approved wearing of clothing protector).On 5/11/26 at 11:27am, an interview was conducted with certified nursing assistant (CNA) H. CNA H was assigned to the care of R2 when the burn was sustained. CNA H was asked to describe what happened leading to the burn. CNA H stated, we had a busy morning that day and I was unable to get her out of bed for breakfast. I asked her if she wanted to stay in her room for breakfast and she said yes. I had a clothing protector on her and I fed her breakfast. I left her cup of liquids (hot tea) with her, within arm's reach and it had a lid on it. I left the room to provide care for another resident, then I heard her (R2) yelling and I didn't think much of it right away because she is irritable at times and yells. Then my unit manager came and said she spilled hot tea on herself. CNA H was asked if they have fed R2 or had her eat in her room before. CNA H stated, yes, she is care planned to choose whether or not to get out of bed. CNA H was asked if R2 has ever had any issues with handling the cup. CNA H stated, no, and she is able to feed herself as well. But we do assist her if she needs it. My unit manager told me it looks like she fell asleep and spilled it on herself. CNA H was asked if she ever left R2 alone in her room with hot liquids before. CNA H stated, I want to say yes, I have left her in her room alone before and there has never been an issue. On 5/11/26 at 1:16pm, an interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked about the care plan intervention, I require assistance with eating,. The NHA stated, that is what we came to the conclusion on during the investigation, the care plan interventions were confusing. Some residents can eat on their own, but if they get tired then they would need assistance. We have updated certain residents to being a total assist with eating.On 5/11/26 at 1:22pm, an interview was conducted with the Director of Nursing (DON). The DON was asked what does I require assistance with eating, on the Kardex mean to the floor staff providing care. The DON stated that it means, they (the staff) have to assist her completely with feeding and it is also on the dietary ticket. The DON was asked if R2 should have been left alone with the hot liquid, even with a lid on the cup. The DON stated, no, she should not have been left alone with a hot liquid because she is a total assist with feeding. The DON was asked when hot liquid screens were being completed. The DON stated that initially they were being completed on admission and now they are being done on admission, quarterly and if there is a change. On 5/11/26 at 2:07pm, an interview was conducted with unit manager (UM) E. UM E was asked how long it was from the time you heard R2 yelling until you entered the room of R2. UM E stated, I got to work at 8am and I was down that hallway around 8:45am and I went into the room to figure out why she was crying. UM E stated I saw her cup with the lid, turned upside down and I immediately pulled back the covers to see what was wrong. UM E stated, I undressed R2 and applied cold washcloths to her stomach. Then I went to notify the DON about what was going on. UM E was asked if R2 had a clothing protector on. UM E stated, I truly don't recall if she had one on or not at the time. UM E then stated, I don't remember removing a clothing protector from her. She had a blanket, a sheet and she had a t-shirt on, but I don't remember removing a clothing protector. UM E was sked if they were the first staff member in the room and did you undress R2 alone. UM E stated, yes, there was no one else with me, I looked out into the hallway at one point to ask for something and a CNA helped me.On 5/11/26 at 2:51pm, an interview was conducted with Registered Nurse (RN) G. RN G was asked if they would you leave R2 alone in her room with a cup of hot liquids without supervision. RN G stated, no, I would be more comfortable supervising her in case it was to tip or if she lost a grip on it. RN G was asked what the care plan intervention I require assistance with eating, mean to you. RN G stated, the resident requires assistance with all meals. There are times when she can hold the cup and pull it up to her mouth to drink from the straw, she can do finger foods as well. But I would still want to supervise her. On 05/11/2026 at 3:30pm, during the onsite survey, Past Non-Compliance (PNC) was cited after the facility implemented actions to correct the non-compliance which included: 1. The facility implemented interventions for the resident involved.2. All facility residents are at risk for sustaining a burn from hot liquids.3. The nursing policy on hot liquids was reviewed and updated. All nursing staff were educated on the policy between 4/14/26 and 4/20/26. The dietary hot liquid policy was reviewed and updated along with a dietary hot liquid log. All dietary staff were educated on the policy and the log between 4/14/26 an 4/20/26.4. Audits are being completed to ensure compliance.5. Date of compliance: 4/22/26.Staff education was provided to include:Assisting with meals: ensure you stay with the resident until they have finished with their meals and liquids.Review of the policy titled, Hot Beverage or Liquids, revealed:Procedure:1. Screeninga. Residents will be screen on admission for the use of assistance in managing hot beverages/liquids based on but not limited to the following criters:-Cognition-Functional Abilities-Contractures-Strength-Posturec. Be screened quarterly or with a change in condition to implement appropriate changes for safe care.3. Care and Care Plansc. care plan will be updated with new assessments and/or for changes in cared. care plan will be reviewed quarterly

This citation pertains to Intake Number 2677656. Based on interview and record review, the facility failed to reconcile enteral feeding (tube feeding) orders for one resident (Resident #1) of two residents reviewed for enteral feeding resulting in approximately 19 hours of no enteral feeding/nutrition and rehospitalization. Findings include: Resident #1: On 12/17/25, at 9:30 AM, a record review of Resident #1's electronic medical record (EMR) revealed a readmission on [DATE] with diagnoses that included Chronic Hypoxic Respiratory Failure, Severe protein-calorie malnutrition, Septic shock, Diabetes Type 2 and Gastrostomy. Resident #1 had severely impaired cognition. A review of the . admission Assessment Date: 10/17/2025 12:46 . revealed Resident #1 was readmitted at 12:46 PM. There was no hospice documents scanned into the EMR that clarified when the hospice company/nurse visited the resident on 10/17/25. A review of the Physician orders revealed no order for enteral feeding/nutrition for Resident #1 and the following order NPO (Nothing By Mouth) . Start Date 10/17/2025 14:40 (2:40 PM) . A review of the MEDICATION ADMINISTRATION RECORD 12/1/2025 - 12/31/2025 revealed no documented administration of enteral feeding/nutrition on 10/17/25 or 10/18/25. A review of the Progress Notes revealed the following: 10/17/2025 14:30 . Note Text: Late entry: Resident returned from the hospital today and is now on (company) hospice . There was no documentation that clarified the tube feed/nutrition order. 10/18/2025 08:00 . Note Text: Received morning report from night nurse and was notified that resident had not received his Glucerna feed since he left the hospital. The feed was not hung when he made it to the facility. This writer research and made calls to confirm orders. Feed was hung @ approximately 0745 hours, Hospice nurse came in to visit resident, this writer confirmed med list with hospice nurse. Resident currently receiving feed and relaxed in bed with call light in reach. There was no clarification who the nurse called for the order and if the Medical Doctor and/or Physician was notified of the missed tube feeding. 10/18/2025 12:38 . Note Text: Late entry: Resident appeared lethargic and eyes were rolling back as this writer was assessing resident and asking questions to keep him alert. Resident O2 (oxygen) sats (saturation) decreased from 94% to 72%. This writer increased O2 up to 5L (liters), which is the max on the concentrator. His O2 sat held @ 88% 20 bs (glucose level) 600. (ambulance) (company) hospice, the On-call physician, management, and (guardian) were all contacted. Resident transported to the hospital. On 12/17/25, at 10:20 AM, a record review along with the Director of Nursing (DON) of Resident #1's EMR was conducted. The DON was asked to review the admission assessment dated [DATE] and was asked what time Resident #1 was readmitted and the DON stated, 12:46 around that time. The DON was asked for assistance to provide/locate any hospice documents for that day as the DON offered, that the hospice nurse was in and accidentally took the hospital discharge medication list with them when they left. No Hospice documents were located in the EMR. A review of the miscellaneous tab in the EMR for Resident #1 revealed no discharge instructions/medication list from their hospital discharge on [DATE] AM. The DON was asked to provide active Physician Orders for Resident #1 for the admission on [DATE]. On 12/18/25, at 11:24 AM, a record review along with the DON of the Active Orders as of: 10/17/2025 for Resident #1 was conducted which revealed no tube feeding/nutrition directions and/or orders. The DON was asked why Resident #1 did not receive tube feeding/nutrition the day of readmission and the DON offered, He got it the next morning when we got here. The DON clarified there was no physician's order for the tube feed/nutrition and or administration documentation on the MAR. The DON was asked if they were notified of the lack of tube feeding/nutrition for nearly 19 hours and the DON stated, No I was not and I just saw that note. The EMR revealed no notification to the physician of the missed tube feeding/nutrition and the DON was asked if the doctor was notified and the DON responded, they need to review the hospice documentation before they answer any more questions. The DON offered, they contacted the hospice company to get the records and there may have been a hospice reason as to why they did not provide the tube feeding. On 12/18/2025, at 11:35 AM, an interview with Assistant Director of Nursing (ADON) A was conducted with the DON present. ADON A was asked if they did see Resident #1 on 10/17/2025 and ADON A offered, that they did and assessed their wounds on their skin. ADON A offered, they do remember the hospice nurse at bedside with the discharge medication list/orders from the hospital and does believe the hospice nurse took them that day. ADON A was asked if they had to roll the resident to assess their skin and ADON A offered, yes. ADON A was asked if the resident had their tube feed/nutrition hooked up that day and ADON A along with the DON clarified that Resident #1 did not have tube feeding hooked up during their skin assessment. On 12/18/2025, at 2:00 PM, a review of the facility provided HOSPICE CERTIFICATION AND PLAN OF CARE Current Benefit Period/Range: 10/17/2025 to 1/14/2025 . Nurse's Signature and Date of Verbal SOC . (hospice nurse signature) 10/17/2025 . Orders of Discipline and Treatments: TRAIN (FACILITY) STAFF REGARDING MEDICATION SHCEDULE WITH CONSISTENT INTERVALS OF ADMINISTRATION AND PROVIDE WRITTEN MEDICATION SCHEDULE INCLUDING PRN MEDICATIONS . MODIFY DIET TO TUBE FEEDS . TRAIN SYMPHONY STAFF IN PROPER TUBE FEEDING PROCEDURES AND SAFETY MEASURES AS FOLLOWS: GLUCERNA 10 ML/HR (MILLILITERS/HOUR) . The only hospice document available for review during survey was the above 3-page certification and plan of care for 10/17/2025 admission. The oldest hospice document in the EMR was a visit note dated 11/8/2025. A review of the facility-provided Move In/admission Policy Revised 1/25 . revealed . All guests must be admitted to the facility with the following information: A written record of the clinical history and physician examination, together with a diagnosis and treatment plan . written physician orders for immediate care which will allow staff to provide essential care to the guest in a manner that is consistent with the guest's mental and physical status upon admission. These orders shall, at a minimum, include dietary instructions, medications and routine care to maintain or improve the guest's functional abilities until staff can conduct a comprehensive assessment . On 12/18/2025, at 2:50 PM, during exit conference, the Social Worker brought in numerous hospice documents for Resident #1 that were being printed out at that time. Most of the document dates were from 11/2025 and the Social Worker B was alerted, the need for the admission to hospice on 10/17/2025. During exit the DON offered that the physician will be notified regarding the lack of tube feed/nutrition for Resident #1.

This citation pertains to Intake Number 2677656. Based on interview and record review the facility failed to clarify admission orders, reconcile medications, provide medications timely, and coordinate with hospice and the physician for two residents (Resident #1, Resident #3) of three residents reviewed for nursing care resulting in delayed care and rehospitalization. Findings include. Resident #1: On 12/17/25, at 9:30 AM, a record review of Resident #1's electronic medical record (EMR) revealed a readmission on [DATE] with diagnoses that included Chronic Hypoxic Respiratory Failure, Severe protein-calorie malnutrition, Septic shock, Diabetes Type 2 and Gastrostomy. Resident #1 had severely impaired cognition. A review of the . admission Assessment Date: 10/17/2025 12:46 . revealed Resident #1 was readmitted at 12:46 PM. There was no hospice documents scanned into the EMR that clarified when the hospice company/nurse visited the resident on 10/17/25. A review of the Physician orders revealed no order for enteral feeding/nutrition for the Resident #1 and the following order NPO (Nothing By Mouth) . Start Date 10/17/2025 . A review of the MEDICATION ADMINISTRATION RECORD 12/1/2025 - 12/31/2025 revealed no documented administration of enteral feeding/nutrition on 12/17/25 or 12/18/25. A review of the Progress Notes revealed the following: 10/17/2025 14:30 . Note Text: Late entry: Resident returned from the hospital today and is now on (company) hospice. This wound care nurse performed a skin assessment on resident since returning from (hospital). Resident has DTIs to b/l buttocks and his rt heel, per hospital documentation these DTI's were formed while resident was in their hospital. Foam dressings were applied to each DTI at this time. Resident does continue to have lt great toe wound and lt medial fot wound that were present prior to medial foot wound that were present prior to hospitalization. Both of these wounds are stable and left OTA, but will continue to be monitored. Resident agreed to assessment and photographical documentation of his wounds. Resident agreed to have staff continue to monitor and treat wounds, as well as allow staff to reposition him every 2 hours and PRN. Resident was education on the importance of wearing his prafo boots while in bed. This RN placed prafo boots on resident at this time. Resident's nurse, (name) aware of all these findings. 10/18/2025 08:00 . Note Text: Received morning report from night nurse and was notified that resident had not received his Glucerna feed since he left the hospital. The feed was not hung when he made it to the facility. This writer research and made calls to confirm orders. Feed was hung @ approximately 0745 hours, Hospice nurse came in to visit resident, this writer confirmed med list with hospice nurse. Resident currently receiving feed and relaxed in bed with call light in reach. There was no clarification who the nurse called for the order, what rate and the type of enteral nutrition and if the Medical Doctor was notified of the missed tube feeding. 10/18/2025 12:38 . Note Text: Late entry: Resident appeared lethargic and eyes were rolling back as this writer was assessing resident and asking questions to keep him alert. Resident O2 (oxygen) sats (saturation) decreased from 94% to 72%. This writer increased O2 up to 5L (liters), which is the max on the concentrator. His O2 sat held @ 88% 20 bs (glucose level) 600. (ambulance) (company) hospice, the On-call physician, management, and (guardian) were all contacted. Resident transported to the hospital. There was no progress note that documented any contact to the Physician, the hospital for discharge medication list/orders and no contact to the hospice company who was accused of taking the hospital discharge paperwork. On 12/17/25, at 10:20 AM, a record review along with the Director of Nursing (DON) of Resident #1's EMR was conducted. The DON was asked to review the admission assessment dated [DATE] and was asked what time Resident #1 was readmitted and the DON stated, 12:46 around that time. The DON was asked for assistance to provide/locate any hospice documents for that day as the DON offered, that the hospice nurse was in and accidentally took the hospital discharge medication list with them when they left. A review of the miscellaneous tab in the EMR for Resident #1 along with the DON revealed no discharge instructions/medication list from their hospital discharge on [DATE] AM. The DON was asked to provide active Physician Orders for Resident #1 for the admission on [DATE]. On 12/18/25, at 11:24 AM, a record review along with the DON of the Active Orders As Of: 10/17/2025 for Resident #1 was conducted which revealed no tube feeding/nutrition directions and/or orders. The DON was asked why Resident #1 did not receive tube feeding/nutrition and the DON offered, He got it the next morning when we got here. The DON clarified there was no physician order for the tube feed/nutrition and or administration documentation on the MAR. The DON was asked if they were notified of the lack of tube feeding/nutrition for nearly 19 hours and the DON stated, No I was not and I just saw that note. The EMR revealed no notification to the physician of the missed tube feeding/nutrition and the DON was asked if the doctor was notified and the DON responded, they need to review the hospice documentation before they answer any more questions. The DON offered, they contacted the hospice company to get the records and there may have been a hospice reason as to why they did not provide the tube feeding. A review of the Facility provided active orders for Resident #1 revealed the following: NPO (Nothing By Mouth) diet NPO . Order Date 10/17/2025 Docusate Sodium Oral Tablet 100 MG (milligrams) (Docusate Sodium) Give 1 tablet by mouth two times a day for constipation . Order Date 0/17/2025 hydralazine HCI Oral Tablet 10 MG (Hydralazine HCI) Give 0.5 tablet by mouth in the morning for hypertension . Order Date 10/17/2025 LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety . Order Date 10/17/2025 MiraLax Oral Packet 17 GM (grams) (Polytheylene Glycol) Give 1 packet by mouth in the morning for constipation . Order Date 10/17/2025 OLANZapine Oral Tablet 5 MG (Olanzapine)Give 1 tablet by mouth at bedtime for mood and behavior . Order Date 10/17/2025 Pallperidone ER Oral Tablet Extended Release 24 Hour 6 MG (Pallperidone) Give 2 tablet by mouth in the morning for mood and behavior . Order Date 10/17/2025 Sertraline HCI Oral Tablet 100 MG (Sertraline HCI) Give 2 tablet by mouth in the morning for Mood and Behavior . Order Date 10/17/2025 Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for prn pain A review of the MEDICATION ADMINISTRATION RECORD (MAR) 12/1/2025 - 12/31/2025 revealed five medications given orally despite the NPO order: Sat 18 . Sertraline Miralax Amantadine . were all documented as administered orally. Fri 17 Sat 18 . Docusate Sodium . both doses were documented as administered orally. There was no documented contact with the doctor to clarify and/or change the medications from oral to Peg Tube. On 12/18/2025, at 12:35 PM, an interview with Assistant Director of Nursing (ADON) A was conducted with the DON present. ADON A was asked if they did see Resident #1 on 10/17/2025 and ADON A offered, that they did and assessed their wounds on their skin. ADON A offered, they do remember the hospice nurse at bedside with the discharge medication list/orders from the hospital and does believe the hospice nurse took them that day. ADON A was asked if they had to roll the resident to assess their skin and ADON A offered, yes. ADON A was asked if the resident had their tube feed/nutrition hooked up that day and ADON A along with the DON clarified that Resident #1 did not have tube feeding hooked up during their skin assessment. A further record review along with the DON of the Active Orders and MAR for Resident #1 was conducted. The DON was asked why a nurse would sign out an oral medication as given if the resident had an order for NPO and the DON offered they couldn't answer that. On 12/18/2025, at 2:00 PM, a review of the facility provided HOSPICE CERTIFICATION AND PLAN OF CARE Current Benefit Period/Range: 10/17/2025 to 1/14/2025 . Nurse's Signature and Date of Verbal SOC . (hospice nurse signature) 10/17/2025 . Orders of Discipline and Treatments: TRAIN (FACILITY) STAFF REGARDING MEDICATION SHCEDULE WITH CONSISTENT INTERVALS OF ADMINISTRATION AND PROVIDE WRITTEN MEDICATION SCHEDULE INCLUDING PRN MEDICATIONS . MODIFY DIET TO TUBE FEEDS . TRAIN SYMPHONY STAFF IN PROPER TUBE FEEDING PROCEDURES AND SAFETY MEASURES AS FOLLOWS: GLUCERNA 10 ML/HR (MILLILITERS/HOUR) . The only hospice document available for review during survey was the above 3 page certification and plan of care for 10/17/2025 admission. There was no fax cover nor any date the document was provided to the facility. The oldest hospice document in the EMR was a visit note dated 11/8/2025. A review of the facility provided Move In/admission Policy Revised 1/25 . revealed . All guests must be admitted to the facility with the following information: A written record of the clinical history and physician examination, together with a diagnosis and treatment plan . written physician orders for immediate care which will allow staff to provide essential care to the guest in a manner that is consistent with the guest's mental and physical status upon admission. These orders shall, at a minimum, include dietary instructions, medications and routine care to maintain or improve the guest's functional abilities until staff can conduct a comprehensive assessment . On 12/18/2025, at 2:50 PM, during exit conference, the Social Worker brought in numerous hospice documents for Resident #1 that were being printed out at that time. Most of the document dates were from 11/2025 and the Social Worker B was alerted, the need for the admission to hospice on 10/17/2025. During exit the DON offered that the physician will be notified regarding the lack of tube feed/nutrition for Resident #1. Resident #3:On 12/18/2025, at 9:30 AM, a record review of Resident #3's electronic Medical Record (EMR) revealed a readmission on [DATE] with diagnoses that included ulcer of the esophagus, Reflux disease with esophagitis, unspecified with bleeding and cognitive impairment. A review of the Physician Orders revealed NexIUM (stomach pill to reduce stomach acid production) Oral Capsule Delayed Release 40 MG Give 1 capsule via Peg . Start Date 12/16/2025 A review of the MEDICATION ADMINISTRATION RECORD 12/1/2025 - 12/31/2025 revealed NexIUM . 0900 (9:00 AM 2100 (8:00 PM) Tue 16 Wed 17 . both doses had been documented as not given. On 12/18/25, at 10:20 AM, a record review along with the DON of Resident #3's EMR was conducted. The DON was asked what time Resident #3 was admitted into the facility and the DON offered, at 4:28 PM on the 16th. The DON was asked why Resident #3 did not receive their scheduled gastrointestinal medication (Nexium) as they were just readmitted from the hospital with a gastrointestinal bleed and the DON stated, if we don't have the medication in back up it gets ordered and should be delivered the next morning. The DON further explained, he missed the night on the 16th and the morning on 17th and got his first dose at 8PM on the 17th. The DON was asked with the diagnoses of Barret's Esophagus wouldn't the stomach medication be important and the DON stated, it would be. A record review of the facility provided Meds Available in Back-Up revealed Nexium was not on the list.

Based on observation, interview, and record review, the facility failed to prepare and store food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen.Findings include: On 08/05/2025 at 9:30AM During the kitchen tour with the Manager of Kitchen V, observed the inside of the ice machine visibly soiled with black residue in the sub kitchen in [NAME] hallway. When interviewed about the cleaning schedule of the ice machine, the Manager of the Kitchen V stated Maintenance is supposed to clean it. and proceeded to tell staff not to use the ice in that machine. On 08/05/2025 at 11:45AM during lunch observation, observed [NAME] W removing gloves and then proceeding to don gloves without washing hands while preparing lunch. According to the 2022 Food Code 4-602.11 Equipment Food-Contact Surfaces and Utensils, Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.Record review of facility policy Food & Nutrition Services/Sanitation and Food Safety states Food and nutrition services employees will thoroughly wash their hands and exposed areas of their arms with soap and water in the designated hand-washing sink at the following times: .Between removing gloves or aprons and before putting on new gloves or aprons. According to the 2022 Food Code, 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single -use articles and . before donning gloves to initiate a task that involves working with food.

Based on observation, interview and record review, the facility failed to ensure food palpability and preferred temperature for a total of 8 resident's (Resident's #2, #13, #22, #26, #63 and #66), and follow provided food menu for a census of 53 of 53 resident's, resulting in the potential for weight loss, dislike of facility served foods, anger towards dietary department and management, refusing to eat served foods, and relying on family member's to bring in favored foods. Findings Include: Observation made on 8/6/25 at 10:26 a.m., in the main dining room revealed the facility food menu posted was dated July, 2025. Resident #26:Review of Face Sheet and Minimum Data Set/MDS dated 3/25, revealed Resident #26 was admitted to the facility 3/25, and was alert and able to be interviewed.During an interview done on 8/5/25 at 12:19 p.m., the resident revealed she did not like what the facility served, she often requested a cheeseburger which was overcooked and hard to chew. The resident said the facility serves the same foods over and over again.Resident #2:Review of Face Sheet and Minimum Data Set/MDS dated 2/25, revealed Resident #2 was admitted to the facility 2/11/25, and was alert and able to be interviewed.During an interview done on 8/5/25 at 9:53 a.m., Resident #2 said he hates the food, and the staff do not give him anything else if he does not like the food. The resident was upset about the food; he said it was often cold.Resident #13:Review of Face Sheet and Minimum Data Set/MDS dated 5/25, revealed Resident #13 was admitted to the facility 5/15/25, and was alert and able to be interviewed.During an interview done on 8/5/25 at 10:23 a.m., the resident stated, I don't like the food, it's the same thing all the time.Observation of the noon meal done on 8/6/25 at 12:15 p.m., revealed the following: -The majority of residents had 1 toco on their plate with rice. The toco's of several residents had grease dripping out of them when picked up to eat; plates were noted to have an excessive amount of pooling dark amber colored grease on them. There was 1 to 2 pieces of lettuce on each toco, and several observed had wilted lettuce. During an interview done on 8/6/25 at 11:00 a.m., Dietary Manager V stated Some did not get eggs this morning, she (one of the cooks) never told me we did not have eggs. We did have eggs, but they were frozen. I did see the grease (on toco's) yesterday (on 8/5/25). I did tell her (cook) to drain the meat. Review of the facility Resident's Council notes revealed the following: -On 3/27/25: Chef will come put and see what food is served.-On 4/24/25: Wrote up concern about meat, not having items, getting what ordered.-On 6/5/24: Tastes bad (served food), often cold, dislikes options.-On 7/10/25: Portion sizes questions, options for diabetics, wonder if too many carbs.During an interview done on 8/6/25 at 1:20 p.m., Director of Activities N stated We do hear complaints in the meeting (Resident Council meeting), I believe we are down in the kitchen. (Kitchen Manager V) does come to the meetings (Resident Council).Review of the facility Food & Nutrition Services Organization & Staff Competency Checklist Dining Observation Meal Services checklist (un-dated), revealed staff were to ask and address if the food served was the residents preference.

Based on observation, interview and record review, the facility failed to 1) maintain clean wheelchairs for 5 resident's (Resident's #6, #15, #38, #41 and #44), 2) ensure a clean and comfortable environment for randomly selected resident rooms and 3 of 4 hallways (Hall's 100, 200, and 400), and 3) maintain plumbing in good repair, for a census of 53 resident's, visitors and staff, resulting in the potential for cross contamination, resident illness, complaint's of resident environment cleanliness, and flooding concerns regarding plumbing. Findings Include: DPS 2 Based on observation and interview the facility failed to maintain plumbing in good repair. This deficient practice increases the likelihood of contamination of the water supply, potentially affecting any or all staff, residents, and visitors in the facility. Findings include: Observation of 100 hall was done on 8/5/25, starting at approximately 9:20 a.m., the following was found: -In the hallway (at 10:07 a,m,), numerous black scuff marks on walls and resident doors. -Room103 had food and pieces of paper on the floor, the walls had scuff marks on them and the corners of the wall molding had paint chipped off. -room [ROOM NUMBER] had pieces of paper on it, walls were scuffed up and bathroom floor was dirty. -room [ROOM NUMBER] (at 9:57 a.m.) had food under and on the right side of the bed, and pieces of paper on it. The bedside table had a “sticky” substance on top of it and a urinal was on the floor partly under the bed. Part of the wallpaper above the white rail was torn off and the bathroom floor was dirty. Observation of 400 Hall was done on 8/6/25 at 1:30 p.m., revealed a large gray trash bin with food and dirty medical gloves inside, sitting in the hallway in front of the office, with no lid on it. During an interview done 8/6/25 at 10:30 a.m., Housekeeper “L” stated We do surfaces, dust, vacuum or mop in the resident's rooms. In the bathrooms we clean the toilet, sink and floor. I come in at 7am, we get in the rooms at around 10am. Housekeeper “L” said they have to do public area's first before they start on resident's room's and they only have 2 Housekeepers for all resident's rooms. During an interview done on 8/5/25 at 1:41 p.m., Housekeeping Supervisor “M” stated “Yes, there are complaints about the room's (resident room's) about wallpaper, marks on wall's, dirty carpet's; our carpets are stained and nasty. The problem is we need new floors. We are trying to get the wallpaper down; the public area's first. They (Housekeepers) are supposed to be in the resident's room about 9:00 a.m.; I have 2 housekeepers for the LTC (Long Term resident room's, census: 53). They (Housekeepers) clean about 25 to 26 rooms plus public areas. I have asked for more Housekeepers; I don't understand how they think two Housekeepers can do everything. The families came to me with complaints about the rooms. We shouldn't have any trash cans in the hallways, and they need tops.” Review of the facility Morning Run 7-3 Person sheet (undated), revealed Housekeeping were to vacuum, clean public bathrooms, the movie theater, breakroom, therapy's, cottage, therapy, and family dining room. Review of the facility resident room list of what to clean in each room list (given to the Housekeepers daily) revealed staff were to clean daily the toilet, bathroom mirror, sink, showers, dusting, floor, bed table, TV, TV stand, marks off walls, vacuum floors, mop floors, spot clean carpets, window as needed, window seals, empty trash. During an interview done on 8/7/25 at 12:49 p.m., Infection Control, RN Nurse “S” stated “I do daily morning sweeps and I look into the resident's rooms. I do tell them at the Infection Control meeting that Housekeeping should do a better job, but they don't have the money to hire more.” Infection Control Nurse S said she did not document any observations of IC rounds on hallways nor resident rooms. On 8/5/2025, during initial screening of facility residents, it was observed that some of their wheelchairs were soiled with strands of hair, dried on/sticky substances and dust/debris. The residents reported their wheelchairs had not been cleaned during their time at the facility. The following residents were observed: Resident #6 Was observed in his room watching television, both footrests were observed with a layer of dust, debris and sand like particles building up at the back of footrests. Other outer areas of the wheelchair were also soiled, with the crevices of the chair with particle buildup. The Resident reported he does not believe his chair has been cleaned since he admitted to the facility. Resident #38 Was observed in his room after morning care was completed. His chair was observed to have red, tacky substance on the wheels, the crevices of the chair were riddled with unknown built up material. The area by the wheelchair brakes had built-up particles. Resident #15 Was observed in her room finishing breakfast. She reported her wheelchair has not been cleaned in the 1.5 years that she has been a resident of the facility. She stated she was informed staff are supposed to clean her wheelchair when is showered. Her chair was observed to have unknown debris particles in some areas. During Resident Council on 8/6/2025 at Resident #41 was asked when the last time her wheelchair had been cleaned. She reported it is not routinely cleaned by facility staff. On 8/6/2025 at 4:00 PM, the DON (Director of Nursing) was asked who is responsible for cleaning resident wheelchairs. She reported the aides are responsible for cleaning the resident chairs. The DON observed the soiled wheelchairs of Resident #6 and #38. Resident #44 was observed sitting by the nurses' station in her wheelchair was observed to be riddled with a slew of unknown particles, hair and dust. The DON reported she will enact a process to ensure resident chairs are cleaned going forward. On 8/7/2025 at approximately 10:30 AM, a review was conducted of Resident #6's medical records. It revealed the resident admitted to the facility on [DATE] with diagnoses that included, Major Depressive Disorder, Diabetes, Ataxia, Anxiety, Insomnia and Heart Disease. On 8/7/2025 at approximately 10:45 AM, a review was conducted of Resident #15's medical records. It revealed the resident was admitted to the facility on [DATE] with diagnoses that included Diabetes, Hypokalemia, Syncope and Collapse and Orthostatic Hypotension. On 8/7/2025 at approximately 11:00 AM, a review was conducted of Resident #38's medical records. It revealed the resident was admitted to the facility on [DATE] with diagnoses that included Ataxic Cerebral Palsy, Hyperlipidemia, Hemiplegia and Hemiparesis. On 8/7/2025 at approximately 11:10 AM, a review was conducted of Resident #41's medical records. It revealed the resident admitted to the facility on [DATE] with diagnoses that included, Bipolar, Anemia, Major Depressive Disorder and Paroxysmal Atrial Fibrillation. On 8/7/2025 at approximately 11:15 AM, a review was conducted of Resident #44's medical records. It revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Delusional Disorder, Alzheimer's Disease, Adjustment Disorder, Dementia and Hypertension. It can be noted there was no documentation located in the above charts related to wheelchair cleaning. DPS 2 On 08/05/2025 at 12:26 PM, observed the atmospheric vacuum breaker missing from the top of the utility sink in Bay 1, leaving the water system open to the environment. When the utility sink was turned on, water began to spew out from the top where the missing vacuum breaker was supposed to be. On 08/05/2025 at 12:26 PM, during an interview with Maintenance Director T on the broken atmospheric vacuum breaker, he stated the vacuum breaker has been ordered and when asked about the policy and procedure of when things are repaired, he stated whenever they notice it's broken, they'll fix it.

Bassed on observation, interview and record review, the facility failed to ensure a dignified dining experience and follow care planned interventions for 6 residents (#22, 27, 28, 29, 33, 38 and 44) out of 10 residents reviewed during dining task, resulting in no assistance offered, food spills on clothing, fluids not offered, meals not served timely and in a dignified manner with the likelihood of overall decreased nutritional intake. Findings include:On 8/05/2025, at 12:20 PM, During dining task in the small dining room the following observations were made: On 8/05/2025, at 12:18, during dining task, Resident #38 was sitting at table alone asking if he can have some more pop. Resident #33 had a cup of soup that had spilled down his shirt, pants and all over the table. Resident #33 did not have on a clothing protector. There were no staff in the area. On 8/05/2025, at 12:19, Resident #33 was sitting alone at another table. There was an empty cup of soup with a spoon and no napkin. Resident #33 had spilled soup onto their clothing and face. Resident #33 was using the tablecloth for a napkin. Resident #33 did not have a clothing protector on. There were still no staff in the area. On 8/05/2025, at 12:20 PM, Residents #27, 28, 29 and 44 were sitting in their wheelchairs. They were not offered any food items. On 8/05/2025, at 12:25 PM, Resident #33 was observed using the tablecloth to wipe their nose. On 8/05/2025, at 12:33 PM, Resident #44 now had their meal and quickly drank their cup of lemonade. Resident #44 had a second glass of lemonade out of reach. Residents #27, 28 and 29 still do not have their meals. On 8/05/2025, at 12:36 PM, Resident's #27, 28 and 29 still do not have their meals and were offered a glass of juice each which was placed in front of them on the table. No sips were offered. On 8/05/2025, at 12:39 PM, Resident #27 was being assisted with their shoes by CNA X. CNA X was asked if Resident #27 was going to eat lunch and CNA X stated, yes, but she's an assist. On 8/05/2025, at 12:41 PM, CNA H placed clothing protectors on Resident #33 and #38 walked over to Resident #44 cut their taco in half and walked away. Resident #44 was picking up their taco meat with their fingers. CNA H did not provide Resident #44 with their second glass of lemonade which remained out of reach. On 8/05/2025, at 12:43 PM, Resident #28 and Resident #29 were offered their meals and two staff sat down and assisted with their meals. On 8/05/2025, at 12:45 PM, Resident #44 continued to use their fingers to eat. No staff assistance was offered. Resident #44 still was not offered additional fluids to drink. On 8/05/2025, at 1:03 PM, Resident #44 remained seated at the lunch table. They were using their napkin to cover up spilled liquid from a plastic cup which appeared to be a supplement drink. The second full cup of lemonade remained out of reach. Resident #44 continued to consume their lunch with their fingers. On 8/06/2025, at 12:24 PM, during dining task in the small dining room the following observations were made: On 8/06/2025, at 12:24 PM, CNA H brought in silverware for Resident #38 although did not offer any to Resident #33. Resident #44 was offered a glass of milk. Resident #44 drank their milk and set their glass down. Resident #44 lifted their empty glass numerous times and attempted to sip milk from the empty glass. On 8/06/2025, at 12:38 PM, Resident #44 remained at the lunch table with no assistance. They continued to attempt to drink milk out of their empty glass. Moments later, Resident #44 placed their butter packet into their empty milk glass. Resident #44 ate their meal with their fingers and were not assisted by any staff. The resident did not receive any more fluids to drink and continued to pick up the empty glass as if there was a drink in it. The glass was filled with a butter packet and no fluids. On 8/06/2025, at 12:40 PM, the DON was asked if a certain staff member was assigned to the residents in the dining area and the DON provided the assignment sheet. The DON explained that the hall trays are passed first and the residents who are feeds are passed last. The DON was alerted of the lack of assistance noted in the dining room during the survey. On 8/06/2025, at 12:45 PM, Resident #44 was observed trying to eat their butter packet that they had removed from their milk glass. Unit Manager (UM) A was sitting behind the nurses' desk and was alerted that Resident #44 was trying to eat garbage out of their empty glass. On 8/06/2025, at 1:30 PM, the following record reviews were conducted: Resident #27: A review of Resident #27's electronic medical record revealed a readmission on [DATE] with diagnoses that included Dementia, need for assistance with personal care and protein calorie malnutrition. Resident #27 required assistance with all ADL's and had severely impaired cognition. A review of the care plan I need help with my ADL's because I am confused and don't remember how to perform my ADL's . Interventions . EATING: I need assistance to feed myself. Date Initiated: 10/03/2020 . Resident #28: A review of Resident #28's electronic medical record revealed an admission [DATE] with diagnoses that include Alzheimer's disease, Dementia and Stroke. Resident #28 required assistance with all ADL's and had severely impaired cognition. A review of the care plan I have a nutritional problem r/t Dementia . Interventions . I need total assist with all meals Date Initiated: 11/07/2022 . Resident #29: A review of the electronic medical record revealed an admission on [DATE] with diagnoses that included Dementia, Alzheimer's disease and Dysphagia. Resident #29 had severely impaired cognition. A review of the ADL: Self-care deficit, require assist with ADLS . Interventions .Eating: I need assistance with eating. Date Initiated: 01/03/2025 . Resident #33: A record review of Resident #33's electronic medical record revealed an admission on [DATE] with diagnoses that included Parkinson's disease, Dementia and Need for assistance with personal care. Resident #33 required assistance with all Activities of Daily Living (ADL's) and had severely impaired cognition. A review of the care plan SKILLED THERAPY/ADL: Self-care deficit, require assist with ADLS . Interventions . Eating: I need limited assistance with eating please place all my liquids in a covered mug I would also like to use weighted silverware for my meals. Provide clothing protector for every meal. Date Initiated: 04/02/2025 . Personal hygiene: I need extensive assist of 1 to help me . Resident #38: A record review of Resident #38's electronic medical record revealed an admission on [DATE] with diagnoses that included Cerebral Palsy, Hemiplegia affecting left side and cognitive communication deficit. Resident #38 required assistance with all ADL's and had impaired cognition. A review of the care plan SKILLED THERAPY/ADL: Self-care deficit, require assist with ADLS r/t (related to) mobility, debility and impaired balance . Interventions . Eating: I am independent, set up my tray covered lids on all liquids. Date Initiated: 05/08/2025 . Please offer me a clothing protector at meals as I will allow. Date Initiated: 05/28/2025 . Resident #44: A review of the electronic medical record revealed an admission on [DATE] with diagnoses that included Dementia, Alzheimer's disease and a history of significant weight loss. Resident #44 had severely impaired cognition. A review of the care plan Risk for malnutrition . Interventions . Staff to assist with guest at meals to provide encouragement. Date Initiated: 01/02/2024 . Resident #22: On 8/05/2025, at 9:49 AM, Resident #22 was resting in their bed on their back. There was a plastic cup of water and a glass of water with a straw. On 8/06/2025, at 8:38 AM, Resident #22 was in bed flat. Their breakfast meal was on their overbed table and slightly pushed in front of them. Resident #22 complained they couldn't eat their oatmeal because I need milk. There was no egg on their breakfast sandwich and no milk on their tray. There was a regular coffee cup with a plastic lid. On 8/07/2025, at 8:20 AM, Resident #22 was in bed lying flat. Their breakfast was untouched. There was a strong urine smell in the room. There was a coffee cup and a small juice cup without handles on the tray. The cups did not have lids. On 8/07/2025, at 8:22 AM, the Nurse Manager (NM) C entered Resident #22's room. A record review of their meal ticket revealed mug with lid for all liquids. NM C was asked why Resident #22 did not have the lidded mug for their liquids and NM C offered, I am thinking the aides should be getting that. NM C was alerted the resident was resting all three mornings and hadn't appeared to have assistance with their breakfast meals. NM C offered, they would get the resident cleaned of urine and assist with their meal. A review of the facility provided policy Dignity DATE REVIEWED 4/24 revealed Each resident shall be care for in a manner that promotes and enhances quality of life, dignity, respect and individuality . Residents shall be treated with dignity and respect at all times .

Based on interview and record review the facility failed to consistently provide scheduled showers to four (#15, #35, #35, #37) residents of four reviewed for Activities of Daily Living. Resulting in, unmet care needs and feelings of frustration. Findings Include: Resident #15On 8/6/2025 at approximately 8:20 AM, Resident #15 reported her shower days are Mondays and Thursdays, but she did not receive one this Monday. She continued if she does not ask if she is being showered on her scheduled day, many aides will not mention anything about it. Resident #15 stated she did refuse one shower as it was closer to midnight when the aide offered.On 8/6/2025, a review of the last 30 days of Resident #15's showers were completed. Within the 30-day period, Resident #15 was provided with one shower on 7/20/25. There was one progress note related to a shower provided on 8/1/2025 that was not listed in the 30-day look back document. On 8/7/2025 at approximately 3:45 PM, a review was conducted of Resident #15's medical records. It revealed the resident was admitted to the facility on [DATE] with diagnoses that included Diabetes, Hypokalemia, Syncope and Collapse and Orthostatic Hypotension. Further review yielded the following:Kardex: .I prefer a shower twice a week.Monday/Thursday night shift. During resident council on 8/6/2025 at 1:00 PM, Resident #35 & #37 stated they are not regularly receiving their showers as scheduled. They explained they have to ask staff for their showers and it is rare they will come in and say its their shower day.Resident #35On 8/6/2025 at approximately 3:30 PM, review was conducted of Resident #35's medical records and it indicated she was admitted to the facility on [DATE] with diagnoses that included, Dysphagia, Hypertension, Social Phobia, Major Depressive Disorder and Diabetes. Further review of the records yielded the following: 30-day Shower lookback:Over the last 30 days Resident #35 only received one shower on 7/31/2025.Kardex: .Bath: Wed/Sat night . Resident #37:On 8/6/2025 at approximately 3:45 PM, record review was conducted of Resident #37's chart and it revealed the resident admitted to the facility on [DATE] with diagnoses that included Obstructive Pulmonary Disease, Major Depressive Disorder, Hemiplegia, Hypertension, Polyneuropathy and Diabetes. Further reviewed yielded the following: 30-day Shower lookback:Resident #37 received a shower on the following days- 7/9/25- 7/16/25- 7/29/25- 7/30/25- 8/6/25 Resident #37's showers were not consistent and skipped weeks. Resident #4108/05/2025 at 3:50 PM, Resident #41 stated she is supposed to receive showers on Wednesdays and Saturdays, but she does not regularly receive them as scheduled. The resident stated she will ask about showers the day prior to remind them and typically when it's time for her shower the staff cannot be located. Resident #41 stated she should be able to be showered twice a week and it's frustrating that it does not occur. On 8/6/2025 at approximately 11:30 AM, a review was conducted of Resident #41's medical records and it indicated she was admitted to the facility on [DATE] with diagnoses that included, Atrial Fibrillation, Anemia, Bipolar Disorder and Hyperlipidemia. Further review yielded the following:30-Day Shower Look Back:Review was conducted of Resident #41's showers over the last 30 days and she only received three showers. It can be noted there is also progress note documentation of showers that is not listed in the look back document provided. It appears there is also a documentation issue surrounding resident showers. Kardex: Bathe: Every Wednesday and Saturday.I prefer a shower twice a week.On 08/06/2025 at 10:00 AM, Unit Manager A reported there was a recent staff meeting with the aides and they were informed of their responsibility to complete showers and subsequent shower sheet. Manager A now reviews all of the shower sheets and inputs a progress note, but this process just began recently.On 8/6/2025 at 1:15 PM, the DON (Director of Nursing) stated she recognized there was an issue with showers, and they are working on holding staff accountable. They are working on an actionable plan to rectify resident showers.Review was conducted of the facility policy entitled, Shower and/or Bathing, approved 7/25. The policy stated, .All residents will be offered the opportunity to bathe twice weekly. A complete shower will be taken under staff supervision at least weekly.document giving the shower/bed bath in the medical record. If the resident refuses their shower and/or bed bath notify their nurse and try again later.

Based on observation and interview the facility failed to ensure 3 of 4 medication carts were maintained clean and sanitized, free of crushed pills, pieces of loose papers and dust in the drawers, resulting in the likelihood of cross contamination, low medications count with increased cost and missed resident medications. Findings Include: Observation was made on [DATE] at 11:32 a.m., with Nurse, LPN I of the 300 Hall medication cart. During the observation the following was found: -Resident's #1 and #16 had partly used insulin pen's with no expiration date written on the sticker (sticker with open and expiration date spaces to fill in) on the pen. During an interview done on [DATE] at 11:32 a.m., Nurse I was unable to tell this surveyor when the insulin's expired, and why there was no expiration date on the resident's insulin pens. Nurse I stated yes, they need a expiration date. -In the med cart's third drawer on the bottom was a large area of a sticky substance, crushed medication, dust, small pieces of paper, 1 whole blue oval pill, and 1 round whole peach pill. Observation was made on [DATE] at 11:40 a.m., with Nurse, LPN J of the 200 Hall medication cart. During the observation the following was found: -In the second drawer was found 1 loose tan colored pill, crushed medications, small pieces of paper and dust on the bottom. -In the fourth drawer there was observed an area of a sticky substance on the bottom. During an interview done on [DATE] at 11:40 a.m., Nurse, LPN J stated We all clean the carts Observation was made on [DATE] at 11:45 a.m., with Nurse, LPN K of the 400 Hall medication cart. During the observation the following was found: -In the second drawer there was two cream colored round pills found on the bottom. During an interview done on [DATE] at 11:45 a.m., Nurse K said the nurses on third shift clean the medication carts. During an interview done on [DATE] at approximately 11:30 a.m., the Administrator revealed the nurse's on the night shift clean the medication carts. On [DATE], at 2:30 PM, Nurse “Y“ was observed pushing the medication cart behind the nurses station. Nurse “Y” then walked into the locked mediation room with another staff member. The medication cart was unlocked and facing outward towards the main lobby. Nurse “J” was standing at another medication cart in the lobby and was asked if the medication carts are supposed to unattended while unlocked and Nurse “J” looked at the unlocked medication cart and stated, No. The Director of Nursing (DON) was walking up the hallway and was asked if medication carts were to be left unattended while unlocked and the DON, stated, no. Nurse “Y“ walked out of the medication room, stood in front of the medication cart and engaged the lock.

Based on observation and interview, the facility failed to maintain general cleanliness of clean linen and sanitary supply storage. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, for any residents in the 100 and 300 hallways. Findings include: On 08/05/2025 at 12:26PM during the environmental tour with the Housekeeping Manager M and Director of Maintenance T, the cleaning supply room floor was visibly soiled with debris. During the interview with the Housekeeping Manager M, when asked what the cleaning schedule is, they stated they are coming in and sweeping the floor on a regular basis. On 08/05/2025 at 1:00 PM observed clean linens stored on the floor of the clean linen room in 300 hall. Housekeeping Manager M proceeded to pick up the clean linens from the floor and removed them from the clean linen closet. On 08/05/2025 1:05PM observed unused urinal on floor along with other trash in the clean linen closet in the 100 hall. The Housekeeping Manager M proceeded to pick up the urinal and trash and removed them from the clean linen closet. While removing the urinal from the closet, the Housekeeping Manager M commented I'm not even sure how that got in here.

Based on interview and record review the facility failed to ensure one resident (#6) of one reviewed for behavioral health had an accurate mental health diagnosis.Findings Include:On 8/7/2025 at 10:40 AM, Social Worker P was queried regarding Resident #6's diagnosis of paranoid schizophrenia and current medication regime. She reported he is not prescribed any medications for his schizophrenia diagnosis. She was asked to provide further documentation on if his diagnosis was long standing or newly added. We reviewed his diagnosis list that revealed the Paranoid Schizophrenia diagnosis was initiated upon admission and the physician note dated 5/3/24 that stated, history of paranoid schizophrenia. Social Worker P reported after investigation it was found it was an incorrect diagnosis as it was unsubstantiated from the Level II OBRA completed in May 2025 and unsubstantiated by their contracted psychiatric group who evaluated him as well. Social Worker P was asked why the diagnosis was indicated if it was inaccurate and why it was still listed in his record if they have known for three months that it was a mistake on their end. The Social Worker shared she as unsure where the physician garnered the information to make the diagnosis and it should have been removed from his medical record timely. On 8/7/2025 at approximately 11:00 AM, review was conducted of Resident #6' medical record and it indicated he was admitted to the facility on [DATE] with diagnoses that included, Paranoid Schizophrenia, Anxiety, Insomnia, Diabetes and Hypertension. MDS (Minimum Data Set) Assessment reviewed indicated the Paranoia Schizophrenia diagnosis in 2/14.2025, 5/13/2025 and 8/14/2025. Further review yielded the following:Physician Notes:5/6/2024: .(Resident #6) is a [AGE] year old right handed divorced male with PMH of acute coronary artery disease s/p PTCA.generalized anxiety, major depressive disorder, paranoid schizophrenia.5/9/2024: .(Resident #6) is a [AGE] year old right-handed divorced male with PMH of acute coronary artery disease s/p PTCA.generalized anxiety, major depressive disorder, paranoid schizophrenia. 5/13/2024: .(Resident #6) is a [AGE] year old right handed divorced male with PMH of acute coronary artery disease s/p PTCA.generalized anxiety, major depressive disorder, paranoid schizophrenia. 5/16/2024: .(Resident #6) is a [AGE] year old right handed divorced male with PMH of acute coronary artery disease s/p PTCA.generalized anxiety, major depressive disorder, paranoid schizophrenia.5/26/2024: .(Resident #6) is a [AGE] year old right handed divorced male with PMH of acute coronary artery disease s/p PTCA.generalized anxiety, major depressive disorder, paranoid schizophrenia. Level II OBRA 6/2/2025 DSM Diagnoses: Major Depressive Disorder, Recurrent episode, Moderate - Primary, Generalize anxiety disorder, Unspecified Personality Disorder.(facility) sent (Community Mental Health) change in condition 3877 form due to facility social worker reporting that while reviewing his medical records, it was discovered that he had been psychiatrically hospitalized in November 2024. Moreover, there have been behavioral health medications changes since his admission and additional mental health diagnoses. According to the CIC received on May 7, 2025, (Resident #6) is diagnosed with anxiety disorder, unspecified: paranoid schizophrenia; claustrophobia: major depressive disorder, recurrent, unspecified; insomnia; anxiety disorder.Nursing facility staff reported (Resident #6) diagnosis of Paranoid Schizophrenia was given to him by a medical physician from the nursing facility. A review of (Resident #6's) admission note from is physician at ( the facility) dated May 3, 2024, states history of paranoid schizophrenia. Nursing facility staff are uncertain why he was given this diagnosis and what his symptoms were that led to the diagnosis.(Resident #6 stated he received a diagnosis of paranoid schizophrenia last year but does not know how he got this. (Resident #6) reported he feels this is an inaccurate diagnosis. He denied having delusions and/or hallucinations. Psychiatric Evaluation 5/30/2025: .Major Depressive Disorder, recurrent, severe with psychotic symptoms, Generalized Anxiety Disorder, Claustrophobia. Resident #6 does have mental health diagnoses but does not have Paranoid Schizophrenia, the facility physician diagnosed the resident and there was no further clarification or query regarding this. From the review of the record Resident #6 did not display persistent signs/symptoms of the diagnosis.

Based on observation, interview and record review, the facility failed to provide food items per scheduled menu for all residents and failed to provide milk per menu for Resident's #22, 63, 64, 65 and 66) of a census of 53 out of 53 residents who eat facility provided meals, resulting in frustration, no breakfast egg, no milk and overall likelihood of hunger. Findings include. Resident #63 On 8/06/2025, at 8:28 AM, Resident #63 was resting in bed with their breakfast tray on their overbed table untouched. There was no egg on their breakfast sandwich. There was no milk provided. A record review of their meal ticket revealed . EGG, SAUSAGE & CHEESE SANDWICH . 2% MILK . On 8/06/2025, at 8:38 AM, Resident #22 was in bed flat. Their breakfast meal was on their overbed table and slightly pushed in front of them. Resident #22 complained they couldn't eat their oatmeal because they needed milk. There was no egg on their breakfast sandwich. There was no brown sugar on the tray. A record review of their meal ticket revealed . EGG, SAUSAGE & CHEESE SANDWICH . [NAME] Sugar was written on the meal ticket. On 8/06/2025, at 8:39 AM, Resident #64 did not receive an egg on their breakfast sandwich nor any milk. On 8/06/2025, at 8:45 AM, Resident #65 complained they did not get an egg on their sandwich, milk or oatmeal. On 8/06/2025, at 8:49 AM, Resident #66 complained they did not get an egg on their breakfast sandwich. On 8/06/2025, 8:50 AM, an observation along with the Director of Nursing (DON) of Resident #66's breakfast tray in their room was conducted. There was no egg on their breakfast sandwich The DON was alerted it appeared there were more residents that didn't receive egg on their breakfast sandwiches. On 8/06/2025, at 9:11 AM, an observation of the kitchen refrigerators along with the Dietary Manager V was conducted. DM V was asked if they ran out of eggs for the breakfast meal and DM V was unaware. The refrigerator housed a large container of boiled eggs and a few bags of liquid eggs. DM V asked [NAME] W if they cooked eggs for breakfast and [NAME] W offered, no they were frozen. [NAME] W further explained they did their check the night before but a 6:15 AM during preparation for breakfast they realized the liquid eggs were still frozen. [NAME] W was asked if they cooked any eggs for any of the residents and [NAME] W stated, no. [NAME] W was asked if they notified anyone and [NAME] W offered, no. [NAME] W was asked if they sent anyone to the local store to get eggs so they could follow the menu and [NAME] W did not answer. DM V offered to [NAME] W If you called me, I could have stopped and grabbed eggs. [NAME] W was asked why some of the breakfast trays did not have milk and [NAME] W stated, they call out the meal ticket and the CNA's get the drinks.

Based on observation, interview and record review, the facility failed to honor food preferences and food allergies for two (Resident #38 and 66) out of two residents reviewed for food allergies and preferences, resulting in frustration of allergy food items being served, the likelihood of food allergy reactions and overall decreased nutritional intake. Findings include. Resident #66 On 8/05/2025, at 12:49 PM, Resident #66 was sitting in their room and complained they get food items they are allergic to. Resident #66 stated they get strawberry jelly almost every morning for breakfast and they are allergic to strawberries. There were strawberry jelly packets on their over bed table. Resident #66 had their lunch tray of a taco with a flour shell. They complained they had a wheat allergy. On 8/06/2025, at 8:49 AM, Resident #66 complained they were provided an English muffin (wheat) and complained they have not been offered gluten-free food items. On 8/06/2025, 8:50 AM, an observation along with the Director of Nursing (DON) of Resident #66's breakfast tray in their room was conducted. There was no egg on their breakfast sandwich which was an English muffin (wheat). The DON was alerted the resident also received a flour tortilla the day prior. Resident #38:On 8/06/2025, at 12:22 PM, Resident #38 was sitting at the lunch table in the dining area. They had what appeared to be cream of broccoli soup. Moments later, Resident #38 was offered their lunch tray that consisted of ham, scalloped potatoes and spinach. The resident spoke out and stated, I don't like spinach. Resident #38 was asked if they wanted something else by the surveyor and Resident #38 stated, yeah, a hotdog. DM V was alerted Resident #38 received all three food items they disliked and DM V approached the resident asked the resident if they would like a hotdog or something else. A record review of Resident #38's electronic medical record revealed an admission on [DATE] with diagnoses that included Cerebral Palsy, Hemiplegia affecting left side and cognitive communication deficit. Resident #38 required assistance with all ADL's and had impaired cognition. A review of the care plan . has nutrition risk due to small appetite . Interventions . Provide and serve diet as ordered. Date initiated: 05/15/2025 . There was no care planned intervention to follow food preferences. A record review of Resident #38's meal ticket revealed: DISLIKES: Broccoli, Spinach, Potatoes.

Based on observation, interview and record review, the facility failed to 1) Prevent bruising and sling indentations on both thighs during a mechanical transfer for 1 resident (Resident #102), and 2) Ensure that 1 resident (Resident 106) was free of injury of an unknown origin (fracture of the leg) of 2 residents observed for transfer and injury of unknown origin, resulting in 2 sling indentations on the thighs and a bruise on the outer right knee with the possibility of developing skin breakdown and a fracture of the leg, pain and hospitalization.Findings Include:Resident #102: Review of the face Sheet, care plans dated 6/25, nursing notes dated 7/23/25 and physician orders dated 7/23/25, revealed Resident #102 was [AGE] years old, alert but not able to make her own healthcare decisions, immobile, and totally dependent on staff for all Activities of Daily Living/ADL’s. The resident was receiving Hospice services at the facility and malnourished weighting 74.6 pounds. The resident’s diagnosis included, protein-calorie malnutrition, fracture of the right tibia, impulsiveness, Alzheimer’s disease, Dementia, pelvic and perineal pain, degeneration of brain, anxiety, mood disturbance, major depression, adjustment disorder and Dysphagia (difficulty swallowing). Review of the facility ADL care plan dated 1/25, stated “use mechanical lift for all transfers, small sling size.” Observation was made on 7/23/25 at 9:50 a.m., of Hospice staff members (Nurse, LPN “F” and Aide “E”) transferring Resident #102 from bed to the shower chair. When this surveyor entered the resident’s room, the resident was not covered and then Hospice Aide “E” quickly covered her with 2 small white towels (a bath blanket was folded sitting in the chair) to the left of the resident’s bed. As Nurse “E” and Aide “F” were lifting the sling with the Hoyer, Resident #102 was talking Spanish and said the word “shoulder” and then the rest was in Spanish (the resident had documentation of pain in her right shoulder due to osteoarthritis), the resident was crying/winning with facial grimacing of pain noted. This surveyor noticed a red indication mark on the resident’s left thigh, the same indication shape as the sling material. A second observation of Resident #102 was done on 7/23/25 at 10:05 a.m., with Nurse Managers, RN’s “C” and “D”; she was in the shower with Hospice Aide “E” giving her a shower. An irregular round shaped bruised area on her right outer knee was observed at this time. The bruise was red/blue in color, and it matched up to the pattern of the large sling she was sitting on; unable to do an observation of all skin due to being transferred into the shower chair. Review of the facility New Skin Condition form dated 7/23/25, at 10:15 a.m. (after this surveyor observed a bruise and lift indication on leg), stated “This writer was notified that this patient had been observed transferring from wheelchair to shower chair by hospice nurse and hospice in a Hoyer sling around the back of the thighs indenting into skin. No bath blanket present. Bruise noted above lateral right knee 4.5 cm x 3 cm blue in color (newly acquired). Attempted to assess while patient was still in shower chair. Unable to fully assess areas where sling was with patient in chair. Intervention: Smaller Hoyer sling brought into room for transfers. Hospice Aide and Hospice Nurse transferred patient to bed. Skin assessment completed at this time. Bruise noted above lateral right knee 4.5 cm x 3 cm blue in color. Left 4th toe bruise dark purple 1 cm x 0.5 cm. Sling indentation noted to the back left thigh and right thigh. Left hip red indentation measuring 4.5 cm x 0.2 cm. Right hip red indentation 12 cm x 0.2 cm.” Review of facility nursing progress note dated 7/23/25 at 11:21 a.m., stated “This writer was notified that this patient had been observed transferring from wheelchair to shower chair by hospice nurse and hospice in a Hoyer sling around the back of the thighs indenting into skin. No bath blanket present. Bruise noted above lateral right knee 4.5 cm x 3 cm blue in color (newly acquired). (Family Member #1), Administrator, DON (Director of Nursing) notified. Intervention small Hoyer sling in room.” During an interview done on 7/23/25 at approximately 10:10 a.m., Nurse Manager “D” had gone and gotten a size small Hoyer sling; when asked where she got it, she stated “in the laundry room.” The facility had available a size small sling and it was documented to use a small sling on her ADL care plan dated 1/25. Review of a physician's order, dated 7/23/25, stated “Monitor bruising q (every) shift until healed to left 4th toe and above lateral right knee until healed.” Review of the facility Altercation in skin integrity care plan updated on 7/23/25, stated “Bruise to lateral rt (right) knee, 6/13/25 (previously, the resident had a bruise the same location as on 7/23/25), ensure size small sling is used for all transfers.” Review of facility staff education dated 7/23/25, revealed the Director of Nursing educated nurse’s and Nursing Assistant’s/CNA's regarding proper Hoyer sling size usage. Review of the facility Transfer Using a Lift policy dated 7/17/25, stated “Ensure the proper size sling is used based on the resident’s size and weight.” Resident #106: Record review of Resident #106’s ‘Injury of unknown origin’ incident report dated 7/18/2025 at 4:28PM revealed Resident #106 had right ankle bruising, swelling and was hot to the touch. In facility Xray was ordered with acute fracture of the fibula and tibia bones with displacement and soft tissue swelling. Pain assessment noted occasional moan or groan, facial grimacing, rigid, fist clenched, knees pulled up, pulling or pushing away and striking out. Both lower extremities with severe contractures and overlap each other. Record review of Resident #106’s electronic medical record revealed and elderly female with medical diagnoses of: muscle weakness, dysphagia, protein calorie malnutrition, diabetes, mood disorder, insomnia, major depressive disorder, Alzheimer’s, gastro-esophageal reflux disorder, hypertension, peripheral vascular disease, irritable bowel syndrome, osteoarthritis, heart disease. A Brief interview of mental status (BIMs) score of 4 out of 15, severe cognitive impairment was noted. Record review of Resident #106's medical record revealed the resident was non-ambulatory/non-weight bearing and had bilateral lower extremities contractures. Observation and interview on 7/22/2025 at 11:58AM with Resident #106 regarding her tibia and fibula (leg bones) fractures revealed: “I don’t know what happened, it just started hurting. It was hurting so badly, and then they sent me to the hospital. It hurt so badly, I couldn’t stand it anymore”. Observation of Resident #106’s right leg/foot gray plastic orthopedic boot to immobilize the right foot/leg. Resident #106 was lying in bed with family members at bedside visiting. In an interview on 7/22/2025 at12:04PM with Resident #106’s family member “G” revealed that the family was called on Friday to see if Resident #106 could go to emergency room (ER). The family member stated that they had called ER around 10:30PM that night and they told them it was a fractured leg, and they asked the ER how that could happen. The family member told them Resident #106 can’t turn herself or roll over and could not stretch out her legs (contractures bilateral lower extremities), was non-weight bearing and basically bedridden. The family member stated that the ER stated that they did not know how this happened because the resident was non-mobile. They had stated that they had asked the facility/nursing home, and no one knew anything. The family member stated that if it was brittle bones the ER and x-rays would have stated so. The family member “G” stated that “So, we have no clue what happened. We were here last Tuesday (7/15/2025) visiting, and she complained of her leg hurt. Usually, her right leg is folded under her left leg at the knee and contracted in that position. She is totally bedridden with a Hoyer lift for transfers but chooses not to get out of bed”. In an interview on 7/22/2025 at 2:00PM Certified Nurse Assistant (CNA) “H” revealed that she was changing Resident #106’s brief on that 7/18/2025 in the morning and noted the resident’s right ankle/leg was swollen and the way she was laying you could not see any coloration. I did notice it had swelling and then when she turned Resident #106 that was when she noticed the color of bruising, color of yellow, purple and green, that was not a fresh bruise. CNA “H” called nurse, licensed Practical Nurse (LPN) “I”. CNA “H” stated “LPN “I” took forever to go to the room, so I snap a photo of just the ankle to take to the LPN “I”, at the end of my shift, we work 6AM to 6PM, only LPN “I” was leaving early that day around 2:00PM, to go to a casino or something. CNA “H” stated that she brought the photo to the LPN “I” to visualize that she needed to go look at the bruising. LPN “I” then went to the Resident #106’s room to look at the leg, CNA “H” went with the LPN “I” and nurse said it was from the mattress, a red pressure area. So LPN “I” put soft Provalon boot on Resident #106, to relieve the pressure, and did not report the change of condition, but reported to the next nurse (Registered Nurse “D”) it was just a red mark. CNA “H” went up to Registered Nurse “D” to make sure that LPN “I” reported it to her. LPN “I” had only stated a red spot and did not report any bruising. Once again CNA “H” showed the photo to RN “D” and then to the Director of Nursing (DON) and Nursing Home Administrator (NHA) and that’s when things got moving. The DON/NHA all went to the resident room and looked at the leg, got x-rays, and sent her out to the hospital. CNA “H” stated that Resident #106 does not stand, does not walk, cannot roll over by herself, cannot move her legs or spread them. Record review of the electronic medical record revealed that there was no documented physical assessment on 7/18/2025 for the bruising or red marks by LPN “I”. Under the skin/wound tab there were no photos of the bruising or of skin monitoring. In an interview on 7/23/2025 at 9:23 AM with the Director of Nursing (DON) there is no nursing assessments policy, in the electronic medical record program there is an admission assessment in the program. We use the nurse’s judgement to assess the resident condition and document the changes. The skilled rehab residents are assessed daily, and the Long-Term Care (LTC) are done monthly. Any change in condition is the responsibility of the nurse’s education and judgement. We train the staff and nurses to identify the changes in residents. In an interview on 7/23/2025 at 9:36AM with Registered Nurse (RN) D regarding Resident #106's fracture ankle incident: The Certified Nurse Assistant (CNA) H came up to me and stated that Resident #106's leg was red, we had 3 nurses for all halls and so I did not have her until the previous nurse Licensed Practical Nurse (LPN) I, left the shift early around 3PM. Licensed Practical Nurse (LPN) I, in report very vagally stated that Resident #106’s leg was red from laying on the leg. It was a weird report from her, and not 10 minutes later the Certified Nurse Assistant (CNA) H came and asked me what did (LPN) I tell you about Resident #106's foot? I stated that (LPN) I told me it was red in a spot from the resident lying on the foot. I went to the room with Certified Nurse Assistant (CNA) H, and there was a soft Prevalon boot on the foot/ankle which had no order for the boot. Licensed Practical Nurse (LPN) I had not gotten an order for the boot. I peeled back the Velcro straps on the right foot/ankle and saw it was swollen, warm to the touch and bruising of yellow/purple/green in color. As soon as I touched the boot Resident #106 moaned n pain, so I did not take the boot off. I went to get the Director of Nursing and then the wound nurse and the unit manager were in the office when I went to tell them what was going on. So then I stated it looks broke, and I want an Xray, they assisted in getting the order from doctor, and then I was still present when the Xray tech/guy came and I sent in Certified Nurse Assistant (CNA) H to assist him, and the Xray guy stated unofficial report of fracture and not to move her. There was another resident here that had a fracture, and she was immobile also. They got the Xray results and sent Resident #106 out after I left at 6PM, Resident #106 has contracture of the legs and had no other areas of concern, for me her legs are a fragile spot; to turn her we have to use the lift sheet and assist both legs. Resident #106 is basically bed bound so it has to have been with her turning. Record review of Resident #106’s Emergency/hospital record dated 7/18/2025 revealed the resident came from nursing home facility due to concerns for right lower extremity ankle swelling. The nursing home facility staff was unable to tell emergency transport when the ankle first started swelling, however they just noticed it today. Unsure of the length of time since the injury. Musculoskeletal assessment: Contractures bilateral lower extremities, pulses intact bilaterally, right ankle swollen, obvious deformity, bruising. Lateral X-ray results: There is acute distal right tibial fracture as well as distal fibular fracture.

This Citation Pertains to Intake Numbers 1256062 and 2564418.Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures for fall prevention for two residents (Resident #101 and Resident #105) of three residents reviewed, resulting in a lack of planned interventions, a lack of implementation of meaningful interventions to prevent falls, resulting Resident #101 and Resident #105 experiencing falls with injuries necessitating emergency medical treatment, unnecessary pain, and a decline in overall health status. Findings include: Resident #101: Review of Intake documentation revealed concerns that on 6/24/25 a staff member was giving Resident #101 a bed bath and the Resident rolled out of the bed because there was only one staff member assisting the Resident when they required the assistance of two staff per their care plan. As a result of the fall, Resident #101 suffered a broken hip which required emergency surgery. On 7/22/25 at 12:50 PM, Resident #101 was not in their room. The Resident’s bed was positioned against the wall and a fall mat was in place on the floor beside the bed. At 1:00 PM on 7/22/25, Resident #101 was observed sitting in a Broda chair (specialized wheeled, reclining chair with solid footrests used for individuals with limited mobility). Certified Nursing Assistant (CNA) “J” was feeding the Resident lunch. When queried regarding care in the facility, Resident #101 stated, “I fell, and they had to put screws in me. I broke my hip.” A follow-up interview was completed with Resident #101 on 7/22/25 at 1:23 PM in their room. When queried what happened when they fell, Resident #101 stated, “I rolled out the bed real hard. Landed on the floor real hard.” When queried if the fall mat was in place beside the bed when they fell, Resident #101 replied, “Didn’t have that mat there then. They just put that mat down.” Resident #101 was queried regarding the height of the bed when they fell and stated, “About a foot higher than it is now.” The bed was noted to be at waist height. When asked why the bed was so high, Resident #101 replied, “I don’t know.” Resident #101 was then asked if there were staff in the room at the time of the fall and responded that a CNA was in the room. When asked what they were doing, Resident #101 stated, “Supposedly cleaning me up but only had one person (CNA). They were supposed to have two (CNAs).” Resident #101 was asked why only one CNA was cleaning them up if there are supposed to be two staff to assist them and replied, “I don’t know. That what they do around here.” When queried what happened after they fell, Resident #101 stated, “(The CNA) went screaming and the nurses came in and they had to get a lift to get me off the floor.” Resident #101 was asked if they went right to the hospital and stated, “I went to (one hospital) and they didn’t find nothing wrong so I went to (different hospital) and they said they needed to do emergency surgery and that’s what they did.” When queried what was broken, Resident #101 revealed they broke their hip and had to get a plate and screws. Resident #101 revealed (Family Member “L”) would be able to provide additional information regarding the care they received and requested they be contacted. Record review revealed Resident #101 was originally to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included displaced intertrochanteric right hip fracture, falls, chronic kidney failure with dialysis dependence, heart failure, left below the knee amputation (LBKA), and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, dependent upon staff for bed mobility, and required total assistance from staff for transfers. Review of Resident #101’s Electronic Medical Record (EMR) revealed a care plan entitled, “Skilled Therapy/ADL: Self-care deficit, require assist with ADLS r/t (related to) limited mobility, debility, and impaired balance” (Initiated: 1/17/25). The care plan included the intervention: - “Bathing: I need extensive assist with 2 people to help me” (Initiated: 1/17/25) - “Bed mobility: I need extensive assist of 2 to help me” (Initiated: 1/17/25) - “Toileting: I need extensive assist of 2 to help me” (Initiated: 1/17/25) - “Transfers: I need extensive assist of 2 to help me” (Initiated: 1/17/25) Review of progress note documentation in Resident #101’s EMR revealed the following: - 6/24/25 at 10:00 AM: “Follow-up/Monitoring… Has the resident reported changes in their experience of pain? Yes, pain in right shoulder and right hip. Has the resident reported changed in their ability to perform ADL tasks or mobility? Yes, cannot flex right shoulder… Have any new orders been received… Yes, X-rays for nasal, right shoulder, and right hip.” - 6/24/25 at 10:14 AM: “Health Status/Progress Note… Resident observed lying on back, next to bed. Head against nightstand. Resident stated doesn't know what happened. He also stated that fell on the right side of body before lying on back; pain in right shoulder and right hip… answered yes when asked if hit head… Swelling noted to left nare. Hand grasp equal and strong but cannot flex right shoulder. Movement in lower extremities. Complaints of pain noted… Orders for x-ray of the nasal bones, right shoulder, and right hip have been placed. To prevent future falls during dressing, care plan will be updated to extensive two assist for dressing.” - 6/25/25 at 3:44 AM: “Health Status/Progress Note… Guest just returned from (Hospital) for right sided pain. X-Ray of 2 View right ankle and right shoulder complete were all negative of fracture and breakage…” - 6/25/25 at 10:17 AM: “Plan of Care… IDT met to review fall. Resident was receiving care from the aide and was rolled on to side when the aide turned to get more needed items (Resident #701) lost grip on the side of the bed and rolled out of bed. Resident was assessed and reported right hip and shoulder pain… Intervention is to have care plan updated to have 2 person assistance with self care to reduce the risk of falls.” - 6/25/25 at 9:00 PM: “Health Status/Progress Note… Guest transferred to hospital on stretcher… Guest demanded be sent to hospital… stated The pain medication is the same medication I was taking already. It's not helping. I want to go to (different Hospital) .” - 6/25/25 at 2:35 PM: “Health Status/Progress Note… Dr into see guest. New order given for Baclofen (muscle relaxer) 5 mg (milligrams) q (every) 8 hours for muscle spasms…” - 7/8/25 at 4:37 PM: “admission Note… Client arrived to facility via (ambulance), on stretcher… Wound vac to right hip, catheter in place and draining yellow fluid… Client c/o pain in hip…” - 7/10/25: Physician “History and Physical… Chief Complaint / Nature of Presenting Problem: Fall… presents to the hospital after a fall. The patient was found to have been treated for right lesser trochanteric fracture, fall, urinary tract infection with MDRO (Multi Drug Resistant Organism) … Upon my exam… admitting to pain of the right hip… patient has profound weakness… moves left upper extremity with severe weakness of the right upper extremity… does not move the right lower extremity… has a left above-knee amputation… toes were amputated from right foot… Plan: right lesser trochanteric fracture: Pain management… Follow-up with orthopedic surgery as indicated.” Resident #101’s Census List documentation in the EMR revealed the Resident was transferred to the hospital on 6/25/25 and returned to the facility on 7/8/25. Upon request for Resident #101’s Incident and Accident (I and A) reports and facility investigations, one I and A with investigation documentation was provided. Review of the I and A revealed: - “6/24/25 9:45 AM… Incident Location: Resident’s room… Nursing Description: Resident observed lying on back, next to bed. Head against nightstand. Resident Description: Resident stated doesn’t know what happened… stated fell on the right side of body before laying on back, pain in right shoulder and right hip… answered yes when asked if hit head… Injuries Observed at Time of Incident… Injury Type: Unable to Determine… Location: Face…” - Undated, Signed Statement by CNA “K”: “I was doing a routine bed bath on (Resident #101) and I had finished washing front and turned (Resident) on left side towards me to make sure they were securely on their side. Once I knew (Resident #101) was secure and holding the side of the bed, I walked around to the opposite side of the bed and went to wash their back. I noticed (Resident #101) reach down and before I could say anything or at least try and catch them, they rolled off the bed and landed on right side going down. Nurses were notified.” - Printed EMR progress note and assessment documentation An interview was conducted with Family Member “L” on 7/23/25 at 8:28 AM. When queried regarding Resident #101’s fall at the facility, Family Member “L” stated, “(Facility) called me on 6/24 or 6/25 and told me that (Resident #101) was getting washed up and the CNA told them to turn over to get the other side but (Resident #101) can’t turn because they are paralyzed.” Family Member “L” then stated, “How do you wash somebody up yourself and turn them when you don’t have no body on the other side?” When queried regarding Resident #101’s mobility including ability to use their arms to help reposition themselves, Family Member “L” revealed the Resident can use one arm “most of the time” but not consistently. Family Member “L” verbalized Resident #101 did not have anything to hold on to if they were on their side and indicated the Resident may be able hold a bed rail if there was one. When queried if the facility had ever assessed or discussed enabler bars or bed rails for Resident #101 to assist with positioning, Family Member “L” responded they were told they could not have any rails on beds because of State regulations. Family Member “L” was asked if the facility provided any other information related to how Resident #101 fell and indicated they did not. Family Member “L” stated, “I know (Resident #101) didn’t roll over themself.” Family Member “L” then stated, “(Resident #101) fractured their hip and leg.” When queried when the facility sent the Resident to the hospital, Family Member “L” revealed Resident #101 went to the ER at two different hospitals. With further inquiry, Family Member “L” revealed the first hospital ER the Resident went to “couldn’t find anything” wrong and sent the Resident back to the facility. Family Member “L” was queried what happened after Resident #101 returned to the facility and replied, “That same night (Resident #101) kept calling me and saying they were having pain. I called (the facility) and said I wanted them to send (Resident #101) out” to a different hospital.” Family Member “L” continued, “The nurse said they had to talk to the Director of Nursing (DON) before they could send (Resident #101) out” to a different hospital. When asked if Resident #101 was transferred to the other hospital ER then, Family Member “L” revealed the Resident was not sent to ER until the night of 6/25/25. Family Member “L” revealed they were informed Resident #101 needed to have emergency surgery in the morning when they got to the hospital. Family Member “L” then stated, “(Resident #101) had to rod in their leg and screws in their hip.” When asked, Family Member “L” revealed Resident #101 was in the hospital for over a week following the fall and surgery to repair the fracture. On 7/23/25 at 10:05 AM, an interview was conducted with Licensed Practical Nurse (LPN) “M”. When queried regarding Resident #101’s fall on 6/24/25, LPN “M” verbalized they were not working when the Resident fell. LPN “M” was then queried regarding the Resident’s upper extremity mobility and revealed the Resident has some “gross motor skills but not fine motor skills.” When queried if the Resident is able to grasp items and hold them, LPN “M” replied, “Some days (Resident #101) can feed themselves and some days can’t.” When queried if Resident #101 would be able to hold and/or grasp an enabler bar in bed to assist with positioning, LPN “M” indicated they may be able to. LPN “M” was then asked if Resident #101 had been assessed for enabler bars and replied, “We don’t have that stuff here.” An interview was completed Registered Nurse (RN) “O” on 7/23/25 at 10:13 AM. When queried if they were working on 6/24/25 when Resident #101 fell, RN “O” confirmed they were. When asked what happened, RN “O” stated, “I was on the hall. (Resident #101) fell when I was passing meds.” RN “O” continued, “During med pass one of the CNAs came out and let me know” Resident #101 fell. RN “O” was asked what happened and stated, “The CNA said they were doing hygiene care and (Resident #101) lost their grip on the side of the bed.” When queried what they observed when they entered the Resident’s room after being notified of the fall, RN “O” replied, “(Resident #101) was on the left side of the bed with their head by nightstand. I documented everything” in the EMR. When asked how high the bed was and how far the Resident fell, RN “O” replied, “Like waist high.” When queried regarding their assessment following the fall, RN “O” revealed the Resident complained of pain in their leg and hip.” With further inquiry, RN “O” revealed they put “muscle rub” on Resident #101’s hip and put in orders for a nasal and hip x-ray. When asked why a nasal x-ray was ordered, RN “O” replied, “Looked like it was swelled.” When asked if they noted any abnormalities in Resident #101’s leg, RN “O” replied, “(Resident #101) landed on right on their hip” and indicated they did not observe any signs/symptoms of obvious fracture. When queried, RN “O” revealed the CNA was providing care to Resident #101 by themselves. RN “O” was asked if Resident #101 was care planned to be one assist for bed mobility and ADL care and revealed they were supposed to be two -assist. RN “O” revealed they reviewed the care plan following the fall and made Resident #101 an “extensive two assist for everything.” On 7/23/25 at 10:17 AM, an interview was conducted with CNA “K”. When queried regarding Resident #101’s fall from their bed on 6/24/25, CNA “K” stated, “I was just doing a routine bed bath.” CNA “K” verbalized they turned the Resident and told them to hold onto the metal bed frame. CNA “K” revealed the Resident fell when they went to walk to the other side of the bed to wash the Resident. CNA “K” stated, “(Resident #101) was reaching for something and let go (of the metal bed frame).” When asked if there was something on the floor that the Resident was reaching for, CNA “K” replied, “No.” When asked how they knew the Resident was reaching down when they were walking to the other side of the bed, an explanation was not provided. CNA “K” was then asked if Resident #101 was supposed to be a one assist with bathing and bed mobility and replied, “Always do one assist for bed bath.” When queried why they asked the Resident to hold the metal bar/bed frame under the mattress, CNA “K” responded, “That is how we always did it.” When asked if the Resident was care planned to be a one assist with bathing and bed mobility, CNA “K” stated, “I didn’t know (Resident #101) was a two assist until after (the fall).” When queried how they know what level of assistance residents require for care, CNA “K” indicated it is in their care plan/Kardex (care guide). CNA “K” was then asked if they reviewed Resident #101’s care plan/Kardex before providing care on 6/24/25 and stated, “I did afterwards and saw (Resident #101) was supposed to be a 2 (assist).” When queried why they did not review the care plan/Kardex prior to providing care, CNA “K” stated, “I just did what I was trained to do by another CNA.” An interview was completed with CNA “P” on 7/23/25 at 10:25 AM. When queried regarding Resident #101’s upper extremity strength, CNA “P” replied, “Has good days and bad days” and indicated the Resident’s ability fluctuates. CNA “P” was asked if they were working on 6/24/25 when Resident #101 fell and revealed they were but were not assigned to Resident #101’s area. When queried regarding the level of staff assistance Resident #101 required for bathing and bed mobility prior to the fall, CNA “P” stated, “(Resident #101) has always been a two (assist).” A review of CNA “K’s” employee file and disciplinary actions revealed an Employee Coaching Form dated 7/16/25. The Employee Coaching Form specified, “The following employee is in violation of the following rule: Did not check residents Kardex (care plan guide) before providing care. Description of Incident: Employee was providing bed bath and did not ask for assistance…” On 7/23/25 at 2:35 PM, an interview was completed with the DON. When queried they were involved in the investigation of Resident #101’s fall on 6/24/25, the DON replied, “I knew that (the Resident) was sent out. It wasn’t brought to my attention that we were doing a bed bath with only one assist.” When asked to clarify, the DON revealed they were not immediately notified that the Resident’s fall occurred during care and that the care plan was not being followed. When asked what happened, the DON stated, “(Resident #101) was sent to one hospital and they sent them back. Then (Resident #101) was sent to a different hospital, they found a fracture and then came back over a week later.” The DON revealed they were unaware Resident #101 had suffered a fracture until they returned to the facility from the second hospital. When queried what they identified as the cause of the fall, the DON verbalized CNA “K” did not follow the Resident’s care plan and provided a bed bath with one staff when the Resident required two staff for care. When asked why two staff were not providing care, the DON stated, “(CNA “K”) admitted they didn’t check” the care plan/Kardex. A policy/procedure related to expectation for staff to review the care plan/Kardex prior to providing care was requested at this time and the DON revealed they did not know if that information would be in a policy/procedure. The DON stated, “I feel like that is common sense for them to check the Kardex.” When queried regarding CNA “K” having the Resident grab the metal bar/frame of the bed when they were turning them, the DON revealed they “have seen that before.” The DON continued, “I think it is more that (Resident #101) is grabbing for something to hold themselves when they are being turned. When queried if the Resident had been evaluated for an enabler bar, to provide them something to grab while being turned, the DON replied, “I don’t know.” When queried if they understood the concern, the DON replied, “Yes.” No further explanation was provided. Review of Hospital documentation for Resident #101 revealed the following: - 6/25/25 at 11:55 PM: “ED Provider Note… Physical Exam… Right Lower Extremity Significant tenderness to palpation of the lateral aspect of right hip… unable to move the leg at baseline… Decreased sensation from the midcalf distally… Right upper extremity… Passive range of motion is severely limited due to pain… Admit… symptomatic with right subtrochanteric hip fraction and had not achieved medical stability… Condition: Guarded…” - 6/26/25 Right Femur X-Ray: “Acute nondisplaced subtrochanteric fracture right femur… probably also chip fracture of the lesser trochanter…” Resident #101 had surgery on 6/26/25. Resident #105: Record review of Resident #105's electronic medical record progress note revealed an admission date of 6/25/2025 from the hospital setting. Medical diagnosis included: Urinary tract infection, chronic obstructive pulmonary disease, hypertension, spondylosthesis, alcohol abuse, transient ischemic attack (TIA), dementia, low back pain, metabolic encephalopathy, insomnia, retention of urine, myocardial infarction. Record review of resident #105’s previous hospital medical record dated 6/24/2025 revealed the resident was treated for pneumonia with no mention of fractured rib. Record review on 7/23/2025 of Resident #105’s ‘Incident by incident types’ of report revealed 5 (five) “Fall” incidents had occurred: 6/25/2025 at 8:30PM 6/26/2025 at 6:15AM 6/26/2025 at 8:00PM 6/28/2025 at 4:40AM 6/29/2025 at 9:40PM Record review of Resident #105’s ‘Incident report’ dated 6/28/2025 at 4:40AM revealed the nurse was alerted to the resident being on the floor next to his bed. When entering the room, the resident was back in bed. When the nurse asked the Certified Nurse Assistant (CNA) how the resident got up, the CNA stated, “He did it himself”. The nurse noted that the resident #105 stated he jumped on the floor and that he wants his Pepsi. No injuries observed at the time of incident. Record review of Resident #105’s nursing progress note dated 6/28/2025 at 5:01AM revealed: Nurse alerted to resident being on the floor next to his bed. When the writer entered the room the resident was back in bed. When writer asked the CAN how resident got up, she stated “He did it himself”. The resident stated he jumped on the floor and that he wanted his Pepsi. Vital signs taken, skin assessed and intact, Range of Motion (rom) assessed and present in all extremities, denies pain, neuro (checks) initiated physician notified, family to be notified in the morning, management notified. Record review of the next nursing progress note dated 6/28/2025 at 9:49AM revealed: Interdisciplinary team met to review fall. Resident was observed on the floor by the Certified Nurse Assistant (CNA) and while the nurse was coming for assessment resident got himself u and got back in bed. Resident was sent out to the hospital, and he noted to have a rib fracture and Urinary Tract Infection (UTI) returned from ER with antibiotic. Resident stated he was trying to get his Pepsi. Intervention will be to keep drinks on side table within reach to reduce the risk of falls. Record review of Resident #105’s hospital emergency room record dated 6/28/2025 revealed resident was sent for a fall with rapid heart rate. emergency room work up revealed a Urinary Tract Infection (UTI) and right 7th rib fracture without any callus and likely an acute fracture.

Based on observation, interview and record review, the facility failed to update and/or revise individualized, person-centered care plans to reflect the changing care needs for 1 resident (Resident #106), of 8 residents reviewed for care plans, resulting in the potential for unmet care needs.Resident #106:Record review of Resident #106's electronic medical record revealed and elderly female with medical diagnoses of: muscle weakness, dysphagia, protein calorie malnutrition, diabetes, mood disorder, insomnia, major depressive disorder, Alzheimer's, gastro-esophageal reflux disorder, hypertension, peripheral vascular disease, irritable bowel syndrome, osteoarthritis, heart disease.Observation and interview on 7/22/2025 at 11:58AM with Resident #106 in regard to her tibia and fibula (leg bones) fractures revealed: I don't know what happened, it just started hurting. It was hurting so bad, and then they sent me to the hospital. It hurt so badly, I couldn't stand it anymore. Observation of Resident #106's right leg/foot gray plastic orthopedic boot to immobilize the right foot/leg. Resident resting in bed with spouse at bedside and daughter visiting. In an interview on 7/22/2025 at12:04PM with Resident #106's family member G revealed that the family was called on Friday to see if Resident #106 could go to emergency room (ER). The family member stated that they had called ER around 10:30PM that night and they told them it was a fractured leg and they asked the ER how that could happen. The family member told them Resident #106 can't turn herself or roll over and could not stretch out her legs (contractures bilateral lower extremities), was non-weight bearing and basically bedridden. The family member stated that the ER stated that they did not know how this happened because the resident was non-mobile. They had stated that they had asked the facility/nursing home, and no one knew anything. The family member stated that if it was brittle bones the ER and x-rays would have stated so. The family member G stated that So, we have no clue what happened. We were here last Tuesday (7/15/2025) visiting, and she complained of her leg hurt. Usually, her right leg is folded under her left leg at the knee and contracted in that position. She is totally bedridden with a Hoyer lift, but does not get out of bed. Record review of Resident #106's Emergency/hospital record dated 7/18/2025 revealed the resident came from nursing home facility due to concerns for right lower extremity ankle swelling. The nursing home facility staff was unable to tell emergency transport when the ankle first started swelling, however they just noticed it today. Unsure of the length of time since the injury. Musculoskeletal assessment: Contractures bilateral lower extremities, pulses intact bilaterally, right ankle swollen, obvious deformity, bruising. Lateral X-ray results: There is acute distal right tibial fracture as well as distal fibular fracture. Record review on 7/22/2025 of Resident #106's Care plans pages 1-29 revealed that there were no updates or revisions for interventions related to the care needs that included the fractured right tibia and fibula or the orthopedic boot that was on the resident. Record review of the chronic pain care plan had no new interventions to address the acute fracture of the right ankle, positioning of resident or follow up care for fracture.

This Citation pertains to Intake Number MI00153516. Based on observation, interview and record review, the facility failed to prevent two (2) Stage II (blisters) pressure injuries for one resident (Resident #102) of 3 residents reviewed for pressure ulcers, resulting in two (2) upper left shoulder, Stage II pressure ulcers, pain/discomfort, wound treatments and the likelihood for a decline in overall health. Findings include: A Stage II pressure ulcer is partial-thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents as an abrasion, shallow center or blister. High risk residents (immobile, bed bound) should be assessed weekly, when a condition, change or as needed and preventive measures should be in place including pressure relieving devices, position changes, and dietary supplements. National Pressure Ulcer Advisory Panel (NPIAP). Resident #102: In an observation on 6/13/25 at 9:50 AM, Resident #102 was observed seated up in reclining Broda chair in the main area in front of nursing station. Dressed in red checked Pajama bottoms and a tan sweatshirt with pink sock on left foot and a gauze batting wrapped with an Ace bandage on the right foot/leg. Resident #102 appeared to be sleeping and did not respond to her name. Observed position to be leaning to the right side of chair with pillow between her legs curled in a fetal position with knees pulled upward with the right heel positioned in the leg extension crack between the blue padding of chair leg rest. An observation on 6/13/25 at 10:00 AM of room [ROOM NUMBER], revealed a clean room free of odors, bilateral fall mats on each side of bed, and a private bathroom, which was clean with no odors. No dirty laundry located in room. Observation in the closet revealed a white laundry basket with a few items were noted with no odors. Observation of upper shelves noted 2 Tide laundry pod packages noted on shelf in closet. Clothing Items hanging up, and a large round blue laundry bin noted in closet with clean clothes, no odors. Mattress on bed with contour edges, reviewed sheets to be clean with mint green lift pad on bed, bed is made. Record review of Resident #102's Care plans revealed Resident #102 had a history of falls, behaviors related to dementia, and risk for alteration in skin. Review of the care plan revealed 'Risk for Alteration of Skin' care plan was last updated on 2/8/2025 with interventions of: Pressure reduction mattress, apply pressure reduction cushion when up in wheelchair, remind/assist resident to reposition frequently, provide peri-care after each incontinent episode and apply barrier cream, discuss plan of care with responsible party and notify MD (physician) of any significant changes. There were no new added interventions related to the development of left should pressure ulcer injuries. Observation on 6/13/2025 at 1:05 PM in the facility's main dining room of Resident #102 showed the resident seated in the same position of leaning to the right of Broda chair with knees drawn upward with right heel in the crack of the wheelchair footrest cushion, no change of position noted since early morning observation. Certified Nurse Assistant (CNA) H was seated at a table with 3 residents, Resident #102 and 2 others, feeding all residents. Resident #102's plate had: pureed fish, mashed potatoes, a vanilla pudding cup, coffee, and fruit punch. Record review of Resident #102's June 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed: Wound care left outer shoulder- cleanse with wound cleanser, apply xeroform and cover with border gauze daily and as needed every day-shift. The dressings started on 6/6/2025 and were signed out by nursing staff as done daily through 6/12/2025. Observation and interview was conducted on 6/13/2025 at 2:45 PM with Licensed Practical Nurse (LPN) F of Resident #102's left upper shoulder skin areas. LPN F stated that Resident #102 has contractures of the left arm, and the nurse had to undress/remove the shirt sleeve to get access. Left upper arm/shoulder dressing observed dated 6/9/2025 (4 days prior), Dressing removed, and the first left shoulder pressure wound was cleansed and measured 3.5 cm length X 3.0 cm wide no depth measured. Observation of the second left should pressure ulcer area was cleansed and measured 2.0 cm length X 2.0 cm in width, no depth measured. LPN F stated that the pressure areas were noticed after the right leg fractures and the resident was staying in bed more, the 2 weeks after the fractures. Observation of wound care: areas cleansed with wound cleaner, patted dry with gauze, xeroform Vaseline gauze treatment applied to wounds, covered with foam border dressing, and dated by LPN F 6/13/2025. In an interview and record review on 6/13/2025 at 3:50 PM with the Director of Nursing (DON), the State surveyor requested all pressure ulcer/skin policies of the facility. DON stated that the left shoulder wounds started last week on 6/5/2025 from blisters or denuded skin. DON acknowledged that there were two (2) separate wound sites on the left should area. The DON stated that he had just done wound measurements today, after the state surveyor had done the wound care treatment observation and measurements. The DON stated that he has no photos of the wounds nor any measurements prior to the state surveyor observation. Record review with DON of Resident #102's wound/skin tab in the electronic medical record revealed that on 6/5/2025 the left shoulder wound was noted as blister (8 days prior to interview). Record review of Resident #102's physician progress notes by the DON revealed that there were no doctor's progress notes since 3/11/2025 which were by a nurse practitioner. There were no notes about the right leg fractured tibia & fibula, nor the left shoulder pressure ulcer/wounds by physician. Record review of the nursing progress notes revealed a left shoulder note on 6/5/2025 at 4:00 PM the date of discovery and no other skin note related to pressure injuries of the left shoulder, no measurements and no photos. Record review of the facility 'Pressure Injury Treatment Guidelines' policy, dated 12/2019, revealed treatment guidelines for at risk individuals included: Activity/Mobility: assess resident for degree of physical activity. Provide appropriate pressure redistribution devices, teach resident to weight shift if appropriate, and ensure proper body alignment. Residents will be repositioned with consideration to the individual's level of activity, mobility and ability to independently reposition. Reposition/shifts the body position, and/or encourage repositioning as needed per the individualized plan of care.

This citation pertains to intake Numbers MI00149500 and MI00149604. Based on observation, interview and record review, the facility failed to implement appropriate interventions timely to prevent a pressure ulcer for one resident (Resident #1) of three residents reviewed for pressure ulcers, resulting in an unstageable coccyx pressure injury (full-thickness pressure injury where the base of the wound is covered by a layer of dead tissue, making it impossible to determine the stage of the injury), pressure ulcer infection and hospitalization . Findings include: Resident #1: On 1/17/25, at 12:30 PM, a record review of Resident #1's electronic medical record revealed an admission on 12/16/24 with diagnoses that included aftercare following surgery on the circulatory system, need for assistance with personal care and Dysphagia. According to the Minimum Data Set assessment on admission, Resident #1 required 2-person assistance for bed mobility and had moderate cognitive impairment. A review of the Braden Scale admitted : 12/16/2024 revealed a Score of 16.0. A review of Minimum Data Set assessment Section M . Signed . Fri [DATE] . Is this resident at risk of developing pressure ulcers/injuries? . Yes . Does this resident have one or more unhealed pressure ulcers/injuries? . No . A review of WOUND ASSESSMENT DETAILS REPORT Coccyx Assessment Date 01/06/2025 3:49 PM . Facility Acquired . Date Identified 01/02/2025 . Clinical Stage Partial Thickness . Tissue Types Deep Maroon=10%, Slough Loosely Adherent=40%, Necrotic Soft, Adherent=50% . Exudate Amount - Moderate Type - Serosanguinous . Pain Scale 8 Odor Yes Signs of Infection Present Yes . Size (centimeters) 12.00 x 14.00 x Unknown (L x W x D) . A review of the Collection Date: 01/05/2025 . Culture Source Wound Heavy Growth Proteus Penneri . Heavy Growth Escherichia Coli . A review of the progress note 1/8/2025 02:10 (2:00 AM) . Observe guest skin clammy and sweaty . Guest was shaking and had chills. When conversing with guest, guest could not converse back appropriately due to confusion . DR gave order to send to hospital . A review of the Focus Potential/At Risk for alteration in skin integrity due to risk factors associated with impaired mobility. Date Initiated: 12/16/2024 Created on: 12/16/2024 Revision on: 12/16/2024 Goal Resident will have no complication thru next review date Date Initiated: 12/16/2024 Created on: 12/16/2024 . Interventions Pressure redistribution mattress Date Initiated: 12/16/2024 . Apply pressure redistribution cushion when up in chair/wheelchair Date Initiated: 12/16/2024 . Remind/Assist resident to reposition frequently Date Initiated: 12/16/2024 . Float heels off mattress Date Initiated: 12/16/2024 . Encourage ambulation/mobility Date Initiated: 12/16/2024 . Provide peri-care after each incontinent episode and apply barrier cream Date Initiated: 12/16/2024 . Check skin daily Date Initiated: 12/16/2024 . Keep linens dry and wrinkle free Date Initiated: 12/16/2024 . A review of the Focus Alteration in skin integrity - Resident has Pressure Injury. site coccyx. factors that may inhibit wound healing: Immobility, Incontinence. AEB: Wound is considered unavoidable at this time due to poor intake and refusal to reposition. Date Initiated: 01/03/2025 Created on: 01/03/2025 . Revision on: 01/03/2025 Goal Resident will be free from complications thru next review date. Date Initiated: 01/03/2025 . Interventions Administer pain medication as ordered Date Initiated: 01/03/2025 . 01/03/2025 Apply specialty mattress when in bed. Date Initiated: 01/03/2025 . 01/03/2025 Apply pressure redistribution cushion when up in a chair/wheelchair. Date Initiated: 01/03/2025 . Reposition/Shift weight at frequent intervals to resident's comfort. Date Initiated: 01/03/2025 . Assess and document wound status weekly and PRN (as needed) Date Initiated: 01/03/2025 . Daily Skin checks during care. Date Initiated: 01/03/2025 . Discuss plan of care with resident and responsible party. Date Initiated: 01/03/2025 . Monitor for infection: Peri-wound swelling - Exposed bone - Pressure wound deterioration. Date Initiated: 01/03/2025 . Notify MD and responsible party of any significant change in wound status. Date Initiated: 01/03/2025 . Peri-care after each incontinent episode and apply barrier cream. Date Initiated: 01/03/2025 . Treat as ordered per MD. Date Initiated: 01/03/2025 . A review of the progress notes prior to pressure ulcer development on 1/2/2025 revealed no mention of Resident #1 refusing to be repositioned in bed. On 1/21/25, at 2:21 PM, a record review along with the Administrator of Resident #1's record was conducted. The administrator offered, the wound went bad real fast and the day he went to the hospital he was supposed to sign onto hospice. The administrator offered, the resident quit eating, they added supplements and assisted with meals to aide with the weight loss. A record review of the admission assessment revealed no coccyx wound on admission. The administrator offered that the resident had malnutrition and had lost weight in the hospital before admitting to the facility. The administrator was asked what interventions they placed to reduce the risk of development of pressure ulcers and the Administrator offered, a pressure reduction mattress. The Administrator was asked with Resident #1's history of weight loss, recent Heart surgery and illnesses why they wouldn't implement all interventions, such as an air mattress on admission and the Administrator offered, absolutely, I agree. A review of the facility provided Skin Management Program DATE REVIEWED 7/24 revealed . Residents with wound and /or pressure injury and those at risk for skin compromise are identified, assessed, and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes . A Braden Scale will be completed upon admission . Appropriate preventative measures will be implemented on residents identified at risk (a score of 18 or less on the Braden Scale) and the interventions documented on the care plan .

Based on interview and record review, the facility was placed in Immediate Jeopardy on [DATE]. The facility failed to initiate Cardiopulmonary Resuscitation (CPR) and call Emergency Services (911) for one resident (Resident #1) who began choking during medication administration resulting in Resident #1's death. Immediate Jeopardy (IJ): The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE]. The abatement plan was received on [DATE]. The Immediate Jeopardy was removed on [DATE]. The abatement plan was verified on [DATE]. Findings include: Resident #1: On [DATE], at 9:00 AM, a record review of Resident #1's electronic medical record revealed a progress note on [DATE] signed by (Nurse B)that revealed: [DATE] 04:30 Late Entry: Note Text: Guest awake & alert laying in bed. Guest accepted scheduled Tylenol crushed in applesauce. When offered water via straw guest initially was unable to suck on straw. Guest began biting at straw & blowing into straw then sucked up some water & appeared to aspirate. Guest began gurgling and appeared to be attempting to cough but was unable to. Elevated HOB (head of bed) & provided firm pats on guest's back. Guest still unable to cough. Face began to turn pale & lips turning blue. Unable to obtain O2 (oxygen) sat (saturation) Supplemental oxygen applied via NC (nasal cannula) @ (at) 2L/Min. (liters per minute) Gurgled breathing became apneic. Attempted Heimlich maneuver & suctioning which were both unsuccessful. Unable to obtain pulse. Apneic breathing ceased. Time of death 04:30 am . A review of the facility provided policy GUIDELINE FBAO-Foreign-Body Airway Obstruction/CHOKING: Heimlich maneuver REVIEW DATE ,d+[DATE] revealed The Heimlich maneuver is performed on victims whose airway is severely or completely obstructed by a foreign object . To identify a complete obstruction, determine if the victim can speak or cough. Ask are you choking? . Do not do Heimlich maneuver on anyone who is coughing or talking . Perform thrusts until the foreign body is expelled or victim becomes unconscious . Once the victim is unconscious: Call for Help Start CPR and begin with 30 chest compressions CPR is to be started if a resident goes unresponsive due to foreign body airway obstruction even if resident has elected to be a Do Not Resuscitate Look for the object in the airway, if present, remove If no object present attempt 2 rescue breaths and repeat process Repeat sequence until resident is breathing, or paramedics arrive . On [DATE], at 9:30 AM, a record review of Resident #1's electronic medical record revealed an admission on [DATE] with diagnoses that included Dementia and Hypertension. Resident #1 was signed onto Hospice services in November, 2023. A review of the I need help with my ADL's (Activities of Daily Living) because I get tired . Interventions . EATING: The guest is able to feed self after set, Assist with cueing during meal time . A review of the physician orders revealed: Standard Diet, diet, REGULAR texture, Thin consistency . Code Status: DNR A further review of Resident #1's progress notes revealed: [DATE] 07:11 . Cremation Society . here to pick up remains. [DATE] 17:44 (5:44 PM) Health Status/Progress Note . Guest is alert and able to make needs known most of the time. Guest up in chair some of the day. Received massage through hospice services that he enjoyed. Guest was calm with no issues or concerns to report . [DATE] 14:41 (2:41 PM) Hospice . Routine visit completed. NO s/s (signs and symptoms) pain, anxiety or respiratory distress . On [DATE], at 10:20 AM, a phone interview was conducted with Nurse B regarding Resident #1's death in the facility. Nurse B stated that they crushed two Tylenol tablets and mixed them with applesauce for Resident #1. I gave him the medication. I gave him a drink of water. It was almost when he choked. He was gurgling. He could get air in. He was trying to cough. Nurse B further explained, they could not get an oxygen level so they placed oxygen on him and pulled the emergency call light. Nurse B stated, they got behind the resident and attempted the Heimlich maneuver. Nurse B was asked how many times they attempted the Heimlich maneuver thrust and Nurse B stated, just once. A second nurse (Nurse C) entered and left quickly to get the crash cart. A short moment later, (Nurse C) attempted to suction Resident #1. Nurse B stated, it appeared like he aspirated, like he was in respiratory distress. Nurse B stated the resident did swallow the medication and apple sauce and barely got a sip of water through the straw. Nurse B was asked if the resident was able to cough at this time and Nurse B stated, No. Nurse B offered that Resident #1 had no trouble prior to the incident and required assistance with meals. Nurse B was asked how long after the medication/water administration did the resident pass away and Nurse B stated, the entire process was about three minutes. Nurse B was asked if they felt they did everything they could for Resident #1 and Nurse B stated, He was a DNR and felt they did everything they could. On [DATE], at 3:55 PM, the Administrator was asked if there aware of the incident/death of Resident #1 and the Administrator stated that they were not aware. On [DATE], at 12:46 PM, Nurse C was interviewed regarding Resident #1 and their death in the facility. Nurse C explained they were alerted to the room via emergency call light and when they entered the room Resident #1 appeared normal in color. Nurse C stated that (Nurse B) offered that they gave the resident his medication and didn't know if he had choked. Nurse C offered that they quickly left and came back with the suction machine. Nurse C stated, they tried to suction Resident #1 but there was nothing in his mouth. Nurse C stated, at that time the resident appeared dead, they had checked for a pulse and didn't feel anything. Nurse C stated that they felt the resident may have had a massive stroke or heart attack and didn't feel they could have choked to death on applesauce. Nurse C stated, they quickly discussed the DNR status for Resident #1 with (Nurse B). Nurse C stated, the entire time frame was about 15 minutes. Nurse C was asked why they chose not to call 911 to initiate emergency services and Nurse C stated, I didn't think we needed to, but now know if someone is choking to call 911 and treat them as if they are a full code. On [DATE], at 11:30 AM, a review of the Abatement Plan INSERVICE SIGN-IN RECORD DATE: [DATE] TOPIC: Advance Directives DNR Policy Code Heimlich Maneuver Choking Duration: 35 minutes revealed all nurses received education on the above stated education. The Removal Plan noted that Like guests have been identified and reviewed with no changes. The Removal Plan also noted that 1. Education will be provided immediately to ensure that the Licensed Nurses are re-educated on the following policies. Education began on [DATE] 3:30pm. 1) Code Status 2) Obstruction /Choking: Heimlich maneuver 3) Advance Directives and DNR Policy

Based on observation, interview and record review, the facility failed to provide supervision to prevent falls/accidents for five residents (Resident #5, Resident #6, Resident #37, Resident #155, Resident #203,), resulting in injuries, pain, and hospitalization s. Findings include: Record review of the facility provided CMS 672 upon entrance to the survey on 7/19/2023 revealed a resident census of 54. record review of facility provided CMS 802 revealed 26 out of 54 Residents were identified as having a fall (F), fall with injury (FI), or fall with major injury (FMI). 26 Residents divided by total 54 Residents equals 48% fall rate. Record review of facility 'Safety and Supervision of Residents' policy dated 9/2022 revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Monitoring the effectiveness of interventions shall include the following: (a.) Ensuring that interventions are implemented correctly and consistently. (b.) Evaluating the effectiveness of interventions. (c.) Modifying or replacing interventions as needed. (d.) Evaluating the effectiveness of new or revised interventions. Systems approach to safety: (1.) The facility-oriented and resident oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual residents risk factors, and then adjusts interventions accordingly. (2.) Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. (3.) The type and frequency of resident supervision may vary among residents and over time for the same resident. for example, resident supervision may need to be increased when there are temporary hazards in the environment or if there is a change in the resident's condition. Record review of the facility 'Stand up for Falls (Falls Management and Prevention Program Guidelines) policy, dated 06/2021, revealed it is the intent of the facility to provide residents with assistance and supervision to minimize the risk of falls and fall related injuries. Resident reviews: Resident #5: Record review of Resident #5's Minimum Data Set (MDS) quarterly dated 7/5/2023 elderly female with a Brief Interview of Mental Status (BIMS) score of 5 out of 15, cognitively impaired. Medical diagnosis of medically complex condition, coronary artery disease, hypertension, Alzheimer's disease, non-Alzheimer dementia, anxiety, depression, psychotic disorder. Review of Section G: Functional Status noted transfers, ambulating, dressing and toileting with one person assist. Section J: falls noted 2 falls with no injuries during the assessment quarter. Record review of Resident #5's six month look back revealed falls on: Fall incident reports: -On 1/6/2023 at 3:30PM Resident #5 was observed on floor in her room. No injury was observed. Resident #5 was re-educated on call light. No witnesses were noted. No Neuro sheet was provided by facility. -On 2/23/2023 at 2:57 PM Resident #5 was found on the bathroom floor. Witness statement noted resident was paced on the toilet with call light in reach and left alone prior to fall. Resident #5 was noted to state that she hit her head. Cause was noted as resident is impulsive. Neuro sheet completed. -On 2/26/2023 at 2:57 PM Resident #5 was found on floor next to recliner chair in room. No witnesses to fall noted. Neuro check sheet incomplete. -On 3/31/2023 at 6:30 AM Resident #5 was found on the floor in room next to chair. Fall report noted staff rounded at 5:50 AM. Incomplete Neuro check sheet noted. -On 4/6/2023 at 8:00 PM Resident #5 was heard yelling 'Help me, Help me' by staff. Resident #5 found on floor laying on her back in room. No witnesses noted to fall note. Neuro check sheet completed. -On 4/15/2023 at 1:30 PM Resident #5 was found sitting on bathroom floor. No witnesses noted on fall report. Neuro check sheet complete. -On 5/15/2023 at 3:10 PM Resident #5 call light was ringing and when staff entered room Resident #5 was found on the floor in room. No witnesses noted on fall report. -On 5/26/2023 at 9:45 AM Resident #5 was heard yelling for help by housekeeping staff. The housekeeper enters the room and lowered the resident to the floor. -On 5/29/2023 at 4:53 PM Resident #5-bathroom call light was ringing. Resident #5 was found standing the bathroom holding onto the rails. Resident #5 went to sit in wheelchair and the wheelchair moved from behind her (breaks not set). Observation on 07/21/23 at 08:13 AM of Resident #5 was observed by surveyor to be seated up in her recliner in room with no call light, call light located across room tied to the wheelchair near the restroom. The surveyor stepped into the hallway and on 07/21/23 08:15 AM Licensed Practical Nurse (LPN) E was brought into the room. Resident #5 was observed to be standing up in front of the recliner at time of nurse entry to fix the call light situation. Resident #5 states no one talks to me, they don't do nothing or say anything to me. Call light taken from wheelchair and clipped it to the recliner by nurse E. Resident #6: Record review of Resident #6's Minimum Data Set (MDS) quarterly dated 5/26/2023 elderly female with a Brief Interview of Mental status (BIMs) score of 2 out of 15, severely cognitively impaired. Medical diagnosis of medically complex condition, coronary artery disease, hypertension, Alzheimer's disease, non-Alzheimer dementia, Parkinson's disease, traumatic brain injury, anxiety, depression, psychotic disorder, syncope and collapse, muscle weakness, dysphagia, repeat falls. Review of Section G: Functional Status noted transfer with extensive assist of two people, ambulating did not occur, dressing, eating and toileting with extensive assist of one person. Bathing of total assist of one person. Section J: falls noted 2 falls with no injuries during the assessment quarter. Record review on 07/19/23 at 02:56 PM of Resident #6's progress notes revealed falls. Surveyor requested accident incident reports for 6 months. Interview and record review on 07/20/23 at 01:54 PM with the Director of Nursing (DON) of Resident #6's fall timeline for falls. Number of falls? - 6-month review of falls, 10 falls per fall report presented by Director of Nursing. Record review of Resident #6's nine month look back revealed falls on: Fall incident reports: -On 8/22/2022 at 7:00 AM Resident #6 found sitting on floor in doorway to room facing hallway. Resident #6 was noted incontinent of urine and had fresh nosebleed and hematoma noted to left eye and top of left head. Hematoma noted to appear dark blue/purple. No witnesses noted on fall report. Later that day resident went to pacemaker appointment with family member. -On 8/22/2022 at 2:00 PM Resident #6 found lying face down on left side of bed. Assisted back to bed, pressure applied to bloody nose. Resident #6 was sent to emergency room for evaluation. Resident #6 was admitted for subarachnoid hemorrhage. -On 8/31/2022 at 12:00 PM Resident #6 found on floor in front of closet. Abrasion noted to right eye noted. No witnesses found. -On 9/7/2022 at 9:05 PM Resident #6 found on floor at bedside. Resident #6 hit head on right side of bedside table bottom. Noted blood to right side of head, right ear split in half and goose egg on top of head with hematoma, right top of hand with hematoma noted. No witnesses noted. -On 9/9/2022 at 4:45 PM Resident #6 was found on the floor in room with right scapula/shoulder injury noted. No witnesses noted. [NAME] placed at bedside. Right shoulder X-ray negative for fracture. -On 10/4/2022 at 4:30 PM Resident #6 found on floor on right side of bed. Laceration to right side of head. Resident #6 was sent to emergency room for evaluation. No witnesses noted on fall report. Floor matt placed on left side of bed. -On 12/4/2022 at 10:15 PM Resident #6 was found in doorway on bottom. Fall matt in place. Resident was not wearing gripper socks at time of the fall. Redness to bottom and back noted. No witnesses noted on fall report. Record review of undated neurological checks were incomplete. -On 12/17/2022 at 11:36 AM Resident #6 found on floor in dining room. Fall from wheelchair with breaks unlocked. No witnesses noted on fall report. Current Broda chair large. Record review of dated 12/17/2023 neurological checks were incomplete. -On 1/18/2023 at 11;15 AM Resident #6 found lying face down on floor matt on right side of bed. Fall report noted Resident #6 was laid down at 9:00 PM and found on 11:15 PM by certified Nurse assistant. -On 1/22/2023 at 4:00 PM Resident #6 was noted the Certified Nurse Assistant (CNA) informed nurse she saw Resident #6 fall as she came out of the bathroom while getting gloves to change her brief. Fall report did not list the name of the certified nursing assistant. -On 2/13/2023 at 11:30 PM Resident #6 was found on floor laying on her back on mat at bedside. Certified Nurse Assistant (CNA) was noted to be walking down hall when they heard Resident #6 yell out Help. CNA was noted to see Resident approximately two hours prior. -On 2/16/2023 at 4:00PM Resident #6 was found on dining room floor. Fall from wheelchair/Broda. Resident #6 was noted to have impulsiveness and poor safety awareness. -On 2/24/2023 at 7:15 PM Resident #6 was observed by other resident to slip to floor in front of wheelchair in the dining room. Other resident was noted to state Resident #6 stood up from the wheelchair and fell to the floor. -On 2/27/2023 at 3:37 PM nurse walked past Resident #6's room and observed Resident #6 on floor at bedside. Scrape/abrasion noted to lower back of 4cm X 1.5cm. No witnesses noted on fall report. -On 2/27/2023 at 7:00 PM Resident #6 was found on the floor at the end of the 200 hall. No witnesses noted on fall report. Record review of dated 2/27/2023 neurological checks noted incomplete neuro checks. -On 3/30/2023 at 6:40 PM resident #6 was found on floor in dining room in front of wheelchair. Abrasion noted to left trochanter. Witnesses did not see Resident #6's fall. Record review of dated neurological checks noted pupils to not be equal. -On 4/11/2023 at 8:00 PM nurse was passing bedtime medications on 200 hall, when Resident #6's call light rang. Upon entering room nurse found Resident #6 lying on the floor. No witnesses were noted on the fall report. Record review of undated neurological checks noted pupils to not be equal. -On 6/10/2023 at 11:05 PM Resident #6 was found on floor half in bed and half out of bed. Abrasion to forehead noted and dressing applied. No witnesses were noted on the fall report. Resident #37: Record review of Resident #37's electronic medical record profile noted an elderly female with cognitive impairment. Medical list diagnosis of muscle weakness, unsteady on feet, abnormality of gait and mobility, lack of coordination, diabetes, disorder of bone density, nontraumatic subdural hemorrhage, fracture of right radius, neuromuscular dysfunction, fracture of pelvis and impulsiveness. In an interview on 07/19/23 at 12:12 PM with a family member revealed that Resident #37's falls started in March 2023. Resident #37 had a fell and dislocated the pinky finger and was sent to the emergency room and went back to facility. Resident #37 fell again in April 2023, and fractured her hip, had surgery at hospital, and was sent back to the facility. In May 2023 she (Resident #37) was found in the bathroom on floor with fractured wrist and was sent back to the hospital. The hospital found hematoma to head, from the April 2023 fall. They sent her back to the facility on Hospice and they come weekly. She had a cast on her wrist for 8 weeks and it was removed 2 weeks ago. The family member was at the facility on Monday, and they put the call light on and waited a long time, then walked down to the nursing station to get help. In an interview on 07/20/23 at 09:22 AM with Resident #37 was lying in bed. Resident #37 stated that she did fall in here (at facility). I fell and I get heck from my daughter. Surveyor observed large purple hematoma to right forearm area. Resident #37 is able to move the arm. Record review of Resident #37's six month look back revealed falls with fractures on: Fall incident reports: -On 3/23/2023 at 12:03 PM Resident #37 was noted to stand up from chair and fell down while staff in room. Resident #37 was noted to hit her head on the bottom of bedside table (metal roller ball under table). Laceration to left hand, bruise to right lateral eyebrow, left pinky finger is bruised and swollen with cut on pinky finger. The left pinky finger was noted to not be in the anatomical position. In an interview on 07/21/23 at 01:04 PM with Certified Nurse Assistant (CNA) K revealed that the CNA had Resident #37 that day. CNA K stated that she was in the bathroom getting some towels to clean her up. I was cleaning her up to put on clean clothes for the day. Resident #37 stood up and lost her balance and fell . She hit her head on the metal tray table bar under the table. I pulled the emergency cord, no one came. CNA K ran to the nurse's station and told the nurse. The nurse did come to the room with me. When we got to the room Resident #37 was sitting up on the side of the bed. Resident #37's pinky finger was broken, sticking out to side, not natural. Resident #37 just sat there, and we sent her to the emergency room , for the pinky finger. She came back that day. -On 4/23/2023 at 11:01 AM Resident #37 was found on floor in bathroom with skin tear to right elbow of 2.3cm, area cleansed and steri strips applied. Resident #37 was noted to guard right lateral lower extremity. -Record review of Resident #37's hospital surgical documentation dated 4/25/2023 noted right intertrochanter fracture after a fall. -On 5/5/2023 at 7:00 PM Resident #37 was found on the floor in front of closet in room. Hematoma noted to right side of forehead, skin tear to right elbow measuring 2.5cm, area cleansed and steri strips applied. Resident #37 was noted to be guarding right swollen wrist. Witnesses were noted to not have seen Resident #37 fall. -Record review of Resident #37's hospital discharge documentation dated 5/8/2023 revealed principal diagnosis for discharge: (1.) Traumatic subdural hematoma. (2.) Distal radial fracture (wrist). (3.) Elevated troponin. (4.) Diabetes mellitus. (5.) Coronary artery disease. (6.) Hypertension. (7.) Hypothyroidism. (8.) Hyperlipidemia. (9.) Dementia. (10.) Cerebral hyponatremia. (11.) Frequent falls. In an interview and record review on 07/20/23 at 01:32 PM with Director of Nursing (DON) typed up a timeline of Resident #37's falls, dislocated pinky finger from fall on 3/23/23, then on 4/23/2023 at 11:01AM fall with fractured hip in bathroom, sent to hospital had repair, came back. The next fall was on 5/5/2023 in the bathroom, fractured wrist on 5/07/20/23 01:41 PM from fall. She did have a subdural hematoma (brain bleed also). In an observation and interview on 07/21/23 at 11:07 AM of Resident #37 with the Assistant Director of Nursing (ADON) L observed right forearm, with dark purple bruise noted. ADON L stated that she did not measure the bruised area but will. Observation of right forearm bruise measurements revealed 12.5 cm length X 16cm wide, around the arm. ADON L stated that the facility did not know what the hematoma came from. we just don't know. ADON L will investigate the bruise. She did have a wrist cast but it was removed 2-3 weeks ago. Resident #203: Record review of Resident #203's Minimum Data Set (MDS) readmission assessment dated [DATE] elderly female with a Brief Interview of Mental status (BIMs) score of 3 out of 15, severely cognitively impaired. Medical diagnosis of medically complex condition, anemia, hypertension, renal failure, non-Alzheimer dementia, depression, unsteadiness on feet, muscle weakness, abnormalities of gait and mobility, lack of coordination and difficulty walking. Review of Section G: Functional Status noted bed mobility with extensive assist of two people, transfers with total dependence with assist of two people, ambulating did not occur, dressing with extensive assist of two people and toileting with total dependence with two people assist. Record review of Resident #203's nine month look back revealed falls on: Fall incident reports: -On 9/21/2022 at 1:00 PM resident #203 was found the floor by housekeeper. No witnesses were noted on fall report. Care plan updated to lay resident down after meals. -On 11/16/2022 at 9:30 AM Resident #203 was found on the floor in hallway by her room. Resident #203 was last seen (no time given) up in wheelchair in hallway. Care plan update to assist resident as needed. -On 12/6/2022 at 8:30 PM Resident #203 was heard yelling Help. Resident #203 was found on floor outside of bathroom. Resident #203 was noted to be seen approximately one-hour prior self-propelling in wheelchair in hallway. No new orders for care plan noted on fall report. -On 12/26/2022 at 2;15 PM Resident #203 was found on floor at bedside. Red area of 1cm noted to mid-back area. No witnesses noted on fall report. Care plan update to encourage resident to lay down after lunch. -On 1/22/2023 at 9:10 PM Resident #203 was found on floor in front of her doorway. No witnesses were noted on the fall report. Care plan to keep wheelchair on left side of bed. -On 2/14/2023 at 7:30 PM Resident #203 was found on floor in room [ROOM NUMBER] other resident's room. Resident was heard yelling Help me. No care plan updates found. -On 2/21/2023 at 8:30 AM Resident #203 was found sitting upright on buttocks on left side of bed with wheelchair behind resident to the left of her. Witness statements noted staff did not see what had occurred. No care plan update found. -On 3/15/2023 at 7:10 PM Resident #203 found on floor laying on her right side by room [ROOM NUMBER]. Injury of skin tear to right elbow, area cleansed and steri strips applied. Witness statement noted another resident came to nursing station notified staff that Resident #203 was on the floor by her room. No care plan update found on fall report. Hospital consultation note dated 4/9/2023 revealed (Resident #203) suffered a sub capital fracture around March 19th, 2023, and had (hip surgery) for bipolar hemiarthroplasty inserted. Resident #203 was admitted on [DATE] through the emergency room with infection plus fracture of the greater trochanter of her right hip. Plan to culture wound, begin antibiotic treatment, surgery for debridement to get rid of the infection plus antibiotic spacer. 38471 Resident #155: On 7/2023 at approximately 3:00 PM, a review was completed of Resident #155 medical records, and it revealed the resident admitted to the facility on [DATE] after a knee replacement. She also has diagnoses of Hyperlipidemia, Carpal Tunnel, Abnormalities of Gait and Mobility and Muscle Weakness. Further review of Resident #155's records revealed the following: Progress Notes: 4/20/2023 at 18:30: Guest arrived to room [ROOM NUMBER]-2 at 1830 via private auto. Guest admitted to hospital and underwent a Total R (right) knee replacement .Guest is extensive assist for transfers, WBAT (weight baring as tolerated) to RLE (right lower extremity). Meriplex dressing in place and per orders from hospital dressing to stay in place post-op 72 hours .Underneath dressing are staples that are to stay in place and will be removed at follow up appointment . 4/21/2023 02:30: Guest observed sitting on her buttocks on the bathroom floor with her back to the door. She was positioned next to the toilet (between sink and toilet). Blood and guest's tooth noted on the bathroom floor next to her. Right leg was twisted a little next to the leg of the high rise seat of the toilet. Guest self transferred to toile, when finished she stood up and when standing her foot got caught on high rise where she lost balance and fell face forward . 4/21/2023 10:24: IDT (Interdisciplinary Team) met to review fall. Guest had unwitnessed fall. Guest was observed on the bathroom floor. Guest was noted to have taken her self to the bathroom she was observed on the floor with her knee twisted and blood on the floor with her toot (tooth) out. Tooth was placed in a glass of milk. Guest was assessed and DR call with order to send her out to the hospital for assessment . At time of fall CNA was in the room assisting bed 2 asked had asked for help CNA stated she would be able to help her in just a few minutes as she finished care on bed 2 . Guest choose to not wait and took self to bathroom. Guest was able to describe how fall happened and how she took her self to the bathroom . 4/22/2023 11:20: .Resident c/o pain and swelling to right hand. Resident had a fall recently and she states her hand was not x-rayed. She reports pain and difficulty closing her right hand. Nurse has paged on-call provider and is waiting a call back. Will request a STAT x-ray. Resident also damaged her lips during aforementioned fall and her lips are scraped, bruised, and scabbing . 4/24/2023 07:33: Immobilizer in place ( right knee) . emergency room Records: .patient is [AGE] year old female who is post-op day 1 from right knee replacement who presents to the emergency department via EMS after fall. Per patient was attempted to use a commode which was too high for her and in doing so urinated on the floor. She ultimately slipped on this and fell striking her head on the ground as well as hurting her knee which was operated on yesterday. She did lose the front right incisor which was an implant .place the patient in knee immobilizer .follow up with oral surgeon for management of her tooth fracture . Incident & Accident Report: 4/21/2023 at 2:30 AM: Guest observed sitting on her buttocks on the bathroom floor with her back to the door. She was positioned next to the toilet (between sink and toilet). Blood and guest's tooth noted on the bathroom floor next to her. Right leg was twisted a little next to the legs of the high rise seat of the toilet. Assigned CNA (Certified Nursing Assistant) was in room helping 307-2. Guest states that she was unable to wait for assigned CNA to help so she got up and self-transferred to bathroom. Guest finished using bathroom, she stood up and when standing her food must have gotten caught on high rise where she lost balance and fell face forward .No injuries observed post incident .CNA yelled down 300 hall, writer and other nurse ran down the hall to 307. Upon entering resident noted sitting on the floor in the bathroom on her buttocks facing toward the toilet. Residents' mouth was bleeding, resident states I knocked my tooth out. Cold cloth given to resident to hold to mouth to stop the bleeding .Writer noted residents right knee and calf were not in alignment with body Resident states, I can't feel pain from my leg, just my face .Right leg (knee) appeared to be twisted . I just took he roommate 307-2 to the bathroom. The curtain was closed. As I was taking care of 307-2 back to the bed and helping 307-1 said I have to pee. I then said, Hold on one minute I am almost done and I will be over to help you. I then heard her say, I can't wait I gotta pee. I then said , I am almost done and I will be right here. I finished up with 307-2 and I heard a yell from the bathroom. I went and seen that she was on the floor. I went and got the nurses. It can be noted the sequence of events differ provided in facility documents differ from hospital documentation. Due to staff inaction Resident #155 fell in the bathroom, reinjured her knee that was replaced 1 day ago and dislodged her tooth. Resident #155's fall was avoidable. On 7/21/ 2023 at 9:17 AM, Human Resource file of Nurse J was reviewed in the presence of Human Resource Director V. There was a 1:1 coaching dated for 5/19/2023, both this writer and Human Director V were under the impression the disciplinary action was not related to Resident #155's fall on 4/21/2023 given it was a month later. The 1:1 Coaching stated, One to one coaching was held with the above listed employee covering the following topics: 1. Check list not completed for falls. 2. Note not in chart completed late after verbal cueing to complete. 3. Reported by guest she requested assistance to bathroom assistance was not offered and reciprocated. Went to break guest fell . You must attend to guest needs prior to break. There is a handwritten response from Nurse J on the form that stated, Guest never ask for me to help her go to bathroom guest had already taken herself and was getting back in bed. During the investigation attempts were made to contact CNA Y that was in the room during Resident #155's fall to no avail. CNA Y was no longer employed at the facility and the number they had for her was disconnected. On 7/21/23 at 03:21 PM, an interview was conducted with the DON (Director of Nursing) regarding Resident #155's fall on 4/21/2023. The DON explained a full investigation was completed of the fall and Nurse J was disciplined as she failed to complete the appropriate assessments and documentation after the falls. Additionally, Resident #155 asked Nurse J for assistance going to the bathroom (prior to CNA Y entering the room to assist 307-2) and instead of attending to the resident's need Nurse J went to the break and then the resident fell . The DON stated Resident #155 was cognitively intact and described Nurse J to them in detail. The DON was queried if CNA Y was interviewed, and the DON stated she was, but they are still looking for the full investigation. The DON was asked exactly what care CNA Y was providing to 307-2 and the DON did not have a response. It was explained this is an important detail because dependent on what type of care CNA Y was doing was it plausible and/or safe to stop and assist Resident #155 given she just admitted after a knee replacement. It also leaves to question if CNA Y knew Resident #155 required toileting/walking assistance why did she not enable the call light? Resident #155 was able to get up from her bed, walk to the bathroom, use the restroom, stood up and then fell and all on a knee that was replaced days ago. It can be noted there was more the CNA could have done to assist timelier or request assistance for Resident #155, rather than continuing care on 307-2 with no attempt at intervention. The DON was queried why Nurse J was disciplined for her inaction almost a month later and DON reported there was delay in completion of the investigation as she was off work and it took some time to investigate all staff involved. The DON acknowledged the concern with the incomplete and timely fall investigation, thorough root cause analysis of staff failures and appropriate trainings to prevent another like incident. On 07/21/23 at 04:05 PM, the Administrator shared there was a grievance completed as Resident #155's family requested the facility pay for the tooth that was dislodged during the fall. The Administrator stated it was found Nurse J observed Resident #155 get out the bed and walk toward the bathroom but did not intervene. Nurse J asserted Resident #155 was walking fine and did not ask for any assistance. At the conclusion of the survey the investigation into Resident #155's fall was not located by facility management. 39059

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to prevent development of pressure ulcers (wound caused by pressure) for two residents(Resident #2 and Resident #44) of three residents reviewed, resulting in a lack of implementation and monitoring of interventions to prevent pressure ulcer development. Resident #2 developed a Deep Tissue Injury (DTI- unstageable pressure injury with unknown depth) pressure ulcer and Resident #44 developed an unstageable and Stage II pressure ulcers, unnecessary pain, and the likelihood for infection and decline in overall health status. Findings include: Resident #2: On 4/11/22 at 10:53 AM, Resident #2 was not present in their room. An alternating air mattress controller was noted sitting on the floor at the end of the Resident's bed. On 4/12/22 at 8:47 AM, Resident #2 was observed in their room. The Resident was in bed, positioned on their back with their heels directly on the mattress. A wound dressing was present on the Resident's left foot. The alternating air mattress controller remained in the same place on the floor. A light was noted on the alternating air mattress control and observation revealed the light indicated alarm. An interview was completed with the Resident at this time. When queried regarding the dressing on their foot, Resident #2 stated, My foot opened up again. When queried if their foot hurt, Resident #2 revealed they were and stated their pain was at an 8 out of 10 (10 being the worst possible pain). When asked if they were receiving pain medications and/or treatments to help with the pain Resident #2 replied, Yes, but it doesn't help. With further inquiry Resident #2 elaborated, I've been wanting them to give me a stronger pill, but they don't. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited to extensive assistance to perform Activities of Daily Living (ADLs) with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers at the time of the assessment. Review of documentation in Resident #2's Electronic Medical Record (EMR) revealed the following: - 1/17/22 at 2:24 PM: Skin Event . New Skin Condition . Left Dorsal Blister is open with Yellow Purulent Drainage . Called ortho who referred writer to Infectious disease . - 1/19/22 at 3:25 PM: Skin/Wound Note . Assessed wound to the left anterior ankle, proximal to the dorsal aspect of the left foot. There is a moderate amount of serosanguineous exudate . Spoke with guest regarding getting a foot cradle in place to prevent blankets from rubbing against the feet . states would like to try it. - 3/11/22 at 2:32 PM: Skin/Wound Note . Guest returned from f/u (follow up) appointment with surgeon. Surgeon states that wound is healing, and that tissue is healthy . - 4/5/22 at 1:01 PM: Skin/Wound Note . Patient was seen today for wound care. Wound is resolved x 2 weeks. Will continue to monitor for skin breakdown. An interview was completed with Wound Care Licensed Practical Nurse (LPN) E on 4/12/22 at 3:00 PM. When queried regarding Resident #2's left foot and complaints of pain, Wound Care LPN E indicated the area had healed. A wound care observation was requested at this time. On 4/12/22 at 3:24 PM an observation of wound care for Resident #2's left foot was completed with Wound Care LPN E. Upon entering the room, Resident #2 was observed in bed, positioned on their back with their feet directly on the mattress. A blanket cradle was not in place on the mattress. The Resident's left dorsal, anterior ankle was noted to be bright red. A raised area, approximately the size of a quarter, was present in the center of the red area. The area had a blister type appearance and was approximately two centimeters (cm) in height. A small amount of drainage was noted from an opening in the raised area. When Wound Care LPN E washed the wound, Resident #2 cried out in pain. Wound Care LPN E reapplied a dressing and indicated they would contact the Resident's physician. An interview was completed with Wound Care LPN E on 4/12/22 at 3:24 PM. When queried what the wound on Resident #2's left foot was classified as, Wound Care LPN E indicated the Resident was going to go to the wound clinic. On 4/13/22 at 8:35 AM, an interview was completed with Wound Care LPN E. When queried regarding Resident #2's left foot wound, Wound Care LPN E revealed they had called the surgeon who performed surgery on the Resident's ankle following and accident because (Resident #2's) ankle doesn't bend. Wound Care LPN E was asked what the etiology of the wound was and stated, I think it is from their shoes. Wound Care LPN E revealed the Resident's shoes are too big to accommodate for being unable to normally bend their ankle. With further inquiry regarding the wound, Wound Care LPN E stated, It's a blister from the friction of their shoes. When asked what they would classify the blister, Wound Care LPN E stated, Well in wound terms, it would be an unstageable (pressure ulcer). Wound Care LPN E was then asked if the pressure ulcer was facility acquired and replied, Yes, because it (prior wound) was healed for over two weeks. Wound Care LPN E was then asked what meaningful interventions were in place to prevent pressure ulcer development, due to the Resident's identified and assessed risks, and acknowledged there was a lack of meaningful interventions in place to prevent pressure ulcer development. Resident #44: On 4/11/22 at 9:52 AM, Resident #44 was observed in their room in bed. The Resident was in bed, positioned on their back, with their eyes closed and their heels directly against the mattress. A lower extremity positioning pillow was noted on the windowsill in the room. Record review revealed Resident #44 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive assistance to perform all ADLs with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers. On 4/11/22 at 2:20 PM, Resident #44 was observed in their room in bed. The Resident was in bed, positioned on their back, with their eyes closed and their heels directly against the mattress. A lower extremity positioning pillow was noted on the windowsill in the room. An interview was completed at this time. When queried regarding the pillow on the windowsill, the Resident indicated staff do not place it under their legs and they are unable to do it themselves. When queried if they had any wounds on their skin, Resident #44 revealed they fell , broke their hip, and had to have surgery. The Resident also indicated they had a sore on their heel. Review of documentation in Resident #44's EMR revealed the following: - 3/15/22 at 9:45 PM: Admission Assessment . Section C. Skin Integrity . Right trochanter (hip) . surgical incision . Note: Per Admission Assessment documentation, Resident #44 did not have any pressure ulcers. - 3/24/22 at 12:06 PM: Skin/Wound Note . Therapist states that guest c/o (complain of) right heel pain. Assessed heel and noted a 2.5 cm (centimeter) x 3.0 cm DTI (Deep Tissue Injury). Area is deep maroon and intact. Tissue is mushy and guest has s/s (signs/symptoms) of discomfort when the area is palpated. Surrounding tissue is pink . Implemented bilateral heel protectors . - 3/29/22 at 3:31 PM: Pressure Injury Assessment . Right Heel . Pressure . Length 2.7 (cm) . Width 2.5 cm . Stage: Suspected Deep Tissue Injury . Most Recent Pain Level: 4 (3/29/22 at 12:47 PM) . - 4/5/22 at 11:17 AM: Wound Assessment . Present on Admission: No . Facility Acquired: Yes . Date: 3/29 . Right Heel . DTI . Length: 4.3 (cm) . Width: 2.5 (cm) . Exudate/Drainage: None . Exudate/Drainage: Serous . - 4/5/22 at 1:20 PM: Skin/Wound Note . assessed by wound care. Surgical incision is resolved. Skin is intact and doing well. Patient right heel has bogginess and suspected DTI measures 2.9 x 4.3. Area is still closed and has begun to [NAME] . - 4/6/22 at 12:13 PM: Skin/Wound Note . Assessment of buttocks/skin during routine brief change. Guest noted to have open area to left inner buttock measuring 0.25 cm x 0.25 cm . Additionally right inner buttock open area suspected stage 2 (shallow open ulcer with tissue loss) partial thickness skin loss and exposed wound bed/dermis (pink) measuring 2.5 cm x 1 cm . Review of facility provided CMS-802 Resident Matrix form indicated Resident #44 did not have any pressure ulcers. Review of Resident #44's care plans revealed a care plan entitled, Alteration in skin integrity - Resident has Pressure Injury. Site: Right Heel Factors that may inhibit wound healing: Immobility (Created and Initiated: 3/24/22). The care plan included the interventions: - Patient will use elevated heel cushion (Created and Initiated: 3/29/22) - Off Load Heels (Created and Initiated: 3/24/22) - Reposition/Shift weight at frequent intervals to resident's comfort (Created and Initiated: 3/24/22) - Treat as ordered by MD (Created and Initiated: 3/24/22) A wound care observation was completed with Wound Care LPN D on 4/12/22 at 3:34 PM. Upon entering Resident #44's room, the Resident was observed in their bed with the lower extremity positioning pillow on the windowsill. Resident #44's right heel was noted to have a dark colored, necrotic appearing cap over the heel. Wound Care LPN D measured the dark colored pressure area and stated, It's 3.5 (cm) by 2.6 (cm). After measurements were obtained, Resident #44 asked Wound Care LPN D what the pressure ulcer on their heel was from. Wound Care LPN D replied, Its from having your heels directly on the mattress. Following care, Wound Care LPN D elevated the Resident's heels off the bed. An interview was completed with Wound Care LPN D after exiting the Resident's room. When queried regarding the pressure ulcer, Wound Care LPN D revealed the pressure ulcer was first identified about 3/29/22 as a suspected DTI and stated they implemented the pillow for positioning then. With further inquiry, Wound Care LPN D detailed the wound was an unstageable pressure ulcer. When queried regarding observations of the Resident's heels being directly on the mattress, Wound Care LPN D revealed the Resident's heels should be elevated when in bed. When queried regarding the facility acquired stage II pressure identified on 4/6/22, Wound Care LPN D revealed a Duoderm (wound dressing which stays in place for three days) was in place. When queried regarding the Residents risk for pressure ulcer development and interventions in place for prevention, Wound Care LPN D indicated they were going to review and update the care plan interventions. On 4/13/22 at 8:55 AM, Wound Care LPN D was observed talking to two Certified Nursing Assistants (CNAs) in the hallway outside of Resident #44's room. Wound Care LPN D stated to the CNAs, I'm getting a specialty mattress (for Resident #44). Wound Care LPN D revealed the reason they were implementing the mattress was because (staff) did not utilize the (lower extremity elevation) pillow. An interview was completed with the Director of Nursing (DON) on 4/13/22 at 11:05 AM. When queried regarding Resident #2's pressure ulcer development in the facility including lack of interventions related to their limited ankle mobility, the DON revealed they were made aware of the pressure ulcer but did not provide further explanation. When queried regarding Resident #44 developing a stage II pressure ulcer on their buttocks and an unstageable right heel pressure ulcer including lack of implementation of interventions, the DON acknowledged the concern but was unable to provide further explanation. Review of facility provided policy/procedure entitled, Wound Evaluation and Documentation (Reviewed: 1/22) revealed, To report and gather data for the purpose of planning and implementing wound care treatment procedures . Wounds will be evaluated, a photo taken, and the following areas documented every 7 days . 11. Wounds will be measured every 7 days. If a wound shows no signs of healing after 2 weeks, a reevaluation of the wound will be done. Reevaluation of the treatment plan, including determining whether to continue or modify the current interventions, is also indicated. If the decision is made to retain the current regimen, documentation of the rationale for continuing the current plan should appear .

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure identification, investigation, and analysis of the cause of injuries and falls and failed to implement meaningful interventions to prevent injury and falls for three residents (Resident #3, Resident #23, and Resident #35) of six residents reviewed for accidents. This deficient practice resulted in lack of investigation and documentation of an injury with bruising for Resident #35. Resident #3 suffering a right [CONDITION(S)], and Resident #33 suffering a lumbar spinal fracture. Findings include: Resident #3: An interview was completed with Resident #3 on 4/12/22 at 9:36 AM in their room. When queried regarding the reason for their admission, Resident #3 revealed they fell at home, had to have surgery, and then came to the facility for therapy. When queried if they had any falls at the facility, Resident #3 indicated they had fell and broke their hip again while at the facility. When queried regarding pain, Resident #3 revealed the pain was severe following the fall at the facility but was decreasing as the fracture healed. Record review Resident #3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included [CONDITION(S)] ([CONDITION(S)]) with oxygen dependence, anxiety, falls, and intertrochanteric right femur fracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to limited assistance to perform all Activities of Daily Living (ADLs) with the exception of eating. Review of Resident #3's care plans revealed a care plan entitled, I have pain in my R (right) Hip because R femur FX (fracture) (Created: 10/19/21; Initiated and Revised: 12/27/21). The care plan included the interventions: - Give me (state med) 30 minutes before I have therapy (Created: 10/19/21; Initiated and Revised: 12/27/21) - Identify and record my pain level and my response to pain medication (Created: 10/19/21; Initiated and Revised: 12/27/21) - Monitor me for the side effects of pain medication, especially constipation, new onset or increased agitation, restlessness, confusion hallucinations, dizziness . and falls and make sure that my doctor knows if I am having these . (Created: 10/19/21; Initiated and Revised: 12/27/21) - Movement makes my pain worse (Created: 10/19/21; Initiated and Revised: 12/27/21) Another care plan titled, My Fall risk assessment scores me at Moderate risk for falls r/t (related to) Deconditioning, Gait/balance problems, ineffective gas exchange/confusion, history of falls with fracture (Created: 10/19/21; Initiated: 12/27/21; Revised: 12/28/21) was present in Resident #3's medical record. The care plan included the interventions: - Be sure call light is within easy reach (Created: 10/19/21; Initiated and Revised: 12/27/21) - Autobrakes to wheelchair (Created: 10/19/21; Initiated and Revised: 12/27/21) - Ensure that guest is wearing appropriate footwear (shoes, bedroom slippers, nonskid socks) when ambulating or up in the wheelchair (Created: 10/19/21; Initiated and Revised: 12/27/21) - Frequent safety checks (Created: 11/8/21; Initiated and Revised: 12/27/21) - Keep water glass & frequently used objects within reach (Created and Initiated: 12/28/21) - Non-Slip grip to wheelchair and recliner (Created: 11/8/21; Initiated and Revised: 12/27/21) - STAT CMP (Complete Metabolic Panel - blood laboratory test) ordered 11/8/21 (Created: 11/8/21; Initiated and Revised: 12/27/21) Transfer guest with the use of gait belt and follow the transfer status recommended by therapy (2 Person Extensive Assist) (Created: 10/19/21; Initiated and Revised: 12/27/21) - U/A (Urinalysis) with C&S (Culture and Sensitivity) ordered 2/27/22 (Created and Initiated: 2/28/22) Review of Resident #3's documentation in the Electronic Medical Record (EMR) revealed the following: - 11/8/21 at 1:09 AM: SBAR . Reason for Report: Fall . - 11/8/21 at 1:33 AM: Health Status Note . Guest was observed on knees in front of recliner . Red mark to left knee noted. Guest stated was trying to go to the bathroom. Guest yelling 'open the garage' . Guest last seen at 0000 (midnight), sleeping in recliner . - 11/9/21 at 1:37 PM: Health Status/Progress Note Late Entry . F/U on fall in room that occurred on 11/8/21 . Guest continues on frequent safety checks . - 12/16/21 at 1:45 AM: SBAR . Reason for Report: Fall pain in right hip. New Orders: (Blank) . - 12/16/21 at 5:34 AM: Health Status Note . Guest was sent to (Hospital) due to a recent fall at 2:15 AM 12/16/21 - 12/23/21 at 5:40 PM: Health Status Note . Guest arrived via ambulance . Guest discharge DX (Diagnosis): right hip hairline fx (fracture) that is inoperable . Guest states pain with movement to right hip . - 12/28/21 at 2:29 PM: Health Status/Progress Note . F/U (follow up) on fall in room that occurred on 12/16/21 @ 0145. IDT reviewed. Care plan updated for water glass & frequently used objects to be kept in reach. Guest was treated at (Hospital) for non-displaced subtrochanteric fracture of right femur & acute on chronic [CONDITION(S)] with [CONDITION(S)] (decreased blood oxygen level) & hypercapnia (increased carbon [MEDICATION(S)] level in blood) following fall. CO2 (carbon [MEDICATION(S)]) levels were noted to be high on 12/16/21 hospital labs. Guest returned to facility on 12/23/21 for further rehab. - 12/29/21 at 10:20 AM: Nurse Practitioner Narrative/Physician Assistant Note . Seen and evaluated this afternoon . Debility following hospitalization for exacerbation of [CONDITION(S)]/fall with right femur fracture . admitted . from acute care after treatment for recurrence of [CONDITION(S)] with [CONDITION(S)] and elevated CO2 with change in mental status and fall with right femur fracture . states the pain is pretty bad and is wondering about [MEDICATION(S)] (anti-anxiety medication) and [MEDICATION(S)] (narcotic pain medication) for anxiety and pain . - 2/1/22 at 10:30 AM: IDT/Bedside Conference Note . no depression, guest without any behaviors . Guest with a fall at 12/16/21 at 0145, guest was confused self-transferred out of bed and fell then crawled to the bathroom. Guest was care planned for 1 person assistance for transferring and bed mobility at the time of the fall. Sent to ER due to c/o (complaints of) right hip pain. During hospitalization noted that guests CO2 was elevated and new fracture to the right hip . Recently drawn CO2 level of 34 which is slightly elevated, but an improvement . - 2/26/22 at 5:38 PM: Health Status Note . Guest complaining of sob (shortness of breath), feeling shaky, dizzy, and weak, with increased confusion. [CONDITION(S)] +3 noted to BLE (Bilateral Lower Extremities) [MEDICATION(S)] dose adjusted two days ago by NP (Nurse Practitioner) per nursing notes and (blood laboratory tests) were ordered . Breath sounds auscultated diminished BBS (Bilateral Breath Sounds), Ronchi noted. Received second dose of Covid vaccine on 2/25/22. [MEDICATION(S)] stopped prior to vaccine administration . Order a STAT chest X-ray 2 view at this time . - 2/27/22 at 4:00 AM: SBAR .Fall. New Orders: CXR (Chest Xray) done on 2/26/22 and was negative. - 2/27/22 at 4:35 AM: Health Status Note . Guest is A&O (Alert & Orientated) x 1 (to self) at time of fall. Guest confused at this time . Lung sounds dim bilaterally . some SOB due to fall . Neuros initiated . - 2/28/22 at 2:38 PM: F/U on fall from bed that occurred on 2/27/22 @ 0400 (AM). Guest reports they were trying to go to the bathroom . observed sitting on bottom on floor on right side of bed. Confusion was noted. IDT reviewed. U/A (Urinalysis) with C&S (Culture & Sensitivity) ordered. Guest did receive Covid- 19 vaccination on 2/25/22 which may have contributed to guest's change in condition noted 2/26/22 . Will f/u with U/A & evaluate the need for further intervention. - 3/3/22 at 7:32 PM: Health Status/Progress Note . F/U on fall from bed that occurred on 2/27/22 . C&S received & [MEDICATION(S)] (antibiotic) ordered for [CONDITION(S)] (Urinary Tract Infection) . Review of facility provided Incident and Accident (I and A) reports for Resident #3 detailed the following: - 11/8/21 at 1:09 AM: Fall . (Resident Room) . Nursing Description: Guest was observed on knees in front of recliner. Resident Description . stated trying to go to the bathroom . Mental Status: Orientated to Person . No Injuries Observed Post Incident . Predisposing Physiological Factors . Noncompliant with Safety Guidance . Attempt to Perform ADL . Predisposing Situational Factors . During Transfer . -11/21/21 at 3:40 PM: Fall . (Resident Room) . Nursing Description . guest was assisting by 2 CNAs (Certified Nursing Assistants) with transferring from w/c to bed . Guest reports knees gave out and was lowered to the floor . Fall was witnessed and guest did not hit head . Resident Description: Guest reports therapy got them up in w/c . approximately 3 PM . only tolerate sitting up for approximately 30 minutes before asking to get back in bed . No Injuries Noted . - 12/16/21 at 1:45 AM: Fall . (Resident Room) . Nursing Description: guest had emergency bottom on . found laying on the floor on right side, head placed on the trash can, soiled in urine, complaining of pain in right hip, would not let me touch them and was asking for ambulance to take to hospital . Resident Description: Guest states woke up confused, got out of bed without help to get a drink of water, thought they were home, then fell and crawled to the bathroom to pull the emergency button for help . Immediate Action Taken . called doctor to get permission to send to hospital . gave ibuprofen for pain . called (ambulance), and then took to the hospital . No Injuries observed at time of incident . Level of Pain: 10 (out of 10) . Injuries Report Post Incident . Fracture Verified by X-Ray . Right trochanter (hip) . Predisposing Environmental Factors . Tubing (oxygen) . Predisposing Physiological Factors . Attempt to Perform ADL . Predisposing Situational Factors . During Transfer . Ambulating without assist . Reaching for Item . - 2/27/22 at 4:00 AM: Fall . (Resident Room) . Nursing Description: guest observed sitting on bottom on the floor next to the right side of the bed. Resident Description: Resident stated they were trying to go to the bathroom . Immediate Actions . Guest A & O X 1 at time of fall . confused at this time . No Injuries observed at time of incident . Predisposing Physiological Factors . Confused . Gait Imbalance . Predisposing Physiological Factors . Noncompliant with Safety Guidance . Attempt to Perform ADL . An interview was completed with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 4/13/22 at 11:05 AM. When queried regarding the reason for Resident #3's initial admission to the facility, both the DON and ADON indicated the Resident had been admitted following a fall at home with resulting right [CONDITION(S)] necessitating surgical intervention. When asked about Resident #3's falls in the facility including injury, the DON replied, (Resident #3) fell on [DATE] with a right [CONDITION(S)]. Resident #3's medical record documentation and fall I and A Reports were reviewed with the DON and ADON at this time. When queried if Resident #3 was a fall risk, the staff indicated they were. When asked what interventions were implemented following the Resident's fall on 11/9/21 to prevent future falls, the ADON stated, STAT CMP (Complete Metabolic Panel) and labs. The ADON revealed the Resident had High CO2 levels and the NP was notified. When queried regarding actions taken in response to the altered labs, the ADON replied, No new orders. The ADON was asked if the Resident sustained any injuries following the fall and replied, Red mark on knee. When queried why there was no follow up documentation related to the skin alteration, an explanation was not provided. Review of the care plan revealed the intervention, Frequent Safety Checks was created on 11/8/21. When asked what frequent checks meant the DON stated, It's a standard of care to reposition every two hours. When queried regarding the meaningfulness of the intervention due to documentation indicating staff observed the Resident less than two hours before the fall, an explanation was not provided. When queried if the facility completed an investigation following the fall with fracture on 12/16/21, the DON revealed they were unable to locate a file and would ask the Administrator. When asked what interventions were implemented following the fall, the ADON revealed an intervention to keep water and frequently used items within the Resident's reach was implemented. When queried why personal items and water being in reach were not in place as a standard of care, a response was not provided. When queried regarding interventions implemented following the fall on 2/27/22, the DON revealed the Resident was diagnosed with a Urinary Tract Infection ([CONDITION(S)]) following the fall and antibiotic treatment was initiated. EMR documentation indicating Resident #3 had a change in condition with increased confusion on 2/26/22 was reviewed with the ADON and DON at this time. When queried if Resident #3 was experiencing any other signs/symptoms of a [CONDITION(S)] including the color, clarity, and odor of their urine, the ADON indicated they did not know as urine characteristics are not typically documented by staff. When queried why a UA with C & S was ordered on 2/27/22, the ADON revealed it was related to confusion. No further explanation was provided. When queried regarding the lack of meaningful interventions to prevent falls, the ADON did not provide an explanation. Review of Resident #3's hospital documentation detailed the following: -12/16/21 at 10:30 AM: History and Physical . Right hip pain post fall and surgery two months ago . presented to emergency department with right hip pain after sustaining a fall at (facility) . Apparently was attempting to use the restroom when fell on to right hip and was unable to weight- bear. X-Rays in emergency department revealed . long intramedullary femoral rod in place from previous intertrochanteric proximal femur fracture suffered in October 2021 . new x-rays in emergency department also revealed an acute (new) nondisplaced subtrochanteric fracture right proximal femur . Musculoskeletal: Right lower extremity: Previous surgical incisions right thigh and distal femur are well-healed . An interview was completed with the facility Administrator and DON on 4/13/22 at 12:13 PM. When queried if the facility completed an investigation related to Resident #3's fall with fracture, the Administrator stated, (ADON) didn't put the file together. With further inquiry regarding facility policy/procedure pertaining to investigation of injuries and fractures in the facility, the Administrator indicated an investigation should be completed. The Administrator then stated, There is an email containing actions taken by the facility as part of the investigation and indicated they would forward the email documentation to this Surveyor. Review of facility provided staffing documentation for 12/16/21 revealed one nurse and one CNA were working when Resident #3 fell . An interview and review of provided staffing information was reviewed with the DON on 4/13/22 at 2:47 PM. The DON reviewed the staffing documentation and confirmed there was only one nurse and one CNA on the schedule. On 4/14/22 at 12:21 PM, the Administrator emailed the following documentation, as a Word document attachment to the email: Background Information: (Resident #3) was admitted . on 10/18/2021 for rehabilitation therapy after a brief stay at (Hospital) . after a traumatic trip and fall the resulted in a Closed nondisplaced intertrochanteric fracture of the right femur requiring surgical intervention of IM (Intermuscular) nailing . Guest BIMS (Brief Interview Mental Status) is a 15 and has been since admission. Guest still resides in the building . Description of Incident: Guest was transported toER on [DATE] at 0215 (AM) after a fall in room. At the hospital x rays showed suspicion for a nondisplaced subtrochanteric fracture of the right proximal femur that was stable and did not require further intervention. Hospital referred to it as a hairline fracture. Investigation: Guest had a fall that occurred on 12/16/2021 at 0145 (AM). At the time of the fall guest had bathroom emergency light on and was witnessed laying on the bathroom floor on right side with head placed on the trash can, complaining of right hip pain and was requesting to go to the hospital. Guest stated at the time of the fall that they woke up confused, got out of bed without help to get a drink of water, fell and crawled to the bathroom to pull the emergency cord for help. Guest also stated that when they got out of bed . thought (they were) home so was going to kitchen for water. Guest did have 2 previous falls on 11/8/2021 and 11/21/2021. On 11/8/21 guest slid out of recliner and on 11/21 guest had to be lowered to the floor during a transfer due to the guest's knee giving out during transfer. Both previous falls were reviewed and POC (Plan of Care) was updated appropriately. Review of medical records shows CT (Computed Tomography- diagnostic imaging) done on 10/13/21 showed guest has advanced [CONDITION(S)] in bilateral hips more prevalent in the right hip. Conclusion: Guests advanced [CONDITION(S)] coupled with recent IM nailing procedure leads facility to believe guests fracture was pathological and lead to fall. Even if fall caused fracture, the plan of care was being followed and had been updated appropriately when needed. This is determined to not be reportable. Review of the Properties section of the Microsoft Word document revealed the document was created on 4/14/22 at 12:08 PM by the DON. The email documentation provided did not include any witness statements and/or reenactment information related to the fall with fracture. On 4/14/22 at 1:25 PM, the Administrator was queried regarding the document properties indicating the Word document was created today and when the investigation was completed. The Administrator indicated the information was put into a summary format today and stated, We did all the work, (the ADON) just didn't summarize and put everything in a file as expected. No further explanation was provided. Resident #35: On 4/11/22 at 12:15 PM, Resident #35 was observed in bed, she stated she is discharging home later this week. While speaking with Resident #35, a burgundy circular shaped bruise was noticed on her right hand. The bruise was in the webspace between her thumb and index finger. Resident #35 stated while staff were putting on her shirt some days ago, they grabbed her hand hardly as they were pulling her shift through the sleeve. The resident reported it is no longer painful but when it occurred it was but she never alerted staff to the incident. Resident #35 was unable to recall which staff were in her room at the time the incident occurred but stated it was an accident . On 4/11/22 at approximately 1:00 PM, a review was completed of Resident #35's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder, [CONDITION(S)], Anxiety, [CONDITION(S)] and Hepatomegaly. Resident #35 required 1-2 person assist for all her cares and was assessed as having upper extremity impairment on one side. A 30-day review was completed of Resident #35's skin assessments with the last one being dated 4/9/22. Resident #35's skin was assessed as being intact, most of the month. On the two days it was checked at not being intact the documentation showed the areas of concern were her coccyx. On 4/11/22 at 2:30 PM, MDS Nurse A was queried if she was aware of the bruise on Resident #35's hand and the nurse reported she was not. Nurse A went to assess Resident #35's bruise in the presence of this writer. Resident #35 informed Nurse A staff were holding her hand and trying to pull her arm through her sleeve. The resident stated the bruise was not causing her any pain as the incident occurred three days ago. Resident #35 stated she did not alert anyone to the incident. Nurse A reported the bruise was burgundy in color and circular in nature with some yellowing around the perimeter of the bruise. This writer and Nurse A reviewed the medical records for Resident #35 and were unable to find any documentation related to the bruise. The last skin assessments last completed on the resident were on 4/4/22 and 4/7/22 and there were no new areas of concern documented. On 4/12/22 at 10:44 AM, the ADON (Assistant Director of Nursing) completed a progress note that stated the following, F/U (follow up) on bruise to top of right hand between thumb & index finger noted on 4/11/22 . Guest reports obtaining bruise during dressing when her hand was squeezed/pinched secondary to a tight fitting shirt. IDT reviewed. Care plan was updated for guest to be encouraged to wear loose fitting clothing. Guest denies pain or concerns r/t bruising & is in agreement with intervention. Will continue to monitor. It can be noted the facility was not aware of the bruise on Resident #35's hand until this writer brought it to their attention. On 4/12/22 at 12:40 PM, an interview was conducted with the ADON regarding Resident #35's bruise. The ADON reported the resident's last skin assessment was on 4/7/22 which was completed by her and she does not recall seeing the bruise. The ADON reported the resident required assistance for all cares and it was expressed there is concern that staff have been in/out the room and did not notice the highly visible bruise on her hand. The ADON stated, Maybe it was not reported to the nurse to assess further. A discussion was held with ADON regarding the staff failing to comprehensively assess the resident, no educational piece for staff, further investigation to find out which staff were assisting the resident the day of the incident and other interventions that did not solely rely on the resident wearing loose fitting clothes. The ADON acknowledged the concern of this writer but had no further information provide. Resident #23: During initial tour on 4/11/22, Resident #23 was observed watching television in his recliner. He was well dressed and reported he has fallen multiple times since his admission at the facility. Due to his disease process, he was unable to provide specifics. On 4/11/22 at approximately 10:00 AM, a review was completed of Resident #23's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] and Collapse, Dementia, Chronic Kidney Disease, Adjustment Disorder and Hypertension. Resident #23 does require some assistance with his everyday cares. Resident #23's Durable Power of Attorney has been activated and the resident is not able to make own decisions Further review was completed of Resident #23's records and it yielded the following in relation to his falls at the facility: Progress Notes: 11/23/2021 02:30: On 11/23/21 at 0230 guest was observed on bilateral buttocks on floor with back against cabinet where t.v. is. Walker was in front of guest upright near foot of bed and bedside table vertical of walker against wall. Guest states that he was trying to get glass of water where he lost his balance hit floor first onto his bottom then hit his back on the cabinet. Guest had complaints of lower back pain initially then post incident guest started having complaints of pain radiating up to neck . On call Dr. called and order to send guest out .Ambulance arrived and guest transported to ( emergency room ) at 0345 . 11/23/2021 09:05: Guest returned from ER no fractures or dislocations noted. No new orders upon return. Guest daughter at guest side. Guest sitting up in wheelchair at this time. 11/23/2021 at: 13:49: F/U on fall in room that occurred on 11/23/21 @ 0230. Guest was sent to ER for evaluation & returned at approximately 9 am. No fractures/dislocations noted upon return. No N.O.'s received . 11/26/2021 at 16:15: Daughters and son in for a visit this afternoon. Daughter conveyed that guest called her last night and stated that he fell again and complaining of medications pain in RLQ of abdomen and lower back. guest appears to be confused and speaking about his fall from 11/23. writer conveyed that no falls were reported last night. guest not guarding or grimacing on palpation. Tylenol was administered. Family discussed with writer about testing done inER on ,d+[DATE]. Writer informed that head ct, cervical ct and cxr were all negative and that is why guest was discharged back to facility. family insists that they feel the hospital might have missed something on assessment .CNA reports that guest was complaining of dizziness when assisting him into the wheelchair for his visitation. Spoke with (Physician) about guests previous fall, recent labs, hospital discharge paperwork, c/o nausea and dizziness and family concerns about pain. (Physician) suggests a Lumbar x-ray and conveys to inform family that xray services could take a few hours via mobile and that if they are requesting we could send guest to ER for in depth evaluation . 11/26/2021 20:52: Guests daughter brought back from ER. New prescription for [MEDICATION(S)] gel and [MEDICATION(S)]. Closed compression Fracture of lumbar vertebra noted . 11/27/2021 at 13:55 : Reviewed discharge paperwork. no notation of which Lumbar disk was fractured . Confirms the fracture was at L2 . 11/28/2021 at 23:30: Guest observed laying on his back on the floor, next to the bed with the back of his head laying on the bed rail. He was alert with some confusion, complaining of pain in his lower back, right side and right side of head . 12/1/2021 11:59: Note Text: F/U on fall in room that occurred on 11/28/21 @ 2330. Guest completed f/u apt with Neurosurgeon . on 11/30/21. Per daughter additional x-rays were taken but not read at apt. Daughter verbalizes she will be following up .this afternoon to review x-ray results & determine next course of action. Daughter verbalized intentions to bring copies of x-rays to facility to place in guest's medical record. 12/3/2021 18:15: On 12/03/21 guest was observed lying on floor on his right side with back against wall/closet door. Guest unable to state what happened or why he had tried to get up. Guest skin was assessed, neuros initiated, PERRLA, and able to move all 4 extremities. Guests daughter, Dr. and on call were notified of incident. Review was completed of Resident #23's fall's while at the facility. The resident fell on [DATE] which resulted in a lumbar fracture. Days after he suffered two more unwitnessed falls; he was found on his back on 11/28/21 and on his right side with his back against the wall/closet. The facility failed to complete an investigation regarding Resident #23's lumbar fracture and add meaningful interventions after each incident. The falls are as follows: 8/27/2021 at 2:30 PM: - Guest was observed laying on his right side on the floor with head laying again built-in dresser, yelling Help. Guest stated, he was trying to go to the bathroom and just went down. He had skin tear noted to right wrist, mole on forehead bleeding. Skin tear bleeding noted to right cheek, scrap noted to right knee & left thumb. 11/23/2021 at 2:30 AM: - Guest was observed on bilateral buttocks on floor with back against cabinet where t.v. is. Walker was in front of guest upright near foot of bed and bedside table vertical of walker against wall. Guest states that he was standing trying to get glass of water where he lost his balance hit floor first on to his bottom then hit his back on the cabinet. This fall resulted in Resident #23 sustaining a lumbar fracture. - New Intervention: Lack of meaningful interventions implemented 11/23/2021 at 2:00 PM: - Guest observed on knees on the right side of the bed. Guest stated, he didn't fall, he was on his knees praying to feel better. - New interventions: Lack of meaningful interventions implemented 11/28/2021 at 11:30 PM: - Resident was observed by cena on the floor laying on his back with the back of his head laying on his bed rail. Resident was confused and could not tell me what happened, he is complaining of his lower back, his right side and the right side of his head hurting . - New interventions: Low bed, mats on floor (care-planned item was resolved on 12/6/21), teach guest/family/staff to change positions slowly. These interventions were added after another fall and 5 days following the lumbar fracture. 12/3/2021 at 6:15 PM: - Guest was observed laying on floor on right side with back against wall/closet door. Guests' wheelchair was diagonally form guest facing hallways door. Guest pants were around his knees with one shoe on. Guest was unable to state why he had gotten up or what he was trying to do . - New intervention: Lack of meaningful interventions implemented It can be noted it was at the behest of Resident #23's family that he was evaluated at a different emergency room for his continued back pain, three days later. It was on this visit at the emergency room that Resident #23's lumbar fracture was discovered, and he was referred to a Neurosurgeon for further evaluation and treatment. Review was completed of emergency room records which stated, .Compression fracture deformity is noted of the inferior aspect of L2 vertebrae .Acute compression fracture of the L2 vertebrate . On 4/13/22 at 1:30 AM, an interview was conducted the Administrator regarding Resident #23's lumbar fracture. The Administrator stated they did complete an investigation that included witness statements, root cause analysis and reenactment. During the survey, the facility was unable to locate the file the previous DON was tasked with compiling. This writer did convey their concerns regarding the lack of meaningful interventions after the fall and the resident having two more falls after the lumbar fracture was discovered. The Administrator did show this writer an email that was sent to their corporate office with the investigative information. This writer was asked if the Administrator could forward that email to this writer for review and she reported she would. On 4/14/22 at 11:02 AM, the Administrator sent the following documentation related to Resident #23's lumbar fracture investigation: Background Information: Guest (Resident #23) was admitted to ( the facility) on 8/12/2021 for rehabilitation therapy .(Resident #23) comes to us with diagnoses of dementia without behavioral disturbance, history of falling, other symptoms and signs concerning food and fluid intake, [CONDITION(S)] and collapse, [CONDITION(S)] without lower urinary tract symptoms, chronic kidney disease, unspecified [CONDITION(S)], constipation, essential hypertension, [CONDITION(S)], adjustment disorder, [CONDITION(S)], cognitive communication deficit, lock of coordination, abnormalities of gait and mobility, difficulty in walking, and muscle weakness . Description of Incident: Guest was taken to (emergency room ) on 11/26/2021 at 1520 per guest and family request related to guests continued complaints of neck pain after a fall that occurred on 11/23/2021. Guest returned to facility on 11/26/2021 at 2030 with a diagnosis of compression fracture of the L2 vertebrae. Investigation: Guest had fall that occurred on 11/23/2021 at 0230. At the time of the fall guest was observed on bilateral buttocks on floor with back against cabinet where t.v. is. Walker was in front [TRUNCATED]

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure assessment, monitoring, and the timely provision of care, per professional standards of practice, for two resident (Resident #15 and Resident #200) of two residents reviewed for a change in condition, resulting in a lack of care coordination, documentation, and assessment of Resident #15's back brace and lack of monitoring and assessment of bowel movements/constipation, timely and comprehensive nursing assessment for new onset chest pain, delay in emergency medical care/treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #200: On 4/11/22 at 8:40 AM, Certified Nursing Assistant (CNA) F was observed walking down the hallway of the facility. CNA F was heard telling Registered Nurse (RN) C that (Resident #200) was complaining of chest pain. RN C continued what they were doing, told CNA F the other nurse working was assigned to that Resident. CNA F was observed locating the Assistant Director of Nursing (ADON), Resident #200's assigned nurse, and informing them that Resident #200 was complaining of chest pain. The ADON proceeded to go the nurses' station and sat down in front of a computer without going to assess the Resident. At 9:06 AM on 4/11/22, CNA F was observed in Resident #200's room. The CNA was sitting next to the Resident and obtaining a manual blood pressure measurement. An interview was completed with CNA F on 4/11/22 at 9:30 AM. CNA F was queried if they routinely obtain manual blood pressure measurements on Residents and replied, I took it manual because (Resident #200) wasn't feeling good. When asked what was wrong, CNA F revealed the Resident told them they were having chest pain and just did not feel well. CNA F was queried when the Resident told them they were having chest pain and replied, About 8:30 (AM). When asked, CNA F revealed they had informed both RN C and the ADON but were unsure of any actions taken by the staff. On 4/11/22 at 9:33 AM, Resident #200 was observed in their room. The Resident was in bed, laying on their right side in the fetal position with their knees bent. The Resident's call light was not within reach of the Resident. An interview was completed with Resident #200 at this time. When queried if they were having pain, Resident #200 replied, Yes. When asked the location of their pain, Resident #200 stated, Chest and indicated the pain was located on the left side of their chest and across to the center. Resident #200 was then asked to rate the severity of their pain on a scale of 0 to 10 with 10 being the worst possible pain and replied, 10. When speaking, Resident #200 was visibility short of breath. When asked if they felt short of breath, Resident #200 stated, Yes and indicated they were not normally short of breath. With further inquiry regarding the chest pain, Resident #200 revealed the chest pain was sharp, new, not like any pain they previously experienced, and that their chest felt heavy. Resident #200 then stated, I feel like I gotta throw up, but it won't come up. When asked if their nurse had assessed them since the pain started, Resident #200 replied, I don't know and revealed staff did not consistently introduce themselves and they were unsure of each staff members role. Resident #200 stated, I need to go somewhere where they can help me and indicated they wanted to go to the hospital. An interview was completed with the ADON on 4/11/22 at 9:40 AM. The ADON was asked about Resident #200 and stated, They are constipated. When asked, the ADON revealed Resident #200's last Bowel Movement (BM) was on 4/6/22. The ADON was then queried regarding the Resident's complaints of new onset chest pain and the correlation to constipation. The ADON stated, Called (Resident #200's family member) who said (the Resident) usually has chest pain when they get constipated and that if they have a BM, they will probably feel better. When asked if they assessed the Resident to evaluate if their current pain was similar to pain experienced previously, the ADON did not provide a response. The ADON was asked if it was normal for a Resident to not have a BM for five days, the ADON indicated it was not and reiterated Resident #200 was constipated. When queried regarding facility staff assessment and when identification occurred of Resident #200 not having a BM, the ADON replied, Yes, we started [MEDICATION(S)]. The ADON was then asked when [MEDICATION(S)] was started and replied, 4/7. When queried how initiation of [MEDICATION(S)] one day following the Resident's last BM was a treatment/intervention for not having a BM in five days now, the ADON did not provide an explanation. The ADON was then asked about Resident #200's current bowel sounds and revealed they did not listen to them. When queried regarding the Resident's complaints of shortness of breath and Resident #200's current Oxygen Saturation (SPO2) and breath sounds were the ADON replied, The CNA did (Resident #200's vital signs [SPO2]). The ADON was asked what the Resident's vitals signs were and reiterated, I didn't do their vital signs. When queried regarding auscultation (assessment via listening with a stethoscope) of the Resident's lung and heart sounds, the ADON revealed they did not know. The ADON was then asked if they assessed and/or auscultated Resident #200 following the Resident's complaint of new onset chest pain and stated, No, I just looked at them. When asked to clarify what they meant, the ADON revealed they visualized the Resident but did not complete a nursing assessment after being notified of the Resident's new onset chest pain. Following the interview, the ADON began passing medications to residents on a different hall in the facility. The ADON did not go to check on and/or assess Resident #200. On 4/11/22 at 9:54 AM, an interview was completed with the Director of Nursing (DON). When queried what actions should be taken by nursing staff when a resident complaints of chest pain, the DON stated, Immediately get vital signs and assess (the resident). The DON was then asked if nursing assessment included auscultation and replied, Yes, absolutely and notify the Doctor. When queried regarding facility policy/procedure regarding monitoring and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was the told about Resident #200's complaints of chest pain, including the ADON's statements regarding Resident #200 being constipated, and lack of assessment completed. The DON revealed the Resident should have been assessed by nursing staff but did not provide further explanation. At 10:02 AM, on 4/11/22, the DON was observed entering Resident #200's room and completing a nursing assessment with auscultation. When queried regarding assessment findings and plan of care, the DON revealed they were calling the Doctor to transfer (Resident #200 to the hospital). Record review revealed Resident #200 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to extensive assistance to complete Activities of Daily Living (ADLs) with the exception of eating. Review of Resident #200's care plans revealed a care plan entitled, I am at risk for constipation r/t (related to) chronic constipation, decreased mobility (Initiated and Created: 3/28/22). The care plan included the interventions: - Administer laxatives, stool softeners as ordered and monitor for side effects, effectiveness (Initiated and Created: 3/28/22) - Assess/record/report to MD (Medical Doctor) prn (as needed) s/sx (signs/symptoms) of constipation/ fecal impaction: abdominal pain, abdominal distention, straining at stool, hard stool, nausea/vomiting, fever, altered mental status (Initiated and Created: 3/28/22) - Notify nurse of no BM in 3 days (Initiated and Created: 3/28/22) - Record bowel movement pattern each day. Describe amount, color and consistency (Initiated and Created: 3/28/22) Review of Resident #200's progress note documentation revealed the following: - 3/26/22 at 2:31 AM: Health Status Note . Guest c/o (complain of) of pain to lower left abd (abdomen) and b/l (bilateral) feet . (Physician) paged. Guest stated (they) want to go to the emergency room (ER). While awaiting call back (from Physician) guest called 911. Other nurse talked with 911. (Physician) called back and ordered to send guest out (to ER) . - 3/26/22 at 10:26 AM: Health Status/Progress Note . Guest returned to facility around 8 am N.O. (New Order) noted for [MEDICATION(S)] muscle relaxer to start BID (twice a day) x 14 days guest complaining of pain . Review of Resident #200's BM record documentation from their 3/25/22 to 4/11/22 revealed the following: - 3/28/22: Medium BM - 4/3/22: Medium BM - 4/6/22: Small BM On 4/12/22 at 1:34 PM, an interview was completed with the DON and facility Administrator. When queried regarding Resident #200, the DON revealed the hospital found the Resident had a Urinary Tract Infection ([CONDITION(S)]). With further inquiry regarding the assessment, care, and transfer of Resident #200, the DON indicated they were initiating staff education regarding how to address changes in resident conditions. Both the DON and Administrator acknowledged there was a delay in care/treatment and inadequate nursing response and assessment to Resident #200's complaints of chest pain. Resident #15: On 4/11/22 during initial tour, Resident #15 was observed sitting in his room after been administered his shower by facility staff. On top of his clothing was a back brace that interlocked with elastic-like material and brackets in the front. The resident was unable to tell this writer why he required the brace. CNA X reported they place the back brace on the resident during the day and take it off at night but was uncertain if this was care planned for the resident. On 4/11/22 at approximately 12:30 PM, MDS Nurse A was observed at the medication cart and was asked the reasoning for Resident #15's back brace. Nurse A reported the resident had a lumbar fracture and he wears it daily. This writer and Nurse A reviewed Resident #15's medical records and were unable to locate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . We additionally, reviewed the Resident's care plan and it was not listed there either. Nurse A reported she was unsure why the proper order and care plan were not added back in for the resident in February when he readmitted . On 4/12/22 at 1:25 PM, a review was completed of Resident #15's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #15's records showed the following: Care Plan: There was no care plan related to Resident #15's back brace Physician Order: There was no physician order related to Resident #15's back brace On 4/13/22 at 12:40 PM, the DON (Director of Nursing) was alerted to the concern related to the resident's back brace. The DON acknowledged the concern presented by this writer. A policy/procedure pertaining to assessment and monitoring was requested from the facility Administrator on 4/12/22 at 11:17 AM but not received by the conclusion of the survey.

This Citation pertains to Intake Numbers MI 367 and MI 168. Based on interview and record review the facility failed to 1) ensure appropriate safety devices were used during transfer and ambulation for one resident (Resident #2) and 2) failed to offer appropriate supervision and implement appropriate interventions for one resident (Resident #303)of four residents reviewed for falls, resulting in five falls in a 30-day time period for Resident #303 and a fall causing a fracture and increased pain for Resident #2. Findings include: Resident #2: During an interview on 10/19/2020 at 1:58 PM, Occupational Therapist (OT) A reviewed and discussed Resident #2's therapy notes and care plan with the surveyor. OT A reported Resident #2 fluctuated between contact guard and minimum assist. When asked if Resident #2 should have had a gait belt in use, during the 7/15/2020 fall, OT A reported in therapy a gait belt is used for everyone unless they are independent and, on the unit in the facility, a gait belt would be used if they were a minimum assist. OT A reported a gait belt would be used for a minimum assist because it (gait belt) gives you (staff member) the control. When the care plan was reviewed, OT A confirmed the extensive assist of 1 (person) as being indicated for Resident #2's transfer status. This would require a gait belt for transfer/ambulation from the bed to the toilet. Review of correspondence via email was conducted with the Nursing Home Administrator on 10/20/2020 at 9:10 AM. Documentation was requested as to whether Resident #2 refused gait belt use and stated, I could not see in her notes where they documented which days she felt she was contact guard or extensive assist. No documentation was provided that indicated Resident #2 refused gait belt use or should not have had a gait belt in use. Review of the facility's fall (occurred on 7/15/2020) investigation (Administrative Statement Investigative Analysis), dated 7/22/2020, indicated staff assisted Resident #2 to the bathroom in her room, Resident #2 lost her balance on the way, and the staff present wrapped their arms around Resident #2 to prevent Resident #2 going to the floor. Resident #2 reported left ankle pain following this event. Staff obtained an x-ray, and a fracture was found. The investigation stated, The Certified Nursing Assistant (CNA D) followed the plan of care with extensive assist of 1. When (Resident #2) stated she wasn't going to make it to the bathroom, the Certified Nursing assistant (CNA D) supported her by placing her hands/arms through (Resident #2)'s arms, circling her torso, to ensure she didn't fall to the floor .X-Ray showed recent distal (situated farthest from point of attachment) fibula (calf bone) fracture .(Resident #2) was sent to the hospital for evaluation and treatment .(Resident #2) is an extensive assist of 1 for most of her ADLs (Activities of Daily Living) including transferring with the use of her standard walker. A gait belt wasn't utilized as care planned and instead CNA D wrapped their arms around Resident #2. Resident #2 sustained a fracture. Review of Certified Nurse Aide (CNA) E 's hand written witness statement, dated 7/15/2020, stated, I entered (Resident #2's Room number) to assist with the care and as she (Resident #2) was on her way to the bathroom she stated she didn't' think she would make it .She (Resident #2) then proceeded to slump. CNA D grabbed on arm and I (CNA E) grabbed the other, we lifted her to the chair. CNA E 's typed statement, signed/dated 7/22/2020 (one week later), stated, At that time (CNA D had her arms propping her (Resident #2) while (Resident #2's hands were still on her walker. I (CNA E) got under the left side of her arm and CNA D got under the right side of her arm and we place her in the wheelchair. (Resident #2) was limp . Review of the facility's Lifting policy, revised 7/17, stated, Goal: 1. To transfer guests safely and without injury .A. Prevent Injury .Use gait belt unless guest is independent . B. Gait Belts 1. Transfer belts make moving guests MUCH safer, 2. Gait belts must be used when transferring any guest unless you are using a lift., 3. Gait belts must be worn when ambulating with a guest unless the guest is independent with ambulation, 4. The gait belt is to be placed around the guest's waist, 5. Guests should not be lifted by placing hand under their arm/shoulder. Review of Resident #2's fall risk care plan, dated 7/9/2020, stated, Transfer guest with the use of gait belt and follow the transfer status recommended by therapy .Date Initiated: 07/09/2020. Resident #2's activities of daily living (ADL) care plan, dated 7/9/2020, stated, I need help with my ADL's because I get tired easily, impaired balance, Limited Mobility with an interventions of TRANSFERS:I need extensive assistance of 1 and TOILET USE: I need extensive assistance of 1 for toilet use. Review of Resident #2's Situation Background Assessment Recommendation (SBAR) Report, dated 7/15/2020, post fall stated, The symptom/sign/change .left ankle pain frature (fracture) .This started 7/15/20 .This has gotten worse since it started .Things that make the condition worse are movement .Pertinent history fall 7/15/2020 .Location of Pain left ankle .I think that the problem may be fracture .The resident appears to be in pain .Transfer to the hospital. Review of Resident #2's progress notes, dated on 7/15/2020, stated, (Resident #2) called nurse to room and had nurse look at left ankle due to pain. Ankle is swollen and light green in color. NP (Nurse Practitioner) ordered xray and Left ankle pain frature (fracture). Review of Resident #2's Medical Diagnosis, dated 10/19/2020, included Unsteadiness on feet, muscle weakness, and history of falling. admitted was noted to be 7/9/2020 and was discharged after the fall on 7/15/2020 reflecting the resident was in her first week at the facility. Review of Resident #2's Minimum Data Set, dated dated [DATE], indicated for walking in room to be Limited Assist for self-performance and one-person max physical assist for support. Toilet use was noted to be extensive assist with max assist provided as two plus persons physical assist. Review of Resident #2's therapy documentation, dated 7/10/2020, stated, Reason for Referral: Patient exhibits new onset of decrease in strength, decrease in functional mobility, decrease in transfers and reduced balance indicating the need for OT (occupational therapy) to .facilitate dynamic standing balance, increase functional activity tolerance . Standing Balance . = Poor - (Stands with Min A (minimum assist) .Assessment Summary .patient presents with generalized weakness, impaired balance, and an increased need for assistance from others for mobility and self care. Review of Resident #2's physician's orders, dated 7/9/2020, indicated occupational and physical therapy evaluation orders. Certified Nurse Aide (CNA) D was contacted via phone on 10/19/2020 at 2:34 PM to gather more information of Resident #2's 7/15/2020 fall. CNA D reported they would call and talk to the surveyor when they could, but never called back or provided additional information. Resident #303: On 10/19/20, at 4:30 PM, a record review of Resident #303's Electronic Medical Record (EMR) revealed an admission on 6/22/20 with [DIAGNOSES REDACTED]. Resident #303 required extensive assistance with Activities of Daily Living (ADL's) and had severely impaired cognition. Resident #303's wife was their Durable Power of Attorney. A review of Admission Fall Risk Assessment 6/22/2020 revealed Resident #303 was at moderate risk for falls. A review of Resident #303's falls revealed the following: Fall Date 6/22/2020 19:15 (7:15 PM) . Incident Location: Resident's Room . guest had slid out of his wheelchair . Injury Type Abrasion . No Witnesses Found . Fall Date 6/23/2020 13:41 (1:41 PM) Incident Location: Resident's Room . Guest observed in front of room entrance on right side. Wheelchair above head . No Injuries . No Witnesses Found . Fall Date 6/27/20 03:20 (3:20 AM) Incident Location: Resident's room . Guest was observed lying on his back next to his bed . No Injuries . No Witnesses Found . Fall Date 6/30/20 03:27 (3:27 AM) Incident Location: Resident's Room . Guest laying on left side of bed . No Injuries . No Witnesses found . Fall Date 7/6/2020 06:07 (6:07 AM) Incident Location: Resident's Room . patient lying on the floor next to the bed lying on side . No Injuries . No witnesses found . Notes 7/28/2020 Signed for Nurse on 7/28/20 . r/t (related to) last week of work and nurse not present. A review of Resident 303's fall care plan revealed: Fall risk assessment scores me at High risk for falls r/t Gait/balance problems, Unaware of safety needs Date Initiated: 06/22/2020 . Revision on: 07/11/2020 . Goal I will reduce my risk of falls utilizing interventions and/or education through next review . Intervention Please use gait belt with me, as I am extensive assistance of 1. Date Initiated: 06/22/2020 Revision on: 07/14/2020 . Allow me to use a perimeter Mattress for more mobility and comfort Date Initiated: 07/07/2020 . Autobrakes to wheelchair Date Initiated: 06/22/2020 . Be sure call light is within easy reach for me Date Initiated: 06/22/2020 . Ensure that guest is wearing appropriate footwear . when ambulating or up in the wheelchair Date Initiated: 06/22/2020 . Fall risk assessment to be completed on admission, quarterly and prn Date Initiated: 06/22/2020 . I prefer to have my bed in Low Bed Date Initiated: 06/22/2020 . Non-Slip grip to wheelchair Date Initiated: 06/22/2020 . Offer and encourage me toileting throughout the night. Date Initiated: 06/29/2020 . There was no intervention added to the care plan to offer more supervision to ensure safety. On 10/21/20, at 2:00 PM, Per the Director of Nursing, they were not in the facility during Resident #303's falls. A review of the facility policy provided policy Identifying Fall Risk, Revised 5/19, Policy Guest will be assessed on admission, quarterly and with any change in condition to determine each individual's risk for falls. Goals: . Guest safety will be maintained . The guest's plan of care will then be updated if needed to include any new interventions .

This Citation pertains to Intake Number MI 367. Based on interview and record review, the facility failed to implement appropriate interventions in a timely manner for elevated glucose levels and notify the family of the elevated glucose levels for one resident (Resident #303) of three residents reviewed for diabetes, resulting in ongoing high glucose levels and the need for hospitalization for a glucose level of 996. Findings include. On 10/19/20, at 4:30 PM, a record review of Resident #303's Electronic Medical Record (EMR) revealed an admission on 6/22/20 with [DIAGNOSES REDACTED]. Resident #303 required extensive assistance with Activities of Daily Living (ADL's) and had severely impaired cognition. Resident #303's wife was their Durable Power of Attorney. A review of DETERMINATION OF ABILITY OR INABILITY TO PARTICIPATE IN MEDICAL TREATMENT DECISIONS revealed, This determination is made pursuant to and shall be made a part of Durable Power of Attorney for Health Care executed by (resident's name) on 6-23-20 . Based upon examination of Patient, I determine that Patient is unable to participate in medical treatment decisions . The document was signed by two physicians. A review of glucose levels revealed the following: 6/22/2020 17:35 (5:35 PM) 280.0 mg/dl (milligrams per deciliter) 6/27/2020 10:08 (10:08 AM) 329.0 mg/dl 6/28/2020 17:29 (5:29 PM) 329.0 7/3/2020 17:18 (5:18 PM) 282.0 7/5/2020 16:55 (4:55 PM) 344.0 7/7/2020 17:14 (5:14 PM) 350.0 7/11/2020 16:56 (4:56 PM) 284.0 7/14/2020 08:22 (8:22 AM) 318.0 7/18/2020 17:25 (5:25 PM) 369.0 7/21/2020 08:11 (8:11 AM) 356.0 7/21/2020 18:49 (6:49 PM) 324.0 7/22/2020 03:21 (3:21 AM) 600.0 A review of progress notes, dated 7/21/2020 21:06 (9:06 PM), Order Note Text: Received lab results, guest glucose reading was 996. Assessed guest glucose with the house glucometer and the reading glucose level was HI. Contacted physician, physician order [REDACTED]. Guest has no signs or symptoms of [MEDICAL CONDITION]. Resident #303's family was not notified of the high glucose reading from 7/21/20, the order for insulin and the ongoing high levels of glucose. On 10/20/20, at 2:45 AM, a phone interview with Nurse Practitioner (NP) I was conducted regarding Resident #303's ongoing high glucose levels. NP I stated, I saw that he was on sliding scale with acu-checks so I thought that would be covered. Resident #303 did not have a sliding scale for insulin while at the facility. A review of physician's orders [REDACTED]. A review of the Diabetes Mellitus Care Plan, Date Initiated: 06/23/2020, revealed Goal I will have minimal or no complications related to diabetes through the review date . Interventions Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 06/23/2020 . Inspect feet daily . Date Initiated: 6/23/2020 . Notify Nurse Immediately s/sx (signs and symptoms) of [MEDICAL CONDITION] . Date Initiated: 06/23/2020 . Notify Nurse Immediately s/sx of [DIAGNOSES REDACTED] . Date initiated: 06/23/2020 . There were no new interventions added for the ongoing high glucose levels. On 10/22/20, at 9:00 AM, a record review was conducted of Resident #303's hospital ED Course: Date 7/22/2020 . presents to emergency department today from (the facility) with high blood sugar . Diagnosis: [REDACTED]. UTI (urinary tract infection) 3. Leukocytosis 4. [MEDICAL CONDITION] Condition: Guarded . Glucose 875 . EKG (electrocardiogram) Sinus [MEDICAL CONDITION]@ 137 bpm (beats per minute) . [MEDICAL CONDITION] Fibrillation, new . Ischemic changes on EKG, likely result of demand related to [MEDICAL CONDITION] . A review of the facility-provided policy Responding to an Acute Change of Condition Revised: 5/19 revealed . If the guest is not presenting with a medical emergency but presents with an acute change of condition that, based on the assessment of the licensed staff, is not emergent or requiring prompt treatment, the licensed staff member will inform the physician of the change of condition. The responsible party and/or emergency contact person . A review of University of Michigan High Blood Sugar ([MEDICAL CONDITION]) educational document revealed What is high blood sugar? In general, a blood sugar reading of more than 180 mg/dl or any reading above your target range is too high. A blood sugar reading of 300 mg/dl or more can be dangerous. If you have 2 readings in a row of 300 or more, call your doctor .

This Citation pertains to Intake Number MI 847. Based on interview and record review, the facility failed to follow a care-planned intervention for one resident (Resident #48) of three residents reviewed for accidents, resulting in Resident #48 being left unsupervised in the bathroom, falling from the toilet causing a nose bleed, abrasions to bilateral knees and left mid back, purple discolorations to bilateral hands and a hematoma to left temporal head and left eye, hospitalization with neurological changes and, ultimately, death. Findings include. On 2/12/20, at 1:20 PM, a record review of the facility-provided FRI information for Resident #48 revealed On 1/3/2020, at 11:46 am . Guest was sitting on the toilet previous to fall. Guest was observed on the floor on her left side between the toilet and the sink. Guest was noted with a nosebleed, pressure applied bleeding subsided. Bilateral knee abrasions, abrasion to left mid back, purple discoloration to bilateral hand. Hematoma noted to left temporal and left eye. Neuro's initiated, first aide given. Tylenol given for pain. Family denied transfer to hospital. (physician) aware. Guests neuros declined at 1830 (6:30 PM). Guest was transferred to the ER for Eval and treatment. Family aware. (physician) aware. All concerns addressed. Immediate Intervention, of staff to be within an arms reach at all time while guest is in the bathroom. On 1/4/2020 the guest's son arrived at the facility. He informed the staff that the guest had passed away at the hospital . A review of progress notes revealed 1/3/2020 19:30 . called into room by staff, at this time obtunded, had emesis, only responsive to deep pressure stimulus . guest left facility in route to hospital via EMS . A review of the staff statements revealed the following On 1/3 around lunch time . I went to check on her and took her to the bathroom. I was standing just outside the bathroom door with the bathroom door wide open. I peeked into the hallway to look for the other CNA and a therapist walked by. We were talking and I heard (the resident). I saw her lying on the floor . Further review of the FRI investigation, revealed no written statement from the therapist that walked by and talked to the CNA during the fall. On 2/12/20, at 2:20 PM, Physical Therapy Assistant (PTA) S was interviewed regarding Resident #48's fall. PTA S was asked if they knew Resident #48 had fallen and PTA S stated that they were talking to the CNA when the resident fell . PTA S and surveyor walked to room [ROOM NUMBER] and PTA S stood in the position where the CNA was standing when Resident #48 fell . PTA S stated that the CNA was leaning against the door frame of the entry door into the room, not the bathroom doorway. The toilet is approximately 4 feet inside the bathroom door. With the bathroom door open, while standing in the doorway to the hallway, the toilet is not in view and is approximately 8 feet from the doorway. PTA S was asked if they had made a statement and PTA S offered a copy of their statement. A record review of PTA S's Witness Incident Verification Form revealed What do you know about the incident? CNA was standing at Guest (102) doorway when I was walking by. CNA asked me a question as we were discussing her question. We heard a loud noise from inside the room [ROOM NUMBER] . I followed CNA into 102 room and to the bathroom (Resident #48) was laying on the floor on her left side beside the toilet . A review of Resident #48's care plan revealed My Fall risk assessment scores me at high risk for falls r/t confusion, Poor communication/comprehension, Unaware of safety needs. I am very impulsive and self transfer on my own. I am unable to retain information . Date initiated: 06/09/2019 . Do not leave guest alone in the bathroom, and stay within an arms reach of the guest r/t (related to) impulsiveness. Date Initiated: 06/09/2020 Revision on: 01/03/2020 . On 2/12/20, at 2:30, a record review of the facility-provided policy Plan of Care Approved: 3/2018 revealed A comprehensive person centered plan of care will be developed for each guest, consistent with the guest rights and to allow the guest to attain or maintain his/her highest practicable physical, mental, and psychological well being .

This Citation pertains to Intake Number MI 128 Based on interview and record review the facility failed to provide prescribed medications for two residents (Resident #8 and Resident #9) of three residents reviewed for medications resulting in 1) hospitalization for respiratory distress for Resident #9 and 2) discomfort related to untreated restless leg syndrome for Resident #8. Findings include: Resident #9: According to Admission Record and Census List, printed 10/23/2019, Resident #9 was a [AGE] year-old female admitted to the facility on [DATE] at 4:55 PM with [DIAGNOSES REDACTED]. Resident #9 discharge to the hospital less than twenty-four hours after admission (10/3/2019 at 1:43 PM) due to low oxygen levels and difficulty breathing. According to Resident #9's Medication Administration Record [REDACTED]. Resident #9 did not receive the following medications on 10/3/2019: [MEDICATION NAME] (for respiratory), [MEDICATION NAME], sprivia (for respiratory), [MEDICATION NAME] (for cardiac), [MEDICATION NAME] (steroid anti-[MEDICAL CONDITION] for respiratory), [MEDICATION NAME] (for urine flow), [MEDICATION NAME] (for health maintenance) and [MEDICATION NAME] (for nausea). According to medication incident report (10/3/2019; revision date 10/23/2019), Resident #9's doctor was notified of the missed doses of medication on 10/3/2019 at 14:58. The report identified admitted within the last 72 hours, medication not delivered/available and missed dose as the predisposing factors for the incident. Review of Resident #9's progress notes revealed no documentation that a physician, nurse practitioner (NP) or physician assistant (PA) was contacted at the time it was discovered that the medications were unavailable for orders to give upon arrival or for orders for how to proceed with treatment of [REDACTED]. According to progress note, dated 10/2/2019 at 16:55 PM, Resident #9 admitted to the facility from the hospital with an oxygen saturation of 93% (90-100% is within normal limits) on two liters of oxygen. According to progress note, dated 10/3/2019 at 12:40PM, Resident #9 was having a hard time breathing and staff were unable to obtain an oxygen level. The note stated the Resident #9's physician was notified, and resident was transported to the emergency department. The note documented Resident #9's oxygen level was 76% at the time of transport. In an interview on 10/23/2019 at 11:35 AM, the Director of Nursing (DON) stated that the nurse that admitted Resident #9 on 10/2/2019 no longer works here. She stated, Her employment here did not go well, and she quit without notice. The DON agreed there were no progress notes or documentation that the nurse notified Resident #9 physician, NP or P[NAME] The DON explained that education was done with the nursing staff on 10/3/19 related to medications orders, delivery and administrations. The educational outline stated, .call pharmacy and request a STAT (immediately) drop shipment for medications that are not in backup supply. Pharmacy has 4 hours to deliver a STAT shipment. Let pharmacy know that the (DON) has instructed you to request STAT shipment to prevent a delay of treatment. Keep track of the delivery and follow up if the medications are not delivered until they are delivered During an interview with Resident #9's physician A on 10/23/2019 at 11:54 AM, he confirmed he was not informed that Resident #9's medications were not available to her at the facility. Physician A stated, Upon admission I told them to continue all the medications. I was not told that they didn't have some of the medications. When asked if there were any risks associated with missing doses of the missed medications, Physician A stated, If it was my mom, I would have sent her back to the hospital. On 10/23/2019 at 2:53 PM during an interview with Human Resources [NAME] the employee file of Nurse B was reviewed. Record review revealed a letter of resignation from Nurse B that read, Putting in 2 weeks resignation as of today 10/2/19. Nurse B cited negative work environment and too much stress. Human Resources [NAME] explained that Nurse B's resignation was accepted effective immediately. On 10/23/2019 at 11:50 AM Nurse B was phoned for interview with no return call. According to facility policy titled Medication Pass (dated revised 2/18) stated, Medications will be administered according to physician order. Resident #8: According to Admission Record and Census List printed 10/23/2019, Resident #8 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon record review of Resident #8's physician orders, Resident #8 was noted to have an order for [REDACTED]. Upon record review of Resident #8's Medications Administration Record (MAR) for (MONTH) 2019, revealed that nursing staff documented 9 (9=other / see nurse note) for one dose of [MEDICATION NAME] on 9/14/2019 and for seven consecutive doses of [MEDICATION NAME] from (MONTH) 15th to (MONTH) 17th, 2019. Record review of Resident #8's medical record revealed the following: 9/14/2019 at 22:10: [MEDICATION NAME] .awaiting deliver from pharmacy. 9/15/2019 at 22:15 PM: [MEDICATION NAME] .med not available. Called pharmacy to pull from back, can not get authorization to pull because need a new C2 script. Filled out C2 form awaiting Dr. signature. 9/16/2019 at 13:06 PM: [MEDICATION NAME] .call placed to pharm 9/16/2019 at 23:04: [MEDICATION NAME] .N/A (not available) 9/17/2019 at 04:21: [MEDICATION NAME] .still awaiting C2 signature. During a phone interview with Resident #8's physician A on 10/23/2019 at 11:54 AM he could not recall whether or not he was notified about Resident #8's [MEDICATION NAME] being unavailable for more than three days or the need for CII signature to fill the prescription. Physician A stated he would have to review the progress notes to see. During an interview with the Director of Nursing (DON) on 10/23/2019 at 12:33 PM she explained that the medication administration notes it indicated the CII script (Schedule II substance that requires additional care because of the potential for abuse of the drug) for Resident #8's [MEDICATION NAME] was signed on 9/13/2019 but she was not sure why it didn't come in from pharmacy. The DON agreed that there was no documentation that Resident #8's physician was notified of the unavailable medication. Record review of facility policy titled, Controlled Substance Prescriptions, noted, Before a controlled drug can be dispensed, the pharmacy must be in receipt of a prescription from a person lawfully authorized to prescribe. A chart order is not equivalent to a prescription for controlled drugs. Therefore, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription to ensure delivery of medications.

Based on interview and record review, the facility failed to use two-person assist and adequately supervise a transfer for (Resident #6) of four residents reviewed for transfers, resulting in Resident #6 falling, hitting their head and fracturing their left hip requiring hospitalization and surgical repair. Findings include. On 9/11/2019, at 1:00 PM, a record review of Resident #6's electronic medical record revealed an admission on 4/16/19 with the following diagnoses; after care following a left hip joint replacement on 4-11-19, Dementia and muscle weakness. A Review of Resident #6's Minimal Data set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 defining Resident #6 had moderately impaired cognition. A review of Section G revealed resident required extensive assistance with two-person physical assist for transfers. A review of Resident #6's discharge assessment dated [DATE] Section C revealed number 2 was checked moderately impaired decisions poor; cues/supervision required. A review of Resident #6's care plans revealed: Focus I need help with my ADL's (Activities of daily living) because I get tired easily. I have impaired balance, Limited Mobility, pain in my left hip and impaired cognition. Date Initiated: 04/17/2019 Revision on: 04/17/2019 Goal . I want to improve my Bed Mobility, Transfers, Eating, Dressing, Toilet use and Personal Hygiene to supervision to facilitate return home . Date Initiated: 04/24/2019 Revision on 04/24/2019 Interventions/Tasks . I use a Rolling Walker, during transfers Date Initiated: 04/17/2019 Revision on: 05/02/2019 TOILET USE: I need extensive assistance of 2 to use toilet. Please do not leave me unattended in the bathroom. Date Initiated: 04/17/2019 Revision on: 05/02/2019 TRANSFERS: I need extensive assistance of 2 Date Initiated: 05/02/2019 . A review of Resident #6's hospital admission records dated 5/9/2019 revealed; (Resident #6) presents for evaluation of left hip and leg pain after experiencing a mechanical fall this morning. The patient states that he was in the bathroom this morning when he fell and landed on his left hip. He states that he did hit his head . Diagnosis: [REDACTED]. Head injury, closed, initial encounter . On 9/11/19, at 1:55 PM, an interview with Aide A was conducted regarding Resident #6's fall on 5/9/19. Aide A stated, I remember the light was on and it was the beginning of my shift. The nurse was with him and she left. He started to get antsy. He was saying lets go and tried to get up quickly. He ended up getting up and walking to the sink. He had a gait belt on. Aide A was asked if at that time should she have called for help and Aide A stated, I told him ok stay right there so I can grab the chair. Aide A further offered, I should have pulled the light but my main concern was to get the chair so he can sit down. Aide A was asked why they felt the chair was more important than staying with the resident and waiting for help and Aide A stated, because sometimes when he walked he would shuffle his feet, he was a two-person assist at that time. I think for all transfers. He was already standing up at that time. He wouldn't listen to me. Aide A was asked if she would have yelled for help would someone come to assist her and Aide A stated, I'm not sure. Aide A was asked how she could have assisted Resident #6 differently to ensure their safety and Aide A stated, I would ask him to sit back down until I could get some help. I guess I wasn't thinking at that moment I was just trying to hurry up and grab the chair. Aide A was asked where the wheelchair was located and Aide A stated, the wheelchair was outside the door of the bathroom right around the corner. Aide A stated, yes to having to turn away from the resident to be able to get the wheelchair. Aide A was asked how they would know Resident #6's transfer needs and Aide A stated, at the beginning of our shift we have a sheet that tells what section we have then we log in and look at each care plan. I always write on my paper what kind of assist they are. Aide A further offered, I should have pulled the cord so somebody could have come in and stayed with him the entire time and not walked away for that split second. On 9/11/19, at 2:33 PM, an interview with the Director of Nursing (DON) was conducted regarding Resident #6. The DON was asked to provide the Kardex, Physician orders, Therapy recommendations and care plans for Resident #6 at the time of their fall on 5/9/19. The DON stated they were unable to provide a Kardex copy for the date of the fall due to the Kardex already being updated. The DON explained the care plans and revisions to the care plans transfer to the Kardex. A review of Resident #6's care plans along with the DON revealed Resident #6 was a two-person assist for transfers. The DON stated, when (Resident #6) came back from the ortho appointment, he went back to 50% weight bearing so that's why he got changed to a two-person. The DON was asked if Aide A should have left Resident #6 alone while she grabbed the wheelchair and the DON stated, No, I think she realized that too. The DON was asked to provide the facility Fall and ADL policies. On 9/11/19, at 3:30 PM, a record review of the facility provided investigation file of Resident #6's fall revealed; 1:1 coaching FOLLOWING THE PLAN OF CARE Employee name (Aide A) Date: 5/9/19 [NAME] One-on-One Coaching was held with the above -listed employee covering the following topics: On 5/9/19 you were informed that one of the job responsibilities that you have as a nurse aide is to ensure that the plan of care for the guest is followed. This means that when a guest has an intervention, it must be followed. This includes when providing care for a guest you must follow the Kardex for each individual. The Kardex is linked to the care plan. It is unacceptable to not follow the plan of care. You can always use more assistance than required, but you may never use less assistance than what the Kardex has listed. You must check the ADL & Kardex to ensure the plan of care is being followed and the guest is in a safe environment . On 9/11/19, at 4:38 PM, a record review of Resident #6's therapy notes revealed the facility provided therapy notes from dates of admission up to 4/23/19. The DON was asked again for all of the therapy notes for Resident #6. On 9/11/19, at 4:43 PM, a record review of Resident #6's Therapy Discharge Summary revealed the following Physical Therapy PT Discharge Summary Dates of Service: 4/17/2019 - 5/8/2019 LTG (long term goal) #3.0 . Patient will safely perform functional transfers with Modified Independence for proper use of upper extremity during push-off, for maintaining hip precautions and for correct use of assistive device in order to return to prior level of functional abilities Transfers Baseline (4/17/2019) Min (A) (MDS-Extensive Assist) Previous (5/7/2019) Mod (A) (MDS - Extensive Assist) Discharge (5/8/2019) Mod (A) (MDS - Extensive Assist) Comments: Perform stand and pivot from W/C (wheelchair) level with RW (rolling walker), verbal/tacile (tactile) instruction to maintain TTWB (toe touch weight bearing) on LT (left) LE (lower extremity) during pivot phase. Conducted sit to stand x 5 reps from W/C level with verbal/tacile (tactile) instruction for hand placement and technique to push up from surface and maintain LT hip precautions. On 9/11/19, at 5:00 PM, a record review of facility provided Lifting policy Original Prior to 8/2004 Revised: 8/12, 4/15;7/17 . revealed Policy: Proper body mechanics will be used when lifting and transferring guests to reduce the likelihood of injury . Goal: 1. To transfer guests safely and without injury. Procedure: [NAME] Prevent injury 1. Explain procedure to guest. 2. Ensure guest has adequate footwear 3. Ensure correct number of employees for a safe transfer. On 9/11/19, at 5:10 PM, during exit conference, Corporate Nurse B stated, (Aide A) was never farther than an arms reach away. Corporate Nurse B was asked to read the investigation to clarify the distance and Corporate Nurse B stated, it said 10 feet.

Based on observation, interview and record review, the facility failed to 1) treat a severe skin infection for 1 resident (Resident #178) of 12 residents reviewed for skin care, 2) manage IV (Intravenous) access and IV medication for 1 resident (Resident #127) of 5 residents reviewed for IV medications and 3) manage medications via insulin pump for 1 resident (Resident #134) of 1 resident reviewed for insulin pump usage, resulting in Resident #178 suffering discomfort, pain, unnecessary topical medication, Resident #127 suffering a severe adverse medication reaction and Resident #134's diabetes to not be properly managed. Findings Include: Resident #178 On 4/23/2018, at 9:30 AM, an observation of a bottle of [MEDICATION NAME] (medication prescribed by a physician for skin yeast infection treatment) powder was sitting at Resident 178's bedside and was not labeled with resident's name. A record review of Resident #178's face sheet, Minimum Data Set assessment (MDS), physician orders [REDACTED].#178 was a [AGE] year old alert and orientated female and required assistance with Activities of Daily Living (ADL's). Resident #178 had [DIAGNOSES REDACTED]. On 4/25/18, at 09:22 AM, Resident #178 was asking surveyor to come into room. During an interview, resident #178 revealed that the [MEDICATION NAME] powder that was observed on day one of survey is now missing out of their room. Resident #178 stated, I had a powder that they were putting on my breast and a cream on my bottom. What am I going to do once I go home will I get a script for the powder? On 4/25/18, at 09:26 AM, an interview with staff nurse I was conducted regarding the [MEDICATION NAME] powder that was at bedside and now is gone and that the resident is asking for it along with Resident #178 in their room. Staff nurse I stated to Resident #178, I will make sure you go home with some in fact there are 2 full bottles for you. Resident #178 agreed to a skin assessment with Nurse I which revealed the skin under Resident #178's left breast extremely excoriated and red with a strong yeast odor. The area measured approximately 10 inches by 6 inches and was under the left breast. There was also a red excoriated area on Resident #178's right side of abdomen measuring approximately 2 inches by 2 inches with a line of reddened area under entire abdominal fold. Resident #178's coccyx and buttocks were reddened and excoriated with 2 linear scabbed areas measuring approximately 1cm (centimeter) x 3mm (milimeter) to Resident #178's left buttock and 1 area to the right buttock measuring approximately 1cm x 3mm which appear to be scratch marks. There was no dressing to the coccyx area and no cream to Resident #178's buttocks. Resident #178 complained of pain at this time Oh yes it hurts so bad I can hardly sit on it. Per staff nurse I, Resident #178 was discharging home that day. On 4/25/18, at 10:46 AM, an interview with the Director of Nursing (DON) B regarding why the [MEDICATION NAME] powder was at the bedside on 4/23/18 and on 4/24/18 it was gone. I will have to look and see. The DON further offered, it would be the nurses putting on the powder. The DON stated, I will have to go back and look when asked why the nurses were applying [MEDICATION NAME] powder without a physician's orders [REDACTED].#178 did not have an [MEDICATION NAME] dressing on her coccyx area and had a physician order [REDACTED]. Review of Resident #178's physicians orders revealed the following: [MEDICATION NAME] Powder apply to LLQ, RLQ (left and right lower abdomen), Left Breast topically every shift for candiasis (yeast infection) for 10 days . start date 3/11/2018 stop date 3/21/2018. Review of Resident #178's skin assessments revealed the following, skin assessment 3/19/2018 . under breast slight pink . skin assessment 3/24/2018 . LLQ redness/moist . RLQ redness/moist . under left breast redness/moist . skin assessment 3/31/2018 . abd (abdominal) folds pink . skin assessment 4/7/2018 . abdominal folds slight pink areas . skin assessment 4/14/2018. There was no mention to Resident #178's breast or abdominal areas being excoriated and red. Review of Resident #178's discharge instructions revealed the following; Discharge instructions . current treatments [MEDICATION NAME] powder under abd fold and under breast daily. Cleanse first, pat dry then apply [MEDICATION NAME]. Calmo lotion to guest buttocks. On 4/26/18, at 09:28 AM, an interview with nurse F regarding Resident #178's skin assessments, physician orders [REDACTED]. Nurse F stated, Yes. We were doing the powder. Nurse F further offered that I could have swore she still had it (the physician order) because (nurse W) was giving it to her at night this whole time. She had 2 bottles left in the back that I sent home with her. Nurse F, was queried as to why Resident #178 was getting the powder without a physician order, Oh I see so she was on it for the 10 days and no one reassessed her after that. On 4/26/18, at 02:59 PM, an interview with Nurse W, via phone in regards to Resident #178's [MEDICATION NAME] powder at the bedside and nurse W stated, Oh yeah the last time I put it on her was the night before she left and it was redder than it's ever been. It was flaming red and further up on her breast farther than before. The redness was coming and going but that's the worst I'd ever seen. We have been putting the powder under her breast for quite some time. I think she had an order for [REDACTED]. When asked if nurse W does treatments with medications without a physician order, nurse W responded No. During an interview on 4/30/18, 09:31 AM, the DON was asked what her expectations were of the nursing staff following physician orders [REDACTED]. Resident #127 During a record review, on 4/24/18 at 10:15 am, of the face sheet, progress notes, assessments, Minimum Data Set (MDS) assessment, physician orders, care plans and medication administration records, they indicated Resident #127 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The admission MDS assessment, indicated the resident had mild cognitive impairment. On 4/23/18 at 11:29 am, during the initial tour, an interview with Nurse F revealed, Resident #127 was admitted with [MEDICAL CONDITION] related to a spinal wound infection and pneumonia. The resident was receiving intravenous (IV) [MEDICATION NAME] (Vanco, an antibiotic) twice a day via a PICC (peripherally inserted central line catheter) in his right arm. It was not administered via an electronic pump. A plastic dial device was on the IV tubing. On 4/23/18 at 11:31 am, Resident #127 was observed sitting in a chair in his room, there was bright red skin on his body, face, neck and arms. Large patches of skin were peeling. The resident said he had Red Ma[DIAGNOSES REDACTED] (Red ma[DIAGNOSES REDACTED] is an infusion-related reaction peculiar to [MEDICATION NAME]. It typically consists of (severe itching), an (red skin) rash that involves the face, neck, and upper torso. Less frequently, (low blood pressure and facial swelling) can occur. Patients commonly complain of diffuse burning and itching and of generalized discomfort. They can rapidly become dizzy and agitated, and can develop headache, chills, fever, and paresthesia around the mouth. In severe cases, patients complain of chest pain and dyspnea). 4/24/18 4:55 pm, an interview with Nurse I, nursing supervisor. We have PICC lines, mediports, and a variety of other types. We have 2 PICC lines and a mediport on the floor now. I tried to provide education to the nurses on how to access them . Nurse I was queried about staff education related to administration of IV [MEDICATION NAME] and stated, I tried to provide education to the staff. Nurse I provided a copy of the education document used for training titled, Nursing Care and Maintenance of IV's, dated 3/1/2008, and provided All IV Medications will be given by IV Pump. On 4/25/18 at 11:53 am, Nurse F stated, The resident (#127) is receiving IV Vanco. It was initially given not on an IV pump, but by Vanco Ball. The resident developed an adverse reaction to the medication, Red Ma[DIAGNOSES REDACTED]. He developed redness, rash, itching and peeling skin. An order was changed to use the flow meter. On 4/26/18 at 10:00 am, Resident #127 was queried how the nurse would administer his IV Vanco and he replied, Sometimes they use a pump, but they don't have the cord for it. They set it on the shelf about a week ago and then took it. They couldn't use it. On 4 /26/18 at 10:16 am, an interview with Nurse F, We tried to use an IV pump, but we don't have a power cord for it. The pharmacy sent the dial a flow and that's what we use. I don't know if I had an in-service on it or not. A phone interview with Pharmacist GG, on 4/26/18 at 10:30 am, related to administration of IV antibiotics including [MEDICATION NAME], Usually I believe they (the facility) have pumps on site and we can provide pumps and tubing. Usually it's ([MEDICATION NAME]) infused at a certain rate. Usually via an IV pump. On 4/26/18 at 4:25 pm, Nurse X was queried if she had received training from the facility on IV Vanco Balls and stated, we didn't have them when I first started. These are new. A nurse showed me that isn't here anymore. Nurse X said she did not have any formal training for the IV Balls. An interview with the Director of Nursing on 4/30/18 at 4:45 pm, revealed We are working on IV pump training. We are getting more electronic pumps in. Resident #134 During the initial tour/interview on 4/23/18 at 2:03 pm, Resident #134 stated that he had an insulin pump (a device that deliver rapid- or short-acting insulin 24 hours a day through a catheter placed under the skin) and was just in the hospital for low blood sugar. On 4/25/18 at 9:00 am, during a record review of the progress notes, physician orders, admission nursing assessment, care plans, Minimum Data Set (MDS) assessment and face sheet, they indicated the resident was admitted to the facility on [DATE] with an implanted insulin pump and Diagnoses: [REDACTED]. Review of the Insulin Care Plan, dated 4/19/18, revealed, I am on Insulin pump related to brittle diabetes, follow insulin pump instructions as provided by family. On 4/25/18 the interventions were updated, To do glucose levels based on reading of the insulin pump QID (four times a day) and as needed. An interview with Nurse I, on 4/25/18 at 9:50 am, revealed the nursing staff were not trained on how to use the insulin pump. The facility nurses are not managing the insulin administered from the pump but are calling the residents daughter for instructions for the insulin dose. Per the Hospital discharge papers, dated 4/19/18, the resident had a recent hospitalization (prior to admit) for Diabetic Coma due to [DIAGNOSES REDACTED] ( condition caused by a very low level of blood sugar). The resident had an insulin pump prior to hospitalization . During an interview on 4/26/18 at 10:00 am, with Nurse X, she said she did not receive education related to use of the Insulin pump. My understanding is we call the guest's daughter and tell her what he ate, and she tells us how to program the Insulin pump. I don't know if it is the right amount. She was caring for the resident that day. Nurse Y stated, I think I received training. I didn't sign an In-service sign in sheet. Nurse F stated, I have not received any training on the Insulin pump. On 4/26/18 at 10:30 am, Nurse I provided an In-service Sign-In Record, titled Glucose Pump and dated 4/19/18. It had 4 nurses' names on it. There were 12 nurses employed at the facility. During an interview on 4/26/18 at 11:00 am, Resident #134 stated, I've had the insulin pump for about 3 years. My blood sugar is 327 right now. Resident #134 showed the screen on the meter and it read 327. I'll have to go to the doctor and have it adjusted. They (the nurse yesterday) asked me to do it myself. Before that they were helping me to program it. They would call my daughter and she would tell them what to do. They probably don't know how to do it. There is a lot to it, but as of yesterday, they said I have to do it. My daughter would tell them what to do. I called her myself today. She tells me how to do it. At home she would come over about once a day and help. I don't know how it was so low this last time, before I went to the hospital. My daughter fills the insulin syringe every 3 days. She brings it from home. Resident #134 further stated, I've never seen the doctor since I've been here. I don't even know what he looks like. My Blood sugars have been pretty high since I've been here. I've been eating so much, 3 meals. I used to eat apple sauce and milk at home. Review of a physician's orders [REDACTED]. The order does not indicate the family was managing the insulin pump. The order was changed on 4/25/18 twice, once to reflect the staff would manage the insulin pump and next that the resident would manage the pump. On 4/26/18 at 11:30 am during a review of the new orders, Director of Nursing (DON) B stated, Yes, we changed the orders yesterday. Review of an assessment titled, Self-Administration of Medication, dated 4/19/18 revealed, Does guest prefer to Self-Administer medications? And No, was checked. Review of the physician's H&P (history and physical) was not present in the medical record. During an interview at 11:40 am, on 4/26/18, DON B stated, I can't find one (a H&P). There is a note 4/24/18, but not an H&P. I will call the physician. There was no mention of the insulin pump in the note. The physicians progress note dated 4/24/18 at 9:40 am revealed, Most recent blood sugar 324 mg/dl, (milligrams per deciliter, this is a High level) DM II, watch sugars. Review of the physician's progress note dated 4/24/18 at 9:40 am, did not indicate the case was discussed with guest, family, RN or DPOA. Each option was blank. Time spent face to face, was blank. On 4/26/18 at 11:26 am, the Director of Nursing provided an policy titled, Insulin pens, and said there was no specific policy for an Insulin pump. DON B stated I know it's our fault. We own that, when queried why the nurses had not all been trained to use the Insulin pump and the physician did not mention use of the pump. On 4/26/18 at 12:30 pm, during an interview with Nurse Practitioner S, she was queried why there was no mention of an insulin pump for Resident #134 and stated, I don't know. On 4/30/18 at 11:18 am, Pharmacists Z, AA and BB were interviewed about the Insulin pump for Resident #134. Pharmacist A stated, We don't provide insulin for the pumps. Is there a patient on an Insulin pump? We haven't had any Insulin pumps. I'll look into it. During the interview, Pharmacist AA stated, Nursing would manage the pump. On 4/30/18 at 5:18 pm, during a phone interview Confidential Person HH stated, I walk them (the staff) through it (on the phone.) Ever since he got the insulin pump, he has never been able to run it on his own. When queried how the nurses learned how to use the Insulin pump, the Confidential Person replied, Really only from me walking them through it. I learned from a rep. I provide the insulin. I fill the syringe at home and bring it in. When queried how the nurses would know what type of Insulin was in the syringe, she stated, I don't know. I don't label it.

Based on observation, interview and record review, the facility failed to order and dispense [MEDICATION NAME] anti-coagulant medication (High risk medication) for 4 (#1, #2, #3, #4) of 4 sampled residents, resulting in Resident #1 receiving excess dose of [MEDICATION NAME] anti-coagulant (blood thinner), Resident #2 not receiving a dose of [MEDICATION NAME] anti-coagulant (blood thinner), Resident #3 not receiving a dose of [MEDICATION NAME] anti-coagulant (blood thinner), Resident #4 not receiving a dose of [MEDICATION NAME] anti-coagulant (blood thinner). Findings include: Record review of facility past non-compliance dated 6/28/16, submitted during the survey on 7/25/16 revealed that the facility was aware of Resident #1 having received an excess dose of [MEDICATION NAME] anti-coagulant medication when a staff nurse failed to discontinue a previous order of [MEDICATION NAME] when putting in a new, higher dose [MEDICATION NAME] order. This resulted in two active [MEDICATION NAME] orders at the same time appearing on the medication administration record and being administered. Upon facility review of the clinical record it was discovered that the physician had ordered the 4 mg dose to be stopped that day and for the Resident #1 to receive 7.5 mg of [MEDICATION NAME] one time dose, and that 5 mg of [MEDICATION NAME] to be started the following day. Failure to discontinue the 4 mg dose when the 5 mg was received resulted in Resident #1 receiving a total of 9 mg of [MEDICATION NAME] versus the 5 mg that was ordered. Record review of facility 'Nursing 2015 Drug Handbook' Wolters/Kluwer 2015, located at the nursing station, page 1467 through 1470, revealed that [MEDICATION NAME]/[MEDICATION NAME] anti-coagulant medication black box warning: [MEDICATION NAME] can cause major or fatal bleeding, which is more likely to occur during the starting period and with higher dose. Regularly monitor INR in all patients. Consider more frequent monitoring of those at high risk for bleeding. Record review of facility 'Preparation and General guidelines IIA2: Medication Administration-General Guidelines' policy dated 8/2014 identified medication administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . Procedure (A) (5.) The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders [REDACTED]. When a medication order is changed and the current supply can continue to be used, the container should be flagged right away and the order change communicated to the provider pharmacy so that the next supply of the medication is labeled with the current directions. (B.) (3.) If a dose seems excessive consider the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. The interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. Resident #1: Record review of Resident #1's Minimum Data Set (MDS), dated [DATE], revealed an [AGE] year-old female with Brief Interview of Mental status (BIMs) score of 12 out of 15, moderately impaired cognitively. Medical [DIAGNOSES REDACTED]. Record review of Resident #1's 'Medication Error Report Form', dated 6/26/16 at 8:30 PM, revealed that an agency Licensed Practical Nurse made an error of overdose/multiple dose of multiple doses given to patient, two pills instead of one of [MEDICATION NAME] tablets 5 mg and 4 mg (both tablets) were given when only the 5 mg was to be given. Transcription error: Order was not correctly marked/copied in MAR or other record. Additional description of cause: Staff Registered Nurse I 'Got a new order for [MEDICATION NAME], but did not d/c (discontinue) the old order. Agency nurse worked following night and gave both new order and old order. Patient Impact: Error occurred that reached the patient and required monitoring or intervention to prelude harm. Record review of Resident #1's Medication Administration Record (MAR) for June 2016 was reviewed. Resident #1 was receiving [MEDICATION NAME] anti-coagulant, Aspirin 81 mg antiplatelet, [MEDICATION NAME] 75 mg antiplatelet daily and [MEDICATION NAME] 70 mg low molecular weight [MEDICATION NAME] subcutaneous two times a day. On 6/25/16 at 8:30 PM the agency nurse administered [MEDICATION NAME] (generic for [MEDICATION NAME]) 4 mg by mouth and at 9:00 PM administered [MEDICATION NAME] 5 mg by mouth. Record review of Resident #1's admission assessment dated [DATE] revealed multiple bruising on upper bilateral extremities, left buttocks, bilateral hips, lower right leg and over left chest area where pacemaker was placed. Record review of Resident #1's physician 'History and Physical', dated 6/20/2016, revealed PT/INR ([MEDICATION NAME]/International Normalized Ratio) daily while on [MEDICATION NAME] until INR >2. Record review of Resident #1's laboratory results revealed that on the PT/INR were missed on 6/21/16 and was given [MEDICATION NAME] 70 mg on 6/25/16 but no PT/INR was drawn. On 6/24/16 staff Registered Nurse (RN) I noted in the nurse note dated 6/24/16 at 10:28 PM eMAR medication Administration Note 'order for today should 5mg'. On 6/25/16 an agency nurse administered medications. On 6/26/16 at 10:43 AM staff RN K phoned the physician related to Resident #1's left arm from elbow to wrist is purple with swelling. Resident also stated she had numbness in her fingers and pain. Per physician the resident was to ice and elevate the arm as needed. Also new order to increase [MEDICATION NAME] to 10/325 every 6 hours as needed. An interview on 7/26/16 at 9:50 AM with Registered Nurse (RN) K revealed that she had worked on 6/25/16 and noticed Resident #1's left arm to be a reddish/purple color from elbow to hand and administered pain medication. Record review of Resident #1's nurse notes dated 6/25/16 revealed that there was no documentation of bruising noted for the date of 6/25/16. RN K stated that she also worked 6/26/16 and that she noticed the left arm was worse, dark purple from elbow to wrist/hand and resident complained of numbness in finger tips with increased pain and swelling. RN K stated that she called the physician and the physician stated it was a hematoma in her elbow that was his thought that it was draining down into her arm to cause swelling/bruising. The physician ordered elevation of the arm and to ice it, and increased the pain medication to 10/325 [MEDICATION NAME] every 6 hours form the 5/325 every 6 hours. RN K stated that she also worked 6/27/16 and had checked Resident #1's arm. That day Resident #1 had reddish/purple color extending into palm and pinkie finger, also her left breast was purple and the pacemaker site was swollen which was new, more pronounced sticking outward. RN K stated that she called the Nurse Practitioner E and received orders for venous/arterial Doppler ' s for the arm and the NP would come into see resident. During the interview with RN K explained the physician order [REDACTED].' to change the dose, but that RN I implemented a new order and not an update, which left in the old order. RN K stated that all new orders are double checked by a second nurse. Record review of Resident #1's nurse note, dated 6/27/16 at 0:02 AM, by Registered Nurse L revealed: Dual orders for [MEDICATION NAME] ([MEDICATION NAME]) existed in the PCC (Point Click Care electronic charting) eMAR system. They were 4 mg and 5 mg QD (everyday) PO (by mouth) respectively. Called doctor and he confirmed dosage. [DIAGNOSES REDACTED]. Skilled nursing D/C'd 4 mg order and kept 5 mg order as appropriate. Lab to do PT/INR 6/27/16. In an interview via phone on 7/25/16 at 5:44 PM with Registered Nurse L revealed that Resident #1 had an INR of 1.5 and the doctor wanted the resident at 2.5-3.5 therapeutic. RN L stated that another nurse had gotten an order and added the order of 5 mg [MEDICATION NAME] on top of the 4 mg, doubling the dose. RN L stated that he was looking at the MAR and noted the two orders and thought that no one would give 2 doses, but that they did. RN L stated that he wrote up a report on the internal medication error report that an agency nurse had given the doses. RN L stated that the mistake was that both orders were left on the MAR and the Resident #1 got a total of 9 mg that night. Record review of Resident #1's lab results dated 6/20/16 revealed a hemoglobin of 8.9 and INR 1.43. Lab results on 6/21/16 were not done. Lab results on 6/22/16 INR of 1.3. Lab results dated 6/23/16 INR of 1/4. Lab results on 6/24/16 INR 1.6. The next lab results are on 6/27/16 INR 4.3 (in red and flagged as high). Record review of Resident #1's nurse note dated 6/27/16 at 1:57 PM revealed: Lab results hbg (Hemoglobin) 6.5 and hct (hematocrit) 20.7, INR 4.3 nurse practioner in building and notified, new orders to type and cross (match) 2 units of PRBC (Packed Red Blood Cells). Discontinue [MEDICATION NAME], Hold Aspirin and [MEDICATION NAME] for one day. Continue daily PT/INR call with new orders to start tomorrow. In an interview on 7/25/16 at 3:20 PM with Registered Nurse H revealed that on 6/27/16 she received labs on Resident #1 with a hemoglobin of 6.5 and received new orders to type and cross 2 units PRBC's and sent the resident out to an infusion center for blood [MEDICAL CONDITION]. Record review of employee file for RN I revealed that the nurse had taken on 4/6/6 an 'Medication/Post Quiz' true or false which included question that pertained to [MEDICATION NAME] medication. Resident #2: Record review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed an [AGE] year-old female with Brief Interview of Mental status (BIMs) score of 7 out of 15, severely impaired cognitively. Medical [DIAGNOSES REDACTED]. Record review of Resident #2's 'Medication Error Report Form', dated 7/9/16 at (untimed), revealed dose omission of medication not given of [MEDICATION NAME]/[MEDICATION NAME] 3 mg oral. Possible cause noted that staff did not follow current policies and procedures. Patient impact was noted that error occurred that reached the resident but did not cause harm. Resident #3: Record review of Resident #3's Minimum Data Set (MDS), dated [DATE] in progress, revealed a [AGE] year-old male with admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Record review of Resident #3's 'Medication Error Report Form' dated 7/21/16 at 5:00 PM revealed that [MEDICATION NAME]/[MEDICATION NAME] 5 mg oral dose omission medication not given due to the medication was not confirmed (double noted) in the system. Possible cause: Current policies and procedures in place were at fault-existing 'medication system' contributed to error. 7/21/16 INR 3.6, 7/23/16 INR 1.2. Resident #4: Record review of Resident #4's Minimum Data Set (MDS), dated [DATE] in progress, revealed a [AGE] year-old female with admission date of [DATE], with Brief Interview of Mental status (BIMs) score of 15 out of 15, cognitively intact. Medical [DIAGNOSES REDACTED]. Record review of Resident #4's 'Medication Error Report Form', dated 7/21/16 at 8:30 PM, on 7/20/16 [MEDICATION NAME] 2 mg dose omission medication not given. Additional description noted that 'the computer system thought medication had been given for the day'. Possible causes: Transcription error order was not correctly marked/copied in MAR or other record. An interview on 7/25/16 at 2:45 PM with the Nurse Practitioner (NP) E revealed that Resident #1 started with bruising and that she ordered Doppler to rule out [MEDICAL CONDITION] ([MEDICAL CONDITION] and that a H & H lab came back with hemoglobin of 6.5, when the resident had been above an 8, and the resident was sent to the infusion center for 2 units of PRBC's and the hemoglobin increased to above 8. NP E stated that there seems to be a [MEDICATION NAME] dosing issue at the facility with a dosage change. NP E had recommended that pharmacy services dose the [MEDICATION NAME]. An interview on 7/26/16 at 8:40 AM with the physician J revealed it seems to be a facility process problem and that he has 2 other buildings in which the pharmacy services get the lab work and the pharmacy doses the [MEDICATION NAME] adjusted to the INR results. The physician revealed that in this case the nurse failed to remove an order of 4 mg [MEDICATION NAME] when she changed the order to 5 mg, so that both orders were in the system and the next shift nurse administered both doses for a 9 mg total. Observation on 7/26/16 at 1:25 PM with Registered Nurse K of the 100 hall medication cart revealed that [MEDICATION NAME] was dispensed by the pharmacy as individualized pill packet which contained both the name brand and generic names on the packet. During the on-site investigation a packet of past non-compliance dated 6/28/16 was submitted. Medication errors involving [MEDICATION NAME] continued to continue post staff education and facility stated substantial compliance date of 7/5/16. Case discussed in depth with survey monitor JR. #

This citation has a 2-part Deficient Practice Statement (DPS). Based on observation, interview and record review the facility failed to ensure safe resident transfers with a mechanical lift in 1 of 5 residents (Resident #16) reviewed for transfers in a total sample of 9 residents resulting in Resident #16 being subjected to an unsafe mechanical lift transfer by 2 staff members that were not adequately trained to use the mechanical lift for 5 residents that were transferred with the mechanical lift out of the facility census of 46. Based on observation and interview the facility failed to prevent a potential hazard for residents on the 300 unit from a total sample of 9 residents resulting in the potential in cross contamination and safety with scissors left in the hall unattended for a potential hazard of 13 residents out of a total facility census of 46. Findings include: The facility was placed in Immediate Jeopardy as a result of the facility's failure to ensure a safe resident mechanical lift transfer for Resident #16, who required the use of a mechanical lift for all transfers; on 4/13/16 at 2:15 PM, observed an unsafe transfer according to the facility policy and manufacturer's guidelines. This deficient practice placed a minimum of 5 residents, who are transferred with a mechanical lift at the facility at risk. On 4/14/16 at 10:40 AM the Nursing Home Administer (NHA) A was notified of Immediate Jeopardy that began on 4/13/16 at approximately 2:15 PM, due to the facility's failure to adequately train staff and ensure safe resident transfers with the mechanical lift. On 4/18/16 PM, the surveyor verified the following: 1. On 4/13/2016 a skin assessment was immediately performed for Resident #16. On 4/13/2016 a PHQ 9 assessment was performed which indicated mild depression (score of 5), an improvement from the assessment performed in February 18, 2016 which showed moderate depression (score of 10). The guest was also provided with a proper mechanical lift sling on 4/13/2016 and slings without tags were discarded. 2. On 4/13/2016 each guest requiring the use of a mechanical lift (five (5) guests) were reviewed to ensure the sling provided was the proper size and in good condition. 3. On 4/14/2016 therapy will evaluate each of the five (5) guests requiring the use of a mechanical lift to determine sling placement during transfer. The plan of care for each guest will be updated. 4. The evaluating physical therapist will evaluate each guest within 24 hours of admission to determine transfer status. If the transfer status requires the use of a mechanical lift, the plan of care will reflect the sling size and position for the optimum transfer. 5. Between 4/13/2016 and 4/14/2016 the Staffing Development Coordinator, Director of Health Services, and Nurse Consultant held face-to-face in-services for CNAs, Registered Nurses and Licensed Practical Nurses on the use of mechanical lifts with a return demonstration validating competency. As of 4/14/2016 at 11:00 am, 14 of 32 CNAs have been in-serviced along with 11 of 23 Nurses. Remaining CNAs and Nurses will receive education prior to working their next scheduled shift. 6. On 4/14/2016 the Director of Health Services initiated weekly audits on guests requiring the use of a mechanical lift. The audit included the use of the proper sling, the condition of the sling, and review of the plan of care to ensure it contained the size and position of the sling for optimum transfer. The Director of Health Services or Designee will continue weekly audits to ensure compliance. The Director of Health Services of Designee will report the findings to the facility Quality Assurance and Process Improvement Committee. The Quality Assurance and process improvement committee will determine further follow up and review. The administrator is responsible for attaining and maintaining compliance with this regulation. The Immediate Jeopardy was removed on 4/14/16, but the facility remained out of compliance with a scope of isolated and severity of No actual harm with the potential for more that minimal harm that is not immediate jeopardy due to all staff had not received the inservice education and completed competencies for safe use of the mechanical lift. Findings include: Resident #16 was a [AGE] year-old male, who was admitted to the facility 2/13/16 and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) date 4/3/16 revealed a Brief Interview for Mental Status (BIMS) score of 2 out of a possible of 15 which indicated the Resident was severely cognitively impaired. According to the Invacare Manufacture (mechanical lift) manual provided by the facility, reflected, page 2 Warning do not operate this equipment without first reading and understanding this manual. page 3. safety summary Do not attempt any transfer without .thoroughly read instructions in this owner's manual, observe a trained team of experts perform the lifting procedures, and then perform the entire lift procedure, several times with proper supervision and a capable individual acting as a patient .always use the color coded strap standing sling closest to the patient while still maintaining patient stability and comfort .bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. Do not exceed maximum weight limitation . Review of Resident #16's Nurse Aide Care Guide revealed, Transfers, Hoyer lift - Use large sling (green trim). On 4/13/16 at 2:15 PM, Resident #16 was observed being transferred from the bed to the wheel chair by a mechanical lift with the assistance of Certified Nurse Aide (CNA) D and Registered Nurse (RN) C. CNA D was observed to place the full body lift sling (sling had blue ribbon around perimeter) under Resident #16. CNA D advised RN C to the upper body they attached the top light blue second loop, (not loop closest to the resident) and to the lower body they attached the closest loop (dark blue). It was then noted Resident #16 was not positioned over the chair in an upright position, when staff continued to lower the lift down, causing the chair to potentially tip and Resident #16 to fall to the floor. This Surveyor requested the staff to stop the lift transfer and requested that Resident #16 be repositioned over the seat of the wheel chair and held in an upright position. It was observed during the transfer there was no manufacture tag or model number present to identify the type, weight limit or model number on the sling. Staff were observed to use the blue ribbon sling instead of the green ribbon sling as indicated on the nurse aide care guide. During an interview on 4/13/16 at 2:30 PM, when asked if she had been trained or completed competency evaluation for the use of the mechanical lifts, CNA D stated, No. Review of CNA D's competency evaluation dated 3/8/16 revealed there was no mechanical lift on the competency training form. During an interview on 4/13/16 at 2:30 PM, when asked if she had been trained on the use of the facility mechanical lifts and slings, RN C stated, I have not had any training. During an Interview in the Physical Therapy Room at 3:40 PM, Resident #16 was observed sitting on a full body sling, when asked, therapy staff Physical Therapist Assistant (PTA) E and Occupational Therapist (OT) F both agreed the colors on the loops of the sling were difficult to determine and they only knew what color they were as they were familiar with the sling and agreed they were faded. Both agreed the manufacture instructions were missing from Resident #16 sling. (# ) On 4/14/16 at 1:05 PM, Certified Nurse Aide (CNA) R and CNA S were observed to transfer Resident #16 with a mechanical lift (Hoyer) from the wheel chair from the middle of the resident room in to the commode into the bathroom. The sling was placed behind resident and was folded in the back of resident. Resident was transferred with the lift sling inaccurately in place under the resident across the room across the threshold of the bathroom and into the bathroom. CNA S had to remove a shower chair out of the bathroom to accommodate the sling in the bathroom, while Resident #16 was hanging in the sling, in the bathroom. CNA S then proceeded to pull at Resident #16 pants and brief that were under the sling while resident was suspended above the commode. Resident was then lowered down to the commode without paying attention to Resident's scrotum and penis potentially causing injury, when this surveyor requested they stop and reposition the commode. Resident #16 was then returned back by Hoyer lift without being dressed, from the commode to the bed. CNA R had difficulty raising the bed, CNA S had difficulty clearing the legs of the sling under the bed, causing the lift to hit the bottom of the bed. This process was repeated three times before the bed was cleared and Resident #16 was lowered to the bed. Resident #16 was dressed and then CNA R and CNA S used the Hoyer to transfer Resident #16 from the bed to the wheel chair. CNA S once again did not clear the area prior to moving the Hoyer and rolled over the call light and nebulizer tubing. Resident #16 was transferred to the wheel chair and the arm of the Hoyer during the transfer came very close to hitting Resident #16 in the face. ( ) On 4/14/16 at 9:30 AM, on the end of 300 hall on a small table there was a pair of scissors left unattended between room 306 and 307. Unit Manager J was asked what concern the scissors would be for residents on the unit and responded, Safety. ( )

This citation has two deficient practice statements, A and B. Deficient Practice Statement A Based on interviews and record review, the facility failed to, 1) follow their own policy and procedure (Pressure Ulcer Prevention, Management, and Staging, Policy Number 1473, revised 6/2015) to document pressure ulcer status, weekly, and 2) provide pressure ulcer care as ordered by the attending physician, for 1 of 3 residents (Resident #1) reviewed for pressure ulcer care issues, from a total of 10 residents sampled, resulting in missed assessments, treatments and the potential for deterioration in medical condition. Findings include: The facesheet revealed Resident #1 was a [AGE] year old man who was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Sets dated 11/28/2015, Resident #1 was cognitively intact, but required extensive to total assistance with activities of daily living (ADL's). According to the Wound Assessment Record dated 10/9/2015 (untimed), Resident #1 was identified with presence of a Stage 2 pressure ulcer of the left buttocks, for which the attending physician ordered treatment. Review of the facility's policy and procedure,Pressure Ulcer Prevention, Management, and Staging, Policy Number 1473, revised 6/2015, specifies under entry (2) If the guest is identified as having a pressure sore at the time of admission, or at any time following admission, the individual's skin will be assessed weekly. The policy/procedure continues under entry (10)The licensed nurse and/or physician will document the following pressure ulcer information during the initial evaluation and weekly: size, location, depth, stage, exudate, wound bed, description of surrounding tissues, and pain. Review of Resident #1's Wound Assessment Records reveal assessments, as specified in the facility's policy and procedure,Pressure Ulcer Prevention, Management, and Staging, were completed for the following dates: 10/9/2015, 10/15/2015, 10/21/2015, 11/4/2015, 11/10/2015, 11/18/2015, 11/25/2015, 12/2//2015, and 12/9/2015; there were no further assessments documented, either on the Wound Assessment Records, the Progress notes, or elsewhere in the Resident's medical file (including e-record's) as identified by DON B on 2/3/2016 at 3:35 PM, for the period after 12/9/2015 until January 26, 2016 (i.e 47 days passed between assessments). During an interview on 2/3/2016 at 3:35 PM, director of Nursing B said, There were no wound measurements done for December 2015 into January 2016 because our wound care nurse left, and the third shift staff, who do the wound care, were not aware that they needed to do the assessments as well and document it. All this came to my attention about 2 weeks ago. Review of the Physician orders [REDACTED].#1 was to receive cleansing of his left buttocks wound, then application of a DuoDerm dressing for treatment of [REDACTED]. According to the Treatment Administration Record (TAR) for January 2016, Resident #1 did not receive pressure ulcer care, as ordered by his attending physician, for the date 1/28/2016. The Resident was provided pressure ulcer care on 1/25/2016, and then again on 1/31/2016, a lapse of 6 days. During an interview on 2/4/2016 at 2:40 PM, Director of Nursing B said it was her expectation that policies and procedures were followed, and physician orders [REDACTED]. Deficient Practice Statement B Based on observation, interview, and record review, the facility failed to monitor and assess the ongoing status of a pressure ulcer for one resident (#8) out of 3 residents reviewed for pressure ulcer care in a sample of 10 residents resulting in the potential for an unreported decline in the condition of the pressure ulcer. Findings include: According to the Admission Record, dated 2/4/2016, Resident #8 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Assessment, dated 12/17/2015, identified the presence of a stage two pressure ulcer that measured 1.5 centimeters (cm) by 1.5 cm. on Resident #8's coccyx. The Admission Assessment form, dated 12/17/2015 defined a stage two pressure area as a wound with partial thickness loss of the skin presenting as a shallow open ulcer with a red pink wound bed, without slough. An unstageable wound was defined as having full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The Minimum Data Set Resident Assessment (MDS), dated [DATE], indicated Resident #8 had an unstageable pressure ulcer measuring 5.5 cm. by 2.0 cm. On 2/4/2016 at 11:45 am, Licensed Practical Nurse (LPN) Staff K was observed as she performed wound care for Resident #8 while the resident was laying in her bed. Resident #8 was observed to have an open area on her coccyx with a beefy red wound base. No measurements were performed by LPN Staff K at that time. The Skin Integrity forms for Resident #8 had the following entries: 12/22 coccyx duoderm in place (note- a duoderm is a type of dressing.) 12/29 wound to Bil (both) buttocks non-healing yellow/red tissue 1/5 wound to buttocks 1/11/16 wound to buttocks noted 1/18/16 no new skin issues 1/25/16 wound to buttock 3.0 cm. x 2.0 cm 2/1/16 coccyx whole are 4 x 2 1/4 cm. wound 3 cm x 2 1/4 0.25 wound bed beefy red During an interview with the Director of Nursing, Staff B, on 2/4/2016 at 1:45 pm, she stated that there were no additional documents for wound assessments or measurements for Resident #8. Review of the facility's policy and procedure,Pressure Ulcer Prevention, Management, and Staging, Policy Number 1473, revised 6/2015, specifies under entry (2) If the guest is identified as having a pressure sore at the time of admission, or at any time following admission, the individual's skin will be assessed weekly. The policy/procedure continues under entry (10)The licensed nurse and/or physician will document the following pressure ulcer information during the initial evaluation and weekly: size, location, depth, stage, exudate, wound bed, description of surrounding tissues, and pain. ( )

This citation pertains to intake number MI 193. Based on observation, interviews, and record review, the facility failed to prevent falls for 1 of 4 sampled residents (Resident #102) reviewed for fall risk from a total sample of 4, resulting in Resident #102 experiencing a fall with left frontal supraorbital, left lateral orbital margin, and left prezygomatic hematoma (facial swellings filled with blood), pain, septal deviation, and hospitalization under Trauma services. Findings include: Resident #102 no longer resided at the facility during the complaint investigation dated 4/22/2015. The facesheet revealed Resident #102 was a [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Fall Risk assessment dated [DATE], Resident #102 was identified at risk for falls. According to the Minimum Data Sets ((MDS) dated [DATE], Resident #102 was severely cognitively impaired, and required extensive assistance from facility staff with activities of daily living (ADL's), including transfers (movements from surface to surface). The Resident Kardex, (utilized by certified nurse aides) dated 4/6/2015, specified Resident #102 required extensive assistance of a staff member with transfers. The facility policy/procedure for transfers revised 8/2012, and provided to the State Surveyor on 4/20/2915 at 11:10 AM by the Director of Nursing as the current policy/procedure utilized by facility staff, states . use a gait belt unless guest is independent. Gait belts must be used when transferring any guest unless you are using a lift. Guests should not be lifted by placing hand under their arm/shoulder. According to the Investigative Analysis, dated 4/20/2015 (untimed), on 4/8/2015 at 12:15 PM, Resident #102 was taken to the bathroom by CNA K. Once the Resident had finished using the restroom, CNA K had the Resident stand and hold the bar on the wall next to the toilet. The CNA provided peri-care and pulled the Resident's pants up. The Resident started to sit then leaned to the left. The CNA attempted to stop the Resident from falling, wrapped his arms around the resident's waist; both CNA and Resident went to the floor. The Resident hit the left side of his face, resulting in a laceration to the lateral side of the left orbit (eye socket area). The Resident was sent to the emergency room for possible sutures and a follow up CT scan. It was identified in the report that CNA K had failed to utilize a gait belt, as specified in the facility's policy/procedure for transfers. During an interview on 4/20/2015 at 11:10 AM, Registered Nurse I said she had responded to Resident #102's fall on 4/8/2015 at 12:15 PM; she acknowledged that Resident #102 was not wearing a gait belt. During an interview on 4/20/2015 at 11:25 AM, CNA K said, He (Resident #102) didn't have a gait belt on (4/8/2015 at 12:15 PM); he was supposed to have one on with transfers. I carry one with me at all times. I don't know why I didn't put it on him. He was supposed to be a one-person assist with use of a gait belt. His head hit the side of the wall, on the left side of his head. His left face then went to the floor of the bathroom. During an interview on 4/20/2015 at 12:35 PM, the Director of Nursing said, That Resident (Resident #102) had a fall on 4/7/2015; that was his first fall. His second fall was on 4/8/2015 at 12:15 PM. It took place in his bathroom. His gait belt wasn't in use. Or policy/procedure is to use a gait belt, and this resident should have had his belt on. On 4/21/2015 at 6:30 AM, an unsampled Resident, witness M, was observed seated on the toilet in his bathroom by the State Surveyor; he was not wearing a gait belt. Witness M told the State Surveyor that the CNA who had placed him on the toilet had not utilized a gait belt, but instead had placed her hand under his arm to transfer him from his wheelchair to the seat of the toilet. The CNA returned to the bathroom within minutes, seeing the State Surveyor present, and removed a walkie-talkie which was clipped to the gait belt she wore around her own waist, and preceded to place the gait belt on the Resident (witness M) to transfer him from the seat of the toilet to the Resident's wheelchair. During an interview on 4/21/2015 at 7:10 AM with witnessN, and on 4/21/2015 at 7:20 AM with witness O, both unsampled Residents said they had not had facility CNA's provide assistance with use of gait belts, for transfers; they said CNA's had lifted them by placing hands under their arms and shoulders. According to the hospital Discharge Summary form dated 4/13/2015 at 10:39 AM, Resident #102 sustained the following facial injuries: post-traumatic left frontal supraorbital, left lateral orbital margin, and left pre-zygomatic hematoma, and moderate nasoseptal deviation to the right. The patient (Resident #102) was admitted to Trauma.

This citation pertains to intake MI 852. Based on interview and record review, the facility failed to monitor and titrate the blood level of an IV (intravenous) antibiotic ([MEDICATION NAME]) administered to one resident (#105), out of two residents reviewed for intravenous antibiotic administration, from a total sample of nine residents, resulting in Resident #105 experiencing [MEDICATION NAME] toxicity and developing acute [MEDICAL CONDITION], acute [MEDICAL CONDITION] (dangerously elevated potassium levels) and acute [MEDICAL CONDITION] (abnormally slow heart rate), placing the resident in immediate jeopardy to her safety, with harm sustained to her health, and increased risk of death. The immediate jeopardy began on 7/5/14 at 7:30 p.m. when Resident #105 was admitted directly from the hospital to the facility and received her first dose of intravenously administered [MEDICATION NAME], 1250 mg (milligrams) at the facility. According to physician orders dated the date of her admission, [MEDICATION NAME] was to be administered to Resident #105 every 12 hours. According to the facility's medication administration records (MAR) for July, 2014, the first dose of the intravenous [MEDICATION NAME] was administered on 7:30 p.m. on 7/5/14 and continued for 8 days, for a total of 16 doses. On 7/13/14 at 13:16 (1:16 p.m.), the facility's electronic Medication Administration Note revealed Resident #105 was vomiting and complaining of continued nausea. On 7/14/14 at 11:14 a.m., Progress Notes stated: "MD (medical doctor) in facility and consulted with guest (resident). Will monitor." According to the Laboratory Summary, dated, 7/14/14, the following tests were ordered by the consulting physician: "cbc (complete blood count), cmp (comprehensive metabolic panel) crp (c-reactive protein) on cardiac - one time only for 1 day" with a start date of 7/15/14. The laboratory work was not ordered "stat" (immediate). The laboratory work was completed on 7/15/14, 10 days after Resident #105's admission tot the facility. There were no other laboratory tests in Resident #105's facility medical record prior to 7/15/14. Resident #105's Progress Notes stated: "Guest to be transferred to ER (emergency room ) for evaluation and TX (treatment). Guest has increased K+ (potassium) 6.7 and increased Cr (Creatinine) 7.1. Dx (diagnosis) Acute [MEDICAL CONDITION] d/t (due to) Vanco ATB (antibiotic) therapy." Resident #105's hospital physician dictation, dated 7/15/14, stated: "...Final Impression: 1. Acute [MEDICAL CONDITION]. 2. Acute [MEDICAL CONDITION]. 3. Acute [MEDICAL CONDITION]." The immediate jeopardy was identified at approximately 10/24/14 at 9:00 a.m. The Administrator and Corporate Liaison "G" and Director of Compliance "I" were notified on 10-24-14 at 1:30 p.m. of the immediate jeopardy, due to the facility's failure to monitor and titrate the blood level of the antibiotic ([MEDICATION NAME]) prescribed to Resident #105. The facility's deficient practice placed all other residents who were prescribed intravenous antibiotics, and/or other medications requiring stringent clinical monitoring, at increased risk for potentially life-threatening adverse side effects of medications. One other resident (#106) was identified as receiving [MEDICATION NAME] at the time of survey in the facility census of 55 residents. Finding Include: Review of the facility Admission Record for Resident #105, dated 10/24/14, and the Minimum Data Set ((MDS) dated [DATE], revealed Resident #105 was a [AGE] year old female, admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the History and Physical, note dated 7/6/14 by Resident #105's physician, stated Resident #105 was "...Transferred from acute hospital with urinary tract infection after continuation of her I.V. (intravenous) antibiotics therapy." Review of the facility MAR, for 07/01/2014 - 07/31/2014, revealed Resident #105 received [MEDICATION NAME] HCL Solution, 1250 mg intravenously every 12 hours, for UTI. An entry on the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #105's last dose of the intravenous antibiotic [MEDICATION NAME] was on 7/13/14 at 7:30 a.m. Resident #105 received a total of 16 doses of [MEDICATION NAME] 1250 mg at the facility. Review of the discharging hospital's Patient Discharge Instructions dated 7/5/14 for Resident #105 revealed [MEDICATION NAME] 1250 mg every 12 hours with a start date of 7/3/2014 (while still in the hospital) and a stop date of 7/13/2014. The Patient Discharge Instructions dated 7/5/14 also stated: "[MEDICATION NAME]-Pharmacy to Dose." Review of the facility Pharmacy Requisition dated 7/6/14 for Resident #105 revealed a list of medications, dosages and frequencies, which included the antibiotic [MEDICATION NAME], a therapy treatment plan, the amount of juice the resident needed to drink, and how often vital signs (blood pressure, pulse, respiration and temperature) should be taken, but did not include the order for Pharmacy to Dose the [MEDICATION NAME]. Review of the facility's Order Summary Report dated 7/1/2014 - 7/31/2014 for Resident #105 revealed a Laboratory Order Summary with only one blood test ordered, a PT/INR ([MEDICATION NAME]/international ratio) for the medication [MEDICATION NAME]. There were no laboratory tests scheduled, such as a [MEDICATION NAME] peak (indicator of the highest level of antibiotic in the blood) or trough (indicator of the lowest level of antibiotic in the blood) or a CMP (comprehensive metabolic panel), pertinent to the antibiotic [MEDICATION NAME] or the effects of that medication on the resident's body. Review of Resident #105's laboratory test results (blood work dated 7/1/14, prior to leaving the hospital) revealed her laboratory indicators for kidney function were within normal range. The resident's Blood Urea Nitrogen (BUN) was 22 mg/dL (milligrams per deciliter); normal results range from 7 to 22. Her Creatinine (Cr) was 0.79 mg/dL, with a normal range of 0.50 to 1.50 mg/dL; and her Potassium (an electrolyte that controls the rate and force of contraction of the heart and cardiac output) was 3.9 mmol/L, with a normal range of 3.5 to 5.0 mmol/L. Notably, Resident #105's laboratory results dated [DATE], obtained prior to hospital discharge, for a [MEDICATION NAME] trough was 11.0, with an "H" meaning High; normal results are 5.0 to 10.0 ug/mL. Review of the facility's electronic Medication Administration Note revealed, on 7/13/14 at 13:16 (1:16 p.m.), Resident #105 was vomiting and complaining of continued nausea. On 7/13/14 at 13:20 (1:20 p.m.), a facility Infection Note revealed: "Resident #105 had finished IV vanco ([MEDICATION NAME]) for UTI this shift. Guest complaining of dizziness and weakness that subsided this A.M. About 12 pm guest complained of nausea. Ginger ale was given but guest started to vomit. Will continue to monitor." Further review of the facility's electronic Progress Notes revealed Resident #105 continued to have nausea and vomiting on 7/13/14 and 7/14/14. Resident #105's Progress Notes failed to reveal that facility nursing staff had notified Resident #105's physician of her nausea and vomiting. On 7/14/14 at 11:14 a.m. Progress Notes stated: "MD (medical doctor) in facility and consulted with guest. Will monitor." According to the Laboratory Summary, dated, 7/14/14, the following tests were ordered by the consulting physician: "cbc (complete blood count), cmp (comprehensive metabolic panel) crp (c-reactive protein) on cardiac - one time only for 1 day" with a start date of 7/15/14. The laboratory work was not ordered stat (immediate). On 7/15/14 at 10:53 (a.m.), ten days after her admission to the facility, Resident #105's Progress Notes stated, "Guest to be transferred to ER (emergency room ) for evaluation and TX (treatment). Guest has increased K+ (potassium) 6.7 and increased Cr (Creatinine) 7.1. Dx (diagnosis) Acute [MEDICAL CONDITION] d/t (due to) Vanco ATB (antibiotic) therapy." Review of hospital emergency room physician progress notes [REDACTED]. This is new for this patient. Apparently, she has a recent history of [MEDICATION NAME] ten-day course [MEDICAL CONDITION] UTI. No other factors were identified that should contribute to this patient's [MEDICAL CONDITION]." The progress note continued to state that the patient (Resident #105) was immediately moved to the emergency room Resuscitation Bay room. The patient had defibrillator paddles placed and maintained throughout her stay in the ED (emergency department). The progress notes stated: "...She recently had normal renal function during her hospital stay, which was several days ago." Resident #105's hospital emergency room physician dictation dated 7/15/14 stated: "...Final Impression: 1. Acute [MEDICAL CONDITION]. 2. Acute [MEDICAL CONDITION]. 3. Acute [MEDICAL CONDITION]." According to "The Drug Information Handbook for Nursing (Lexicomp, 8th edition), "accumulation and toxicity are a risk in the elderly. Careful monitoring and dose adjustment is necessary ...because of its long half-life, [MEDICATION NAME] should be dosed on an every 12 hour basis ..." On 10/23/14 at 11:45 a.m. an interview was conducted with the facility's Director of Nursing, Assistant Director of Nursing "H" and Administrator. Resident #105's recent stay at the facility and hospital admission were discussed. The facility's procedure for notifying the pharmacy of new orders was discussed. It was explained that the facility would fax the discharge instructions to the pharmacy after they were reviewed by the physician. It was explained that the pharmacy gave the orders for laboratory tests, including [MEDICATION NAME] peak and trough levels. When asked if anyone in the facility had called the pharmacy to ask about dosing the [MEDICATION NAME] for Resident #105, the administrator said no one had called the pharmacy. When asked about the facility policy for monitoring blood levels for [MEDICATION NAME] dosing, the Director of Nursing said the pharmacy policy was to check residents' blood work before the fourth dose. When asked who was responsible to check for completion of medication monitoring and laboratory tests, the administrator responded that they did not have a person specifically assigned to over see medications and lab work. During a telephone interview on 10/23/2014 at 2:40 p.m. the facility's consulting pharmacy was called, and this surveyor spoke with pharmacist "F". When asked if the pharmacy managed the residents receiving [MEDICATION NAME] in facilities, Pharmacist "F" said they did not do it for every resident. Pharmacist "F" explained that some facilities had doctors who liked to monitor their own medications and some facilities had an infectious disease doctor who managed the medications. When asked why the pharmacy did not monitor the [MEDICATION NAME] in Resident #105's case (when the hospital discharge instructions stated, "Pharmacy to Dose"), Pharmacist "F" said those orders were the hospital's discharge orders, and the Pharmacy needed the orders specifically from the facility. Pharmacist "F" said he had reviewed the orders from the facility, and the orders did not include an order to dose the [MEDICATION NAME]. Review of the facility policy Medication Monitoring, undated, stated: "...1. therapeutic medication monitoring is done so that effective therapeutic levels of a medication can be determined, and to prevent toxicity...2. The Physician or Pharmacist will determine frequency of laboratory testing." The immediate jeopardy was abated on 10/27/14 at 10:00 a.m. based on this surveyor's confirmation of the following: 1. Resident #105 no longer resides in the facility. Resident #105 was transferred to the hospital on [DATE]. 2. On 10/23/2014, the facility's MDS Coordinator performed an assessment of each resident receiving intravenous [MEDICATION NAME]. The facility currently has one resident (#106) receiving intravenous [MEDICATION NAME]. The assessment for that resident included an evaluation of whether "pharmacy to dose" orders were present, whether laboratory tests for monitoring therapeutic medication levels were obtained correctly, whether nursing staff were recording levels and were familiar with the therapeutic range for the medication, and if the resident was free of any adverse medication side effects. The audit revealed that proper monitoring of the [MEDICATION NAME] was in place. The chart of the guest receiving the medication was reviewed to ensure a plan of care was also implemented. 3. On 10/27/2014 the MDS Coordinator will perform a review of each resident to identify who is currently receiving a medication that requires therapeutic monitoring, such as the anticoagulant medication [MEDICATION NAME]. The MDS Coordinator will review to ensure laboratory monitoring orders are in place. If any resident does not have monitoring orders in place, the MDS Coordinator or designee will contact the physician to obtain the orders. 4. The infection control nurse or designee will review each resident's physician's orders upon admission to identify anyone who is receiving [MEDICATION NAME] or other medication requiring therapeutic monitoring, such as [MEDICATION NAME]. 5. Once the infection control nurse identifies a resident as receiving [MEDICATION NAME], or any other medication requiring therapeutic monitoring, s/he will also check to identify if orders are also present for laboratory monitoring. In addition, if the medication being monitored is [MEDICATION NAME], the infection control nurse will ensure the order clearly states "pharmacy to dose." If any necessary order is not in place, the infection control nurse will contact the physician to obtain orders for "pharmacy to dose" and any necessary laboratory monitoring. Once the orders are obtained, they will be immediately faxed to pharmacy. 6. Between 10/23/2014-10/24/2014, the MDS Coordinator and afternoon supervisor conducted face-to-face inservicing with facility nurses. The inservice covered ensuring dosing orders were present for [MEDICATION NAME], symptoms of [MEDICATION NAME] toxicity, and requirements of therapeutic monitoring for intravenous [MEDICATION NAME]. As of 10/24/2014 at 4:10 p.m., 26 of 27 nurses had received the education face-to-face. One nurse received the education via telephone from the MDS Coordinator, completing inservicing for 27 out of 27 nurses. 7. As of 10/23/2014 the MDS Coordinator initiated weekly chart audits of residents receiving intravenous [MEDICATION NAME]. The infection control nurse or designee will continue weekly audits to ensure compliance. The infection control nurse or designee will report the findings to the Director of Health Services and the Administrator/General Manager. Those findings will be submitted to the facility Quality Assurance Committee. The Quality Assurance Committee will determine further follow up and review. The facility administrator is responsible for attaining and maintaining compliance with this regulation. Although the immediate jeopardy was removed on 10/27/14, the facility remained out of compliance at a scope and severity of an isolated potential for more than minimum harm pending the facility's ability to sustain compliance as verified by the State Agency. ( )

This citation pertains to intake MI 584. Based on interview and record review, the facility failed to provide adequate and appropriate care to prevent weight loss and assess and monitor medications that affect weight loss for 1 (Resident #500) of 4 sampled residents of a total sample of 4, and failed to follow policies related to (1) a decrease in [MEDICATION NAME] dosage (antianxiety medication) and (2) intervening after a rapid weight loss, resulting in increased anxiety, decreased appetite with significant weight loss and a high potential for decline in overall health and psychosocial wellbeing. Findings Include: Review of the face sheet, Minimum Data Set (MDS, resident assessment tool) dated 6/25/13, History and Physical dated 6/3/13 and Hospital records dated 6/3/13, 6/4/13 and 6/5/13, revealed Resident #500 was admitted to the facility on [DATE] for short term rehabilitation services after having abdominal surgery due [MEDICAL CONDITION]. He was alert and able to make his own decisions and dependent on staff for assistance with ambulation and personal care. The resident's [DIAGNOSES REDACTED]. Resident #500 was discharged home on[DATE]. Weight Loss: Review of the hospital [MEDICATION NAME] consultation dated 6/5/13, stated "he (Resident #500) appeared anxious, the patient came in with nausea and vomiting which has been present for about a week. I think this is because of his anxiety which has been heightened by the fact that he was recently diagnosed with [REDACTED]. Review of the hospital records dated 6/3/13; revealed resident #500 had received [MEDICATION NAME] 1 mg in a.m., noon and p.m. for a total of 3 mg daily, [MEDICATION NAME] XL 150 mg daily (medication for depression) and [MEDICATION NAME] 20 mg 3 times daily (medication for depression) at the hospital. Review of the facility hospital inter-agency referral form dated 6/18/13, revealed the resident had "intractable nausea and vomiting". Review of the initial (upon admission) Dietary Care Plan interventions dated 6/18/13, revealed the resident had a "diet as ordered, dietary consult prn (would be done as needed), was encouraged to eat, labs per orders, medications per ordered, food acceptance would be done for 14 days and Provide (a nutritional supplement for low protein level) would be given 2 times per day. Review of the facility admission Nursing assessment dated [DATE], revealed the residents weight was "242.4 lbs" and he had a history of [REDACTED]. Review of the facility Weight and Vital Signs Record (un-dated) and Weekly Weight sheet dated 6/18/13, revealed the residents weight upon admission was "242.4 lbs". Review of the facility lab dated 6/18/13, revealed the residents [MEDICATION NAME] level (protein, needed for healing, post surgical) was "1.3" (normal=3.5-4.8). Review of the facility Weight sheet dated 6/24/13 (6 days after admission to the facility); the resident's weight was documented as "221.2 lbs", a 21.2 lb loss from admission (8.7%). Review of the Weight sheet dated 7/1/13 (13 days after admission) revealed his weight was "212 lbs", a total of 30.4 lb loss,12.5% (since admission, a significant weight loss). Review of the facility Speech Evaluation and Plan of Treatment dated 6/19/13 revealed the resident had been diagnosed with [REDACTED]. Review of Physician diet order dated 6/18/13, revealed the resident received a "mechanical soft diet with thin liquids". Review of the diet order dated 6/20/13, revealed the resident received a "mechanical soft renal diet". Review of the diet order dated 6/27/13, revealed the resident received a "mech (mechanical) soft" diet. Review of the Food Acceptance Record dated 6/18/13 through 7/2/13, revealed the resident had eaten 25%-50% or refused to eat for a total of 22 meals on 11 consecutive days (not including admitted ), without any documented substitutions offered or other foods taken. Review of the facility Weight Loss program educational material (un-dated) stated "if guests (residents) eat 50% or less of meal offer substitutes". Review of the nurse's notes dated 6/19/13 through 7/2/13, revealed no documentation of extra meals or meal substitutes being offered to Resident #500. Review of nurses notes dated 6/19/13 through 7/1/13, revealed a total of 3 days (6/25/13, 6/28/13 and 6/29/13), of documentation regarding the resident having nausea when he smelled foods, decreased appetite and refusing to eat. No documentation was found in the nurses notes of a dietary assessment (food likes/dislikes, when nauseated, amount of food able to consume at one time, preference of times to eat, if any assistance needed, what time of day Resident #500 had symptoms of nausea/vomiting, position of resident when nauseated, depression, anxiety or medication side effects, non-pharmalogical interventions), monitoring of weight with follow-up regarding food acceptance records, physician communication regarding dietary concerns or dietary referrals made. Review of the nurse's notes dated 6/28/13, stated "appetite has been poor, guest (c/o (complain) nausea when he smells food", order obtained for [MEDICATION NAME] 4 mg every 6 hours as needed (medication for nausea), with no documentation of assessment for medication effectiveness found. Review of nurse's notes dated 6/29/13, stated "guest cont. (continued) to ref (refuse) to eat". Review of nurse's notes dated 7/1/13, stated "appetite cont. to be poor". Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the facility Food Acceptance Records policy dated 8/04, #1346 stated "If nutritional intake is less than fifty percent for seven meals or less within a one week period (without substitutions) and 5% weight loss in 30 days or 10% weight loss in 6 month, a preventive nutritional program will be instituted. If the guest consumes less than fifty percent of 6 consecutive meals and significant weight loss physician is to be notified". Review of the closed clinical record revealed no documentation that a preventive nutritional program had been instituted, no up-dated interventions were added to the initial Dietary Care Plan dated 6/18/13 and no comprehensive dietary care plan had been developed, just the initial care plan upon admission. Review of the facility Communication of Weight Concerns policy dated 12/09, #1383 and #7040 revealed if a resident has a confirmed 3 pound weight loss the charge nurse fills out a "weight concern sheet" and notifies the physician and dietician, the physician and dietician chart on the condition in the medical record and recommend appropriate changes to the plan of care and the dietary care plan is to be up-dated. Review of the residents closed clinical record revealed no documentation of the physician, dietician or dietary manager being notified or consulted regarding dietary concerns or weight loss. Review of the physician progress notes [REDACTED]. Review of the initial dietary assessment dated [DATE], revealed the resident had poor fitting dentures, [MEDICATION NAME] level was "1.3" and had his weight was documented as "221.8 lbs", a loss of 20.6 lbs since admission (a total of 7 days). No documentation of physician communication or dietary referrals was found. Review of the physician orders [REDACTED]. An interview was done on 8/19/13 at 12:10 p.m., with Dietary Manager #1. Dietary Manager #1 and the surveyor reviewed the complete closed clinical record and no documentation of dietary notes other than the initial dietary assessment (dated 6/25/13), no interdisciplinary notes regarding weight loss and no physician communication or dietary referrals were found regarding the residents weight loss. Dietary Manager #1 stated "I did not know anything about the resident's weight loss until 7/1/13 (the day before he was discharged ) and I did not know his weight was 242.4 lbs upon admission, he should have had dietary follow-up". An interview was done on 8/19/13 at 3:30 p.m., with Assistant Director of Nursing (ADON) RN #1. ADON RN #1 stated "they should document weight changes and interventions on the care plan (dietary care plan), our dietary manager monitors resident's weights. We (facility management) discuss loss or gains in our stand-up meetings". ADON RN #1 was unable to remember if the team had discussed Resident #500 in the stand-up meetings. An interview was done on 6/20/13 at 12:33 p.m., with the DON #1. DON #1 stated "there should have been follow-up with documentation". An interview was done on 8/20/13 at 10:40 a.m., with Nurse Manager RN #1. Nurse Manager RN #1 stated "there should have been a more specific care plan, a real hard copy" regarding the residents weight loss. A phone interview was done on 8/20/13 at 9:18 a.m., with Resident #500 and Family member #1. Resident #500 said he could not eat because of his depression and high anxiety, he did not want to leave his room or eat anything and the facility had decreased his [MEDICATION NAME] and [MEDICATION NAME] medications which he had been on for [AGE] years, without his consent. The resident stated "when I got up in the morning, I would throw-up. The dietary department didn't ask me why I did not eat or drink my ensure". Family member #1 confirmed the resident was depressed and had high anxiety and due to this was unable to eat and that she had ask staff several times to put the dose of his [MEDICATION NAME] back to what he took at home. Family member #1 stated "they need to listen to the family". [MEDICAL CONDITION] Medications: Review of the hospital consultation dated 6/5/13, revealed Resident #500 was on [MEDICATION NAME] and [MEDICATION NAME] at home and stated "he appeared anxious, background history of anxiety and depression". A phone interview was done on 8/20/13 at 9:18 a.m., with Resident #500 and Family Member #1 (responsible party). Resident #500 and Family Member #1 both said the resident had been on [MEDICATION NAME] 20 mg 3 times daily and [MEDICATION NAME] 1 mg 3 times daily at the hospital and at home prior to admission. Family Member #1 stated "I gave them (SW #1) (Resident #500's physiatrist) phone number, she (SW #1) never got back with me. He had been on the psych med's ([MEDICAL CONDITION] Medications) for [AGE] years for anxiety and depression; he has not been able to work at all. I am very up-set they just changed his med's (the [MEDICATION NAME] and [MEDICATION NAME] medications) like that. She (SW #1) wanted him to stay, I said no". Review of the Mental Illness/Mental [MEDICAL CONDITION]/Related Conditions Identification screening dated 6/13/13, revealed the resident had been diagnosed with [REDACTED]. Review of the MDS dated [DATE], revealed the resident had symptoms of feeling down for 2 to 6 days and feeling bad about himself for 7 to 11 half or more days, was diagnosed with [REDACTED]. Review of the facility Patient Health Questionnaire dated 6/25/13, revealed the resident had been feeling down, depressed or hopeless for several days and was feeling bad about himself more than half the days at the facility. Review of the Activity assessment dated [DATE], revealed documentation that the resident was "anxious". Review of the facility Mood/Behavior Care Plan (un-dated) done upon admission per interview with Social Worker #1 on 8/19/13 at 4:00 p.m., revealed facility staff were to chart to reflect improvements/declines and variations in mood or behavior stability and staff were to observed for variances or declines in the residents mood and reported any to the physician for evaluation and intervention. Review of the Hospital discharge physician medication orders dated 6/18/13; revealed Resident #500 was to receive [MEDICATION NAME] 150 mg daily, [MEDICATION NAME] 20 mg 3 times per day and [MEDICATION NAME] 1 mg a.m. and p.m. and at noon. The total dose of [MEDICATION NAME] was 3 mg per day, a routine medication. Review of the facility admission orders [MEDICATION NAME] 1 mg po (oral) BID (2 times per day)". Review of the MAR indicated [REDACTED]. An interview was done on 8/20/13 at 10:40 a.m., with Nurse Supervisor RN #1. Nurse Supervisor RN #1 said she had done the residents admission on 6/18/13 and had transcribed all medication orders. When the surveyor asked why the dose of [MEDICATION NAME] was not what was the same dose that was on the hospital orders, she said the facility had just gotten cited in 5/13 for over use of [MEDICAL CONDITION] medications and the facility could not go over 2 mg dose of [MEDICATION NAME] in 24 hours. Nurse Supervisor RN #1 said she did not call and inform the resident's physician that she had changed the dose of [MEDICATION NAME] from 3 mg daily to 2 mg daily and explain why she had done this. Nurse Supervisor RN #1 stated "I did not know he was seeing the psych Doctor, I did the admission and I don't remember asking him or (Family Member #1) about his psych med's ([MEDICAL CONDITION] medications) or why he was on them, I should have". Review of the nurse admission notes dated 6/18/13, stated "guest has history of depression, anxiety", with no documentation found regarding decreasing the dose of [MEDICATION NAME] upon admission, mental health history, assessment of why the resident was receiving [MEDICAL CONDITION] medications, if the resident had been under the treatment of [REDACTED]. An interview was done on 6/20/13 at 12:33 p.m., with DON #1. DON #1 stated "we had just got a citation and we were waiting for our re-visit and there was no way we were going to exceed the 2 mg in 24 hours". An interview was done on 8/19/13 at 3:30 p.m., with ADON RN #1. ADON RN #1 confirmed the facility had received a citation in 5/13 regarding [MEDICAL CONDITION] medications usage and said they (nursing staff) had been in serviced not exceed 2 mg of [MEDICATION NAME] in 24 hours. Review of the physician progress notes [REDACTED]. A phone interview was done on 8/20/13 at 12:25 p.m., with Primary Physician #1. Primary Physician #1 said the resident was having symptoms (depression and anxiety) and he wanted to increase his dose of his medications ([MEDICATION NAME] and [MEDICATION NAME]) and he denied being aware that the residents [MEDICATION NAME] had been decreased upon admission by Nurse Supervisor RN #1. Review of the facility Physician orders [REDACTED]. The medications were changed back to what the resident had been taking prior to admission to the facility. Review of the Nurses progress notes dated 6/19/13 through 7/2/13, revealed no documentation of reducing the residents [MEDICATION NAME] upon admission. Review of the MAR indicated 7:30 a.m." on 6/19/13, 6/20/13 and 6/21/13. Review of the Physician orders [REDACTED]. Review of the facility Psychiatric Services notes dated 6/21/13, revealed the resident was kept on [MEDICATION NAME] 20 mg 1 daily and a new order had been written on 6/21/13 (a clarification order). A phone interview was done on 8/22/13 at 8:55 a.m., with the DON #1. The DON #1 confirmed Resident #500 had received [MEDICATION NAME] 20 mg 1 time daily (at 7:30 a.m.) for a total of 3 days. Review of the Medication Error Report Form dated 6/19/13, stated "Date error incident happened, or if unknown, date error was first noted, 6/19/13". DON #1 confirmed per phone interview done on 6/22/13 at 8:55 a.m. that Resident #500 did not receive his [MEDICATION NAME] medication per the facility admission order for 3 times daily, until 6/21/13 and said that a "nurse from first shift" had identified the medication error on 6/19/13. DON #1 confirmed the facility was aware of the medication error on 6/19/13 and it was not corrected until 6/21/13. Review of the facility Reduction of [MEDICAL CONDITION] Medication policy dated 2/05, #1310, stated "Facility psychiatrist will receive a list of all guests receiving [MEDICAL CONDITION] medications, the psychiatrist will complete a consult note on each guest assessed with [REDACTED]. The attending Physician, Director of Health Services and the interdisciplinary team will review the changes made. Families and/or responsible parties and guardians will be notified by the Social Worker of changes in therapy and consent obtained in writing". A phone interview was done on 8/20/13 at 1:02 p.m., with Nurse Practitioner (NP) PHD #1. NP PHD #1 denied the facility had called or communicated to her or the psychiatric services group that they had decreased the residents [MEDICATION NAME] from 3 mg per day to 2 mg per day upon admission to the facility. Review of NP PHD #1's evaluation notes dated 6/21/13, stated "Patient with closed head injury and post traumatic stress following accident at the age of 15". No documentation was found of the change in the dose of [MEDICATION NAME] upon admission to the facility done by Nurse Supervisor RN #1. A phone interview was done on 8/20/13 at 12:27 p.m., with Psychologist PHD #1. Psychologist PHD #1 said "I don't do med's", he did not prescribe medications and was not aware the residents [MEDICATION NAME] had been reduced by the Nurse Supervisor RN #1 upon admission. An interview was done on 8/19/13 at 4:00 p.m., with SW #1. SW #1 confirmed the facility had changed the residents [MEDICATION NAME] to 2 mg when he was admitted and said she had not informed Primary Physician #1, Nurse Practitioner PHD #1 or Psychologist PHD #1 of this change at the time of admission. SW #1 said she had faxed an authorization for release of medical record information to obtain a history regarding psychiatric services and medications to the residents physiatrist on 6/27/13 (9 days after admission to the facility and the change in [MEDICATION NAME] dosage) and again on 6/28/13. SW #1 said she did not attempt to call or follow-up with the resident's physiatrist to inform him of the change or to obtain pertinent mental health history. The surveyor and SW #1 reviewed the residents complete closed clinical record and no Social Service notes or documentation was found except the facility Care Conference Summary dated 6/27/13 (9 days after admission). SW #1 agreed no changes or up-dates had been done on the resident initial Mood Care Plan dated 6/18/13. No documentation of behaviors, changes in mood, changes in levels of anxiety or depression was found in the resident's record. SW #1 said she had put the resident on the Behavioral program and stated "I did not write any notes, the only social worker notes in the chart is on the care conference sheet (dated 6/27/13)". SW #1 stated "I feel I followed what we needed to do, the only thing I did not have is a note". Review of the facility Social Worker job description dated 3/05, stated the social worker was "responsible for all social service responsibilities including charting to ensure proper documentation". Review of the Care Plan Conference Summary dated 6/27/13, stated Resident #500 "was taking 5 mg [MEDICATION NAME] per dose at home, 60 mg [MEDICATION NAME], 150 mg [MEDICATION NAME], under the care of (the resident's physiatrist)". No other documentation of resident interview, assessment of symptoms, medication side effects, mental health history or [MEDICATION NAME] dose change upon admission was found in the summary. Review of the residents Behavioral Intervention Monitoring sheet dated 6/13, revealed no documentation at all under behaviors, interventions, drug side-effects or additional comments and no signatures were on the sheet. Review of the faxed documents dated 6/27/13 and 6/28/13, revealed SW #1 had requested medical information on 6/27/13 from the resident's physiatrist and they had sent her their Medical Release of Information Record to fill out and re-fax back to them, which had been done on 6/28/13. No other documentation was found of the facility or SW #1 attempting to call or communicate was the resident's physiatrist. An interview was done on 8/20/13 at 10:40 a.m., with Nurse Supervisor RN #1. Nurse Supervisor RN #1 stated "the behavioral sheets should have been filled out" and confirmed the [MEDICATION NAME] and [MEDICATION NAME] should have been on the mood care plan as well as medication changes made. ( )

BASED UPON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO INITIATE TIMELY ASSESSMENT, MONITORING AND INTERVENTIONS TO PREVENT PRESSURE ULCER DEVELOPMENT FOR ONE (RESIDENT #6) OF FOUR SAMPLED RESIDENTS REVIEWED FOR PRESSURE SORES FROM A TOTAL SAMPLE OF FOURTEEN RESIDENTS, AND FAILED TO ELEVATE RESIDENTS' HEELS AS ORDERED BY THE PHYSICIAN FOR TWO RESIDENTS (#7 AND #12), RESULTING IN THE DEVELOPMENT OF AN AVOIDABLE UNSTAGEABLE HEEL PRESSURE SORE FOR RESIDENT #6 AND INCREASED POTENTIAL FOR PRESSURE SORE DEVELOPMENT ON THE HEELS FOR RESIDENTS #7 AND #12. FINDINGS INCLUDE: DURING THE REVIEW OF RESIDENT #6'S MEDICAL RECORD, HIS ADMISSION FACE SHEET DOCUMENTED ORIGINAL ADMISSION to the facility on [DATE], WITH A READMISSION ON MARCH 20, 2012. ACCORDING TO THE READMISSION physician's orders [REDACTED]. THE PHYSICIAN ORDERS [REDACTED]. ACCORDING TO A SKIN INTEGRITY NURSING ADMISSION assessment dated [DATE], A DIAGRAM WITH THE LEFT HEEL FOR RESIDENT #6 WAS CIRCLED AND NOTED AS HAVING REDNESS. THE INTERDISCIPLINARY PROGRESS NOTES FROM NURSING DATED MARCH 21, 2012 AT 1:20 P.M. DOCUMENTED PEDAL PULSE PRESENT (INDICATING BLOOD FLOW AND CIRCULATION TO THE FOOT). INTERDISCIPLINARY NURSING PROGRESS NOTES DATED MARCH 22, 2012 AT 6:50 A.M. DOCUMENTED PEDAL PULSE PRESENT BILATERALLY. NURSING INTERDISCIPLINARY PROGRESS NOTES DATED MARCH 25, 2012 (FIVE DAYS LATER) DOCUMENTED RESIDENT #6 HAD DEVELOPED A PURPLE BLISTER AREA TO THE LEFT HEEL MEASURING 2.5 CM (CENTIMETERS) BY 4.5 CM IN SIZE WITH NEW ORDERS OBTAINED. THE physician's orders [REDACTED]. A physician's orders [REDACTED].#6'S LEFT HEEL, ALLOW THE HEEL TO AIR DRY, AND PUT IN THE LEFT HEEL BOOT EVERY SHIFT. BASED ON REVIEW OF THE CLINICAL RECORD FOR RESIDENT #6, THERE WERE NO DOCUMENTED EVALUATIONS OF THE EFFICACY OF THE INTERVENTION PLAN BETWEEN MARCH 20, 2012 AND MARCH 25, 2012 TO PREVENT THE LEFT HEEL REDNESS FROM DEVELOPING INTO A BLISTER. THE REVIEW OF INTERDISCIPLINARY PROGRESS NOTES AND MEDICARE DAILY NURSES NOTES REFLECTED THE FOLLOWING NURSING MONITORING AND ASSESSMENT OF RESIDENT #6'S LEFT HEEL: - 4/1/12 MEDICARE DAILY NURSES NOTES (UNDER THE SECTION "SKIN" "LT (LEFT) HEEL" (ULCER PRESENT) - 4/2/12 MEDICARE DAILY NURSES NOTES SKIN "RT (RIGHT) HEEL" (ULCER PRESENT) AND "1+, 2+" (DEGREES OF PITTING [MEDICAL CONDITION]) PRESENT BILATERAL LOWER EXTREMITIES. - 4/3/12 MEDICARE DAILY NURSES NOTES SKIN "RT HEEL" (ULCER PRESENT) - 4/4/12 MEDICARE DAILY NURSES NOTES SKIN "RT HEEL" (ULCER PRESENT). THE DOCUMENTATION IN THE MEDICARE DAILY NURSES NOTES, FOR DATES 4/2/12, 4/3/12 AND 4/4/12, WAS INCONSISTENT, BECAUSE DOCUMENTATION ELSEWHERE IN RESIDENT #6'S RECORD DID NOT REFLECT THAT THERE WAS AN ULCER ON THE RIGHT HEEL. FURTHERMORE, THE PRESSURE RELIEVING INTERVENTIONS THAT WERE PRE-PRINTED ON THE MEDICARE DAILY NURSES NOTES DID NOT INCLUDE THE SPECIFIC INTERVENTIONS TO FLOAT HEELS OR APPLY THE LEFT BLUE HEEL LIFT BOOT THAT WERE ORDERED BY THE PHYSICIAN. (THE PRE-PRINTED INTERVENTIONS THAT HAD BEEN CIRCLED ON THE MEDICARE DAILY NURSES NOTES WERE "PRESSURE REDUCTION MATTRESS", "PRESSURE REDUCTION CUSHION" AND "FLUIDS/FOOD ENCOURAGED.") REVIEW OF THE physician progress notes [REDACTED]. THERE WERE NO NOTATIONS OF ANY RIGHT HEEL SKIN PROBLEM IN THE physician progress notes [REDACTED]. THE FIRST "WOUND ASSESSMENT RECORD" FOR RESIDENT #6'S LEFT HEEL, DATED APRIL 4, 2012, DESCRIBED AN ELLIPTICAL SHAPED, UNSTAGEABLE LEFT HEEL WOUND WITH PURPLE COLOR MEASURING LENGTH (4.2 CM) BY WIDTH (4.3 CM) BY DEPTH (LESS THAN 0.1 CM). THE THIRD WOUND ASSESSMENT RECORD DATED APRIL 19, 2012 DOCUMENTED A LEFT HEEL WOUND, UNSTAGEABLE, ELLIPTICAL SHAPED MEASURING LENGTH (2.9 CM) BY WIDTH (5.0 CM) DEPTH (LESS THAN 0.1 CM) WITH A BLACK ESCHAR (NECROTIC TISSUE) WOUND BASE. THERE WERE NO TREATMENT CHANGES NOTED DURING THE TWENTY DAYS BETWEEN APRIL 4, 2012 AND APRIL 24, 2012, EVEN THOUGH THE RESIDENT'S LEFT PRESSURE ULCER HAD DETERIORATED DURING THAT PERIOD. ADDITIONALLY, ON THE TWO DAYS BEFORE THE NECROTIC TISSUE (ESCHAR) WAS DESCRIBED ON THE 4/19/12 WOUND ASSESSMENT RECORD, THE MEDICARE DAILY NURSING NOTES (FOR APRIL 17, 2012 AND APRIL 18, 2012) HAD NO NOTES INDICATING ASSESSMENT OF RESIDENT #6'S LEFT HEEL WOUND. THE FACILITY DIRECTOR OF NURSING WAS INTERVIEWED ON JUNE 28, 2012 AT 4:15 P.M. INSIDE THE CONFERENCE ROOM IN ORDER TO DETERMINE WHETHER RESIDENT #6'S LEFT HEEL ULCER PRESSURE SORE WAS UNAVOIDABLE. ON JUNE 29, 2012 AT 8:40 A.M., THE FACILITY DIRECTOR OF NURSING PRESENTED AN "EVALUATION OF PRESSURE WOUND AVOIDABILITY" DATED MAY 7, 2012 FOR RESIDENT #6'S LEFT HEEL PRESSURE SORE. THE DOCUMENTATION FAILED TO SHOW A DIAGNOSIS, NUTRITIONAL, OR SUMMARY STATEMENT TO SUPPORT THAT THE PRESSURE SORE WAS UNAVOIDABLE (EVEN THOUGH THE WORD "UNAVOIDABLE" WAS CHECKED ON THE FORM). IN FACT, THE EVALUATION OF PRESSURE WOUND AVOIDABILITY FOR RESIDENT #6'S LEFT HEEL NOTED A BRADEN SCORE OF 15 (MODERATE, RATHER THAN HIGH, RISK FOR PRESSURE SORE DEVELOPMENT). THE SUMMARY STATEMENT OF UNAVOIDABILITY FOR PRESSURE WOUND DEVELOPMENT DOCUMENTED: "AREAS MORE THAN LIKELY HAVE ARTERIAL COMPONENT" (ALTHOUGH THERE WAS NO SPECIFIC DIAGNOSTIC INFORMATION TO CONFIRM THAT) "(AND)... GUEST (RESIDENT #6) HEELS WERE FLOATED AND HE DEVELOPED AREA ANYWAY." THE 5/7/12 "EVALUATION OF PRESSURE WOUND AVOIDABILITY" WHICH INCLUDED DOCUMENTED ASSESSMENTS OF TREATMENT INTERVENTIONS AND RISK FACTORS, SUCH AS NUTRITIONAL STATUS AND PRESENCE OF [MEDICAL CONDITION] (ABNORMAL FLUID ACCUMULATION IN THE TISSUES) WAS DATED MORE THAN ONE MONTH AFTER THE NURSING INTERDISCIPLINARY PROGRESS NOTES DATED MARCH 25, 2012 HAD IDENTIFIED THE PURPLE BLISTER ON THE RESIDENT'S LEFT HEEL. ON 628/2012 AT 3:40 PM, REGISTERED NURSE SURVEYOR (# ) OBSERVED THE WOUND ON THE LEFT HEEL OF RESIDENT #6. DURING THE OBSERVATION, THE WOUND BED WAS NOTED TO HAVE THE DARK APPEARANCE OF ESCHAR. DURING INTERVIEW AT THE TIME OF OBSERVATION, THE TREATMENT NURSE STAFF "DD" AGREED THAT THE ESCHAR PRESENT IN THE WOUND BED MADE IT UNSTAGEABLE (I.E., PREVENTED VISUALIZATION OF THE FULL EXTENT OF THE DAMAGE TO THE TISSUES BELOW THE WOUND SURFACE). DURING THE OBSERVATION, THERE WERE NO WOUND MEASUREMENTS OBTAINED BY NURSE "DD" DURING TREATMENT. ACCORDING TO THE NATIONAL PRESSURE ULCER ADVISORY PANEL WEB SITE, COPYRIGHTED 2007 AND DOWNLOADED 7/6/12, AN UNSTAGEABLE PRESSURE ULCER HAS THE FULL-THICKNESS TISSUE LOSS CONSISTENT WITH A STAGE III OR HIGHER PRESSURE ULCER BUT, UNLESS THE ESCHAR IS REMOVED FROM THE WOUND, THE TRUE DEPTH AND EXTENT OF TISSUE DAMAGE CANNOT BE VISUALIZED. ( ) DURING THE REVIEW OF RESIDENT #7'S CLINICAL RECORD, HER ADMISSION physician's orders [REDACTED]. ON JUNE 26, 2012 AT 2:45 P.M., RESIDENT #7 WAS OBSERVED LYING ON HER BED IN HER ROOM, SLEEPING. BOTH OF HER HEELS WERE OBSERVED LYING FLAT ON HER MATTRESS. AT 3:05 P.M., RESIDENT #7 WAS OBSERVED STILL LYING ON HER BED, WITH NEITHER HEEL FLOATED ABOVE THE MATTRESS. RESIDENT #7 WAS HEARD ASKING FOR HELP TO GET UP. THERE WAS NO PILLOW, OR ANY OTHER DEVICE, OBSERVED ON RESIDENT #7'S BED THAT COULD HAVE BEEN USED TO FLOAT HER HEELS. ON JUNE 27, 2012 AT 7:50 A.M., RESIDENT #7 WAS OBSERVED LYING IN HER BED. AGAIN, WITH BOTH OF HER HEELS LYING DIRECTLY ON THE BED MATTRESS. THERE WAS NO DEVICE OR PILLOW OBSERVED ON RESIDENT #7'S BED, OR CLOSE TO HER BED, WHICH WOULD HAVE FLOATED HER HEELS. ON JUNE 28, 2012 AT 2:18 P.M., RESIDENT #7 WAS AGAIN OBSERVED LYING ON HER BED WITH HER HEELS DIRECTLY ON THE MATTRESS. A PILLOW WAS OBSERVED BRACING HER LEFT UPPER SIDE ON HER BED. IMMEDIATELY FOLLOWING THE OBSERVATION, THE FACILITY DIRECTOR OF NURSING WAS INTERVIEWED AT THE NURSING STATION AND WAS ASKED WHAT WAS SUPPOSED TO HAPPEN IF A RESIDENT REFUSED STAFF INTERVENTION TO FLOAT THEIR HEELS. THE DIRECTOR OF NURSING STATED THAT THE NURSING AIDE RESPONSIBLE FOR THE RESIDENT WOULD REPORT THE REFUSAL TO THE FLOOR NURSE RESPONSIBLE FOR THAT RESIDENT. FACILITY STAFF NURSE "Q" WAS INTERVIEWED IN THE MAIN DINNING ROOM AT A SMALL TABLE ON JUNE 28, 2012 AT 2:30 P.M. DURING THE NURSING SHIFT CHANGE. STAFF NURSE "Q" STATED SHE WAS NOT INFORMED THAT AFTERNOON THAT RESIDENT #7 HAD REFUSED TO HAVE HER HEELS ELEVATED. DURING THE REVIEW OF RESIDENT #12'S MEDICAL RECORD, HER admission orders [REDACTED]. ON JUNE 28, 2012 AT 2:30 P.M., RESIDENT #12 WAS OBSERVED LYING ON HER BED IN HER ROOM, SLEEPING, WITH HER HEELS DIRECTLY ON THE MATTRESS. THE SAME OBSERVATION WAS MADE AT 3:55 P.M. THAT SAME AFTERNOON. THERE WAS NO PILLOW OR DEVICE OBSERVED ON RESIDENT #12'S BED THAT WOULD HAVE SERVED TO FLOAT HER HEELS. ( )