Every finding on record at Carriage House Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include: On 05/11/2026 at 5:37am during the initial kitchen tour, shredded lettuce with a best buy date of 5/5/26 was observed in the walk-in cooler. On 05/11/2026 at 5:37am parmesan cheese blend with a use by date of 5/10/26 in walk in cooler was observed. During this observation, Dietary Manager S was interviewed on how long the parmesan cheese blend is kept and he stated it's kept for a week.According to the 2022 Food Code, 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.On 05/11/2026 at 5:45am chlorine to the low temperature dishwasher was tested and the result was zero. The sanitizer bucket feeding the dishwasher was very low and Dietary Manager S replaced the sanitizer bucket with a full one. During this observation, Dietary Manager S was interviewed on the process of changing out the sanitizer bucket to the dishwasher and he stated he usually checks the sanitizer when he first gets to work, but today he didn't get a chance to check it yet. According to the FDA 2022 Food Code, 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness, A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under S7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions.According to the facility's policy on sanitizing, sanitizing of environmental surfaces must be performed with one of the following solutions: 50-100 ppm chlorine solution . On 05/11/2026 at 5:53am a tray of corn bread and blueberry muffin left uncovered was observed in the dry storage room. During this observation, Dietary Manager S was interviewed on whether food is normally kept uncovered and he stated no. According to the FDA 2022 Food Code, 3-305.11 Food Storage, Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: in a clean, dry location; where it is not exposed to splash, dust, or other contamination; and at least 15 cm (6 inches) above the floor.On 05/11/2026 at 5:57am the drain line to the ice machine was observed sitting inside drain in the main dining room.According to the 2022 FDA Food Code, 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from equipment in which food, portable equipment, or utensils are placed.On 05/11/2026 at 5:59am built up residue near the blade of the meat slicer was observed stored in the office adjacent to the kitchen area. During this observation Dietary Manager S was interviewed on how often the slicer is used and he said it hasn't been used for a long time, and it would be cleaned before use. On 05/11/2026 at 6:03am undated yogurt outside of its original container was observed in the kitchenette refrigerator on unit 5 and 6. During this observation, Dietary Manager S was interviewed on how long food in the fridge is kept for and he stated 3 days. On 05/11/2026 at 6:09am black splotches and calcification was observed on the interior walls of the ice machine located in the kitchenette on unit 1 and 2. During this observation, Dietary Manager S was asked how often the ice machine is cleaned and he stated it's cleaned at least once a month. According to the FDA 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 05/11/2026 at 6:11am a bacon, broccoli, and cheese meal left undated was observed in the fridge in the kitchenette located on unit 1 and 2.According to the 2022 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 05/11/2026 at 6:51am the sanitizer bucket was tested using quaternary sanitizer test strips and the result was 50 parts per million (ppm). During this observation, Dietary Manager S was interviewed on how often the sanitizer bucket is changed and he stated every two hours. Instructions for use of sanitizer at the 2-compartment sink stated the sanitizer should read between 150-400 ppm with a 200 ppm target. According to the facility's policy, Sanitizing of environmental surfaces must be performed with one of the following solutions .150-200 ppm quaternary ammonium compound (QAC) .According to the FDA 2022 Food Code, 3-304.14 Wiping Cloths, Use Limitation, Cloths in-use for wiping counters and other equipment surfaces shall be .Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114 and The sanitizing solution must be changed as needed to minimize the accumulation of organic material and sustain proper concentration. Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit.On 05/11/2026 at 6:56am ice was observed sitting inside the basin in the hand sink in the dining area. According to the FDA 2022 Food Code, 5-205.11 Using a Handwashing Sink.A handwashing sink may not be used for purposes other than handwashing.

Based on observation, interview and record review, the facility failed to follow Infection Control Practices for enhanced barrier precautions (EBP) during high contact cares for two residents (Resident #3, Resident #16) of two residents reviewed for EBP precautions; appropriately transport clean and dirty linen throughout the facility; and to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP); resulting in the likelihood of contamination of the environment and the likelihood to spread multi-drug resistant organisms causing infection and an increased risk of respiratory infection among all residents in the facility. Findings include. On 05/12/2026 at 10:20am Maintenance Director T tested free chlorine residual on hot water, and the result was zero at the hand sink in lakeview room. In addition, Maintenance Director T tested free chlorine residual on cold water, and the result was zero at the same hand sink. On 05/12/2026 at 11:16am interview with Maintenance Director T on what is the desired range for free chlorine and he stated around 0.5. According to the facility's water management plan, The water management program includes the following elements: .A system to monitor control limits and the effectiveness of control measures .A plan for when control limits are not met and/or control measures are not effective . According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Ensure disinfectant residual is detectable throughout the potable water system. On 5/11/2026, at 9:13 AM, an observation on the 200 hall was conducted. CNA W was observed to drag a large clear plastic bag on the floor in the hallway with a large amount of soiled linen inside. CNA W entered the dirty linen closet with the bag of soiled linen. CNA W was asked why they didn't separate the dirty linens into multiple bags and CNA W offered, that they didn't bag up the dirty linen. On 5/12/2026, at 2:07 PM, Resident #16's room was noted to have an enhanced barrier precaution sign on their entry door along with a caddy that housed PPE (gowns and gloves). Upon entry into Resident #16's room, CNA Y and CNA X were on either side of the bed with their uniforms touching the bedding. Resident #16 was unclothed and per CNA Y they had just received a bed bath. Both CNA's did not have gowns on. There was a pile of dirty clothing directly on the floor. CNA X was observed to toss wash clothes into the dirty pile. CNA X was asked if the wash clothes were dirty and CNA X stated, they are now. On 5/12/2026, at 2:19 PM, an observation of CNA X walking to and from the clean linen closet. CNA X exited the clean linen closet with a pile of uncovered clean bed linens in their left arm leaning on their uniform. CNA X entered Resident #16's room and a moment later exited the room with no linen. CNA X then returned to the clean linen closed then exited with an uncovered clean bed sheet tucked under their left arm. CNA X was observed moments later with another pile of uncovered clean linens in their left arm leaning on their uniform. CNA X flipped half of the clean linen onto their bare right arm, entered Resident #16's room (an enhanced barrier precautions room) with both arms full of linen. CNA X then exited with the clean linens in their right arm walked down the hallway and entered room [ROOM NUMBER]. On 5/12/2026, at 3:30 PM, a review of Resident #16's Physician orders revealed Enhanced Barrier Precautions every shift for H/O (history of) MRSA (a multi drug resistant organism) Start Date 12/8/2025. On 5/13/2026, at 10:48 AM, During Infection Control Task, Infection Control (IC) Nurse L was alerted of the observations of multiple staff not wearing gowns during resident cares and was asked what the facility's expectation was for enhanced barrier precautions (ebp) and IC Nurse L offered, the staff have been reeducated to look at the sign and ebp should be followed for any high contact care. A review of the facility provided policy Laundry and Linen revealed . the purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . all soiled linen must be placed directly into a bag . ensure clean linen will remain hygienically clean . Resident #3 (R3): According to a review of R3's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to medical diagnoses of Acute respiratory failure, bacteremia (infection in the blood), endocarditis (inflammation of the lining of the heart) and Sepsis enterococcus (infection with gram positive bacteria) with a percutaneous inserted central catheter (PICC) present for receiving intravenous (IV) antibiotics. A record review of R3's Minimum Data Set (MDS) record dated 04/30/2026 revealed Brief Interview of Mental Status (BIMS) assessment score of 15/15 indicating the resident was cognitively intact. Indicated in a record review of survey 23055F-H1 infection control task notes, 'On 05/11/2026 at ~ (approximately) 8:15/8:30 AM, during an observation of (R3), (Nurse I) in (R3's) room, the residents IV pump had alarmed that the line had air in it. (Nurse I) donned gloves and disconnected the line from the running from the percutaneous inserted central catheter (PICC), (Nurse I) used a swab and then reattached it' and further revealed At no time did (Nurse I) have on a gown or mask. On 05/11/2026 at 12:03 PM, an observation of enhanced barrier precautions was posted outside R3's door. During an observation of medication administration, R3 received intravenous (IV) medication, Nurse I donned PPE of gloves to access the residents PICC line. Afterwards, Nurse I was queried if she should have additionally worn the personal protective equipment (PPE) of a gown when she handled R3's IV PICC since R3 was in EBP, she said yes, I should have. On 05/11/2026 at ~12:03 PM, during an interview R3 was asked if the staff commonly wore gowns when they accessed her IV PICC line she stated, no they do not, but they did not at the hospital either. On 05/11/2026 at 12:30 PM, during an interview with the infection control prevention (ICP) Nurse L when queried about the observation said she was aware the Nurse I had not worn proper PPE during IV PICC medication administration and that she had be re-educated on it. ICP Nurse L verified that PPE for the IV PICC line minimally included that a gown and gloves was to be worn during an IV medication administration. According to the facilities policy titled Medication administration revealed: the policy statement: medications are administered in a safe and. with the interpretation and implementation. 26. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. On 05/13/2026 at 08:42 AM, during an observation of medication administration, R3 received intravenous (IV) medication, Nurse J donned PPE of gloves to access the residents PICC line. Afterwards, Nurse J was asked why R3 was in EBP to which she replied, it was because of her PICC line. Nurse J was queried weather she had worn the proper PPE during the IV PICC line medication administration and she stated No, I guess not and I didn't think I needed to when I gave the IV medication just if I was changing the PICC dressing. On 05/13/2026 at 12:19 AM, during a follow up interview with ICP Nurse L she was asked if she had re-educated only Nurse I on EBP and IV PICC lines and she said, no that she had re-educated all the nursing staff about it. ICP Nurse L was made aware of additional observation of nursing staff and replied, Oh no, I will address this right now. ICP Nurse L was asked if EBP was to be followed with PPE worn when both the PICC line dressing was changed and medication was administered through the PICC line, and she stated Yes, absolutely. According to the facilities policy titled Enhanced barrier precautions revealed: the policy statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. with the interpretation and implementation: 1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities; 2. apply when: b. A resident. has a wound or indwelling medical device.; 5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies.7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply: a. gloves and gown are applied prior to performing the high contact resident care activity; 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); 12. Enhanced barrier precautions are in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that place that at higher risk; 16. Staff are trained prior to caring for residents on EBPs.

Based on observation, interview and records review, the facility failed to 1) Provide palatable food products for 8 of 10 residents during the dining task, 2) Follow resident preferences in choices in dining for one resident (Resident #13) of 10 residents reviewed for food quality and preferences and, 3) Address food complaints received during resident council meeting, resulting in multiple food/meal complaints of cold food, no condiments with meals, poor taste and appearance of meals and one resident R13 not receiving the meal choice ordered timely. Findings include: Record review of the facility 'Tray Line Service' policy/procedure undated revealed that select menu (which is now the meal ID card/ticket) will be placed on the tray to be used by other tray line associates to complete meal assembly. Accuracy of meals according to the menu will be checked. In an observation and interview on 05/11/2026 at 8:04 AM-Observation of breakfast trays on the 500/600 units was performed. A resident in room [ROOM NUMBER] was seated up in wheelchair in his room and was asked about his meal. The resident stated that the food was either overcooked or under cooked most of the time. An observation on 05/11/2026 at 1:06 PM of the noon meal in the main dining room revealed a Meal was served of Chilli and corn bread, with a baked potato. Beverages were served with meals. A surveyor tested sample tray noted that the tray came with a dollop of sour cream. There was no butter, salt or pepper noted on the tray. Observation and interview on 05/12/2026 at 7:37 AM with Registered Nurse [NAME] LPN on 400 hall-breakfast is in room trays mostly, observed dining room at end of 400 hall unit, no residents in dining room. Observed large stainless steel meal boxes with trays being passed by staff with doors left open to the hallway. Observation on 05/12/2026 at 7:42 AM-Observed main dining room breakfast meal, only 3-4 residents present. Oatmeal, bacon, hard boiled eggs, toast jelly and beverages. Observed tray meal prep in the main dining room into hot boxes and then taken to resident care units. Meal comes directly off the seam table line onto plates from plate warmer. Boxes hold 20 trays. A lot of management noted in hallways passing trays. Certified Nursing Assistance anonymously reports that the management do not help with meal trays when state is not in the building. Observation on 05/12/2026 at 8:01 AM- surveyor observed meal trays being passed on 500/600 halls. Hall staff stated that trays do not get passed this fast unless state is in the building. Observation and interview on 05/12/2026 at 11:55 AM of the noon meal- Observed lunch meal being plated for hall carts. The bottom thermal plate warmer was not being used during this meal. Dietary server F was plating the meal. Food items of grilled chicken patties with a slice of cheese on a bun and Tator tots with cinnamon apple slices. There was no mayonnaise, or sauces dipping on the chicken sandwich. The sandwich appeared dry. Residents in the dining room requested mayonnaises packets or mustard packets for sandwich and extra ketchup for Tator tots. Observed Room trays to have a single ketchup packet for 6-10 total tots, and no other condiments. Resident interviews: In an interview on 05/13/2026 at 7:43 AM with Resident #36 was seated up in soft straight back chair in room with breakfast meal. Resident #36 stated that the food is not good. She does eat in her room, and the food is cold when she gets it. The food texture is too hard for her to chew or cut, and she stated that she is old and needed softer food items. In an interview on 05/13/2026 at 7:45 AM with Resident #89 stated that staff just don't read the meal tickets, He does not get what he ordered, then the aide must run back to the kitchen to get what was ordered to correct it. The Condiments are not on the trays. The residents must request condiments of ketchup, Mustard, Mayonnaise, whatever and the aides have to run back to the kitchen to get it. The meal trays stand in the hallways and get cold while the aides run back to the kitchen. This week it's been better because you have been here, and there's more people passing trays. In an interview on 05/13/2026 at 7:48 AM with Resident #1 when asked about his meals stated It's nothing to brag about the meals. The resident did take the meals in his room, and the trays are the same thing for breakfast every day. The meat sandwiches are very little meat and a whole lot of bread with no mustard or mayonnaise, when he asks for condiments the aide has to run to the kitchen to get it. In an interview on 05/13/2026 at 7:52 AM Resident 1#3 stated that the food is bad. The manager came down yesterday and spoke with him. The surveyor asked about Choices. Resident stated, no, they don't give what is ordered, yesterday he ordered 2 cheeseburgers, and he got a chicken sandwich, he does not like chicken. Sometimes when he orders they come back and tell him that they ran out of the food items. Condiments are only provided if you ask for them and the aides have to run to the kitchen while the food sits on the plate and gets cold. In an interview on 05/13/2026 at 7:54 AM with Resident #109 noted the resident was seated up in Wheelchair in her room. When asked about her meals she stated that the chicken is dry and too often served. Resident stated that she does eat in her room and the meal trays are cool when she gets it. This week the meals have been better because they have more people passing meal trays, so they are not sitting in the hall for so long. Choices? She stated that sometimes she does not get what she orders and the aides must go get the right items and it's a waste of food and time. Condiments? She stated that we have to ask for them and again the staff have to run back to the kitchen to get it. In an interview on 05/13/2026 at 8:05 AM with Resident #3 was seated up in a recliner in room, she stated that she does get her meals in her room. She stated that the food is cold at times, the plate is not warm, the food will be somewhat warm, but if she touches the plate, it's cold. It's institutional food, and she gets that for a facility this size. One day she got chicken parmesan, and it tasted good, but it was cold, and the Penne pasta was not cooked all the way. Until yesterday no one came to ask about my order, she has been at he facility two and half weeks and it was the first time the kitchen had talked to her. Prior to yesterday she would not get what she ordered, the meal ticket items would not match what they brought on the tray, so staff has to run to the kitchen to get the right foods. Condiments offered? She stated that again the staff have to run to the kitchen to get it, they do not come on the meal trays. Yesterday the chicken cheese sandwich? was dry and could have used mayonnaise or sauce, just something. Anonymous interviews with Certified Nurse Assistants (CNA's) and Nurses: Did not want their names used. CNA -stated we always have run back to the kitchen for the correct food items ordered. CNA- Yes, we are always every day at every meal running to the kitchen. Two nurses- both stated, the meals are with the staff running back and forth to the kitchen, no there are not this many staff that pass trays, no management only helps when state is in the building. The state surveyors during survey observed multiple management to be in hallway passing meal trays but are looking at door room names to find the residents. In an interview on 05/13/2026 at 8:09 AM with a non-verbal resident was alert and oriented. Surveyor introduced self and resident responded with head shakes. Resident was asked about Cold food he shook head yes vigorously. Resident was asked if he gets what he orders on his meal trays he shook his head no. Resident was asked about condiments- He shook his head no. In an interview on 05/13/2026 at 8:28 AM with Resident #26 when asked about his meals stated, Don't ask about the food. The resident did choose to eat meals in his room. When asked if he gets what he orders the resident stated that it depends on what day it is. Sometimes he gets what was order. The resident stated that he always orders milk with his meals and he only receives it on the breakfast tray. Then to appease him they will bring both white milk and chocolate milk back from the kitchen. The surveyor asked about condiments. Resident stated that No, if he needs mustard the aide has to go to the kitchen to get it, while my food gets cold Observation on 05/13/2026 at 8:35 AM of the 500/600 hall kitchenette observation revealed peanut butter and jelly packets, fudge round cookie things, freezer with ice cream, and refrigerator with large pitchers of juice's dated 4/11/2026, and gallon of Milk manufacture date 5/19/2026. In the lower drawers were pop and other snacks. Observation and interview on 05/13/2026 at 8:44 AM of the serving tray line area with dietary server F and Dietary manager E, demonstrated the bottom plate warmer function, and surveyor touched the bottom gray/tan thermal plate warmer when heated and the thermal bottom was warm to the touch. The bottom thermal plate warmer was functional and working. The large plate warmer cabinet held a stack of white/cream color ceramic/glass plates that were being During Resident Council meeting held on 5/12/2026 at 9:30 AM, the 11 residents in attendance reported the following regarding meals provided at the facility: Grilled cheese sandwich is not grilled and like just eating two pieces of bread (out of the bag) with cheese in-between it. Vegetables served are either overcooked or undercooked; there is no consistency. Some of the meats are hard to chew. Many times, they are not being delivered what is placed on their meal ticket. The gravy on the hot turkey sandwich served on Sunday was thick, lumpy and cold as if it had been spread onto the bread from the can. R13: According to a review of R13's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to medical diagnoses of toxic encephalopathy (diffuse brain disfunction) due to lithium (antipsychotic medication), protein calorie malnutrition, dyskinesia (uncontrollable movement), schizophrenia, bipolar. A record review of R13's Minimum Data Set (MDS) record dated 04/22/2026 revealed Brief Interview of Mental Status (BIMS) assessment score of 11/15 indicating the resident had moderate cognitive impairment. On 05/11/2026 at 06:40AM, during an interview with R13 when asked about food, he said the food is so-so and seems to be getting worse rather than better. R13 was asked to clarify, and he said that the flavor is and the temperature of the food is cold. R13 said his bigger concern was that he rarely got what he ordered and that when he asked the staff about that he said they told him, 'Well, we are out of that' as a standard answer. R13 said the grilled cheese was soggy and greasy, and that it was the standard replacement they would offer him. On 05/12/2026 at 02:27PM, during an interview with R13 he said he was very upset, when asked for clarification he said, 'I ordered 2 of the cheeseburgers for lunch and they brought me a chicken sandwich; I don't like chicken and they know that'. R13 said that he sent the tray back to the kitchen and requested the 2 cheeseburgers he had ordered. R13 said look this is what they brought back. Observation of R13's meal tray revealed an untouched grilled cheese sandwich and a meal ticket that said chicken sandwich and tater tots. R13 said he was sending it back and that CNA O had re-ordered his 2 cheeseburgers. R13 said he had only eaten the pear slices from the first tray and had no other food for lunch. R13 was on his way to physical therapy and said he would eat his lunch there; he said therapy was his way to get back home so he did not want to miss it. The CNA O was present during the interview and verified that was the residents second meal tray, the first was a chicken sandwich and tater tots and the second was a grilled cheese sandwich. CNA O said that she re-ordered the third lunch meal tray for R13's 2 cheeseburgers and would make sure that he got them. According to a record review of the facilities menu provided on Tuesday 05/12/2026 for lunch service: Turkey burger patty melt, tater tots, ketchup, cinnamon apple slices, sandwich bread, coffee/tea and condiments. According to a record review of the facilities alternate lunch-dinner menu indicated availability of sandwiches: deli meat/tuna, grilled cheese and grilled ham and cheese; hamburger/cheeseburger on a bun; chicken nugget Nuggets with ranch/BBQ sauce. According to the facilities spoken menu program it is revealed: meals and beverage orders are taking ahead of time; residents choices are based on their food and beverage preferences, likes and dislikes diets and food restrictions such as allergies; Residents have a choice to choose from the main meal from the daily menu or from the main meal from always available menu; residence always has a choice to change his meal choice after the order was taken. According to a record review of R13's progress notes dated 05/11/2026 at 14:01 revealed: Nutrition Note Text: RD follow up for weight loss. Resident and provider notified. Weight: (5/6) 143#(pounds), Previous weights: (4/29) 151# (4/20) 149# Resident admitted with. severe PCM. Diet: Liberal/general diet ordered, appetite is good, po intake averages 75-100% of meals. Food preferences honored. Dislikes chicken, rice, and all veggies. According to a record review R13's care plan indicated: Focus: I have a nutritional problem r/t (related to) diagnoses of severe PCM (protein calorie malnutrition) w/ weight loss, toxic encephalopathy. with interventions: Diet as ordered: General, regular texture, thin liquids; Honor preferences as able. See tray card for preferences. On 05/12/2026 at 4PM, during an interview with Corporate Registered Dietician (RD) N she was asked about meal service and tray preparation. Corporate RD N said that the tray line is completed by the kitchen staff and loaded onto the carts to go to the halls, the CNA's deliver the trays to the residents dining in room. Corporate RD N said the tray and ticket should be checked at the kitchen level for accuracy and preferences before trays were sent to the halls. Corporate RD N was asked about R13's lunch meal tray, his concerns and his preferences. Corporate RD N verified that R13's preferences state dislikes: chicken, rice, and all veggies and that she has no idea why they would serve it or why his meal ticket would not be read and followed, or how he got chicken then got grilled cheese when he requested 2 cheeseburgers. Corporate RD N said she was going to follow up with R13. And agreed he was already at risk with his diagnosis of PCM and weight loss.

Based on interview and record review, the facility failed to provide Advanced Beneficiary Notice of Non-coverage (ABN) notices for 2 residents (#7 & #87) of 3 residents reviewed, resulting in the lack of disclosure related to Medicare rights and the inability to appeal the discharge in the time frame allotted by Medicare. Findings include: Record review of the facility-provided 'For Instructions Advance Beneficiary Notice of Non-coverage (ABN,) pages 1 through 7, revealed when Medicare is not likely to cover a specific item or service, health care providers and suppliers must use ABN to let patient (residents) know whey may be financially liable before they get the items or services. Notifiers must: Deliver the ABN to the patient or their representative before providing the items or services; review the ABN with the patient or their representative and answer any questions before it's signed; deliver the ABN far enough in advance that the patient or representative has time to consider the options and make an informed choice; give a copy to the patient or representative, if requested, once all blanks are completed and the form is signed; and retain a copy of the completed, signed ABN on file. Record review of the Beneficiary Notice discharge form within the last six months revealed 35 residents' names. A sample of 3 (#7, #87, #111) residents were chosen. In an interview and records review on 05/12/2026 at 12:45 PM with Registered Nurse/Minimum Data Set (MDS) assessment nurse H revealed that the appropriate Notice of Medicare Non-coverage (NOMNC) was issued to the sampled residents. When asked, RN/MDS H stated that she only does NOMNC's and that the financial Advanced Beneficiary Notices are financial and are issued by the business office person. In an interview on 05/12/2026 at 1:05PM with the business office person G the surveyor requested the Advance Beneficiary Notices for the three sampled residents and the business office person had no answer or documents. In an interview on 05/12/2026 at 1:24 PM the state surveyor had a Meeting in the front office with Nursing Home Administrator (NHA) and business office person G that the Advanced Beneficiary Notices (ABN's) that none were found in residents' charts. The NHA acknowledged that the ABNs are to be issued to the client so that they know of the possible amount due, and it is supposed to be issued after the resident comes off Medicare Part A. The NHA stated that there are none, and the staff have not done them, stating usually, therapy does the ABNs. Business office person G stated that it fell through the cracks and was missed. In an interview on 05/12/2026 at 1:30 PM the Nursing Home Administrator stated that the business office will be doing Advance Beneficiary Notices from now on. The facility had therapy services doing them, but there had been some position changes in therapy. The NHA did not know when the ABN's stopped being issued. The facility was not cited last year at annual recertification survey, so sometime in the last year. Record review of an audit of residents residing within the facility with no Advanced Beneficiary Notices (ABN) issued included six residents. The discharged residents that did not receive ABN notices were not counted.

Based on interview and records review, the facility failed to follow the comprehensive care for post fall interventions for 1 resident (Resident #7) of 2 residents reviewed, resulting in Resident #7's post fall interventions of monitoring every 2 hours and PRN (as needed) with no documentation of the actual monitoring being performed by facility staff. Resident #7:Observation and interview on 05/11/2026 at 9:24 AM of Resident #7 revealed a right wrist with black splint in place. Resident #7 stated that she did fall but does not remember how it happened. In an interview on 05/11/2026 at 9:35 AM, Licensed Practical Nurse (LPN) V stated that Resident #7 had a fall in April 2026 right at shift change. Resident #7 herself transferred and had fallen and fractured her right wrist. The right wrist started to swell so we sent her out to the hospital. Record review of Resident #7's fall incident reports: 12/20/2025 at 6:30AM found on floor by bathroom, stool noted on floor, no injuries. 1/8/2026 at 7:00AM found on floor, no injuries.4/3/2026 at 5:00AM fall in bathroom reported by resident to staff. Right wrist pain, sent to ER, Fractured wrist. New diagnosis of A. fib and dizziness. Record review of Resident #7's comprehensive care plans pages, 1 through 13, revealed that on 4/4/2026 interventions to monitor every two hours and PRN (as needed) for compliance with soft cast and sling, ensure resident assist with all her needs. An interview and record review was conducted on 05/13/2026 at 11:32 AM with Registered Nurse/Unit manager A of Resident #7's repeat falls:Fall on 12/20/2025 at 5:30AM of Resident #7 found on floor by staff in room, no injury, but on 12/21/2025 was sent to hospital for shortness of breath. re-admitted on [DATE], new care plan intervention to monitor and assess. BIMS on 12/21/2025 of 3 severely impaired. Fall on 1/8/2026 at 7:00AM of Resident #7 found on floor in room. The new care plan intervention was a sleep study. Fall on 4/3/2026 at 5:00AM fall of Resident #7 in bathroom reported by resident to staff. Right wrist pain, sent to ER, Fractured wrist. New diagnosis of A. fib and dizziness. Record review of new intervention on 'Fall' care plan dated 4/4/26 to Monitor every 2 hours and PRN (as needed) for compliance with soft cast and sling. Record review of Medication Administration Record (MAR)& Treatment Administration Record (TAR) of April and May 2026 records did not have any monitoring documentation, record review of documentation tab in electronic medical records. RN A found no documentation to support any monitoring. RN/MDS A stated that intervention was missed, we only monitored post fall for 3 days. Usually there is an order put into the physician orders, and it carries over to the MAR/TAR. The monitoring should have been continuous every 2 hours and PRN. We missed it. Care plan was not followed. Record review of the facility 'Care Plans, Comprehensive Person-Centered', dated 1/2026, revealed person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on observation, interview and record review, the facility failed to provide adequate grooming/showers per residents' preferences for three residents (#7, #16, #75) of 6 residents reviewed for Activities of Daily Living (ADL), resulting in resident complaints and unkempt appearances. Findings include: Resident 7: Observation on 05/11/2026 at 5:52 AM of Resident #7 was asleep with rolling walker at bedside with room door closed. Observation revealed an elderly resident asleep with hair that appeared uncombed and a right-hand black splint. Record review of resident #7's medical diagnosis list included: adult failure to thrive, moderate protein-calorie malnutrition, dementia, fracture wrist, anxiety, psychotic disturbance, unsteadiness on feet, personality disorder. Record review of Resident #7's resident care guide Kardex for Bathing/Showering: requires set-up assistance by 1 staff with bathing/showering. Prefers a shower. Record review of Resident #7's care plans revealed that the resident preferred to shower but may refuse. Record review of the Resident #7's task tab in point click care revealed on 4/29/2026 no shower was given. Record review of the residents' progress notes revealed no documentation why shower was not given. On 5/3/2026 no shower given and no progress notes at all. On 5/6/2026 no shower given and there was documentation of attempted shower. On 5/10/2026 no shower was given and the resident received antifungal powder under bilateral breast for redness. Resident 75: In an interview on 05/11/2026 at 10:58 AM with Resident #75 revealed that showers are not the best, not twice, less. no hair washing. In an interview on 05/11/2026 1at 1:08 AM Resident #75 stated that she gets a shower/bath once a week, they try to give bed bath wash-ups that's not a shower, resident would prefer a shower. Once a week wash-up was not enough. Record review of Resident #75's medical diagnosis included: end stage renal disease, dependence on renal dialysis, hypertensive heart and chronic kidney disease, malignant neoplasm of the right breast, heart failure, muscle weakness, diabetes Record review of Resident #75's resident care guide Kardex for Bed Shower/Bed bath Sunday Wednesday afternoons and as needed. : requires 1 assist with bathing after 2 assists for transfer using mechanical lift. Record review of Resident #75's care plans for Activities of Daily Living dated 4/21/2024 revealed self-care deficient related to weakness, gout, pain, decreased mobility, and diabetic neuropathy. I prefer bed baths, showers on occasion. Record review of Resident #75's shower/bath task tab revealed Showers were given on 4/15/2026 and 5/6/2026 Bed bathes were given on 4/19/2026, 4/22/2026/, 4/26/2026, 4/29/2026, 5/3/2026 and 5/10/2026. Resident #16 On 5/11/2026, at 9:06 AM, Resident #16 was lying in bed. Their nails were long and jagged with brown residue. Their facial hair was unshaven. Resident #16 stated they sometimes get a bed bath and not a shower. They offered that their shower days were Tuesday and Friday and needed a shave. On 5/12/2026, at 10:45 AM, a record review of Resident #16's electronic medical record revealed an admission on [DATE] with diagnoses that included Bipolar Disorder, Anemia and Diabetes Mellitus. Resident #16 required assistance with Activities of Daily Living and had intact cognition. A review of the Kardex revealed PATIENT CARE . PERSONAL HYGIENE/ORAL CARE: I require assistance by (1) staff with personal hygiene and oral care . A review of Shower/Bed Bath Look Back: 30 Day revealed no refusals to showers/bathing. On 5/12/2026, at 3:13 PM, Resident #16 was in bed and had just received a bed bath. An observation of their bilateral feet revealed gross amounts of dry skin build up. CNA X and CNA Y were on either side of bed without gowns on and their uniforms were touching the bed. CNA Y provided that they had lotion to provide for the resident's feet and was unsure when their feet were last cleansed. On 5/13/2026, at 11:32 AM, Resident #16 was lying in bed. An observation along with Unit Manager (UM) A revealed their nails were clipped and clean although the resident remained unshaven. Resident #16 complained they still needed a shave. On 5/13/2026, at 11:42 AM, an interview with CNA X was conducted regarding Resident #16. CNA X was asked if they gave the resident a bed bath the day prior and CNA X stated, yes. CNA X was asked if they shaved the resident and CNA X offered, his brother comes in and shaves him. On 5/13/2026, at 11:55 AM, A review of the care plan revealed no intervention listed that Resident #16's brother visits to shave them. A review of the facility provided Fingernails/Toenails, Care of policy revealed . Nail care includes regular cleaning and regular trimmer/filing . A review of the facility provided Shaving the Resident revealed The purpose of this procedure is to promote cleanliness and to provide skin care . Review the resident's care plan to assess for any special needs of the resident . Documentation . If the resident refused the treatment, the reason (s) why and the intervention taken .

Based on observation, interview and record review the facility failed to prevent the formation of a contracture for one resident (Resident 9) of four residents reviewed for range of motion. Findings Include:Resident #9: On May 12, 2026, at approximately 1:30 PM, a review was conducted of Resident #9's medical record and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Hemiplegia and Hemiparesis, Dysphagia, Acute Respiratory Failure, Aphasia and Hypertension. Further review of the chart yielded the following:There was nothing located in Resident #9's Care Plan, Kardex or Progress Notes that indicated any decline, formation of stiffness or contractures.Room Change:Upon admission Resident #9 was placed in room [ROOM NUMBER]-1. On 10/13/25 he was relocated to room [ROOM NUMBER]-1 and he remained there until 12/9/2025 when he was moved back to room [ROOM NUMBER]-1.On 5/13/2026 at 8:51 AM, PT (Physical Therapist) DD stated when Resident #9 discharged from therapy services in the winter he was flaccid (affected muscles are limp, weak and without resistance to movement) on his stroke affected side. PT DD explained his right side upon initial discharge from therapy as a wet noodle. Resident #9 was placed back on therapy services about one month ago with the primary goal of stretching and improving his ability to assist with bed mobility and transfers. She added his right hamstring area is very tight. Upon doing his measurements for his right leg contracture he was -70 flexion (quantity how much a joint can bend with normal ranges). It was not indicated for him to be referred to the restorative program as his unaffected side was within normal limits upon his discharge from therapy services in November 2025.It can be noted -70-degree flexion is indicative of a significant limitation in joint bending, as normal flexion [NAME] are typically positive and much higher depending on the joint. On 5/13/2026 at 12:00 PM, an interview was conducted with Therapy Director CC regarding Resident #9. She reported they (therapy) do not complete baseline measurements of newly admitted residents as they are focused on function in this setting. Resident #9 was flaccid on hit stroke effected side and measurements would not have been completed at discharge due to this reason and his goal was to return home.They are currently working with Resident #9 to get him back to 0 degrees as he is at -70 flexion. Director CC explained the worst a patients contracture measurement could be is -120 . Resident #9's strength is 3/5 and it is the measurement of how they move against gravity if someone was pushing their extremity. He has moderate strength but if someone gave resistance, he would not be able to push back. Resident #9 did develop a right leg contracture after his discharge from therapy services.Therapy screens are completed based on the residents' MDS (minimum data set) assessment schedule. The therapy staff assigned to complete the screen will talk to facility staff members and the residents (if able) to see if there have been any changes that would warrant the resident being evaluated for therapy services. The screens are hands off and it is a fact gathering process. Further review was completed of Resident #9's records:Referral Screen dated 1/9/2026: Resident is not indicated at this time per CNA no changes. 4/2/2026: Per staff noted change to mobility specifically transfers.The form had the following checked, increased difficulty getting in & out bed, increased difficulty transferring to & from w/c (wheelchair). Physical Therapy Discharge summary dated [DATE]: Prognosis to Maintain CLOF (current level of functioning)= good with consistent staff follow-through. PT Evaluation & Plan of Treatment dated 4/8/2026: .Requested referral for an assess of patient due to declining mobility, reduced strength in LUE (left upper extremities)/LLE and contracture formation on RLE (right lower extremity) . R flexion contracture. Physical Therapy PT Recert, Progress Report & Updated Therapy PlanCertification period: 5/5/2026-5/3/2026Pt (patient) will perform STS (sit to stand) mod (moderate) x2 with // (parallel) or bilateral platform RW to improve weightbearing acceptance, reduce tone and improve active participation with upright standing. PLOF(prior level of functioning- at discharge from therapy): 2 personsBaseline (4/8/2026): unable/medical due to R (right) knee flexion tonePatient will improve R knee extension PROM (passive range of motion) -50 degrees in order to increase ability to perform STS and assist with bed mobility independence.PLOF: WNL (within normal limits)Baseline 5/5/2026: -75 deg (degrees) PROM at baseline. No AROM (active range of motion) noted in RLE (right lower extremity) at this time. Goal originally created to demonstrate improvement in ROM, reduction in flexion contracture.Patient will increase AROM right knee extension to -70 degrees in order to increase ability to perform scotting/bridging in bed and facilitate balance during functional mobility. Extension (average range = 0 degrees)PLOF: WFL (within functional limits)Baseline 4/8/2026: -75 degreesPt will improve generalized LLE (left lower extremities) strength to 3+/5 to improve ability to assist with bed mobility and standing transfers to reduce caregiver assistance required:PLOF: WFLBaseline 4/8/2026: 3/5 grossly On 05/13/2026 at 1:40 PM, Resident #9 was observed watching television in bed. He was able to answer simple questions regarding his contractures. He reported he is currently working with therapy, and he does get out of bed sometimes. His right leg was observed to be bent at the knee with his leg/foot resting on his stomach/chest area. On 05/13/2026 at 1:49 PM, CNA Z reported Resident #9 initially admitted to 400 unit and was moved to 200 unit and placed in isolation. Upon returning to their unit, he had the right leg contracture.On 05/13/2026 at 2:11 PM, Nurse J shared Resident #9's hand and foot have been contracted since she started at the facility which was in mid-January 2026. On 05/13/2026 at 2:17 PM, PTA (Physical Therapy Assistant) AA was interviewed regarding Resident #9. She reported they complete therapy screens on a quarterly basis and each month the screens are divided equally amongst therapy staff. For the screens they do not physically touch the resident but will speak to the resident (if able) and their aides. They will ask if they noticed the resident getting weaker, difference in transfers, rolling in bed and walking ( if applicable).In January 2026 when PTA AA completed the screen for Resident #9 and spoke to either CNA Z or BB (but could not recall which aide she spoke too) and there were no concerns reported at that time. PTA AA stated she did not observe or speak to Resident #9 for the January 2026 screen. In April 2026 either CNA Z or BB reported during the screen that Resident #9 was having difficulty getting in/out the bed and with transfers. There was no mention of stiffness in his leg or arm. If that was mentioned she would have checked the box on the screen for stiffness. A review was conducted of the facility policy entitled, Functional Impairment reviewed 1/26. The policy stated, .The staff will monitor and document the resident/patient's function (for example, evidence of reduced ADL dependency, improved ambulation, improved balance and gait, etc.) and will discuss this with the physician periodically in conjunction with a discussion of medical interventions and plans of care.A review was conducted of the facility policy entitled, Specialized Rehabilitative Services, reviewed 1/26.The policy stated, .Once a resident has met his/her care plan goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either nursing or restorative aides will implement to assure that the resident maintains his/her functional and physical status.

Based on observation, interview and record review, the facility failed to timely notify the physician of a positive urine sensitivity result for one resident (Resident #107) of one resident reviewed for Urinary Tract Infections (UTI), resulting in complaints of stomach pain, and a positive urine culture going untreated for approximately 24 hours. Findings include:Resident #107: On 5/11/2026, at 5:55 AM, Resident #107 was resting in their bed. On 5/11/2026, at 11:30 AM, Resident #107 was sitting in their wheelchair in their room. Resident #107 complained that they recently had went to the hospital. On 5/12/2026, at 9:30 AM, a record review of Resident #107's electronic medical record revealed an readmission on [DATE] with diagnoses that included acute cystitis, Diabetes Mellitus and unsteadiness on feet. Resident #107 required assistance with activities of daily living and had intact cognition. A review the progress notes revealed the following: 4/22/2026 . resident stated he was not feeling well at 1355 (1:55 PM). He states is stomach hurt . 4/25/2026 00:23 (12:23 AM) . Physician notified of UA results; waiting on C&S results . 4/26/2026 04:14 (4:14 AM) . Received culture results from UA. Physician notified, waiting for sensitivity. 4/27/2026 09:51 . Resident sent to hospital due to chest pain. All paperwork done and all parties aware of transfer. 5/1/2026 14:35 (2:35 PM) Physician/Practitioner Progress Note .who is being readmitted to SNF following hospitalization. Patient was sent to from SNF to the ED on 04/27/2026 via EMS . Urine culture grew organism resistant to ceftriaxone (Rocephin); antibiotics were changed to cefepime . A review of the Urinalysis Routine . 4/24/2026 1200 Received . Fax Server 4/24/2026 9:09:27 PM . revealed a handwritten message Waiting for C&S per (physician) 4/25/26 A review of the Urine Culture 4/24/2026 1200 Received . Positive Culture > (greater than) 100,000 CFU/ml Proteus Mirabilis . revealed a handwritten message Waiting on Sensitivity Per (physician) 4/25/26 A review of the Urine Culture Final result Verified 4/26/2026 0710 Fax Server 4/26/2026 1:03:07 PM . Susceptibility Proteus mirabilis . revealed a handwritten message hospital on it. A review of the hospital Patient Discharge Summary 04/30/2026 revealed . Discharge Diagnosis: . 9. Acute cystitis (a type of urinary tract infection) . On 5/12/2026, at 3:57 PM, Infection Control (IC) Nurse L was asked to explain the procedure for the facility to be notified of positive urine cultures and IC Nurse L stated, they fax them over to us when they're done. IC Nurse L was asked to clarify the positive UA results for Resident #107 and was the resident, physician and hospital notified of the positive lab. IC Nurse L offered the positive UA was noted to have a written message waiting for sensitivity on it and that they were waiting on the sensitivity before treatment. IC Nurse L was asked to clarify if the resident was treated prior to going to the emergency department/hospital. On 5/13/2026, at 10:40 AM, IC Nurse L offered clarification on Resident #107's positive urine culture. IC Nurse L stated, it was an ongoing assessment; we did the urine and the facility was following. IC Nurse L was asked if the facility was aware of the final culture and sensitivity/susceptibility on 4/26/2026 and why wasn't the doctor notified prior to the resident going to hospital and IC Nurse L offered, that the nurse placed the lab result in the doctors binder rather than calling the doctor right away. IC Nurse L offered, that they educated the nursing staff that anytime a sensitivity comes back you have to call immediately. IC Nurse L was asked if the hospital was ever notified of the positive Urine culture and susceptibility and IC Nurse L provided the hospital gave the resident antibiotics for it. IC Nurse L further explained they had discussed with the Nurse Practitioner and that they had given a copy of the positive lab to the resident to take to the hospital although the progress notes didn't document that. IC Nurse L further offered the lab did come to the facility via fax on 4/26/2026 although could not provide when the nurse took the lab off the fax machine. IC Nurse L was asked to provide any additional progress notes regarding the positive urine culture. There was no additional information shared by the facility prior to exit.

Based on observation, interview and record review, the facility failed to assess and monitor an ileostomy for one resident (Resident #108) of one resident reviewed for ostomy care, resulting in delayed physician's orders for assessment and care. Findings include: Resident #108: On 5/12/2026, at 9:54 AM, a record review of Resident #108's electronic medical record revealed an admission on [DATE] with diagnoses that included total colectomy with ileostomy, Left leg fracture and cerebral palsy. The resident required assistance with all Activities of Daily Living and had intact cognition. A review of the Physician orders revealed the following: Colostomy care every shift and as needed . Start Date 5/7/2026 Change colostomy appliance every 3 days & prn (as needed) . Start Date 5/7/2026 A review of the TREATMENT ADMINISTRATION RECORD 5/1/2026 - 5/31/2026 revealed the ostomy appliance was not changed until 5/8/2026; seven days after admission and colostomy care was not provided until the evening on 5/7/2026; 6 days after admission. A review of the progress notes revealed the following: On 5/12/2026, at 2:37 PM, an interview and record review with Wound Nurse (WN) B revealed Resident #108 was admitted on [DATE]. A review if the admission assessment revealed the resident had a right iliac crest ileostomy. WN B was asked where in the documentation the ostomy was assessed upon admission and WN B offered, the admission assessment. The admission assessment did not document the ostomy size, color, protrusion nor the skin surrounding the ostomy site. WN B was asked to provide ostomy assessment documentation located in the electronic medical record. WN B offered that the admission Minimal Data set assessment revealed the resident was admitted with a colostomy. On 5/13/2026, at 11:30 AM, An observation with Unit Manager (UM) A of Resident #108's ileostomy was conducted. Resident #108 was resting in bed. They had an appliance to their right abdomen, with small amounts of brown stool. The surrounding skin appeared slightly reddened with linear red areas. On 5/13/2026, at 11:40 AM, UM A was asked why the orders for care and ostomy changes were delayed after admission and UM A offered, that they went into the computer on Thursday (5/7/2026) and realized there were no orders (for the ileostomy) so they put them in. According to The National Alliance of Wound are and Ostomy, Nurses caring for patients with ostomies are responsible for: . Assessing the stoma, monitoring for complications, changing and emptying ostomy pouches, and maintain skin integrity around the stoma . According to [NAME], For an Ileostomy, the output is usually more liquid than with a colostomy, so both emptying and changing the pouching system require more frequent attention. Empty when the pouch is about 1/3 to 1/2 full . Changing the pouching system, change the entire appliance every 3 - 7 days, but for ileostomies, many people change it every 2 - 5 days . Some guidelines suggest at least twice a week .

Based on observation, interview, and record review, the facility failed to 1) Label open biologic medications with resident and dates for two residents (Resident #113 and Resident #67) that were refrigerated in two of three medication rooms viewed for medication storage and 2) Secure medications stored in two of three carts reviewed for medication storage, resulting in the potential risk of resident safety, misappropriation and integrity of medications. Findings include: On 05/11/2026 at 5:29AM, Upon entry to the facility an observation was made of medication cart for 400 Hall residents, which was stationary in front of the nurses' station unattended and unlocked, all drawers were able to be accessed when pulled open. There was a medication cup sitting on top with applesauce in it and a crushed red substance swirled in it. There is an undated apple sauce sitting next to the cup. There was no staff in the area. Also located at the same nurses' station was the medication cart for the 300 hall residents, it was unattended and unlocked, all drawers were able to be accessed when pulled open. One resident was observed in hallway near carts; the resident was self-propelled in her wheelchair. On 05/11/2026 at 5:32AM, CNA K was observed in the hallway by the nursing station, she was asked what was in the medicine cup that was located on the top of medication cart 400, she stated I do not know, I am a CNA and I do not pass medications. She was asked if it was standard practice for the medication carts to be unlocked when no staff was present, she said no it is not and stated, let me get the nurse for you. On 05/11/2026 at 5:35AM, Observation of Nurse R approach the nursing station from the 400-hall direction. Nurse R was queried about the medication cup on top of the medication cart, and she said it was a medication that a resident refused. Nurse R was asked if it was ok to leave the medication unattended and not disposed of upon refusal, she said no that she had got called away and just left it out. Nurse R was asked if it was standard practice for the medication carts to be unlocked without staff present and she said 'I was in the middle of passing medications and got called away' so she left them unlocked. On 05/12/2026 at 1215PM, during an interview with Unit Manager (UM) A she was queried if it was standard practice for medication carts to be left unlocked and unattended, she said no it was not acceptable and she was aware of the observation made on 05/11/2026 and that the nurse had been written up for the incident yesterday. When UM A was asked if it was standard practice to leave medication out and assessable to other staff, residents and visitors unattended, she said no it was not acceptable and that the nurse had been written up for that incident as well.R113 According to a review of R113's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to medical diagnoses of metabolic encephalopathy (diffuse brain disfunction), cystitis (bladder infection), diabetes mellitis type 2, anxiety and depression. R113's Minimum Data Set (MDS) record revealed Brief Interview of Mental Status (BIMS) assessment score of 15/15 indicating the resident was cognitively intact.On 05/12/2026 at 12 noon, during medication storage observation of the main medication room stored in the refrigerator there was a box labelled with R113's information that was open, the Ozempic pen (biologic medication) inside the box was open and partially use, the pen had no resident information label and no open date.A record review of R113's orders revealed: Ozempic (2 MG/DOSE)8 MG/3ML Solution pen-injector INJECT 2 MGSUBCUTANEOUSLYONE TIME A DAYEVERY SUNDAYFOR WEIGHT LOSS.R67 According to a review of R67's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to medical diagnoses cerebral infarct (stroke), Parkison's disease (neurological disorder), diabetes mellitus type 2, drug induced obesity, anxiety and depression. R67's Minimum Data Set (MDS) record revealed Brief Interview of Mental Status (BIMS) assessment score of 15/15 indicating the resident was cognitively intact.On 05/12/2026 at 12:10PM, during medication storage observation of the main medication room stored in the refrigerator there was a box labelled with R67's information that was open, the Ozempic pen (biologic medication) inside the box was open and partially use, the pen had no resident information label and no open date.On 05/12/2026 at 1215PM, during an interview with Unit Manager (UM) A she was queried about label and date missing from open biologics, she said the pen should have a label with resident information on it and be dated when it is open. UM A verified with SA the observed the open biologics in both medication rooms and had no explanation why they were not, she said she 'planned to re-educate staff' about the discovered deficiency. A record review of R67's orders revealed: Ozempic (0.25 or 0.5MG/DOSE) 2 MG/3MLSolution pen-injector INJECT 0.5 MG SUBCUTANEOUSLY ONE TIME A DAY EVERY MONDAY FOR DIABETES FOR 4 WEEKS MAYGIVE ZEPBOUND IF HERE UNTIL PHARMACY SENDS OZEMPIC.According to the facilities policy titled Storage of medications revealed: the policy statement: the facility stores all drugs and biologics in a safe, secure, and orderly manner. with the interpretation and implementation: 1. Drugs and biologics used in the facility are stored in locked compartments under proper temperature, light, and humidity controls; 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts.) containing drugs and biologics are locked when not in use; 9. Unlocked medication cards are not left unattended.According to the facilities policy titled Medication administration revealed: the policy statement: medications are administered in a safe and timely manner, and as prescribed with the interpretation and implementation: 1. Only persons licensed or permitted by the state to prepare, administer and document the administration of medications may do so; 12. The expiration slash beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date open is recorded on the container; 17. Insulin pens are clearly labeled with the resident's name or other identifying information period prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident; 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. no medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or other passers by.

Based on interview and record review, the facility failed to ensure appropriate supervision for one resident (Resident #1) of three residents reviewed for falls, resulting in three unwitnessed falls causing an elbow skin tear and a hand laceration, resulting in a hospital visit for sutures. Finding include:Resident #1:On 4/6/2026, at 12:10 PM, a record review of Resident #1's electronic medical record revealed an admission on [DATE] with diagnoses that included Wedge compression fracture of T7-T8 Vertebra, fracture of first thoracic vertebrae, Vascular Dementia and Anxiety. Resident #1 had a Brief Interview for Mental status (BIM) assessment on 3/26/2026 which resulted the resident had severely impaired cognition. Resident #1 required extensive assistance with Activities of Daily Living (ADL's).A review of the Fall Assessment Date: 3/30/2026 . revealed the resident was High Risk for falls.A review of the I am at risk for falls care plan related to: Vascular Dementia, history of falls with injuries prior to admission, history of CVA (stroke), new to surroundings and potential medical side. Resident self transferring in deconditioned state. Date Initiated: 03/19/2026 Revision on: 03/27/2026 My Interventions will minimize my risk of serious injury related to falls. Date Initiated: 03/19/2026 Interventions Have commonly used articles within easy reach Date Initiated: 03/19/2026 Hip protectors on at all times as I will allow. Date Initiated: 03/30/2026 RESOLVED: Keep resident within sight of staff while awake and in wheelchair Date Initiated: 03/20/2026 Revision on: 03/30/2026 Maintain bed at transfer height as resident will tolerate. Date Initiated: 03/19/2026 Observe for signs and symptoms of medication side effects and report to Physician as needed. Date Initiated: 03/19/2026 Reinforce the need to call for assistance Date Initiated: 03/19/2026 RESOLVED: staff to offer bathroom assist in restroom q (every) two hours and PRN (as needed) When resident is up in his chair, as him to come out for an activity or where staff can visualize him. Date Initiated: 03/21/2026 Revision on: 03/30/2026 Resolved Date: 03/30/2026. A review of Resident #1's Incident reports, while in the facility, revealed the following falls: Fall Date: 3/20/2026 14:45 (2:45 PM) Incident Location: Resident's Room . Called to residents' room where staff had observed resident to be on the floor by his bathroom in his room. Resident Description: Resident unable to describe what happen .Was this incident witnessed: N (no) Description: Resident assessed and assisted into bed to complete skin assessment by writer and 2 staff members. See notes for injuries. Root cause: Resident is newly admitted and confused . Immediate Intervention: When resident is up in chair offer activities and encourage and request resident to come out to an activity and/or come to an area where he can be more closely visualized . Injury Type Bruise . Left elbow Skin Tear . Right elbow . Mental Status Orientated to Person . was the only box checked. Predisposing Physiological Factors Confused Impaired Memory were check marked. Fall Date: 3/26/2026 15:45 (3:45 PM) Incident Location: Resident's Room . Resident observed laying on floor near his dresser head towards sink. Back brace and c-Colloar on. Right palm had a deep jagged cut. Minimal bleeding. Resident had no complaints of pain or discomfort. On call md notified, orders to send to ER for evaluation and treatment . Resident unable to give Description Was this incident witnessed: N (no) Immediate Action Taken . palm wound cleansed and ABD with kerlix applied (bandage with wrapping). Root Cause: Confusion Self transferring. Immediate Description: Sent to ER for eval and treat and treat r/t cut on hand. Remove foot pedals on w/c when in room . Injury Type Laceration Right hand (palm) . Fall Date: 3/30/3036 08:45 (am) Incident Location: Resident's room . Nurse was sitting at desk and heard a loud crash. Went down the hallway and found resident on the floor. His head was towards door. Feet towards bed. He was lying next to the bathroom door. He was wearing nonskid socks and c-Collar and brace were on. Resident was able to move all extremities on his own and did not complain of any pain. He did not appear in any distress. Resident Description: resident stated he fell, he was unable to give any further description Was this incident witnessed: N (no) . Resident assessed for injuries, none noted at this time. MD (physician) notified, UCN notified, Spouse was also notified. Root Cause: confusion/Dementia. Immediate interventions: hip protectors for safety. No injuries observed at time of incident . A review of the AFTER VISIT SUMMARY 3/26/2026 revealed 2 sutures have been placed in your hand . Review the attached information Fall Prevention . A review of the progress notes revealed the resident discharged to ER on [DATE] for their Covid-19 symptoms and did not return to the facility. On 4/6/26, at 12:30 PM, the Director of Nursing (DON) was interviewed regarding Resident #1's falls while they were in the facility. The DON offered that all three falls were unwitnessed and in the resident's room. The DON was asked what interventions the facility put in place to ensure the resident's safety for each fall and the DON explained:For the 3/20/2026 fall, the intervention was for the resident to go to activities and to sit at the desk when up. For the 3/26/2026 fall, the DON explained they removed the foot pedals from the residents wheelchair and the resident was sent to the ER for the cut on his hand.For the 3/30/2026 fall, the DON explained the resident was in transmission based precautions for Covid-19 infection and was isolated to their room. They couldn't bring the resident to the nursing desk anymore so the hip protectors were placed. The DON was asked if they were aware Resident #1 had a risk of falls and the DON offered, the resident had a fall at his assisted living, yes. The DON was asked if the facility provided more supervision such as a someone sitting at their bedside keeping a close eye on the resident and the DON stated, if they had that availability they would but they did increase visualization and going in his room more often. The DON was asked if the resident admitted with the back fractures from falls and the DON offered, yes.

Based on observation, interview and record review, the facility: (1.) Failed to ensure proper labeling of medications in 3 of 3 medication carts, (2.) Failed to ensure properly secure/lock 1 treatment cart with medical supplies and prescription creams/ointments, and (3.) Failed to ensure proper completion of medication refrigerator temperature log, resulting in opened and undated medications. Findings include: Record review of facility 'Storage of Medications' policy dated 1/25, revealed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. (5.) Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or for destroyed. (8.) Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Record review of facility 'Medication Administration' policy dated 1/25, revealed medication are administered in a safe and timely manner, and as prescribed. (12.) The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Observation and interview on 03/11/25 at 09:57 AM with Registered Nurse (RN) K offthe 600-unit medication Cart #6 revealed one loose white oval tablet found in the second drawer. Resident #53 had a multi-dose bottle of Dorzolamide 2% eye drops, opened and not dated on the bottle. RN K could not say when the bottle was opened. Resident #37's multi-dose Fiasp flex touch insulin pen, open date 3/7/2025, with no expiration date on insulin pen. Observation and interview on 03/12/25 at 06:20 AM with Licensed Practical Nurse (LPN) P corporate Clinical support of the 400-unit medication Cart #4, revealed she had medications setting out on the top of the medication cart. Observation of Resident #32 Ventolin multi-dose inhaler with box lid missing revealed that there was no open date on the inhaler device or box. Resident #73 Timolol 0.25% ophthalmic eye drop multi-dose bottle, and box had no date when opened. Resident #73 had a second bottle of Timolol 0.25% ophthalmic solution 1 drop right eye daily was also opened with no date on bottle or box. Resident #95 medication Flonase nasal spray 50mcg per spray multi-dose bottle opened with no date on bottle or box. Observation and interview on 03/12/25 at 06:34 AM with Licensed Practical Nurse (LPN) L on 500-unit medication Cart #5, revealed Resident #18 eye drop medication latanoprost 0.005% ophthalmic solution had no date on the open multi-dose bottle or box and the top drawer of the medication cart had a black tablet loose in the drawer tray. LPN L stated that he thought the black tablet was iron. Observation on 03/12/25 at 06:41 AM with Licensed Practical Nurse (LPN) L of the Medication room on the 500/600 unit revealed the refrigerator to have for Resident #91 a bottle of Lorazepam intensol oral concentrate 2mg/ml, give 0.5mg via peg tube. The multi-dose bottle of Lorazepam intensol oral concentrate was not dated and open with 14 ml left the bottle of 30 ml. No date on bottle or the box. Record review of the 'Control Substance Record' form for Lorazepam 2mg/ml concentrate noted first use on 7/1/- and on 8/15/- documented the bottle spilled in the refrigerator, and on 10/28/24 the line was signed out and then crossed out. Observation and interview on 03/12/25 at 06:45 AM with Licensed Practical Nurse (LPN) H of the 500/600 medication room refrigerator of Resident #91's Lorazepam intensol oral concentrate 2mg/ml, reviewed the control substance sign-out sheet and the crossed-out dosing and medication spill revealed that the sheet should not have had cross outs, that's not how to waste a narcotic. Observation and interview on 03/13/25 at 09:42 AM with Registered Nurse (RN) Q of the 100/200 medication room revealed an electronic Med bank dispenser with fingerprint style. RN Q revealed that with narcotics, it takes 2 nurses. Review of the medication refrigerator temperature log revealed that the day shift for 3/12/2025 was not documented. RN Q stated that she has not documented or checked the refrigerator for today. Review of refrigerator temperature noted a manual dial thermometer noted on the second shelf of the refrigerator. observation of medication within the refrigerator noted multiple multi-dose insulin pens, eye drops and other medications that require refrigeration. Record review of the facility 'Temperature Log' form undated revealed: (1.) Record the current controlled room temperature twice daily. (3.) Refrigerator temperature must be between 36 degrees Fahrenheit and 46 degrees Fahrenheit. Record review of the 100/200-unit medication refrigerator temperature logs revealed: April 2024: noted 19 shifts failed to document/check the refrigerator temperature. On 4/28/24 and on 4/30/24 staff documented below the recommended temp. May 2024: noted 22 shifts failed to document/check the refrigerator temperature. June 2024: noted 19 shifts failed to document/check the refrigerator temperature. July 2024: noted 25 shifts failed to document/check the refrigerator temperature. August 2024: noted 24 shifts failed to document/check the refrigerator temperature. December 2024: noted 22 shifts failed to document/check the refrigerator temperature. February 2025: noted 18 shifts failed to document/check the refrigerator temperature. March 2025: noted 1 shift failed to document/check the refrigerator temperature. In an interview on 03/13/25 at 11:13 AM, Registered Nurse F unit manager reviewed the 100/200 medication refrigerator temperature logs which revealed multiple empty/blank check spots. RN F stated the facility replaced the thermometer and we have replaced the refrigerator, if the temperature is not in range staff are to notify the unit manager or Infection Control Preventionist, it's an infection control issue. Record review of facility 'Refrigerator Temperature Monitoring for Medications' policy, dated 1/2025, revealed the purpose was to ensure that medications stored in refridgerators are kept at approriate temperature to maintain thier stability, potency, and effectiveness, in compliance with healthcare regulations and best practices. 37668 On 3/11/25 at 2:36 PM, the treatment cart outside of Unit Five and Six nurses' station was observed unlocked and unattended by staff. Four staff were observed walking past the treatment cart. The staff did not address the cart was unlocked. On 3/11/25 at 2:44 PM, Unit Manager Licensed Practical Nurse (LPN) H was requested to come to the treatment cart. When asked if the treatment cart was unlocked, LPN H confirmed. Upon opening the cart, topical prescription medications as well as stock medications were contained in the cart. When queried if the cart is supposed to be locked, LPN H stated, Yes.

Based on interview and record review, the facility failed to ensure the CMS 802 (form utilized by the facility to list all current residents and to note pertinent care categories) was accurate for three residents (#48 #49 and #93) of 10 residents reviewed for matrix accuracy. Findings include: Resident #48: Upon entrance on 3/11/2025, review was conducted of the CMS 802. The 802 indicated, Resident #48 was being administered an antibiotic due to a current UTI (Urinary Tract Infection). On 3/12/2025 at 9:00 AM, a review was conducted of Resident #48's clinical record and it indicated the resident admitted to the facility on [DATE] with diagnoses that included, Cerebral Infarction, Vascular Dementia, Anxiety, Major Depressive Disorder and Hypertension. Further review yielded the following results: March 2025 MAR (Medication Administration Record): Indicated Resident #48 was not currently prescribed an antibiotic. February 2025 MAR: Bactrim Tablet - Give 1 tablet by mouth two times a day for infection for 14 days. Started on 2/12/2025 and ended on 2/26/2025. Resident #93: Upon entrance on 3/11/2025, CMS 802. The 802 indicated Resident #93 was being administered an antibiotic due to a current UTI (Urinary Tract Infection) for infection indicated at M (multidrug-resistant Organism). On 3/12/2025 at 9:15 AM, a review was conducted of Resident of Resident #93's clinical records and it indicated he was admitted to the facility on [DATE] with diagnoses that included Anxiety, Schizoaffective, Thyroid Disorder, Hyperlipidemia and Heart Failure. Further review of the record yielded the following: February MAR: Macrobid Oral Capsule 100 MG (milligrams) give 1 capsule by mouth two times a day for 14 days. Started on 2/16/2025 and ended on 3/1/2025. On 3/12/2025 at 2:15 PM, Infection Preventionist B was queried if Resident #93 is currently being treated with an antibiotic for an UTI. Preventionist B stated not currently as the resident completed her treatment on 2/26/2025. Preventionist B was further queried if Resident #93 currently has a UTI, and she stated he does not as he finished his course of treatment on 3/1/2025. She was asked how this information is updated for facility usage, and it was explained they go over it in morning meeting but also she emails an updated list at least weekly of current infections with antibiotic usage. On 3/15/2025 at 3:15 PM, an interview was conducted with MDS (Minimum Data Set) Coordinator E regarding accuracy of CMS 802. Coordinator E stated the 802 is a real-time depiction of resident care categories. Coordinator E was queried if Residents #48 and #93 currently have UTI's and are being treated with antibiotics and he stated they are not. He reported Resident #93's treatment ended last week and Resident #48 at the end of February. He stated it was an oversight on his part as he completes the 802 manually. 22927 Resident #49: On 3/11/2025 the survey team received the CMS-802 Resident Matrix form from the facility as an accurate resident assessment overview of residents residing within the facility during the annual survey. The form was hand signed and dated. Observation and interview on 03/11/25 at 09:24 AM with Resident #49 revealed some confusion. Licensed Practical Nurse M came into the resident room and stated that the resident #49 he goes to (local) hemodialysis on Tuesday/Thursday/Saturday schedule. LPN M was able to show the state surveyor Resident #49's right chest hemodialysis catheter with a white bandage dressing with no date. LPN M stated that Resident #49 was dressed and ready to go to his hemodialysis treatment and had a pick-up time of 9:45 AM per order. Record review on 03/12/25 at 10:30 AM of the facility-provided CMS-802 form signed and dated 3/11/2025 by Registered Nurse E did not identify the Dialysis therapy for Resident #49. In an interview on 03/13/25 at 12:24 PM, Registered Nurse (RN) E MDS (Minimum Data Set) assessment nurse revealed that the nurse reviews the resident admission orders for the residents as part of the assessment. Record review of the CMS-802 form by RN E stated that was his signature and date on the CMS-802 form. RN E revealed that the Interdisciplinary Team (IDT) team meets every morning and to discuss residents' diagnoses and any changes. The MD nurses enter the assessment changes manually each Monday of the week and go into (electronic medical record) and run a report on new admits, diagnosis, orders, specialty (UTI/Antibiotics) and update that on the assessment. Record review of Resident #49's CMS-802 dialysis category was blank, Why? RN E stated that's a good question. The Infection Control nurse hands out a sheet with dialysis/hospice residents that is reviewed, I don't have an answer. I probably missed the box. Resident #49 was admitted in February 2025. It didn't transfer over to the CMS-802 form because of the update button. It messes with all residents' assessments. It was just missed.

Based on interview and record review, the facility failed to ensure licensed nursing staff competency for medication administration for one resident (Resident #21) of one resident reviewed, resulting in medication administration without a Health Care Provider's order and inappropriate medication administration per professional standards of practice. Findings include: Resident #21: Record review revealed Resident #21 was originally admitted to the facility on [DATE] with diagnoses which included Coronary Artery Disease (CAD), depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to moderate assistance with bathing, dressing and transfers. On 3/12/25 at 7:39 AM, an interview was completed with Resident #21 in their room. When queried regarding their care in the facility, Resident #21 stated, The care is getting worse. Resident #21 was asked what was getting worse and revealed they had a bad experience with a nurse during the prior night. When asked what happened, Resident #21 revealed a new nurse (LPN R) was working. Resident #21 stated, (LPN R) comes in here and sits the pills down. There were two pills in there and they looked like they were for my bladder. (LPN R) didn't explain it, just left them there. Resident #21 then stated, I went out (to the nurses' station) this morning and found out. When asked what they meant, Resident #21 revealed they did not take the pills they did not recognize that the nurse left in their room and took the pills to the nurses' station to find out what the pills were. When queried if the nurse left any other medications in their room, Resident #21 revealed the only medications they did not take were the ones they did not recognize. With further inquiry, Resident #21 revealed they were told the pills they did not recognize were for gas when they took them to the nurses' station. Resident #21 stated, I guess they ran out of the correct pills. When queried what happened when they went to the nurses' station to ask what the medication was, Resident #21 replied, (LPN R) was madder than hell and threw the pills out. Resident #21 stated, They aren't supposed to leave the pills on the table. When asked how they knew LPN R was mad, Resident #21 stated, (LPN R) was rude to me. (LPN R) told me, go back to your room, I ain't going to listen to you anymore. When asked how that made them feel, LPN R revealed they were upset and angry. LPN R stated, Who the hell does (LPN R) think they are. Don't treat me like that. Resident #21 continued, I can't understand why they have such a problem with the people on third shift. When asked if they had other concerns, LPN R then stated, I had cream in here and the (Certified Nursing Assistant [CNA]) threw it out last night. Resident #21 was asked what kind of cream they had and why the CNA threw it out, Resident #21 indicated it was a cream for the skin irritation under their breasts and revealed the staff told them they had to throw the cream away because the State is here. . An interview was completed with Unit Manager LPN H on 3/12/25 at 8:13 AM. When queried regarding Resident #21, LPN H revealed the Resident had expressed care concerns related to night shift staff and medications to them that morning. LPN H was asked about LPN R and revealed the nurse was new to the facility. When queried regarding the medications, LPN H stated, (LPN R) gave (Resident #21) Tums (Active ingredient: calcium carbonate- neutralizes stomach acid and reduces heartburn/indigestion. Used to treat heartburn and acid reflux) and not Simethicone (Active ingredient: dimethicone- breaks down gas bubbles in the stomach, reduces gas, bloating, and abdominal discomfort). When queried how they knew LPN R administered Tums and not Simethicone, LPN H revealed they spoke to LPN R after Resident #21 verbalized their concerns to them this morning. When queried if they asked LPN R why they gave the Resident Tums and not Simethicone and revealed LPN R told them they were unable to locate the Simethicone. With further inquiry, LPN H revealed simethicone is located in the facility medication storage room and in each medication cart. A review of Resident #21's Health Care Provider (HCP) orders and Medication Administration Record (MAR) revealed the Resident did not have an order for Tums. The Resident did have an order for Simethicone. Resident #21 also had an order for Milk of Magnesia (medication used to treat constipation, upset stomach, and heartburn). Review of progress note documentation in Resident #21's Electronic Medical Record (EMR) revealed no related progress note documentation from the night shift on 3/11/25 to 3/12/25. On 3/12/25 at 8:25 AM, LPN H called LPN R and placed the phone on speaker. A phone interview was completed at this time. When asked what occurred with Resident #21's Simethicone, LPN R stated, I couldn't find it, so I gave (Resident #21) Tums. When queried if the Resident brought the medication to the nurses' station later in the shift, LPN R stated, (Resident #21) came up (to nurses' station) and was upset because the CNA took the things out of their room and threw them away because the State was here. When asked if they understood they were speaking to a Surveyor, LPN R confirmed they did. LPN R was then asked why they gave the Resident Tums if the order was for Simethicone, LPN R stated, I gave it to (Resident #21) with their other pills and they came back out with the Tums and said what are these. I told (Resident #21) I explained it to you. LPN R was stopped and asked if they were saying they left the Resident's medications in the room and stated, No. When asked if the only medication they administered to Resident #21 was the Tums, LPN R replied they Resident had other medications. LPN R was then asked if the Resident brought all the medications out the nurses' station and indicated they only brought the Tums. LPN R was asked again how the Resident brought the medication to the nurses' station if they administered them in the room and did not respond. When asked if they left the medications in Resident #21's room for them to take, LPN R confirmed they did. When asked why they left Resident #21's medications at their bedside for them to take, LPN R stated, I figure she is cognitive enough to take them by themselves. When asked if Resident #21 had a medication self-administration assessment, LPN R responded they did not know. When queried what the facility policy/procedure is regarding medication self-administration, LPN R verbalized they did not know. When asked, Unit Manager LPN H informed LPN R that nursing staff are to administer and stay with residents during medication administration and not leave medications at residents' bedsides. When queried why they administered Tums and not Simethicone to Resident #21, LPN R revealed they could not find Simethicone in the medication cart. When queried if they asked another nurse for assistance in locating the medication in a different area or medication cart, LPN R replied, No. When asked if they reviewed Resident #21's MAR to see if they had orders for any other medications which may assist with complaints of gas and stated, No. When queried if Resident #21 had a Healthcare Provider order for Tums, LPN R stated, No. When asked if they contacted the Resident's Healthcare Provider to inform them of the situation and obtain an order, LPN R verbalized they did not. When asked why they administered Tums instead of simethicone, without a Healthcare Provider order, LPN R replied, I just thought it would be easier. When asked if it is within their scope of practice to administer medications without a healthcare provider order, LPN R stated, No. LPN R was then asked where they documented administration of the Tums and revealed they did not chart it. When queried what they told Resident #21 when they came to the nurses' station regarding the medication, LPN R replied, I told (Resident #21) there was no problem with meds. When asked if the Resident was upset, LPN R confirmed they were. When queried why they told Resident #21 there was not a problem with the medications when there was, LPN R did not provide an explanation. After the phone call was completed, LPN H was asked if they had any additional comments and stated, I got nothing. A review of LPN R's Human Resource (HR) and education/training records revealed they completed medication administration training and competency at the facility An interview was completed with the Director of Nursing (DON) on 3/13/25 at 1:52 PM. When queried regarding LPN R administrating Tums to Resident #21 without a HCP order and leaving the medications at the Resident's bedside, the DON stated, We don't give meds without orders here.

Based on interview and record review the facility failed to effectively monitor four residents (#60, #76 #85, #276) of five residents reviewed for unnecessary medications. Resulting in, Residents # #60, #85 and #276) being administered medications without the proper indications for usage and Resident #76 being administered a prophylactic antibiotic without risk versus benefit analysis. Findings Include: Resident #60: On 3/12/2025 at 8:40 AM, a review was conducted of Resident #60's records, and it indicated the resident initially admitted to the facility on [DATE] with diagnoses that included, Acute and Chronic Respiratory Failure with Hypoxia, Anxiety Disorder, Atrial Fibrillation and Major Depressive Disorder. Resident #60 can make her needs known to facility staff and is her own person. Further review yielded the following: Physician Orders: Risperidone Tablet 0.5 MG (milligram) Give 1 tablet by mouth one time a day related to Major Depressive Disorder. Ordered on 2/25/2025 Risperidone Tablet 0.5 MG Give 1 tablet by mouth one time a day for antipsychotics. Ordered on 2/22/2025 and discontinued on 2/24/2025. While Resident #60 does have a diagnosis of Major Depressive Disorder that is not a proper indication of usage for Risperidone nor is stating the class the medication appropriate. Psychiatric Note dated 2/5/2025 Chief complaint: Psychosis, Anxiety .She is noted to be prescribed Risperdal for reported hallucinations previously experienced . Resident #256: On 3/12/2025 a review was conducted of Resident #256's medical records and it indicated she admitted to the facility on [DATE] with diagnoses that included, Peripheral Vascular Disease, Atrial Fibrillation, Pulmonary Hypertension and Metabolic Encephalopathy. Resident #256 can make her needs known to facility staff. Further review of the records yielded the following: Physician Orders: Ramelteon Oral Tablet 8 MG (Ramelteon) Give 1 tablet by mouth in the evening for sleep. Ordered on 3/10/2025. Aripiprazole Oral Tablet 5 MG Give 2 tablet by mouth one time a day for antipsychotic/antimanic. Ordered on 3/10/2025. It is unknown why Resident #256 was prescribed a hypnotic and antipsychotic when she does not have any mental health or sleep disorder diagnoses. Review was conducted of the signed consent for Abilify and Ramelteon and they did not indicate which specific condition was being treated for the administration of medications. On 3/13/2025 at 8:30 AM, Social Worker Director N was queried regarding Resident #60's Risperidone administration for Major Depressive Disorder and was asked if this was an appropriate indication of use. Social Worker N stated it was not, review was completed of chart and found there was a diagnosis of psychosis listed in a recent psychiatric evaluation that did not integrate into the residents' diagnoses list. Social Worker Director N was further queried regarding Resident #256's antipsychotic and hypnotic usage without proper indications and after review of the record reported it appear that when the resident was in the hospital, she was diagnosed with hospital acquired delirium and prescribed both medications but again the diagnoses were not integrated into her clinical record. 22927 Resident #76: In an interview on 03/11/25 at 11:43 AM, Resident #76 while she was seated up in a high back wheelchair in the resident's room was asked about illness/infections by the surveyor. Resident #76 stated, It was for my pee, I couldn't go to the bathroom very well. In a record review on 03/11/25 at 11:52 AM of Resident #76's Medication Administration Record (MAR)for January 2025, Resident #76 received the antibiotic medication every morning at 7:00 AM from 1/9/2025 through 2/28/2025. An interview and record review on 03/12/25 at 02:52 PM with Registered Nurse/Infection Control Preventionist B revealed Resident #76 was admitted on [DATE] with the antibiotic Cephalexin 250mg one capsule by mouth one time a day for Urinary Tract Infection (UTI) Prophylaxis (recurrent UTI). RN B revealed Resident #76 was on antibiotic because she has a history of re-current Urinary Tract infections (UTI). Resident #76 went to Hospital on 1/1/25 till 1/8/25 for metabolic encephalopathy and recurrent UTI's and came back to the facility on an antibiotic. On 2/24/2025, Resident #76 acquired an in-house acquired UTI with Proteus Mirablis and Cephalexin. On 2/28/2025 Resident #76 was started on Cephalexin 250mg twice daily was started and then stopped on 3/5/25. Resident #76 was started on Cephalexin 250mg one capsule by mouth one time a day for Urinary Tract Infection (UTI) Prophylaxis (recurrent UTI's). prophylactic antibiotic. The state surveyor inquired about a Risk vs Benefit statement for prophylaxis antibiotic therapy? RN B performed a Record review of Resident #76's electronic medical record and revealed there to be no Risk vs benefit by the physician for prophylactic antibiotic usage. RN B did not find Risk vs benefit by the physician for prophylaxis use from December 2024 through March 2025. None were found. RN B stated that Yes we should have gotten a risk vs benefits from our physician prior to use. Record review of the facility 'Antibiotic Stewardship- Orders for antibiotics' policy, dated 9/2024, revealed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing: (4.) Empirical (based on experience; determined from experimental data, as opposed to theoretical. [NAME]-Keen, Encyclopedia & Dictionary of Medicine, Nursing, & Allied Health, 7th edition, page 584.) use of an antibiotic based on clinical criteria of suspected sepsis may be appropriate. The staff and practitioner will document the specific criteria that support the suspicion in the resident's clinical record. Resident #85: Observation on 3/11/2025 around 10:00 AM, during the initial screening process of the annual survey, revealed that Resident #85 was lying in bed with oxygen at 2-liter nasal cannula. Resident #85 opened her eye to her name and did not respond to questions about her care. Record review on 03/12/25 at 12:32 PM of Resident #85's medical diagnosis list revealed admitted : Dementia, severe, with psychotic disturbance; unspecified dementia, severe with anxiety; other mixed anxiety disorders; alcohol dependence with alcohol-induced persisting dementia; cognitive communication deficit . Record review of Resident #85's March 2025 Medication Administration Record (MAR) revealed antipsychotic medication Olanzapine (Zyprexa) 2.5mg give one tablet by mouth two times a day related to unspecified dementia, severe with psychotic disturbance started on 3/9/2025. In an interview on 03/12/25 at 01:43 PM, Social Worker N revealed that Resident #85 was on Zyprexa (antipsychotic) 10mg daily, and the facility lowered the dose down to 5mg daily currently, it's only been since the 3/9/25. The Xanax (anxiolytic) 0.25mg at HS, ordered on 8/30/24, was a 0.5mg dose, and was lowered to a 0.25mg dose. Record review on 03/12/25 at 01:53 PM with Social Worker N of Resident #85's Zyprexa antipsychotic medication consent listed dementia with behavioral features. Improve functionality, reduce adverse behaviors. The proposed course of the medication is: Prolonged treatment. There were no behaviors identified on the consent. What are the behaviors? Social Worker N stated it is the wrong diagnosis, and It was signed by 2 nurses. In an interview and record review on 03/12/25 at 2:01 PM, Registered Nurse (RN) G stated I did get consents for Zyprexa and Xanax for Resident #85. I believe it was her guardian. On 2/27/2025 it was not a new order; we were updating paperwork. No, I did not write a note that I contacted the DPOA. I called to let guardian know that we were changing the paperwork, due to new CMS guidelines. What behaviors are you treating? not on the consent form. RN G stated I was just helping out; she's not my resident. Record review of Resident #85's physician order record states psychotic disturbance? what disturbance? hallucinations, delusions, what? RN G stated I don't know. No, I did not document the call for phone consent either. Record review of the consent form noted 'Also document Obtained Phone Consent in Nurse's Notes. This was not done. Record review of Progress notes with no note for consents.

Based on observation, interview and record review, the facility failed to ensure proper administration of medication for one resident (Resident #83), resulting in Resident #83 receiving levothyroxine (thyroid hormone replacement) with med pass supplement and other medications. Findings include: Record review of facility 'Medication Administration' policy dated 1/25, revealed medication are administered in a safe and timely manner, and as prescribed. (7.) Medications are administered within (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). (8.) If a dosage is believed to be inappropriate or excessive for resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility Medical Director to discuss concerns. (22.) The individual administering the medication initials the resident's EMAR (Electronic Medication Administration Record) after giving each medication and before administering the next ones. (24.) The nurse must ensure residents consume medications before leaving the resident. Resident #83: Observation and interview on 03/12/25 at 07:03 AM with Registered Nurse (RN) I of Resident #83 blood sugar check, revealed a blood sugar level of 69. N I provided cranberry juice to resident. RN I prepared Resident #83's oral medications of: Med pass 120ml, cholecalciferol tablet 1000-unit x 2 tablets, levothyroxine 137mcq, Lasix 40mg, glipizide 10mg, metoprolol 25mg, potassium chloride ER 20meq, xifaxan 550mg, Zyprexa 2.5mg, lactulose solution 10gm/ml, give 30ml. Resident #83 was observed to take the medications after the Med pass solution and lactulose solutions. Record review of Resident #83's March 2025 Medication Administration Record (MAR) revealed Registered Nurse I signed out 7:00 AM medication administration for 3/12/2025 including levothyroxine thyroid hormone therapy medication with the 7:00 AM supplements and medications. Record review on 03/12/25 at 10:25 AM of Resident #83's March 2025 Medication Administration Record (MAR) revealed that on 3/13/2025 Resident #83 received levothyroxine 137mcq medication which was signed out as administered with other medications and supplements. In an interview and record review on 03/13/25 at 10:43 AM, Licensed Practical Nurse (LPN) manager H revealed that Breakfast is served at 8:00 AM to 8:15 AM. The state surveyor inquired of Resident #83's thyroid medication orders; on Monday 3/10/2025 levothyroxine on Monday was at 5:00AM given with no food and on an empty stomach. LPN H reviewed Resident #83's levothyroxine was given at 7:00 AM on 3/12/2025 with other medications and supplements. On 3/13/2025 again levothyroxine was given at 7:00 AM. The state surveyor inquired who entered the medication order on 3/11/2025? Record review with LPN H of the orders revealed that LPN H had put the order in for 7:00 AM. LPN H stated that she knew better and that the medication should have been scheduled to be administered at 5:00 AM. In an interview on 03/13/25 at 11:10 AM, Registered Nurse (RN) Unit manager F revealed that the medication levothyroxine is administered, at 5:00 AM because it is to be given on and empty stomach and before other medications. Record review of 'Nursing 2017 Drug Handbook' page 875, revealed levothyroxine oral medication administration recommended to be given at the same time each day on an empty stomach, preferable 1 hour before breakfast. Interactions noted oral antidiabetics may alter glucose level.

Based on observation, interview and record review, the facility failed to follow care plan interventions for dining for one resident (Resident #8) out of five residents reviewed for dining, resulting in a lack of assistive devices provided. Findings include: Resident #8: On 3/11/25, at 11:45 AM, Resident #8 was sitting up in their bed with their lunch meal. A review of Resident #8's meal ticket on their tray revealed the resident required a Scoop plate (a dining aid plate with a non-slip suction with a high rim) and a Kennedy cup (a dining aid cup with a J shaped handle and is spill proof). Resident #8 was drinking their cranberry juice from a small plastic juice glass. Their meal was housed on a white plate. There was no Scoop plate provided. The Kennedy cup was empty. On 3/12/25, at 9:00 AM, a record review of Resident #8's electronic medical record revealed an admission on 12/16/2024 with diagnoses that revealed Amnesia, Anorexia, and Seizures. Resident #8 required assistance with Activities of Daily Living. A review of the most recent Minimal Data Set assessment (MDS) Date 1/7/2025 revealed a Brief Interview of Mental Status result of 07 which revealed severely impaired cognition. A review of the I have a nutritional problem care plan Date Initiated: 12/03/2024 revealed Goal I will maintain adequate nutritional and hydration status . Interventions Adaptive Equipment: -[NAME] cups -scoop plate Date Initiated: 12/04/2024 . A review of the NUTRITIONAL EVALUATION Effective Date: 03/10/2025 revealed . Weight: 139.5 Date: 03/04/2025 Usual body weight 145 . ADAPTIVE EQUIPMENT Is any adaptive dining equipment used? . The Yes was check marked. On 3/12/25, at 12:08 PM, Resident #8 was sitting up in their bed with their lunch meal. There was no Scoop plate provided nor a Kennedy cup. There was one small plastic glass of cranberry juice. On 3/13/25, at 12:19 PM, Resident #8 was sitting up in their bed with their lunch meal. The Kennedy cup provided on the tray was tipped upside down and empty. The meal was provided on a Scoop plate. The Scoop side of the plate was at 12 O'clock and not closest to the resident. There was a small plastic juice glass of cranberry juice. On 3/13/25, at 12:23 PM, CNA C entered Resident #8's room and was asked why the Kennedy cup was tipped upside down and empty. As CNA C explained that the resident didn't like to use it. On 3/13/25, at 12:29 PM, the Director of Nursing (DON) was alerted Resident #8 was not provided the assistive devices listed on their care plan.

Based on observation, interview and record review, the facility failed to transport clean linen and store gloves in a sanitary manner, resulting in contamination of linen and Personal Protective Equipment (gloves). Findings include: On 3/11/25, at 10:05 AM, an observation of room [ROOM NUMBER] revealed a box of clear gloves on top of the counter. There were gray gloves piled on top of the box of clear gloves. The gray gloves were not covered and some were flopped over the box touching the top of the counter. The resident offered yes, the staff use the gloves. On 3/11/25, at 4:18 PM, an observation of CNA O in the 200 hallway was conducted. CNA O was carrying a pile of clean linens with their left arm. The pile of linen was resting on their uniform top. The linen was uncovered. On 3/11/25, at 4:19 PM, CNA O was asked if that was how they normally carried clean linen and CNA O offered, No. CNA O was asked what the facility expectation was for transporting clean linen and CNA O moved their left arm out away from their body. On 3/12/25, at 7:45 AM, a further observation of room [ROOM NUMBER] revealed the pile of gray gloves remained. It appeared the pile of gray gloves was less than the day prior. On 3/12/25, at 8:27 AM, an observation along with the Director of Nursing (DON) of gloves in room [ROOM NUMBER] was conducted. The DON was asked if the gloves are supposed to be stored exposed and the DON offered, No, they're not supposed to be. The resident offered that they do see the staff use the gray gloves. On 3/13/25, at 10:30 AM, Infection Control Nurse A was alerted of the observations of the glove storage and CNA O with the clean linen touching their uniform. IC Nurse A offered, I heard about that.

Based on observation, interview and record review, the facility failed to document pain medication administration and complaints of ankle pain for one resident (Resident #1) of three residents reviewed for falls, resulting in a lack of documented left ankle assessments and Tylenol administration. Findings include: Resident #1: On 2/4/25, at 9:30 AM, Resident #1 was resting in their bed. Resident #1 was asked how they hurt their ankle and Resident #1 offered, I was trying to get in my chair and my foot got caught in the bed. I heard a pop. Resident #1 offered that no staff were helping her at the time she got her leg caught but then one nurse came in to assist her. On 2/4/25, at 9:40 AM, Nurse B was interviewed regarding Resident #1's left ankle fracture. Nurse B offered that Nurse C reported that she gave her some Tylenol. Nurse B offered that they assessed Resident #1's toe nails, didn't see any ankle swelling and Resident #1 did not complain of pain. Nurse B was asked if they placed a progress note regarding the ankle assessment and Nurse B stated, no. On 2/4/25, at 10:10 AM, the Director of Nursing (DON) was interviewed regarding Resident #1's ankle injury. The DON explained they did an investigation and concluded a hypothesis as to the cause of the injury. The DON offered the complete investigation for review. On 2/4/25, at 10:30 AM, a record review of the injury investigation summary revealed: 12-21-24 . At approximately 1120 AM on 12-31-24 (Resident #1) c/o (complained of) left ankle pain. Some swelling was noted. X-ray left ankle ordered by NP. Bio-freeze and Tylenol ordered as directed. Resident tells NP it started couple days ago, it feels broken . After querying multiple staff members from the unit (Resident #1) resides on the following can be Gleaned: The night of 29th of December when (CNA E) was here for 2nd shift (Resident #1) told her My ankle hurts, I got it caught in the bed. It hurts. (CNA E) says no one was around nor did (Resident #1) blame anyone for her injury. The CENA immediately told the Nurse and had her come and look at (Resident #1's) ankle. The Nurse did see discoloration but did not think it was swollen. She gave her Tylenol and (Resident #1) had no further complaints to the Nurse. Later that night (Resident #1) told another CENA (CENA F) that she was getting in her chair and got her foot stuck. She told CENA F I am not going to do that anymore . (Nurse C) . Did anyone report to you an injury of (Resident #1) left ankle? Yes, Sunday night (CENA E) reported to me that (Resident #1) said her left ankle hurt. I went in to assess her and she had no swelling or bruising so I though it was some arthritis pain. I asked if she would take some Tylenol and she said yes. I brought back two Tylenol and she was only going to take one but I encouraged in to taking the two if it was bothering her. She usually does not take her meds so I reported to (Nurse B) the next morning to continue to monitor her because she normally does not ask for meds or complain. She did have a dark area by her ankle but I thought it was just discolored skin but now I wonder if it was a bruise starting . I worked Monday night and she did not complain of pain at all. I thought it was just that one night it bothered her. She never said anything about it on Monday . A review of Resident #1's electronic medical record revealed an admission on 12/30/2021 with diagnoses that included Dementia, disorders of bone density and nondisplaced Trimalleolar fracture of left lower leg. Resident #1 required assistance with Activities of Daily Living and had impaired cognition. A review of the progress notes revealed an entry on 12/5/2024 and not again until 12/31/2024 11:19 . c/o pain left ankle Observed some swelling to ankle NP examined N.O. (new order) X-ray left ankle Biofreeze to ankle BID (twice a day) Notify NP of results and possible further orders. A review of the MEDICATION ADMINISTRATION RECORD 12/1/2024 -12/31/2024 revealed Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for general discomfort -Start Date-12/31/2024 There was no documented Tylenol administration for the Tylenol administered on 12/29/24 by Nurse C. On 2/4/25, at 11:30 AM, a record review of the investigation report and Resident #1's electronic medical record along with the DON was conducted. The DON offered, that after talking to numerous staff on the night of the 29th, she told CENA E that she hurt her leg and that it got caught in the bed and that (Nurse C) assessed her and gave her Tylenol. A review of the progress notes revealed no documentation of Resident #1 complaints of pain on 12/29/24 or of any Tylenol administration on that night. The DON offered, oh, she didn't put in a note. The DON was alerted there was no progress notes of Resident #1's complaints of ankle pain or that they hurt their leg until 12/31/2024.

This citation pertains to intake number MI00147076 Based on observation, interview and record review the facility failed to maintain professional standards and complete comprehensive and safe discharge for one resident (Residednt #808) reviewed for discharge, resulting in Resident #808 being discharged from the facility with a multitude of another resident's (Resident #807) medications in their possession. Findings Include: Resident #808: On 10/22/2024 at 4:30 PM, Resident #808 was observed watching television in her room. She was in good spirits and when asked about her most recent discharge from the facility she stated the nurse gave her another residents medications. Resident #808 explained she was discharged around 5:30 PM (on 9/20/2024) and provided with a lot of medications which she thought was odd as she was only prescribed 2-3 medications. Resident #808 reported she did take one pill from the blister pack which resembled another one of her medications. When Resident #808's Home Health Care nurse arrived on Sunday (9/22/2024) was when it was discovered the incorrect medications were discharged with the resident. The nurse observed the name on the blister packs were incorrect. Resident #808 reported she did not have any adverse reactions from ingesting the medications. On 10/22/2024 at approximately 4:45 PM, a review was completed of Resident #808's medical record. It revealed the resident admitted to the facility on [DATE] with diagnoses that included Rhabdomyolysis, Adult Failure to Thrive, Hyperlipidemia, Peripheral Vascular Disease and Foot Drop. Further review revealed the following: Progress Notes: 9/20/2024 17:23: Resident discharged home with family, left facility in her wheelchair with all of her belongings. Meds given to family member and reviewed. No belongings left in room. All questions answered. Med rec printed. It can be noted while this discharge note was charted, it is not an accurate depiction of what truly occurred during Resident #808's discharge from the facility. On 10/23/2024 at 8:40 AM, an interview was conducted with DON (Director of Nursing) regarding Resident #808's discharge. The DON reported Nurse L contacted her on 9/20/2024 and asked what medications Resident #808 was being discharged with. The DON explained the resident would either have a bag of medications, scripts completed or provide her with medications from the cart. The DON further explained the social worker completes a discharge folder for each resident and the nurse would have to complete the medication reconciliation document, discharge instructions and obtain the resident signature. The DON let Nurse L know if there were any issues to contact the Unit Manager who would further guide her. Nurse L searched the medication room and was not able to locate Resident #808's medications and the discharge folder did not have the scripts. The nurse contacted the Unit Manager who instructed her to pull the meds needed from the medications cart to last until Resident #808's first doctor appointment. The DON reported on Saturday evening she worked the floor, and another nurse was searching for missing medication blister packs that they knew were there yesterday. The nurse had to go in backup to obtain the medications for the resident. The DON stated upon entering the medication room she noticed a bag of medications for Resident #808 atop the counter and questioned Nurse L about it as she was working. The nurses asserted the bag of medications were not in the facility yesterday and someone was playing tricks on her. The DON reviewed the delivery receipt which indicated the medications were delivered Thursday September 19, 2024, and indeed were in the building upon Resident #808' discharge. Nurse L further expressed she enlisted two other nurses to search for the medications which was unsuccessful. The DON interviewed both nurses and one stated Nurse L provided them with a different resident name and the other nurse stated she never assisted in the search. On Sunday morning, Nurse Q alerted the DON that Nurse L discharged Resident #808 with 7 blister packs for another resident (#807). Nurse Q gathered the residents correct medications and delivered them to her. The DON discussed this with Nurse L who admitted to not reviewing the blister pack of medications she pulled from her medication cart, completing a medication reconciliation nor reviewing the specific medications given to resident prior to her leaving. Nurse L's reasoning was they were busy and room changes were completed that day. The medications that the incorrectly sent home with Resident #808 are as follows: -Seroquel 400 MG 1 card -Trintellix 5 mg- 1 card -Atorvastatin 20 mg 1 card -Seroquel 300 MG 1 card -Potassium 20 MeQ- 1 card -Lasix 40mg- 1 card -Prednisone 5 mg 1 card -Gabapentin 600 mg 1 card -Amitriptyline -25 mg 1 card On 10/23/2024 at approximately 11:00 AM, a review was completed of medication Packing Slip for Resident #808. It indicated Resident #808's medications were delivered to the facility on [DATE]. The medications delivered were: 40 MG (milligram) Atorvastatin tab 40 MG DR (delayed release) Pantoprazole On 10/23/2024 at 11:55 AM, an interview was attempted with Nurse L regarding their discharge of Resident #808 on 9/20/2024. Nurse L expressed she was not comfortable answering questions from this writer and would be contacting her attorney. On 10/23/2024 at 12:10 PM, an interview was conducted with Nurse Q regarding Resident #808's discharge from the facility. Nurse Q explained on Saturday they were not able to find Resident #807's medications and there were only two blister packs in the cart. They pulled what they could from backup but were unable to ascertain where her medications were. Nurse Q reported on Sunday 9/22/2024 the receptionist informed her Resident #808 was on the phone and stated she received another residents' medications when discharged on Friday. The home health care nurse visited her that morning and discovered the discrepancy. Nurse Q delivered Resident #808's correct medications to her home and picked up Resident #807's medications that had been sent with the resident. Upon arrival at Resident #808's home she told the nurse she took the pink/orange pill as Trintellix (identified by Nurse Q) as she thought it would make her depressed. Nurse Q reported Resident #808 had about 10 blister packs of Resident #807's medications in her possession. On 10/23/2024 at approximately 12:30 PM, a review was conducted of the facility's investigation into the incident and following was reviewed: Disciplinary Action for Nurse L dated 9/22/2024: Nurse sent resident home with incorrect discharge meds, and incorrect/missing discharge instructions. Nurse L was suspended on 9/23/24 and terminated on 9/24/24. Medication Error Report: 9/20/2024: Nurse (L) sent resident (#808) home with another resident meds (medications). Resident took one Trintellix 5 mg tab that was not ordered for her . Resident remains at her baseline at home . Education mandatory to all nurses. Nurse terminated. History and Physical from Acute Care Hospital: .Patient states that she was discharged from (facility) on Friday 9/20/2024 due to end of paid rehab days. Patient states that on Friday night and Saturday patient took her discharge medications, patient states that she noticed that the pills made her dizzy which is not a normal side effect of her medications. Patient states that she only takes two medications normally and was wondering why there were more medications now than when she was patient at (the facility). Patient discovered that there was a different patient name on the medications and that they were the medications of the patient she shared a room with. Patient states that she called (the facility) to inquire about the medications and they told her oops we made a mistake. Patient does not know what medications that she took, but she does state after taking the medications, she had dizziness, loss of consciousness, loss of coordination of her lower legs with numbness and tingling from the knee down . Medication Reconciliation Sheet: -The form was not completed under discharge medication/treatment section for Atorvastatin Calcium 40 MG by mouth at bedtime and Pantoprazole Sodium Oral Tablet Delayed release 40 MG in the morning. Investigative Summary: 9/20/2024: Nurse (L) discharged (Resident #808) home as ordered. Prior to discharge she called DON And asked what medications she was to go home with? This DON told her that she needed to Look and see if medications were in med. room from pharmacy for her or if scripts were in the Discharge folder for her. (Nurse L) asked why the med. rec. document was not completed for her? I let her know that is the Nurses job and that we do it right before discharge so that the last time they received each medication will pop up on the med. rec so they know when they Get home .When she called (Unit Manager) She told the unit manager that there were no meds in the med room for her patient to go Home with and no scripts in the folder. Unit manager Looked up her medications on her Computer and told (Nurse L) well she is only on protonix and Atorvastatin so just give Her the cards from the med cart and I will let DON know that we sent those home With her . When DON went in med. room for First time on Saturday I noticed bag of meds on the counter that clearly said the name of the resident that (Nurse L) was supposed to discharge yesterday (Resident #808) I asked (Nurse L) why those meds. were in there still, she said l don't know where those meds Came from but they were not there yesterday, someone is playing tricks on me, l had Three nurses looking with me yesterday for her meds, and no one found them. DON checked delivery receipt and medication bag was delivered on Thursday so they most Certainly were in the med. room when someone looked for them. Nurse says she looked. She Volunteered two other nurse's names that also looked. One of the nurses said she told her A different name to look for. told her the name she had told her was not in there. (The nurse) never Saw (Nurse L) go in med room and look. The other nurse that (Nurse L) said . she had no idea what I was talking about and did not help (Nurse L) look for any meds. (Nurse L) then told DON I don't know why everyone is asking me where this other lady's meds Went. I had nothing to do with anyone losing their meds. Something weird is going on? The next morning we receive a call from resident (#808) that (Nurse L) discharged and she tells Receptionist and Nurse on duty from an agency that she has the wrong meds from when She was discharged .Sunday afternoon DON and Unit manager came in to discuss the adverse event with (Nurse L) When we looked at documentation she did have correct person that discharged Sign the discharge instructions and saved us a copy but there was no med rec completed, Printed or given to resident. Computer showed it was opened by Social worker but Never touched by Nursing. (Nurse L) admitted to grabbing a bunch of med cards and Putting them in a bag and giving them to resident to take home. She states she did not Go over the meds with resident . A review was completed of the facility policy entitled, Discharge Policy, reviewed 11/23. The policy stated, The resident will be discharged from the facility in a safe and orderly manner, consistent with their personal goals and desired outcomes . Provide written and oral instruction to the resident and/or resident representative, regarding treatments, activity restrictions, dietary modifications and follow-up care, in language the resident and/or the resident representative can understand. Document education in the Discharge Plan, Instructions & Summary . Print the Discharge Plan, Instructions & Summary and Medication Reconciliation Form and documents listed in Documents section of the Discharge Plan, Instructions & Summary form. Sign as staff providing the information and obtain resident and/or resident representative signature. Make a copy of signed form, original to the resident or resident representative and copy to medical records. Provide written and oral instruction to the resident and/or resident representative, regarding reconciliation of pre-and post-discharge medications in language the resident and/or the resident representative can understand. Complete the Medication Reconciliation form. Sign as staff providing the information and obtain resident and/or resident representative signature. Make a copy of signed form, original to the resident or resident representative and copy to medical records .

Based on observation, interview and record review, the facility failed to implement timely interventions, provide appropriate supervision and ensure that staff assisted with transfers to prevent recurrent falls for one resident (Resident #5), resulting in a forehead laceration requiring emergency care and neck and rib fractures. Finding include: Resident #5: On 3/4/24, at 11:00 AM, a record review of Resident #5 electronic medical record (EMR) revealed an admission on 12/28/2023 with diagnoses that included Stroke, unsteadiness on feet and Parkinson's disease. Resident #5 required assistance with all activities of daily living (ADL) and had severely impaired cognition. The Fall Assessment, Date 12/28/2023, revealed that Resident #5 was at High Risk for falls. A review of the Incident reports for Resident #5 revealed the following falls: 2/4/2024 12:44 (12:44 PM) Incident Description . This took place on 2/3/24 Resident was sitting on his bed and was attempting to get up and into his w/c (wheelchair) with help from staff. Resident slid too far to the edge of the bed and went onto his knees instead of standing, Resident was assisted back up onto his bed then into his w/c . Immediate Action Take . Assisted resident up and into w/c . No Injuries Observed at time of incident . 2/7/2024 12:00 Incident Description . Resident was sitting on the floor next to his bed with his w/c next to him . Immediate Action Taken Full assessment completed. No change from neuro baseline. Denies any pain. Grippy placed under mattress to keep it in place when resident transferring in and out of it. Root cause: self-transfer Intervention: Reminded to use call light for assistance, gripper pad placed on frame of bed under mattress . No injuries observed at time of incident . No witnesses found. 2/18/2024 02:23 (2:23 AM) Incident Description: CNA heard a thud in resident room, walked in and observed resident lying on the left side of bed on his left side propped up with his hands with laceration and hematoma above the left eye. Pressure applied to forehead, Resident is able to move all extremities independently. Page placed to (physician) DON (Director of Nursing) and wife notified. Ambulance called, resident sent to (local hospital emergency) for eval and treat . Unable to verbalize what happened, crying and trying to get himself up on the bed in spite of the Nurse trying to get him to be still on the floor until paramedics arrive. Roommate states he could hear him raising and lowering his bed throughout the evening. Immediate Action Taken Root cause: rolled out of bed Nurse providing first aid without moving resident while waiting for the paramedics to arrive. Intervention upon return Bed to be kept in low position when in bed. Bedside stand moved away from left side of bed. Sent to ER for eval and treat. Left side of bed placed against the wall, floor mat to the right side of bed when in bed and to be picked up when up in w/c . Injury Type Laceration . Forehead . Mental Status Orientated to Person . was checked . Other Info poor safety awareness, forgetful, playing with his bed controls . No Witnesses found. A review of the care plan I am at risk for falls related to generalized weakness, impaired mobility and lack of balance . Date Initiated: 12/29/2023 . My interventions will minimize my risk for serious injury related to falls . Interventions/Tasks Bed side stand to be kept away from ed. Date Initiated: 02/18/2024 Floor mat to the right side of the bed when in bed and picked up when out of bed. Date Initiated: 02/18/2024 Gripper placed on bed frame under the mattress. Date Initiated: 02/07/2024 Have commonly used articles within easy reach Date Initiated: 12/29/2023 Left side of bed placed against the wall. Date Initiated: 02/18/2024 Maintain bed in low position Date Initiated: 12/29/2023 Observe for signs and symptoms of medication side effects and report to Physician as needed. Date Initiated: 12/29/2023 Remind me often to use call light for assistance. Date Initiated: 02/07/2024 Revision on 02/07/2024 Resident will independently move bed from low position to a high position using the bed remote. Remind him to leave bed in low position for his safety. Date Initiated: 02/18/2024 A review of the I have an ADL self-care performance deficit related to Weakness, Respiratory failure Date Initiated: 12/29/2023 I will improve current level of function in ADL's through the review date . Interventions/Tasks . TRANSFER: I require extensive assist (1) staff assistance for transfers using my walker. Date Initiated: 12/29/2023 . A review of Resident #5's hospital discharge summary Date 2/19/2024 revealed: . All Diagnoses This Visit Fall Traumatic hematoma of forehead C1 cervical fracture C2 cervical fracture Rib fracture . A review of the facility provided Falls and Fall Risk Managing Policy Statement revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . The staff, with the input of the IDT, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls . If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature of category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Prior to exit, the DON was asked if the facility could have done anything else to keep Resident #5 safe from falls and the DON stated, No.

Based on interview and record review, the facility 1) Failed to offer appropriate timely interventions to prevent the development of two unstageable pressure ulcers (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough - yellow, tan, gray, green or brown and/or eschar - tan, brown or black in the wound bed, 2) Failed to prevent the worsening of a left heel pressure ulcer, and 3) Failed to provide a physician's assessment and monitoring of the wounds of one resident (Resident #513) of three residents reviewed for pressure ulcers, resulting in pain, new bilateral Achilles tendon pressure ulcers, Osteomyelitis (bone infection) of left calcaneus and hospitalization . Findings include: Resident #513: On 12/20/22, at 10:00 AM, a record review of Resident #513 revealed an admission on 7/13/22 with diagnoses that included cervical spinal injury, quadriplegia, neurogenic bowel, and bladder. Resident #513 had intact cognition and required assistance with all Activities of Daily Living (ADL's.) A review of the Treatment Administration Record 07/01/2022 revealed . PRAFO splints (Pressure Relief Ankle Foot Orthosis - a device that is worn on the calf and foot similar to a boot and is often used for patients that spend the majority of their time in bed. One reason for its use is to prevent bedsores or ulcers from developing on the back of the heel) on feet bilaterally with kickstands out to keep toes pointed to the ceiling every night. Every evening and night shift for parallized to prevent foot drop-Start Date- 07/20/2022 -D/C (discontinue) Date- 08/29/2022 . A review of the Treatment Administration Record 08/01/2022 revealed . Keep soft black boots on resident while he is in bed. Every shift for wound protection-Start Date-08/29/2022 -D/C Date-09/14/2022 . A review of ADL care plan revealed I have an ADL self-care performance deficit r/t (related to) Quadriplegia Date Initiated: 07/13/2022 . Interventions/Tasks . I also need bilateral PRAFO boots on in bed and in the [NAME] (electric wheelchair.) Date Initiated: 07/18/2022 . Despite the order on the treatment record stated the PRAFO splints every evening and night shift, it appeared the resident wore the PRAFO splints all the time as he was to wear them while up in his electric wheelchair also. A review of the BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK Date: 8/3/2022 . Score: 11 . SCORING . HIGH RISK 10-12 . A review of the Nursing Assessment Admission . Date: 7/13/2022 . Units of Measure: centimeters (cm) Site Left heel Pressure Length 1.3 Width 3.0 Depth 0.1 Unstageable Left Buttock Pressure Length 2.0 Width 1.5 Depth 0.1 Unstageable Right Buttock Pressure Length 4.5 Width 4.0 Depth 0.2 Unstageable . Bloody Drainage from left heel wound. Serosanq (serosanguinous) drainage from bilateral buttocks wounds. All wounds have slough in the wound beds . A review of Section M Skin Conditions . Date: 2022-07-20 . Number of unstageable pressure ulcers/injuries due to non-removable dressing/device 3 Number of these unstageable pressure ulcers/injuries that were present upon admission . 3 . A review of the wound measurements in the Progress Notes revealed 07/14/2022 . IDT met & reviewed. Resident just admitted to the (facility) this week with unstageable ulcers on his left posterior heel & bilateral buttocks. All areas measured and documented upon admission. Treatments are in place and care plans and tasks have been updated . 07/21/2022 . IDT met & reviewed. Lt posterior wound measured 1.0 cm x (by) 3.0 cm x 0.1 cm . 07/28/2022 . IDT met & reviewed. Unstageable ulcers on bilateral buttocks remain . Left posterior heel wound measures 1.0 cm x 3.0 cm x 0.1 cm . 08/04/2022 . IDT met & reviewed. The left posterior heel wound measured 2.0 cm x 4.0 cm x 0.1 cm with the skin peeling off around the wound at this time . He is taking Prostat as ordered and is on an APM mattress. Resident is encouraged to not stay up in w/c any longer than 3-4 hours at a time. He continues to need much encouragement to reposition from side to side and prefers to lay in his back for comfort. Will continue to monitor and encourage compliance with repositioning. There was no mention of off-loading heels while in bed. 08/12/2022 . IDT met & reviewed. The left posterior heel wound has gotten larger this week as the surrounding skin is peeling off around the wound. There is an eschar area noted in the center of the wound but no other s/s of infection are noted. The wound measures 4.5 cm x 3.0 cm x 0.1 cm. Treatment is completed as ordered by physician. PRAFO splint is padded with an ABD pad but does not rub on the back of the heel when worn . Resident has an AP mattress on his bed and a very nice cushion in his custom wheelchair. He is taking Prostat BID (twice a day) and has a good appetite. He continues to like to stay up in his chair for longer periods than 3-4 hours at a time. Much encouragement is needed to allow staff to position him on his sides and his buttocks while in ed. Educated while in bed. Educated on the importance and states understanding. Will continue to encourage compliance and follow weekly . There was no intervention offered despite the left heel wound was documented bigger. 08/15/2022 . The damaged skin on the left posterior heel has all sloughed off at this time and left an eschar area measuring 6.0 x 4.0 cm There was a moderate amount of serous drainage on the old dressing without odor . New order obtained . 08/18/2022 . IDT met & reviewed. The Left Posterior heel wound measured 6.0cm x 4.0cm and is black eschar. The wound was cleansed and Opticel Ag was applied to the wound bed, covered with moistened gauze, ABD and Kling. Resident does wear PRAFO splints when he is in bed and the posterior heel does not rub on the splints. Resident has been having muscle spasms in the left leg and he will stiffen the left leg out and dig his heel into the mattress at times. Baclofen is given as ordered and resident continues to work with therapies as schedule . 08/19/2022 . Resident noted to have open area to right posterior heel measuring 6 x 1.5 cm. Base has eschar present. Comfort foam applied to wound and wound care nurse notified. Soft prafo boot applied to bil feet . NP (nurse practitioner) notified of wound . 08/19/2022 . This RN was notified that resident has been having an increase in muscle spasms in his legs and has been rubbing bilateral posterior Achilles on his PRAFO splints causing DTI. (deep tissue injury) the Rt. Achilles wound measures 4.0 x 1.0 with scant bloody drainage. Area was cleansed and new order obtained to apply Santyl to the wound bed, cover with Telfa, ABD and Kling daily. The Lt. Achilles eschar area is starting to loosen and had a foul odor before cleansing. Area cleansed with wound cleanser and then applied Santyl ointment, cover with Telfa, ABD and Kling daily. Will continue to follow weekly and prn. Will notify NP with changes next week when assessed again. 08/23/2022 . Changed dressing left Achilles d/t (due to) it being saturated. Noted an odor present, will notify physician to see if wound swab or antibiotics are needed. 08/24/2022 . IDT met & reviewed. The posterior Achilles wound on the left measured 6.0cm x 3.5cm with the eschar starting to loosen around the edges. There was a foul odor on the old dressing that subsided after being cleansed with wound cleanser. Large amount of serous drainage on the old dressing. The right posterior Achilles wound measured 4.0cm x 1.0cm with eschar and pink tissue present. No odor from this wound and there was scant bleeding on the old dressing Both Achilles are cleansed and then Santyl ointment is applied into/on the wound beds. Covered with gauze, ABD and wrapped with Kling daily. Soft black boots are to be worn while in bed. Resident reports that he continues to have muscle spasms in both legs and continues to draw legs up but the Achilles area does not really rub in the soft boots. He needs much encouragement to allow staff to reposition him off of his buttocks. He also does not like to return to bed after getting up in his wheelchair. Will continue to educate on the importance of both . Prostat is ordered BID (two times a day) and resident is encouraged to consume for wound healing. (NP) and (physician) aware of wounds and condition of wounds. Will continue to monitor weekly and prn. (as needed) 08/31/2022 Physician/Practitioner Progress Note . seen and examined on 8-30-2022 for an acute visit and note done related to his c/o (complaints of) pain and refusal to take any Norco. He is doing better denies any cp/sob/abd pain or any other specific complaints at this time . There was no documented medical/nurse practitioner assessment of the pressure ulcers from admission to discharge. 09/02/2022 . IDT met & reviewed. Left Achilles wound measures 7.5cm x 4.0cm x 0.2cm with loosening eschar . Scant odor prior to cleaning the wound . The Rt Achilles wound measures 5.0cm x 1.0cm x 0.2cm with the eschar area getting smaller . Moderate amount of serous drainage on the old dressing. No odor or s/s of infection present . Resident wears his soft black foam boots on bilateral feet when in bed to off load pressure from the backs of his heels/ankle area . 09/07/2022 . Wound care completed this morning by this RN and noted decline in the Achilles wounds. (NP) notified and an order obtained to send information to (local hospital) wound clinic and write an order for referral to treat. Resident & his son are aware. Necessary paperwork filled out and information faxed to (local hospital) wound clinic. They will call when they can see resident. 09/09/2022 . IDT met & reviewed. The Left Achilles wound measured at 8.5 cm x 6.0 cm x 0.7 cm with eschar in the middle of the wound bed . There is slough around the wound as well. Large amount of serous drainage on the old dressing with an odor that did subside after cleaning . The Rt Achilles wound measured 6.0cm x 1.3cm x 0.2cm . 09/10/2022 . Completed patient's heels today. No foul smell on right heel, Left heel foul smell noted. Scan amount of yellow discharge noted with no blood noted. Buttocks left and right treatment completed as ordered. Foul smell noted. Yellow discharge noted no blood noted . Despite the documented signs of infection, the physician was not notified. 09/14/2022 . Resident was seen this morning for his initial evaluation and treatment at (local hospital) wound clinic. He had both Achilles and his buttocks wound debrided. The wound on the left Achilles area has progressed down into the lateral ankle area and there was an abrasion on the left dorsal foot. New orders obtained . Resident is not to wear any type of boots on his feet and is to have his heels/ankles floated at all times . Arginaid BID ordered for protein supplement to enhance wound healing. Wound cultures were obtained from the left Achilles wound and will wait for C & S (culture and sensitivity) results before starting recommended antibiotic of Bactrim DS 1 tablet BID x 10 days. Care plans and orders updated. Return appt scheduled at the wound clinic in 1 week. 09/14/2022 . This RN was given the ok from (NP) to start the Bactrim DS 1 tab bid x 10 days for wound infection as recommended by (local hospital) wound clinic . 09/14/2022 Infection Report . 1 or more of the following criteria must be present: a. Pus present at a wound, skin or soft tissue site . was check marked. Four of more new or increasing sign or symptom at the site: b. Redness c. Swelling d. Tenderness e. Serous drainage f. One constitutional criteria: fever (>100.4) leukocytosis, acute mental status from baseline, acute functional decline . were all check marked. 09/15/2022 . IDT met & reviewed . Resident has Prostat and Arginaid ordered for protein supplements and wound healing that he is accepting with encouragement . Resident #513 had no documented Physician, Nurse Practitioner or Physician assistant visits for wound/pressure ulcer assessment despite the worsening and new development of the bilateral Achilles pressure ulcers from admission to discharge. There were numerous Psychiatry Physician/Practitioner Progress notes although none had any wound assessments and all did state . Medical management-Per PMD (primary medical doctor.) . 09/19/2022 . Resident has increase pain that is not controllable at this time. He also had increased drainage from his wounds and slightly confused. When speaking with resident he said he would like to go get checked out at the hospital. Residents wife was notified as well as the doctor. On 12/20/22, at 2:10 PM, an interview Aide T was conducted regarding Resident #513. CNA T offered that Resident #513 did have hard plastic boots on during the day and they would take them off for his showers. Aide T also offered that the boots had kick stands so his feet wouldn't go out or in when he was in bed. On 12/20/22, at 3:00 PM, Infection Control (IC) Nurse F was interviewed regarding Resident #513's infection and IC Nurse F offered, He came back from the wound clinic with the antibiotic order. IC Nurse F was asked to provide the wound culture document. IC Nurse F was asked to review the results tab in the electronic medical record which revealed no lab results. IC Nurse F was asked to provide all blood work/lab results for Resident #513. IC Nurse F offered a faxed resulted culture result for Resident #513 which did not have a source on it. IC Nurse F clarified the result was from the hospital wound clinic when Resident #513 went to the wound clinic for his consult on his pressure ulcers and the culture was from his left Achilles wound. A review of the facility provided wound culture for Resident #513 revealed . Tissue Culture with Gram Stain Source: Tissue . Enterococcus faecalis . Proteus mirabilis . were both found on Resident #513's tissue sample. According to Wikipedia, Enterococcus faecalis is a gram-positive, commensal bacterium inhabiting the gastrointestinal tracts of humans. Proteus mirabilis is a gram-negative bacterium widely distributed in soil and water. On 12/20/22, at 3:30 PM, IC Nurse F and the Director of Nursing (DON) were interviewed regarding Resident #513 . The DON was asked to provide all lab results for Resident 513 and the DON stated, there were no labs drawn. The DON was asked to clarify regarding any labs drawn from admission and discharge for the resident and the DON stated, they would check into it. On 12/21/22, at 8:45 AM, the DON entered the conference room and offered that Resident #513 admitted with the hard PRAFO boots. The DON was asked if Resident #513 was at risk for skin breakdown why did the facility allow the development of the bilateral Achilles pressure ulcers and the DON stated, I'm not denying something didn't develop in the building, but they (prafo boots) were ordered at the hospital. The DON offered the boots could have been the cause for the pressure as he would rub his heel on his bed. The DON was asked to clarify if the resident did this on purpose and the DON stated, he was having spasms and his heel would shift in the splint. The DON was asked why the facility waited to get a second opinion or a specialized wound clinic appointment and the DON stated, he had his first visit at the wound clinic on September 14th. The DON added that the resident refused protein supplements, position changes and turning and that he would stay in his chair longer that he should despite the education provided. The DON was asked, what did the facility assess for Resident #513's risk of further skin breakdown and the DON offered he was at risk for skin breakdown. The DON was again asked why Resident #513 didn't have any labs drawn during his stay and the DON clarified that the resident had labs drawn just prior to admission, had a scheduled lab draw on 9/20/22 but no labs were drawn while at the facility. The DON was asked what defense the facility had that the new pressure ulcers were unavoidable and the DON stated, that he stayed up in his wheelchair longer than he should and also wore his splints while in the chair because he and the family were overly worried about foot drop. The DON further offered he wasn't the easiest guy to deal with as he had depression and would often get mad and refuse care. On 12/21/22, at 9:00 AM, a record review along with the DON of Resident #513's progress notes were conducted. There were no lab results found. The DON was asked where in the record was the physician notified of the odor noted to the wound and the DON offered it was on 8/23 and (wound nurse) had a note on 8/24 notifying the doctor and the Nurse Practitioner. Despite the physician/NP being notified of odor, there were no documented follow-up physician/NP visits for Resident #513's pressure ulcers. On 12/22/22, at 11:00 AM, a phone interview was conducted with Resident #513. Resident #513 stated that he liked to be up in his wheelchair and would lean to the side or use a pillow if he was up for longer than two hours. Resident #513 offered that he wore the prafo boots all the time and they only came off if the staff was doing the wound care. Resident #513 further offered that he felt the staff kept looking at his wound because they all knew it was bad but then wanted to keep him in the building just one more day. Resident #513 stated, I felt like they were ignoring me. A review of the facility provided policy Prevention of Pressure Ulcers/Injuries Revised July 2017 revealed . Support Surfaces and Pressure Redistribution Select appropriate support surfaces based the resident's mobility, continence, skin moisture and perfusion, body, size, weight, and overall risk factors. Monitoring Evaluate, report and document potential change in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. On 1/4/2023, at 11:00 AM, a record review of the hospital provided progress notes for Resident #513 revealed the following: . Decubitus ulcer of left heel Grade 4B ulcer left heel with osteomyelitis of calcaneus and exposed necrotic Achilles tendon . had an in-depth discussion with the patient and his wife that aggressive surgical debridement of the Achilles tendon and some tissue to encourage granulation and create an acceptable wound be for graft of some type. If he does not respond to IV antibiotics the he may require surgical intervention in an operating room . Discharge Summary 10/5/2022 . Discharge Diagnosis and Plan . Osteomyelitis of left foot . ampicillin-sulbactam (intravenous (IV) antibiotic . x 34 days .

Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for 1) its failure to follow appropriate infection control practices in accordance with the Centers For Disease Control (CDC) measures to prevent exposure and transmission of the COVID-19 virus to residents and staff and 2) its failure to separate ten COVID-19 negative residents (Residents #7, #8, #9, #10, #11, #13, #15, #19, #20 and #21) away from five COVID-19 positive residents (Residents #12,# 14, #16, #17 and #18), resulting in a suspected COVID-positive Certified Nursing Assistant (CNA) working with symptoms of COVID-19 on December 5th, 6th and 7th, 2020, resulting in COVID-19 infections for eight of the ten previously-notated COVID-negative residents (Residents # 7, #8, #9, #10,# 15, #19, #20, and #21) with Resident #21 being hospitalized and the likelihood of continued transmission of the COVID-19 virus throughout the facility. Immediate Jeopardy: Immediate Jeopardy began on 12/5/2020. Immediate Jeopardy was identified on 12/9/2020. The Administrator was notified on the Immediate Jeopardy on 12/9/2020 at 4:30 PM. The Immediate Jeopardy was removed or abated on 12/11/2020 after verifying the facility's abatement plan. F880 INFECTION PREVENTION AND CONTROL ABATEMENT PLAN. ON 12/9/20 THE DIRECTOR OF NURSING AND ADMINISTRATOR REMOVED THE SYMPTOMATIC STAFF MEMBER FROM THE SCHEDULE. ON 12/9/20 THE DIRECTOR OF NURSING UPDATED THE STAFF MEMBERS INFORMTION ON THE SUSPECTED COVID-19 INFECTION SURVEILLANCE LINE LISTING. ON 12/9/20 THE DIRECTOR OF NURSING AND ADMINISTRATOR REVEIWED STAFFING AND PLACEMENT OF STAFF WITHIN THE FACILITY TO DETERMINE APPROPRIATE PLACEMENT WITHIN THE FACILITY. ON 12/9/20 THE DIRECTOR OF NURSING ASSESSED CURRENT EMPLOYEES WORKING ON THE DEMENTIA UNIT FOR SIGNS AND SYMPTOMS OF COVID-19. ON 12/9/20 THE DIRECTOR OF NURSING CONFIRMED RESIDENTS WHO DO NOT HAVE CONFIRMED COVID-19, DO NOT RESIDE ON THE COVID-19 UNITS, OR DO NOT HAVE SUSPECTED COVID-19 WILL NOT BE CARED FOR BY STAFF WHO HAVE COVID-19 OR WHO HAE TRIGGERED FOR SYMPTOMS VIA STAFF KIOSK. ON 12/9/20 THE DIRECTOR OF NURSING BEGAN EDUCATING THE STAFF ON THE CDC MITIGATING STAFFING SHORTAGES CONFIRMING 20 OUT OF 116 STAFF Findings include: On 12/7/20, at 1:20 PM, Nurse A was asked how many COVID-19 positive staff and residents there were and Nurse A stated they would have to look, but on the Dementia Unit there were five of the fifteen residents positive as of Friday (12/4/20) and that the Dementia Unit was changed to a COVID-positive unit. Nurse A was asked to provide the resident and staff COVID-19 line lists for suspected case and actual cases. Nurse A stated they were doing the testing and usually get results back in 48 to 72 hours, although they haven't gotten any results from last week. While interviewing Nurse A 2 big boxes of testing kits for the Point of Care (POC) COVID-19 testing machine were observed on the floor. Nurse A was asked for the amount of test kits the facility had and Nurse A stated, we have 18 full boxes of 30 each. Nurse A further offered there were positive people and some were symptomatic so they did a POC on everyone on Friday. Nurse A was asked to provide all the lab test results and was asked if they utilize the POC machine if the lab results are late. Nurse A stated, if they are showing symptoms, we do. On 12/7/20, at 1:30 PM, The Director of Nursing (DON) was now present and was asked to provide test results for the most recent day that the lab had furnished results for the facility. The DON stated that the whole house was POC tested on [DATE] and that if resident is symptomatic or is to be moved out of quarantine, they will POC test them. The DON was asked if they had turned the Dementia Unit into a positive COVID-19 floor and the DON offered that their health department contact M told them to shelter in place on the Dementia Unit. On 12/7/20, at 2:15 PM, this surveyor observed that the Dementia Unit outside door had no signage. Nurse L unlocked the outside door to allow entry which took five minutes. CNA I and Nurse L were in full Personal Protective Equipment (PPE.) CNA I was asked how they enter and exit the Dementia Unit and CNA I stated through the front door, then in through the Dementia Unit door. Nurse L stated that this was their first time working on the Dementia Unit since it was a COVID hall and that they entered through the front door also. There were no divisions or separations observed in the hall. There was no garbage for dirty PPE at the exit door. The garbage for dirty PPE was on the left side of the hall near the door that leads into the main hallway of the facility. On 12/8/20, at 8:00 AM, a record review of Employees with COVID-19 Symptoms Tracking Log revealed Employee Name . (CNA I) was written . Symptoms: cold S + S Date of Onset: 12-4-20 Date of Last Symptom: Test neg. Date of Return: working covid unit . On 12/8/20, at 11:00 AM, the Administrator was again asked to provide the lab results which previously had been requested. On 12/8/20, at 3:00 PM, the DON was interviewed via telephone. The DON was asked if the facility had a delay in obtaining lab results. The DON stated Yes and the last delay was closer to 72 hours. The DON was asked if they were in an outbreak of COVID-19 and the DON stated Yes and that they follow the CDC guidelines for the testing of residents to be every 7 days and that staff are tested bi-weekly. The DON was asked again to provide the most recent lab results for residents and staff and that the lab results provided were from 11/24/20. The DON stated, that the residents on the Dementia Unit were on lock down per their (Bay County) Health Department contact's (PHN M) recommendation and were all tested on Friday (12/4/20). The DON stated that the facility planned to rapid test everybody that didn't have a current test result. The DON was asked to provide any documentation from their (Bay County) Health Department contact. On 12/9/20, at 9:45 AM, a record review was conducted on CNA I's COVID-19 test results and schedules. CNA I had a test result on 12/4/20 that revealed Full Name: (CNA I) . COVID-19 symptoms . cough (circled) . body ache temp 99 . Inconclusive Rapid Test 12/4/20 . was written on the form. A review of the facility provided CNA schedule revealed that CNA I worked on the Dementia unit on 12/5/2020 12/6/2020 12/7/2020 . with E (East Hall/Dementia Unit) written next to their name. On 12/9/20, at 11:45 AM, CNA I was interviewed via telephone. CNA I stated that Friday (12/4/20) they called the facility and went in for testing due to not feeling good. CNA I stated that they were tested outside in the parking lot and that they had two tests done, one of which was positive and one of which was negative. CNA I was unsure which one was done first and was unsure why they were tested twice. CNA I was asked what symptoms they had and when the symptoms started. CNA I stated that the symptoms started on Friday (12/4/20) and that they felt the same on Saturday (12/5/20), Sunday (12/6/20) and Monday (12/7/20). The symptoms were body aches, a draining feeling, a clear-your-throat type cough. CNA I stated that they were taking [MEDICATION NAME] (Fever and Pain reducer) every morning before work to help with the symptoms. CNA I further offered that they were told they could work on the COVID-positive unit. CNA I stated they were feeling too run down to work (after 12/7/20) so they called the scheduler to have themselves taken off of the schedule to rest. On 12/9/20, at 1:00 PM, Nurse A was interviewed via telephone. Nurse A was asked why CNA I had their COVID testing in the parking lot and Nurse A stated, (CNA I) called and said she wasn't feeling good and we met her out in the parking lot. Nurse A further offered that one rapid test was positive and one was negative. Nurse A stated that they talked to (the DON) about it and was told to write the results down as inconclusive. Nurse A further offered that the employee was ok to work the COVID Unit because they only had cold-like symptoms. Nurse A was asked if a cough, body aches, and a temperature of 99 F were COVID-19 infection symptoms and Nurse A stated, Yes, that's why I tested her and it's not my choice when people come back to work. On 12/9/20, at 1:50 PM, the DON was interviewed via telephone regarding the inconclusive test results for CNA I. The DON stated, that they had one positive and one negative and at the time did not have symptoms but a little later she did have symptoms. The DON was advised that the POC test form for CNA I for the date of 12-4-20 did have Cough circled, body aches and a temperature of 99 F. written on it. The DON stated, I got the line listing with cold symptoms on it. The DON was asked if a cough, body aches and a temperature of 99 F were symptoms of a COVID-19 infection and the DON responded, Yes. The DON stated that they talked to their Health Department contact and were told to droplet the entire Dementia Unit and that COVID-positive employees could work on COVID-positive units. The DON was asked to clarify how many of the fifteen residents on the Dementia Unit had positive COVID-19 test results or had symptoms on 12-4-20. The DON stated, five. The DON was asked if they are reading the updated guidelines from the CDC and the DON stated, Yes. On 12/9/20, at 4:00 PM, a record review of the facility-provided Skilled Nursing Facility COVID-19 testing plan . Plan Date 11/1/2020 revealed Testing any resident or staff member with symptoms or suspected exposure . Residents and staff will be tested by contracted lab or POC test at facility. Date expected to begin 11/1/2020 . laboratory to be utilized (the lab), if there is a delay in results, facility will utilize rapid in-house tests and will communicate with lab if this is a short term or long term issue. If a long term issue is present, facility will look for a new lab provider . Weekly testing of all staff in regions of medium risk or higher on the MI Safe Start Map On 12/9/20, at 3:30 PM, a record review of the facility-provided COVID-19 line list revealed that Residents #12, #14, #16, #17, and #18 had positive COVID-19 tests on 12-4-20. These five residents resided on the Dementia Unit and all remained in their original rooms despite testing positive for the COVID-19 virus. Resident #7: On 12/9/20, at 3:35 PM, a record review of Resident #7's Electronic Medical Record (EMR) revealed their room number to be 47A on 12/4/20. Resident #7 had a negative COVID-19 rapid rest on 12/4/20. A progress note, dated 12/9/2020 16:39 (4:39 PM), revealed Resident has tested positive for covid 19 and resides on the Dementia unit. She is unable to be directed at times and has most likely exposed others in her unit. We will shelter in place to her room to the best of our ability at this time. Staff to wear Full droplet precaution PPE at all times . Resident #8: On 12/9/20, at 3:40 PM, a record review of Resident #8's Electronic Medical Record (EMR) revealed their room number to be 44B on 12/4/20. Resident #8 had a negative COVID-19 rapid rest on 12/4/20. A progress note, dated 12/9/2020 17:44, revealed Resident has tested positive for covid 19 and resides on the Dementia unit. She is unable to be directed at times and has most likely exposed others in her unit. We will shelter in place to her room to the best of our ability at this time . Resident #9: On 12/9/20, at 3:45 PM, a record review of Resident #9's Electronic Medical Record (EMR) revealed their room to be 48B on 12/4/20. Resident #9 had a negative COVID-19 rapid test on 12/4/20. A progress note, dated 12/9/2020 17:43, revealed Resident has tested positive for covid 19 and resides on the dementia unit. She is unable to be directed at times and has most likely exposed others in his unit. Resident #10: On 12/9/20, at 3:50 PM, a record review of Resident #10's Electronic Medical Record (EMR) revealed their room to be 48A on 12/4/20. Resident #10 had a negative COVID-19 rapid test on 12/4/20. A progress note, dated 12/9/2020 17:45, revealed Resident has tested positive for covid 19 . Resident #11: On 12/9/20, at 3:55 PM, a record review of Resident #11's Electronic Medical Record (EMR) revealed their room to be 46B on 12/4/20. Resident #11 had a negative COVID-19 rapid test on 12/4/20. Resident #12: On 12/9/20, at 4:00 PM, a record review of Resident #12's Electronic Medical Record (EMR) revealed their room to be 41B on 12/4/20. Resident #12 had a positive COVID-19 rapid test on 12/4/20. Resident #13: On 12/9/20, at 4:05 PM, a record review of Resident #13's Electronic Medical Record (EMR) revealed their room to be 38A on 12/4/20. Resident #13 had a negative COVID-19 rapid test on 12/4/20. Resident #14: On 12/9/20, at 4:10 PM, a record review of Resident #14's Electronic Medical Record (EMR) revealed their room to be 39A on 12/4/20. Resident #14 had a positive COVID-19 rapid test on 12/4/20. Resident #15: On 12/9/20, at 4:15 PM, a record review of Resident #15's Electronic Medical Record (EMR) revealed their room to be 43A on 12/4/20. Resident #15 had a negative COVID-19 rapid test on 12/4/20. A progress note, dated 12/10/20 16:48, revealed Resident had tested positive for covid 19 and resides on the dementia unit . Resident #16: On 12/9/20, at 4:20 PM, a record review of Resident #16's Electronic Medical Record (EMR) revealed their room to be 38B on 12/4/20. Resident #16 had a positive COVID-19 rapid test on 12/4/20. Resident #17: On 12/9/20, at 4:22 PM, a record review of Resident #17's Electronic Medical Record (EMR) revealed their room to be 49A on 12/4/20. Resident #17 had a positive COVID-19 rapid test on 12/4/20. Resident #18: On 12/9/20, at 4:25 PM, a record review of Resident #18's Electronic Medical Record (EMR) revealed their room to be 49B on 12/4/20. Resident #18 had a positive COVID-19 rapid test on 12/4/20. Resident #19: On 12/9/20, at 4:27 PM, a record review of Resident #19's Electronic Medical Record (EMR) revealed their room to be 43B on 12/4/20. Resident #19 had a negative COVID-19 rapid test on 12/4/20. A progress note, dated 12/9/2020 17:42, revealed Resident has tested positive for covid 19 . A second progress note, dated 12/11/2020 07:00, revealed Resident's responsible party was called and requested to change room to maintain covid-19 quarantine guidelines from the CDC . Resident #20: On 12/9/20, at 4:29 PM, a record review of Resident #20's Electronic Medical Record (EMR) revealed their room to be 47B on 12/4/20. Resident #20 had a negative COVID-19 rapid test on 12/4/20. A progress note, dated 12/9/2020 17:39, revealed Resident has tested positive for covid 19 . Resident #21: On 12/9/20, at 4:33 PM, a record review of Resident #21's Electronic Medical Record (EMR) revealed their room to be 39B on 12/4/20. Resident #21 had a negative COVID-19 rapid test on 12/4/20. Resident #21 was not isolated from their roommate (Resident #14), who tested positive for COVID-19 on 12/4/20. A progress note, dated 12/10/2020 16:50, revealed Resident has tested positive for covid 19 . A progress note, dated 12/12/2020 01:40, revealed . originally sats (oxygen blood saturation) were 77% on RA (room air). Oxygen 4 L (liter) sats now 98% . A progress note, dated 12/12/2020 22:32, revealed . send him to hospital. On 12/9/20, at 4:36 PM, the facility was served with an Immediate Jeopardy notice via e-mail while this surveyor was on the telephone with the Administrator. The Administrator was again asked to provide documentation of the steps that the facility took to mitigate staffing shortages prior to allowing the symptomatic staff member to work with negative (non-confirmed positive) COVID-19 residents. On 12/10/20, at 1:00 PM, during a telephone conversation with the Administrator and facility owner, the administrator was asked to provide all the intervening steps that the facility took prior to allowing COVID-19 symptomatic staff to work. The administrator was also asked again to provide all COVID-19 test results for the residents and the staff. On 12/14/20, at 9:30 AM, a telephone conversation with Public Health Nurse (PHN) M was conducted. PHN Nurse M was asked if they recently discussed the COVID-19 outbreak at the facility. PHN Nurse M stated, that they had and had the updated line list from 12-9-20. PHN Nurse M was asked if the facility alerted them that the Dementia Unit has five out if the fifteen residents positive for COVID-19. PHN Nurse M stated that the facility called and asked if they could shelter in place and PHN Nurse M agreed as long as there was a way to separate the ill (COVID-positive) residents from the healthy residents. PHN Nurse M stated that the facility reassured her that the residents would be separated. PHN Nurse M was asked if a CNA, who wasn't feeling good, had a cough, had body aches and a temperature of 99.0 F., would be allowed to work with non-confirmed COVID-positive residents. PHN Nurse M stated, No they should be sent home and that there is only one facility that has the Health Department's permission to do so and this facility is not it. On 12/14/20, at 4:00 PM, a record review of the updated Employees with COVID-19 Symptoms Tracking Log revealed Employee Name . (CNA I) was written . Symptoms: cold S + S Date of Onset: 12-4-20 Date of Last Symptom: Rapid +, Rapid Test 12-4-20 (Lab) Test 12-3 negative Date of Return: Back on 12-15-20 . The columns for Date of Last Symptom and Date of Return now read the above data. On 12/15/20, at 11:15 AM, this surveyor entered the facility to verify the Immediate Jeopardy Removal Plan. The Administrator and the DON were asked which Infection Control Standards the facility follows and the DON stated, CDC. The DON and the Administrator was asked again what the facility did to mitigate their staffing crisis and the DON stated, that they moved residents out to a sister facility, used staff from a sister facility and are still hiring. The DON and Administrator were asked to provide documentation of proof as to what the facility had done to mitigate their staffing crisis prior to allowing CNA I to work. On 12/15/20, at 11:45 AM, Nurse L was asked if any residents on the Dementia Unit were moved due to their COVID-19 results and Nurse L stated, No. Nurse L was also asked if they were working with sick co-workers and Nurse L stated, No, they wouldn't make it pass the front desk area. On 12/15/20, at 2:00 PM, a record review of the Strategies to Mitigate Healthcare Personnel Staffing Shortages, Updated July 17, 2020 on the Centers for Disease Control and Prevention website revealed, If HCP develop even mild symptoms consistent with COVID-19, they must cease patient care activities and notify their supervisor or occupational health services prior to leaving work. These individuals should be prioritized for testing . If shortages continue, despite other mitigation strategies, consider implementing criteria to allow HCP (Healthcare Personnel) with suspected or confirmed COVID-19, who are well enough and willing to work but have not met all Return to Work Criteria, to work. If HCP are allowed to work before meeting all criteria, they should be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) and facilities should consider prioritizing their duties in the following order . 4. As a last resort, allow HCP with confirmed COVID-19 to provide direct care for patients without suspected or confirmed COVID-19 . This citation is being cited at Past Non-Compliance as a result of the surveyor's investigation and the following corrective action plan to attain and maintain compliance for F-880: Element 1-Residents or staff affected by the deficient practice: -As of 12/07/20, CNA I did not work in the facility or care for residents while she was Covid-positive or exhibited signs and symptoms of [MEDICAL CONDITION]. -As of 12/09/20 no staff member who tested positive for COVID-19 or exhibited signs and symptoms of [MEDICAL CONDITION] was allowed to work in the facility. - As of 12/09/20 the staff members working on the Dementia Unit exhibited no signs and symptoms of COVID-19. -All residents who resided on the Dementia Unit on 12/09/20 (Residents #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) remain on the Dementia Unit and are Covid-free with the exception of Resident #12, who was discharged to the hospital on [DATE] and passed away from natural causes, unrelated to the COVID-19 virus. Element 2-Other residents with the potential to be affected by the deficient practice:: -As of 12/09/21 any resident of the facility who tests positive for COVID-19 or exhibits signs and symptoms of [MEDICAL CONDITION] is discharged to a Covid Recovery Center (CRC). Element 3-Systemic changes: -On 12/09/20 the Administrator and the Director of Nursing (DON) reviewed staffing and the placement of staff within the building and determined that staff are appropriately placed as of 12/09/20. -As of 12/09/20 the facility will follow the Centers for Disease Control and Prevention (CDC) guidelines for mitigating staffing shortages sequentially while extensively documenting the results at each level of the sequence and adhering to Return to Work Criteria. - Beginning on 12/09/20 and ending on 12/11/20, all 116 staff members have been educated on CDC Guidelines for Mitigating Staffing Shortages. Element 4-Monitoring: -Beginning on 12/09/20, the Director of Nursing and/or designees will audit adherence to CDC Guidelines in regard to staffing shortages. -As of 12/09/20 a weekly audit will be submitted to the QAPI Committee regarding COVID-19 positive staff members. The facility's Date of Compliance is 12/11/2020.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to prevent the development of pressure ulcers for two residents (Resident #3 and Resident #7) of four residents reviewed for pressure ulcer prevention. This deficient practice resulted in harm with the development of multiple pressure ulcers, the potential for delayed wound healing, infection, and deterioration of condition. Findings include: Review of Complaint Intake, 6/12/20, read in part, (Resident #3's) foot is black in color, green, and full of pus. Her heel is like a hockey puck. She has rotting skin and her foot smells like a dead animal . Resident #3: Review of Resident #3's Minimum Data Set (MDS) assessment, showed an admission date of [DATE] with the following Diagnoses: [REDACTED]. Progress Note, 6/10/20, reflected a planned return to Resident #3's prior Assisted Living Facility. Review of Resident #3's Assisted Living Facility's Charting Notes in part read: 6/10/20 at 11:07 p.m.- foot was hurting 6/11/20 at 7:37 a.m.- was in current pain when attempted to roll, and move her. 6/11/20 at 11:02 a.m.-returned yesterday afternoon .After her shower staff informed this writer she had a large area to her left heel (nothing was written in discharge paperwork (from transferring Nursing Home) or called to admin {administration} or management).Dr. (doctor) looked at wound to heel and wants wound care started .ASAP (as soon as possible). Called daughter to inform her of the open wound to her heel. She was unaware that she had any wounds from previous facility . 6/11/20 at 3:02 p.m.-Did a full body assessment right heel has a area of concern 8.5 cm (centimeter) x (by) 6 cm blister area, red around the edges, no drainage and intact, noted that it does have some dark coloring to the inside blister on the lateral side of the foot. Small area roughly 0.5 x 0.5 cm red, scabbed over , and red around the scabbed area. Left heel is 10 cm wide x 9 cm long black/dark in color in the center of heel, some redness noted with skin hanging, along with red around the edges, still blancheable on edges. Did have some drainage yellow in color. Both areas very tender and painful to resident. Great toes on the left foot has an area starting red in color, blancheable with white edges, 2nd digit has red area starting still blancheable. On inside of foot on the side of great toe red area 1 cm x 1 cm. 6/17/20 at 5:36 p.m.-Dr. increased pain meds today . The Assisted Living Facility provided photos of Resident #3's heels which depicted pressure ulcers to both heels which were dated beginning 6/10/20. Review of Resident #3's (Nursing Home) electronic medical record provided no indication of any wounds to the heels from admission to discharge. During a telephone interview on 8/20/20 at 3:40 p.m., the Assisted Living Facility, Administer (Staff R) and Licensed Practical Nurse (LPN S) both confirmed Resident #3 was found with pressure ulcers to bilateral heels on the same day of transfer from the Nursing Home. During a telephone interview with the Nursing Home Administrator and DON on 8/20/20 at 4:41 p.m., the DON said she was unaware Resident #3 had any pressure ulcers prior to being discharged to Assisted Living Facility. When asked how far the Assisted Living Facility was from the Nursing Home for transfer, the NHA indicated it was about a ten minute car ride. When asked how could pressure ulcer development have possibly occurred with a ten minute car ride, neither the NHA nor the DON responded. Resident #7: During an observation on 8/19/20 at 1:22 p.m., Licensed Practical Nurse (LPN) B performed wound care for Resident #7's pressure ulcer. Resident #7 was found sitting to the left side of her bed in an upholstered chair with her feet lying directly on the floor. Without first performing hand hygiene, LPN B applied a pair of gloves and then lifted Resident #7's right pant leg to expose her ankle sock. The sock was removed and showed the dressing to the posterior side of the ankle. Next, LPN B removed the dressing. A small amount of drainage was noted to the dressing. LPN B then changed her gloves without performing hand hygiene. The soiled dressing was folded and placed directly on the floor without a barrier being placed. The wound bed was cleansed using a saline gauze. LPN B changed gloves (without performance of hand hygiene) and then measured the wound edges. A new dressing was applied. After replacing Resident #7's sock, LPN B discarded the soiled dressing and supplies and then exited the room. No hand hygiene was performed prior to exiting the room. According to Resident #7's MDS assessment, 6/19/20, showed an admission date of [DATE] with the following Diagnoses: [REDACTED]. The Brief Interview for Mental Status (BIMS) score was 8 out of 15 which reflected moderate impaired cognition. Resident #7 required staff assistance for bed mobility, transfers, and toilet use. Review of Resident #7's Progress Notes read in part: 6/24/20 at 10:12 a.m.- Quarterly skin assessment. Resident is at risk for alteration in skin integrity . 7/21/20 at 11:44 a.m.- has an opening on lateral right heel (blister). Measures 2.7 cm x 2.2 cm x 0.2 cm. Wound bed is pink with skin covering. Drainage was noted at site with slight odor . Review of Resident #7's Weekly Skin/Hydration assessment dated [DATE], 6/22/20, 6/29/20, 7/6/20, and 7/13/20 identified no skin breakdown. Review of Resident #7's Care Plan Intervention, 3/22/20, read, Monitor for ill fitting shoes. During a telephone interview on 8/21/20 at 2:00 p.m., Wound Care Nurse/LPN B was asked about Resident #7's Stage II pressure ulcer. LPN B said the pressure ulcer developed due to Resident #7's [MEDICAL CONDITION] and ill-fitting shoes. LPN B said Resident #7 wore her shoes all the time and would sit with her feet directly on the floor.

This citation pertains to Intakes MI 9879 and MI 889. Based on interview and record review the facility failed to 1) ensure all required pain assessments were done for 1 resident (Resident #10), 2) ensure the resident's (Resident #10) change of condition was documented, 3) ensure pain medication ([MEDICATION NAME], pain medication) was given timely and per physician's orders [REDACTED].#10), of 3 residents reviewed for assessment, pain medications, change in condition/status and transfer to an acute care setting upon change in condition, resulting in acute pain and discomfort, transfer to an acute care facility with use of a narcotic pain medication ([MEDICATION NAME]) to control pain, surgery (due to left femur fracture) and post operative [MEDICAL CONDITION] (low iron) which required a blood transfusion. Findings include: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment) dated ,[DATE], physician, nursing and social service note's dated [DATE] through [DATE], revealed Resident #10 was [AGE] years-old, admitted to the facility on [DATE], was alert with confusion, non-ambulatory using a mechanical lift for transfers and required assistance with all Activities of Daily Living (ADL's). The resident's [DIAGNOSES REDACTED]. Review of Resident #10's facility Pain care plan dated [DATE], revealed staff were to administer medications as ordered, assess past effective and ineffective pain relief measures, evaluate effectiveness of pain management interventions, monitor and record any complaints of pain, location, frequency, effect on function, intensity, alleviating factors, aggravating factors, monitor and record any non-verbal signs of pain and pain assessments were to be completed quarterly and as needed (including upon admission and re-admissions). On [DATE] at 8:20 a.m., this surveyor accompanied by Nurse Manager, LPN C reviewed Resident #10's closed Electronic Medical Record (EMR) dated [DATE] through [DATE] and Electronic Medication Administration Record [REDACTED] -Review of the facility nursing notes dated [DATE] at 7:04 p.m., stated (Family Member #1) was in today and showed nurse left knee. Left knee is swollen compared to the right. No redness noted, (Resident #10) does have C/O (complaints) pain with movement. Spoke with MD: N.O. (new order) X-ray left knee. Review of the facility Unusual Occurrence Report dated [DATE], stated (Family Member #1) in to visit, expressed (Resident #10) having C/O (complaints) pain to left knee and swollen. Swelling present and pain. Called MD D/T (regarding) findings, NO (new order) [MEDICATION NAME] 40 mg daily x 5 days and get left knee X-ray. Resting in bed, left knee, swollen and painful; med intervention/X-ray. This was signed by Nurse M on [DATE] at 7:00 p.m. -Review of the facility X-ray dated [DATE], revealed on [DATE] at 9:38 p.m., an X-ray of the residents left knee had been done at facility. -Review of the nursing notes dated [DATE], revealed on [DATE] at 12:39 a.m., Tylenol was given for slight increased temperature and LLL (left lower leg) knee pain, pain does increase with movement. No documentation of a nursing assessment of the residents left leg, knee area was found in the nursing notes dated [DATE] (bruising, color, sensation/numbness, pain/discomfort, movement and length of leg compared to other leg). -Review of the facility X-Ray dated [DATE], stated Results: Acute impacted fracture involving the distal femur, impacted distal fracture (lower left leg). -Review of the facility nursing notes dated [DATE], revealed the residents left leg/knee X-ray results were back, showing a [MEDICAL CONDITION] distal femur and stated spoke with NP (Nurse Practitioner L) r/t (related to) X-ray of left distal femur Fx (fracture) N.O. (new order) Ortho (Orthopedic) consult and [MEDICATION NAME] ,[DATE] mg (narcotic pain medication) for increased pain to her leg. No documentation of a nursing assessment of the residents left leg/knee area was found in the nursing notes dated [DATE] at 4:26 p.m. -Review of Resident #10's nursing notes dated [DATE] (at 10:00 a.m., 10:09 a.m. and 10:53 a.m.), revealed no documentation of a nursing assessment of the residents left leg/knee area (regarding the fracture). During an interview done on [DATE] at 8:20 a.m., Nurse Manager C stated I called the Nurse Practitioner because she did not order anything (after reading the residents X-ray report dated [DATE], of an acute impacted distal femur fracture, just signed she had read the X-ray) about 4:00 p.m. (on [DATE]). She (the NP) said I couldn't find the nurse. I got the order for [MEDICATION NAME] and I got the order for the transfer (to the hospital). During an phone interview done on [DATE] at 9:30 a.m., Nurse Practitioner (NP) L was asked by this surveyor if she had been made informed of Resident #10's fracture (back to the facility on [DATE]) and she said she had seen it and signed it stating I saw the X-ray, it happened the day before, it was all taken care of over the phone. Nurse Manager C called and got the order for pain medication and transfer to the hospital after noticing the NP had not written any orders for pain medication nor transfer to acute car. -Review of the nursing notes dated [DATE] at 4:29 p.m., stated This afternoon writer (Nurse LPN M) gave 2 Tylenol again d/t (related to) no [MEDICATION NAME] in house and script wasn't located at that time. Since then script had been faxed over and an Authorization # was given. This writer pulled for 2nd shift nurse to give tonight. Nurse M did not call the physician and inform him of the missed dose of [MEDICATION NAME] and request to give the [MEDICATION NAME] when available for residents pain due to her fracture; she pulled a locked up medication and held it to give to the next shift nurse so that nurse could give it to the resident. No documentation of a nursing assessment of the residents left leg/knee area was found in the nursing notes dated [DATE] at 4:29 p.m. During an interview done on [DATE] at 10:15 a.m., the Director of Nursing/DON stated on [DATE] at approximately 8:30 a.m., I was on the West Wing, (Nurse M) told me (about the X-ray results regarding Resident #10's fracture). During an interview done on [DATE] at 8:20 a.m., Nurse Manager C said she heard about Resident #10's fracture on [DATE] at approximately noon. She then went down to the resident's unit and found that the X-ray report had been faxed to the facility earlier that morning (on [DATE]) and Nurse M, had not called the physician nor reported the fracture to the Nurse Manager. Nurse Manager C also found that the residents [MEDICATION NAME] (pain medication) had not been given at 1:30 p.m. on [DATE] (missed does), per physician orders. Nurse Manager C stated (Nurse M) had the X-ray report all morning, she was supposed to call the doctor. During a phone interview done on [DATE] at 11:20 a.m., Family Member F stated, they called me on the 29th at 4:30 p.m., told me she had a fracture. -Review of the physician order [REDACTED]. On [DATE], the 1:30 p.m. dose of [MEDICATION NAME] 50 mg, had not been given, it was a missed dose. -Review of the nursing note's dated [DATE] at 9:16 a.m., stated Observed facial grimacing, PRN Tylenol given for LLE (left lower leg extremity). No documentation of a nursing assessment of the residents left leg/knee area was found in the nursing notes dated [DATE] at 9:16 a.m. -Review of the nursing note's dated [DATE] at 11:26 a.m., stated, NP (Nurse Practitioner) called back and stated, We have to have her sent to the ER (emergency room ) for a Fx (fracture) because it is considered a trauma. The facility was attempting to arrange a physician office visit regarding the resident's fracture. The X-ray results of a fracture came back to the facility early on [DATE] (no documentation of time found I the nurses notes, Nurse Manager C stated they came back in the morning on [DATE]) and the resident was not transferred to the hospital for treatment until [DATE] at 11:05 a.m. via ambulance. No documentation of a nursing assessment of the residents left leg/knee area was found in the nurse's notes dated [DATE] at 11: 26 a.m. Hospital records: Review of the hospital X-ray dated [DATE], stated Distal femur fracture. Chief Complaint, Acute distal left femur Fx. Review of the hospital emergency room records dated [DATE], revealed Resident #10 [DIAGNOSES REDACTED]., was assessed to be at a level 3 pain level (using a 0 to 5 pain scale) and received [MEDICATION NAME] 2 mg (narcotic pain medication), [MEDICATION NAME] 4 mg and [MEDICATION NAME] .5 mg narcotic pain medication) while in ER for left knee/leg pain. Review of the hospital record dated [DATE], stated patient did have pain over the past several days, patient did have the hip X-ray which did reveal a fracture which brought her to the emergency department. She (the resident) was noted to have some pain to her left leg about a week ago, X-rays had been ordered and apparently results came back on Monday ([DATE]), but not communicated to the family until today ([DATE]). This fracture appears to be impacted. She is complaining of a lot of pain and is unable to move comfortably from bed to chair. She has quite a bit of tenderness to the femur at the level of the knee, there is moderate swelling, but no bruising noted. The plan is to proceed with the surgery tomorrow evening if possible or on Saturday. Review of the hospital operative report dated [DATE], revealed the resident underwent [REDACTED]. Review of the hospital Discharge Summary dated [DATE], revealed Resident #10's [DIAGNOSES REDACTED]. The resident was transferred to the hospital on [DATE], underwent surgery on [DATE] (due to fracture) and was discharged on [DATE] (a total of 7 days at the hospital). During an interview done on [DATE] at 10:50 a.m., the DON was asked by this surveyor if there was a delay in the transfer of Resident #10 after the facility received the X-ray results (on [DATE]) and she stated, yes I think there was a delay in transfer. Review of the residents closed EMR dated [DATE] through [DATE], revealed one pain assessment dated [DATE] had been done only. Nursing documentation of pain assessments done on [DATE] and on [DATE] were not found. During an interview done on [DATE] at 8:20 a.m., Nurse Manager C stated When they (residents) get readmitted , they are supposed to do a pain assessment for three days when admitted . During an interview done on [DATE] at 9:07 a.m., Restorative Nurse, LPN K stated when there is a re-admit, we write an order for [REDACTED]. During an interview done on [DATE] at 12:10 p.m., Nursing Assistant/CNA G stated I did help her (Resident #10) on Monday ([DATE]). She was not vocal at all, she didn't say anything, she didn't eat at all, she was acting different that day. During an interview done on [DATE] at 1:40 a.m., CNA J stated She would cry if you put her leg (left) in the boots (foot boots). I did tell (Nurse M) earlier in the week (unable to recall the date) she was in pain on her leg. I put her feet in her boots, and she started screaming. I told her (Nurse M) (Resident #10) was in pain about 11:00 a.m. (unable to recall if on [DATE] or [DATE]), she said she would come in a minute; I didn't see her come. After several attempts this surveyor was unable to contact Nurse M; she no longer worked at the facility. Review of the written discipline dated [DATE], stated notified DON of an X-ray for a fracture around 9 AM, advised to contact the physician & write an incident report. Around 3 PM (Nurse M) talked to DON about another issue, (Nurse M) notified the DON (Nurse M) did not write the incident report & did not feel it should be your responsibility. (Nurse M) were instructed for the second time to write the incident report and (Nurse M) did not. (Nurse M) also did not speak to the doctor but instead put the the X-ray report in the physician's office (at the facility). Review of Nurse M's Human Resource file revealed, a total of four resident care verbal and written disciplines (on [DATE]-wound care concern, on [DATE]-resident rights concern, on [DATE]-giving expired medication concern, and on [DATE]-giving thin liquids to multiple residents on nectar thick liquids concern), all prior to the [DATE], written discipline. Review of the facility Change in a Resident's Condition or Status policy dated ,[DATE], revealed a change in condition documentation with notifying the physician, resident and/or responsible party was to be done when a resident has, a significant change in resident's medical, physical/emotional/mental condition (including a fracture), a need to transfer the resident to a hospital/treatment center. Review of the facility Pain Assessment and Management policy dated ,[DATE], revealed staff were to identify pain in a resident, assess the pain and develop interventions that are consistent with the resident's goals and needs that address the underlying causes of pain. Assessing Pain: During the pain observation assessment gather the following information as indicated from the resident (need to document pain assessment), intensity of pain, descriptors of pain, pattern of pain, location and [MEDICAL CONDITION] of pain, frequency, timing and duration of pain. Symptoms that accompany pain (e.g., nausea, anxiety). Facility staff were to document the residents change of condition, including the complaints of pain (verbalized by the resident on [DATE]) accompanied by a complete pain assessment.

Based on observation, interview and record review, the facility failed to prevent facility-acquired Pressure Ulcers, document the ulcers and ensure position changing for 8 residents (#1, #7, #9, #20, #21, #26, #172, and #276) of 10 reviewed residents, resulting in the likelihood of increased size of pressure ulcers, infection and hospitalization . Findings include: Record review of facility 'Pressure Ulcer Risk Assessment' policy dated 2/13/17 revealed the most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows shoulder blades, backbone, hips, knees, heels, ankles and toes. Pressure can also come from splints, cast, bandages and wrinkles in the bed linens. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often become infected. Because a resident at risk can develop a pressure ulcer within 2-6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempted prevent pressure ulcers. Dark purple or dark areas that are surrounded by profound redness, [MEDICAL CONDITION], or induration suggest deep tissue damage has already occurred and additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of an unavoidable Stage III or IV pressure ulcer or progression of a Stage I pressure ulcer to and ulcer with eschar or exudate within days. Record review of facility 'Prevention of Pressure Ulcers' policy dated 2/13/17, revealed the purpose of the procedure was to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. General preventive measures included: (2.) Person in bed- Change position at least every two hours or more frequently if needed. (3.) For person in a chair- Change position at least every hour. (10.) Immediately report any signs of a developing pressure ulcer to the supervisor. Risk factor for moisture: (d.) Place resident on a minimum of a every two-hour check and change program. Additional factors indicated: (1.) Impaired/decreased mobility and decreased functional ability. (2.) Co-morbid conditions, such as end stage [MEDICAL CONDITION], cancer or diabetes. (6.) Cognitive impairments. Record review of 'Facility Acquired Pressure Ulcers' list, dated 12/3/19, revealed that there were 8 Residents listed: Pressure ulcers were noted in stages from Suspected Deep Tissue Injury (SDTI), Stage II, Stage III and Stage IV: Resident #1- Unstageable right heel developed in facility on 5/13/19 and Coccyx wound stage IV developed in facility on 9/12/19. Resident #9- Stage II left heel developed in facility on 10/29/19. Resident #20- Suspected Deep Tissue Injury (SDTI) to lateral left foot developed in facility on 9/5/19. Resident #21- Suspected Deep Tissue Injury (SDTI) to bottom of left foot developed in facility on 10/10/19. Resident #26- Stage III left lateral ankle developed in facility on 11/4/19 and Right lateral foot stage II developed in facility on 11/14/19. Resident #55- Suspected Deep Tissue Injury (SDTI) to right heel developed on 12/2/19 (noted after cast removed from foot). Resident #172- Stage II bilateral buttocks developed in facility on 11/26/19. Resident #276- Stage II left buttocks developed in facility on 12/3/19. Record review of Facility 'Pressure Ulcer Staging System' form WC-0244-0311, staging definitions, provided by licensed Practical Nurse (LPN) OO, whom also was the skin/wound care nurse revealed: Deep tissue injury- Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Stage I- Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I my indicate at risk persons (a heralding sign of risk). Stage II- Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. Stage III- Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Stage IV- Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth or a stage IV pressure ulcer varies on the anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or support structures (fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] possible. Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Resident #1: Record review of Resident #1's Minimum Data Set ((MDS) dated [DATE] revealed an elderly female with section G: Functional Status- extensive assist bed mobility with two-person assist moving from position, turning side to side, and positions body while in bed. Resident #1 was assessed as total dependence with full staff performance every time during the 7-day assessment period. Support of 2-person physical assist was needed. Section M: Skin conditions- Resident #1 was assessed at risk for pressure ulcers with two unhealed unstageable with suspected deep tissue injury. Record review of Resident #1's care plans pages 1-38, revealed that the resident was dependent upon staff for all aspects of care due to dementia and cognitive decline. Resident #1 was non-ambulatory and with poor cardiac tissue profusion. Record review of Resident #1's progress note dated 11/29/19 at 1:58 PM written by Licensed Practical Nurse (LPN) skin care nurse OO revealed: Dressing changed to coccyx per order. Wound measuring 2.3cm X 3.7 cm X 1.4 cm. Undermining noted from 8 O'clock to 4 O'clock. Wound bed beefy red with small amount of slough noted. Small amount of serosanguleous drainage with no odor noted. Surrounding skin pink, warm and dry. Right heel measuring 1cm X 1cm covered in slough. Observation on 12/06/19 at 07:30 AM of Resident #1 while lying in bed with Licensed Practical Nurse (LPN) OO and LPN F of dressing change to observation a stage 4 coccyx wound acquired at the facility. LPN OO the wound care nurse stated that when she first saw the wound it was already a stage III with a dark tissue area in the center, which is now a stage 4. Observations of bed linens revealed yellow urine ring on body positioning with drops of blood dried and fecal stool on pillowcase. Stool smears noted on lift sheet also. Resident #20 was turned to left side and the old dressing was removed. Wound bed packing material was removed with tunneling noted to wound bed. Wound measurements of 2.2cm (width) X 3.0cm (length) X0.9 depth at over bony prominence. Tunneling measurements of: 7 O'clock tunneling depth 2.1cm and 1 O'clock tunneling depth 1.4cm. Saline cleanse wipes to wound, gauze and patted dry. Opticel silver antibacterial ribbon 18 inches packed into the wound bed, Cavaillon skin barrier applied with swab and Opti foam boarder sacrum 7 x 7 dressing applied. Observation of second facility acquired wound on 12/06/19 at 07:50 AM for Resident #1: second wound- Right heel dressing removed, measurement of wound 0.9cm (width) X 1.0cm (length) with slough yellow unable to measure depth. Saline wipe to wound bed, gauze pat dry. Cavaillon skin barrier applied with swab, 4 x 4 foam boarder dressing applied. Resident #7: Record review of Resident #7's Minimum Data Set ((MDS) dated [DATE] revealed an elderly female with Brief Interview of Mental status (BIMS) score of 3 out of 15, severe cognitive impairment. Medical [DIAGNOSES REDACTED]. Section M- Skin conditions assessment: Resident at risk for pressure ulcer but had none at the time of the assessment. Record review of Resident #7, who was not on the Facility Acquired Pressure ulcer list, progress notes dated 11/29/19 at 2;05 PM written by Licensed Practical Nurse (LPN) OO skin care nurse, revealed: Assessed left foot due to resident complained of pain. 1cm X 1cm reddened blanchable area noted to left foot medial bunion. 1.5cm X 1.5cm reddened blanchable area noted to left lateral bunion. Left lateral mid foot with 0.8cm X 0.8cm purple discoloration. Left lateral heel red and blanchable. Left inner heel red with flaky skin, blanchable with 2cm X 2cm scabbed area. Small intact scab to top of left foot. Padding to bedside table where resident rest feet at times. Observation on 12/04/19 at 02:48 PM with Licensed Practical Nurse (LPN) OO skin care nurse of Resident #7's bilateral heels revealed check of right foot with pink heel with skin intact. Observation of resident #7's left foot revealed a stage II open area from pressure. LPN OO stated that is a new area to her left heel also a scab was noted to top of the foot at the base of the leg/ankle area. The state surveyor requested skin care notes. Record review of Resident #7's progress note dated 12/4/19 after the observation with the State surveyor revealed: Assessed left foot due to resident complained of pain. 1cm X 1cm reddened blanchable area noted to left foot medial bunion. 1cm X 1cm reddened blanchable area noted to left lateral bunion. Purple discoloration remains to the Left mid 1cm X 1cm. Left lateral heel red and blanchable with 0.3cm X 0.3cm purple discoloration noted, skin intact. Left inner heel red non-blanchable with 3cm X 3cm with x2 small open areas measuring 0.3cm X 0.3cmscabbed and 0.2cm X 0.2cm. Intact scab remains to top of left foot measuring 0.2cm X 0.2cm. Resident foot is tender to the touch. Record review of Resident #7's progress note dated 12/5/19 at 8:17 AM revealed: New order placed to apply barrier cream to open area on left inner heel. Cover with ABD dressing and Kling wrap. Change daily and as needed. Resident #9: Record review of Resident #9's Minimum Data Set (MDS) quarterly dated 8/24/19 revealed an elderly female with cognitive skill for daily decision making as severely impaired, rarely or never making decisions. Medical [DIAGNOSES REDACTED]. Section G- Functional Status- extensive assist bed mobility with two-person assist moving from position, turning side to side, and positions body while in bed. Resident #9 was assessed as total dependence with full staff performance every time during the 7-day assessment period. Support of 2-person physical assist was needed. Section M: Skin conditions- Resident #9 was assessed at risk for pressure ulcers with no pressure ulcers. Observation on 12/06/19 at 08:05 AM with Licensed Practical Nurse (LPN) OO skin care nurse of Resident #9's Stage II left heel dressing change observed with intact blister, when laid on the mattress heel blister matched up with ankle of foot when on mattress. Dark purple with light areas in blister bed. Measurement 2.7cm X 2.0cm intact. Resident #20: Record review of Resident #20's Minimum Data Set (MDS) quarterly dated 6/24/19 revealed an elderly female with Brief Interview of Mental status (BIMS) score of 6 out of 15- cognitive impairment. Medical [DIAGNOSES REDACTED]. Section M: Skin conditions- Resident #20 was assessed at risk for pressure ulcers with one suspected deep tissue injury. Record review of Resident #20's Minimum Data Set (MDS) quarterly dated 9/20/19 revealed section M: Skin conditions- Resident #20 was assessed at risk for pressure ulcers with one unstageable with slough and/or eschar in the wound bed and two suspected deep tissue injuries. Observation on 12/06/19 at 08:20 AM with Licensed Practical Nurse (LPN) OO skin care nurse of Resident #20's left outer lateral mid foot, dry scab with ridges flaky tan in color. Measurements 0.7 cm x 1.0cm. LPN OO stated that Resident #20 went out for an outside podiatry appointment and the podiatry office found the wound and sent a treatment for [REDACTED]. In an interview and record review on 12/04/19 at 11:53 AM Licensed Practical Nurse (LPN) OO skin care nurse of Resident #20's record review of skin care plan revealed that right heel stage III pressure ulcer developed on 5/8/19, and there was no mention of the left lateral foot SDTI, or intervention to monitor the site, treatments in place or positioning devices needed. Discussed 10 facility acquired pressure ulcers developed in last 6 months, all mattresses are supposed to be pressure relieving mattresses. How do the mattresses relieve pressure? LPN OO was not sure how. LPN OO stated that If a resident is admitted with a coccyx wound then a special alternating air mattress is ordered. When a new resident is admitted LPN OO does a visual skin assessment on admission head to toe, and with quarterly assessments for MDS. When a pressure ulcer develops LPN OO stated that she observes the wound and measures the wound one time a week, the floor nurses do the treatments daily. LPN OO stated that she is not notified of red areas (stage I) until a staff member see's the red area open or become worse and by then it's a stage II. It's all in positioning or moving the residents. LPN OO stated that Resident #202 pressure ulcer area was found by the podiatrist on an outside appointment. Resident #21: Record review of Resident #21's Minimum Data Set (MDS) quarterly dated 9/14/19 revealed an elderly female with Medical [DIAGNOSES REDACTED]. Section G- Functional Status- extensive assist bed mobility with two-person assist moving from position, turning side to side, and positions body while in bed. Resident #21 was assessed as total dependence with full staff performance every time during the 7-day assessment period. Support of 2-person physical assist was needed. Section M: Skin conditions- Resident #21 was assessed at risk for pressure ulcers with no pressure ulcers. Record review of Resident #21's progress note dated 10/9/19 at 4:19 PM revealed: 1.8cm X 1.3cm hard dark area remains to bottom of left foot beneath small toe. maintenance notified to remove foot board to relieve pressure to bottom of foot. Back of left heel with dry flaky skin noted to be peeling 2cm X 2cm reddened area. Record review of Resident #21's progress note dated 10/17/19 at 9:06 AM revealed: 1.8cm X 1.3cm hard dark area remains to bottom of left foot beneath small toe. Back of left heel with dry flaky skin noted to be peeling 1.2cm X 1.5cm opened reddened area. No drainage noted. Non boarder silicone foam dressing in place. Resident #26: Record review of Resident #26's Minimum Data Set (MDS) quarterly dated 9/14/19 revealed an elderly female with Medical [DIAGNOSES REDACTED]. Section G- Functional Status- extensive assist bed mobility with two-person assist moving from position, turning side to side, and positions body while in bed. Resident #26 was assessed as total dependence with full staff performance every time during the 7-day assessment period. Support of 2-person physical assist was needed. Section M: Skin conditions- Resident #26 was assessed at risk for pressure ulcers with no pressure ulcers. Observation and interview on 12/06/19 at 07:15 AM with Licensed Practical Nurse (LPN) OO skin care nurse of Resident #26's right lateral foot with stage II intact blister, discolored with no dressing to the area. Observation of the Left lateral ankle stage III was located over the bony prominence, measurements 1.9cm X 1.3cm with depth 0.2cm with yellow color base, outside rim pink. LPN OO was asked how the wound developed and the surveyor was told that LPN OO was told by aides that the ankle was red, but soft. LPN OO stated she investigated and Resident #26 lays with her leg's externally rotated and crosses her ankles. Resident #172: Record review of Resident #172's Minimum Data Set ((MDS) dated [DATE] revealed an elderly female with Medical [DIAGNOSES REDACTED]. Section G- Functional Status- extensive assist bed mobility with two-person assist moving from position, turning side to side, and positions body while in bed. Resident #172 was assessed as total dependence with full staff performance every time during the 7-day assessment period. Support of 2-person physical assist was needed. Section M: Skin conditions- Resident #172 was assessed at risk for pressure ulcers with no pressure ulcers. Record review of resident #172's progress note dated 11/25/19 at 3:19 PM revealed Left buttocks with 1cm X 0.9cm sheered area. Right buttocks with 1cm X 1cm sheered area noted. Area cleansed and covered with [MEDICATION NAME] (dressing). Order in place to change [MEDICATION NAME] every three days and as needed. Observation and interview on 12/06/19 at 08:15 AM of Resident #172's room [ROOM NUMBER], observed a brown recliner in room. LPN OO had stated that the resident sleeps sitting up in her recliner and that the pressure ulcer areas may have started that way. In an interview and records review on 12/03/19 at 01:58 PM with Licensed Practical Nurse (LPN) OO skin/wound care nurse of 3 months. Records were reviewed of facility acquired pressure ulcers; 10 in-house facility acquired. LPN OO stated that she went through the list and reviewed the pressure ulcers. Review of Resident #21's Suspected Deep tissue Injury (SDTI) bottom left foot started on 10/10/19. LPN OO stated Resident #21 refuses care and repositioning. LPN OO stated that she assessed her, and she would lay her feet on the foot board of bed, dry dark spot to left foot. Record review of Resident #1's unstageable to right heel started on 5/13/19, and opened recently about 2-3 weeks ago, and was a now stage II. Record review of Resident #1's Coccyx stage IV pressure ulcer wound started on 9/12/19. The wound started as a stage II, the skin was open, and it started getting dark in the middle of wound, we did add an air mattress to her bed after that and position side to side and added a Roho cushion in wheelchair. LPN OO stated that the facility did send Resident #1 to wound clinic and were told to keep doing what they are doing, it was slough and gross looking. LPN OO was asked why did it start? LPN OO stated that It's a pressure wound, might be from wheelchair. Record review of Resident #172's bilateral buttocks stage 2 that developed at facility on 11/26/19. LPN OO stated Resident #172 was on the Manor south unit and that Resident #172 had recently moved her to the West unit 2-3 weeks ago. LPN OO stated that the pressure ulcers developed on the West Unit within the last 2-3 weeks. Resident #172 is sleeping in the recliner, so I added a Roho cushion. It was a stage II before anyone told me. The floor nurses should have addressed the issue. Record review of Resident #9's left heel at a stage II was an intact blister on bottom of her heel, LPN OO was asked how did the blister developed? LPN OO stated that she was not sure how, but that Resident #9 had a foot board and she would press down on it. LPN OO stated that she was not told about it until it was already a stage II. Record review and interview of Resident #26's left lateral ankle stage III started on 11/4/19, LPN OO stated that when the aides first showed it to her three weeks ago, it was pink and also had a pale soft intact area in the middle, with damaged tissue under neither. The left lateral ankle opened 2 weeks ago and now is a stage III with slough developing. Record review of Resident #26's right lateral foot stage II pressure ulcer started on 11/14/19. LPN OO was asked how did the pressure ulcers developed? LPN OO stated that Resident #26 sits with ankles rotated external, she has a soft foot cradle and crosses her ankles and rubs them together. LPN OO stated that the blister to the right lateral foot stage II, that she found out about 10 days after the left ankle pressure ulcers. Record review and interview with LPN OO review of Resident #276's left buttocks stage II pressure ulcer revealed that LPN OO did not know how it happened. LPN OO stated that Resident #276 was admitted not even 2 weeks ago and that she had looked at Resident #276's buttocks upon admission and it was fine. So, the stage II had to have developed at the facility within the last 2 weeks, why? staff must not be repositioning her. Record review of resident #20's left lateral foot Suspected Deep Tissue Injury (SDTI) started on 9/5/19. How did it develop? LPN OO stated that Resident #20 went outside the facility to see a podiatrist (foot doctor). Resident #20 was admitted with a right heel SDTI, and what happened was when I went to go see her, that week she had a podiatrist appointment, the podiatrist ordered [MEDICATION NAME] as a treatment for [REDACTED].? LPN OO stated I don't work the floor, according to our schedulers we are staffed, mandated staff to stay over. Clearly not repositioning residents, I get on the staff to reposition residents. But the list is growing of facility acquired pressure ulcers. I gave an educational moment in a staff meeting on that when they do see reddened areas to let the floor nurses know so we can find out what the problem is before it's a stage II. In an interview on 12/05/19 at 09:00 AM the Director of Nursing (DON) related to development of pressure ulcers. The DON stated that, We do have an increase in pressure ulcers, and we have a lot of new staff, change in management and we are weeding out those that do not meet job standards. We are running short staffed at times. The pressure ulcers can come from positioning, some are unavoidable. Stage I -red area turns to a stage II, before the wound nurse is notified. The staff on the floor need to be more proactive in putting immediate interventions in place. The DON stated that there was no documentation of/for Certified Nurse Assistants (CNA) to document when and what position changes they are making to at risk pressure ulcer residents. In an interview on 12/06/19 at 10:31 AM with Licensed Practical Nurse (LPN) OO whom was the skin/wound care nurse, was asked how does the facility ensure that the Certified Nurse Assistants (CNA) CNA's and floor nurses are ensure position changing? There was no CNA documentation, no check list there's and no documentation of residents being re-positioned. Quality Assurance review task done on 12/5/19 at 10:34 AM with Licensed Practical Nurse (LPN) G who ran the Quality assessment and assurance committee revealed that when asked about pressure ulcer or skin issues that there was no performance improvement project form or audits related to pressure ulcers. When asked about (MONTH) skin issues the LPN G revealed that there were only 2 suspected deep tissue injuries (SDTI) on the Manor north unit and 2 SDTI on the Manor south unit that were discussed in the (MONTH) quality improvement meeting. LPN G stated that pressure ulcers are not being looked at in quality improvement at this time, they just were not being actively QA'd. LPN G stated that the last time pressure ulcers were a QA concern was back in (YEAR). Resident #276: On 12/03/19, at 11:41 AM, Resident #276 was sitting in their wheelchair. Resident #276 complained of their bottom hurting. Resident #276 stated, It has been hurting for the last couple of days. It's near my incision so I thought it was my incision. Resident #276 was asked if they get up out of their wheelchair throughout the day and Resident #276 stated, I haven't done that yet. I'm not supposed to. Resident #276 further stated, Well, you sit in your wheelchair, you sit on the toilet. On 12/04/19, at 1:00 PM, a record review of Resident #276's electronic medical record revealed an admission on 11/24/19 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment dated [DATE] revealed that Resident #276 required extensive assistance with bed mobility and transfers between surfaces with two-person physical assistance. Resident #276's Brief interview of mental status revealed Resident #276 had intact cognition. A review of the facility provided bedside care plan revealed Transfers . 2 person all T/F's 12-5-19 . was hand-written on the care plan. A review of the facility provided Weekly Skin/Hydration Assessment . Date 11-28-19 . revealed no skin problem other than incision. A review of Date 12-3-19 . Incision Steri-strips in place . with the left thigh/hip area circled and Pressure Injury Red Firm . with the left buttock circled. A review of progress notes revealed a progress note 12/03/2019 12:36 PM 2 cm x (by) 1.8 cm open area noted to left buttocks. Surrounding skin is pink but blanchable. Area cleansed and covered with [MEDICATION NAME] (dressing.) . On 12/04/19, at 3:08 PM, Nurse OO was asked about Resident #276 developing a stage 2 pressure ulcer to their buttock and Nurse OO stated, I looked at her on admission. She was fine but they came and got me, and it's sheered right off. On 12/05/19, at 8:53 AM, an observation of Resident #276's stage 2 pressure ulcer to their buttock along with Nurse OO was conducted. Nurse OO measured the wound resulting with 1.2 cm wide (centimeters) by 1 cm long open area with a 3 cm wide by a 7 cm long reddened area that was blanchable. There was a raised firmed area about a golf ball size area just above the open wound that Nurse OO palpated with Resident #276 flinching in pain. There was a small dark area measuring approximately 1 cm long by 0.5 cm wide inside the larger reddened area that was not changing color on palpation. Nurse OO was asked what that was and Nurse OO stated, No, it's not dry skin. It appears to be a dark area. Resident #276 was asked by Nurse OO where they'd like to sit and Resident #276 stated, I'd like to be sitting nowhere. Resident #276 further stated, No. when asked if they normally have a firm hardened area to their buttock. Resident #276 further offered, I think I got it from just being on it. On 12/06/19, at 10:32 AM, Nurse OO was asked to provide documentation in Resident #276's medical record where the facility had offered position changes and education on off-loading pressure and Nurse OO stated, there is no check list for CNA's documentation on assurance of position changes.

Based on observation, interview, and record review the facility is placed in Immediate Jeopardy for its failure to provide adequate supervision and respond appropriately to functioning safety devices (door alarms) for one resident (Resident #1) of five residents reviewed for elopement, resulting in an elopement and the potential for serious injury, serious harm, and/or death for Resident #1, such as being struck by a motor vehicle, a fall, or prolonged exposure to the elements. Date IJ (F-689-Elopement) Occurred: 11/05/19 Date IJ Was Identified: 11/19/19 Date IJ Notification Served: 11/19/19 Date Abatement (Removal) Plan Approved: 11/20/19 Date IJ Abated (Removed): 11/20/19 Date Abatement (Removal) Plan Verified 11/21/19 Findings include: Review of the facility's reported incident (FRI) incident summary, dated 11/6/19, stated that (Resident #1) was observed outside in the back parking lot self propelling in his wheelchair on 11/5/19 at approximately 7 PM. He (Resident #1) had exited the facility unsupervised. and included a [DIAGNOSES REDACTED]. The resident was outside alone and unsupervised in the facility's back parking lot in the dark at night with the potential to be struck by a motor vehicle. After review of the facility's elopement investigation and conducting observations and interviews it was determined the facility failed to respond timely to two audible exit door alarms which sounded in the East South and West South halls. A staff member, Nurse E, was seated in their car in the back parking lot and observed Resident #1 outside at approximately 7:30 PM in a fast moving wheelchair. Resident #1 was wearing short sleeve shirt and thin pajama pants. Resident #1 was not wearing shoes, a hat or a coat. The weather forecast on that day was a high of 43 degrees Fahrenheit and a low of 28 degrees Fahrenheit. During an interview on 11/19/19 at 4:47 PM, on the memory care unit, Resident #1 when recalling the elopement event stated, I went out the back door and the alarm went off. There was a ramp. It was curved. It was cold out, about 20 degrees. I only had a tank top and sweat pants .I'm tired of being here. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of eight, which reflected moderate cognitive impairment. Review of Resident #1's elopement investigation, dated 11/6/19, stated the following: - On 11/5/19 at 7:38 PM LPN (Licensed Practical Nurse), LPN [NAME] contacted DON (Director of Nursing) to report that while she was outside on break she was sitting her car and she observed a resident self propelling in w/c (wheelchair) pass by her car .(LPN E) reports (Resident #1) stated he was looking for Administration because he wanted to leave the facility. and as soon as she saw (Resident #1) propel in front of her car she jumped out to protect him. LPN [NAME] reports (Resident #1) stated he went down a ramp to get out of the building. - Spoke with RN (Registered Nurse), (RN C) who worked 2nd shift on MS (Manor South) on 11/5/19. (RN C) states he observed (Resident #1) sitting by the MN (Manor North) nurses station at approximately 6:55 PM on 11/5/19 when he passed by him to go to lunch break. (RN C) reports he had been in the breakroom for approximately 15 minutes when (LPN [NAME] knocked on the back door to the break room with (Resident #1) .(RN C) states (Resident #1) was wearing P.[NAME] pants (pajama) & a t-shirt & gripper socks .RN C states an older blonde haired housekeeper reported to him that a door alarm had sounded on west wing previously during this shift. - (Housekeeper D) states her and a dietary aid (Dietary Aide I went down to WS (West South) wing to look for clothing protectors. (Housekeeper D) states the West South door alarm was going off at that time sometime between 7:00 PM & 7:30 PM. (Housekeeper D) reports she shut off the alarm & her & (Dietary Aide I) went outside to look for anyone who may have exited that door. (Housekeeper D) denies seeing anyone outside who may have set off the alarm. - (Dietary Aide I) states she was working 2nd shift on 11/5/19 when her & a housekeeper (staff D) went to west wing looking for extra clothing protectors. (Dietary Aide I) states she could hear a door alarm sounding as they approached the hall. The alarm was sounding on WS side down by the laundry room .went outside to see if anyone exited out that door & (Dietary Aide I) denies seeing anyone. - (Certified Nursing Assistant (CNA) H) states she was in room [ROOM NUMBER] in the bathroom with a resident when she heard a door alarm sounding. (CNA H) states this was at approximately 7 PM & she did not exit the room to check on the alarm. - Temperatures on 11/5/19 in Bay City were approximately 40 degrees Fahrenheit when (Resident #1) went outside unsupervised .No staff witnessed (Resident #1) leave the building. Review of the facility's Unusual Occurrence Report/Investigation, dated 11/5/19, stated the following: - Date: 11-5-19 .Time: 7:30 p.m. and Elopement .Other door (The blank fill in section of this line selection was left blank; it was not known for sure which door Resident #1 exited) .Time last observed 6:55 PM. - Fall History .Yes Dates: 11-4-19 and Transfer Status: .1 assist. The resident was noted to have a fall the day prior. Resident #1 could have fallen outside and sustained an injury during the elopement. - Resident (Resident #1) was observed outside in the back parking lot unsupervised self propelling in w/c (wheelchair). Resident was in parking lot closest to time clock hallway heading south towards the dumpsters. Review of the facility's investigation indicated Resident #1 exited the facility at night unsupervised wearing inappropriate clothing for the cold weather. Despite the exit door alarms sounding, the alarms and staff response were insufficient to prevent the elopement. It was also not known for sure which exit door Resident #1 exited the building from and Resident #1 could have been outside approximately 20 minutes. During an interview on 11/15/19 at 4:12 PM, Housekeeper D, recalled the elopement event and stated, I was in the main dining room. Ready to clean and dietary aide (Dietary aide I) said there wasn't enough clothing protectors. We started for the west wing to get them from the laundry room (next to West South door) and heard the alarm going off on the door, not a soul was around not a thing, We checked the back porch, all around the ramp and around the side of the building both ways. No one was out there. We didn't see anything, but 2 aides on the back porch near the breakroom door outside. I assumed they didn't see anything. No one was there. I assumed the alarm was from one of them. No one was on the other side of the building, West side parking lot. I didn't know there was anyone out there. I went back to the laundry room to get the clothing protectors and went to the dining room to clean. The 2nd shift nurse came and said the East wing door was alarming. He (Nurse C) said a Resident went out the door. During an interview on 11/19/19 at 5:23 PM, Dietary Aide I recalled the elopement event and stated, Me and (Housekeeper D) were going to get clothing protectors. We were just outside the dining room and heard the alarm. There were no CNA's (Certified Nursing Assistants) around. Nobody. The residents were just looking and no staff came around. (West South door) (Housekeeper D) went out and I was right there to monitor the door. There were no CNA's to be found. The nurse (Nurse E) from west was on lunch and she found him. The nurse that found him said he (Resident #1) went out the other door (East south). During an interview on 11/19/19 at 11:40 AM, Licensed Practical Nurse E, nurse assigned to the West hall at time of elopement, recalled the elopement event and stated, I was on my lunch break in my car.I saw a flash out of the corner of my eye. He (Resident #1) went by the car real fast .He had a wife beater (white, thin tank top), bare arms and a bald head. I asked him why he came out the door and he said, I'm looking for Administration to get the (explicit word) out of here. He said he came out the door and down the ramp .then 2 CNA's said 2 alarms were going off (CNA's M and N). The girl in the kitchen (unknown staff member) said both the East and West doors were going off. During an interview on 11/19/19 at 4:45 PM, Registered Nurse C recalled the elopement event and stated, My memory of (Resident #1) was at 5 minutes to 7:00 PM I went to the breakroom (RN C saw the resident last at 6:55 PM). At about 7:15 PM (LPN E) the west Nurse was wheeling him to the breakroom, and I let them in the door. She said he was outside. We tried to figure out how he got out. We started checking the doors. He said he went out the East door. We tested it, but it was not alarming. The housekeeper (staff D) said the West door was alarming. During an observation and interview on 11/19/19 at 11:21 AM, Environmental Services Supervisor A reported he didn't know which door Resident #1 had exited out of. Exit A/East South had a cement slope from the exit door down to the parking lot. When asked what the grade of the ramp was, Environmental Services Supervisor reported he wasn't sure but when asked for an estimation stated, 15 or 20. If the wheelchair was not properly controlled and this was the exit door during the elopement, Resident #1 could have accelerated to an unsafe speed. The other exit, West South, had a wood ramp which also had a slope that could have generated an unsafe and increased wheelchair speed. Review of Resident #1's Resident Care Guide, undated, indicated Orientation .confused at all times and Problem: .Elopement Risk .Resident has been identified as at risk for elopement, through elopement risk screening process. The goal was Resident will have no incidents of leaving the building without an escort. Review of the facility's Wander Management Program policy, revised 4/2010, stated, It is the policy of this facility to attempt to prevent elopement for residents that have been identified by the Interdisciplinary Team as at risk for elopement. Review of the facility's Wandering/Missing Residents policy, revised 5/2010, stated, Door alarms are in place and are responded to immediately and residents are redirected. When resident is redirected and a safe distance away, the door alarms are immediately reset. and *Pay special attention to meal times when staff is concentrated in dining areas. The facility's staff's response to the sounding door alarms was delayed so that when they did arrive at the sounding door alarm no resident could be found inside or outside the area of that door. As a result, Resident #1 opened and exited the facility without staff being able to redirect the resident safely within the facility. The policy addressed dining time as a time to pay special attention to, and Resident #1's elopement did occur at or around dinner time. It was staff searching for clothing protectors that ultimately led to the first responders to the sounding door alarms. Review of the facility's Elopement Risk Assessment, revised 11/6/18, stated It is the policy of this facility to provide an environment to minimize elopement attempts of our residents. On 11/19/19 at 03:00 PM, notification of Immediate Jeopardy, that began on 11/5/19 at approximately 6:55 PM, was given to the Administrator, which was the result of the facility's failure to prevent the elopement and ensure the safety of Resident #1, who was not safe to exit the building alone but was able to do so, without staff knowing or responding to sounding alarms timely. On 11/21/19, the surveyor confirmed that the facility implemented the following to remove the immediate jeopardy: - Resident, (Resident #1), was immediately assisted back into the building after being observed outside unsupervised on 11/5/19. Staff remained with resident 1 on 1 on 11/5/19 until (Resident #1) went to bed for the night. (Resident #1) was monitored frequently during resting hours the night of 11/5/19-11/6/19. On 11/6/19 (Resident #1) was moved to a secure unit to prevent wandering outside of facility. A surveyor observed Resident #1 on the secure unit on 11/15/19 and resident check documentation was reviewed. On 11/21/19 at 7:25 AM, the surveyor confirmed with the Nursing Home Administrator Resident #1's progress notes showed he was moved to the secure unit on 11/6/19. - On 11/7/19 a re-assessment of elopement risk was completed & risk was identified. On 11/7/19 an elopement care plan was created & (Resident #1) was added to the adventure club (elopement risk residents) to notify staff of risk for elopement. The surveyor observed Resident #1 on the adventure club list on 11/19/19, with that list having a revision date of 11/11/19. Review of Resident #1's care plan included an elopement risk section which was started 11/7/19. - On 11/19/19 an all staff in-service was initiated regarding Elopement Risk Assessment Policy, Wander Management Program Policy & the revised Missing Resident Procedure Policy, supervising of the residents and management of exit door alarms. Each time an exit door alarm sounds without an identified cause a code pink will be called & Missing resident procedure policy will be initiated. Code Pink drills will be done bi-weekly & QA (quality assurance) initiated. 100% satisfaction is goal which will be reached for 3 consecutive months prior to dismissing from Q[NAME] An initial elopement drill was completed on 11/7/2019. Future drills will be completed bi-weekly. In-servicing related to wander management & Elopement Risk Assessment began on 11/7/19. Updated in-servicing began on 11/19/19 & will be completed by 11/22/19 by 3:00 PM. The surveyor confirmed in-service records showing in-service of all staff started on 11/19/19 and policies revised. Approximately 19 residents, per Admissions Director L, were still scheduled to complete the education and would have received it by 11/22/19 at 3 PM. The 11/7/19 elopement drill was reviewed on 11/19/19. There were three elopement drills that had been completed thus far on three separate shifts, dated 11/20/19, 11/20/19, and 11/21/19 and were reviewed by the surveyor. - On 11/20/19 re-assessment of elopement risk for all residents in the building was initiated to identify any residents who were not previously identified as elopement risk. Any resident who are identified as an elopement risk will have proper precautions in place. On 11/21/19 at 7:45 AM, the surveyor reviewed the facility's re-assessment of elopement risk for all residents in the building with Admissions Director [MI] An elopement risk evaluation and progress note was completed for every resident in the building. These assessments were started 11/20/19 and were completed at approximately 6 AM on 11/21/19. - Implementation: Inservice director will teach all employees the importance of the door alarms & setting and re-setting of the alarms. We (the facility) will install louder door alarms on the wings that are not occupied including East-South & West-South (The halls of which Resident #1 likely exited the building; one or the other). Nurses will continue with the monitoring of the door alarms twice per shift. The surveyor observed an alarm company's contact information and price quote/invoice, dated 11/19/19. Estimated completion date per the alarm company's quote/invoice was 5 to 7 days. - Monitoring: Nurses will continue to monitor the doors twice a shift. Inservice Director/designee will in-service all new staff on door alarms and conduct Elopement drills. The surveyor reviewed the twice per shift door checks and confirmed the checks continue to be done routinely. 11/20/19's door alarm check sheet was completed in full. The process of this was discussed with Admissions Director [MI] - Responsible: Don (Director of Nursing) and administrator will be responsible for monitoring the monitors. Although the Immediate Jeopardy was removed on 11/20/19, the facility remained out of compliance at a scope and severity No actual harm with potential for more than minimum harm that is not immediate jeopardy, pending the facility's ability to sustain compliance as verified by the State Agency.

Based on observation, interview and record review, the facility failed to implement preventative measures to avoid the worsening of a facility acquired pressure ulcer for one (#53) of five Residents reviewed for alteration in skin integrity of a total sample of 24, resulting in a Stage II pressure ulcer (partial thickness skin loss) advancing to a Stage III pressure ulcer (full thickness skin loss), a Stage II pressure ulcer developing necrotic tissue (unable to be determined Stage of ulcer) and the potential for further delayed wound healing, infection, pain and overall deterioration in health status. Finding include: On 2/26/18 at 2:35 PM, an observation was made of Resident #53 in their room, laying in bed. A dressing change to Resident #53's sacral wound and left ischium wound was observed, performed by Nurse MM and Acting Director of Nursing (DON)/Wound Care Nurse B. The sacral wound was observed to be pink, moist and had a small amount of slough (a mass of dead tissue separating from an ulcer). The left ischium wound was observed to be covered by darkened eschar tissue (a collection of dead tissue within the wound bed). When the Nurses were queried about the ischial wound, Nurse B stated, It was a stage two, now it is unstageable because of the necrotic tissue. We were using a duoderm (a dressing for the wound) but will call the doctor since there was a change. When queried regarding the sacral wound, Nurse B stated, It is a Stage III. They were both Stage II's until today. Nurse B was queried if the pressure wounds were facility acquired and stated, Yes, they were acquired here. On 2/27/18 at 12:30 PM, a review of Resident #53's medical record revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognition and was total dependant with two person assistance for transferring and bathing. Further review of Resident #53's medical record revealed: Progress Notes that stated: 2/26/18, 5:15 PM, Sacral pressure injury now presents as a stage III wound that measures 4.8 (cm, centimeters) x (by) 3.9 (cm) x 0.2 cm. Wound bed is 90% pink, moist, without drng (drainage), and approx. (approximately) 10% slough . Wound decline is noted. Left ischium now presents as an unstageable pressure injury measuring 5.0 (cm) x 4.3 (cm) with unknown depth d/t (due to) 100% coverage of eschar . Dr. (Doctor NN) updated by primary nurse to inquire about foley cath (catheter) to promote wound healing and to inquire about a new order for wound care d/t eschar and worsening of wounds ., created by Nurse B. 2/20/18, 7:08 AM, Sacral pressure injury wound measures 2.9 (cm) x 2.3 (cm) x 0.2 cm. Wound bed is pink, moist without drng, 100% granulation noted . Previously identified area to left ischium now presents as a stage II pressure injury measuring 2.8 (cm) x 2.3 (cm) x 0.1 cm. Wound bed is red/dusky in color, moist ., created by Nurse B. 1/13/18, 11:16 AM, Dr. (Doctor NN) in to see res. (Resident). She states that skin condition to sacral region is a stage II pressure injury. She trimmed area non-viable tissue at the crease that is scar tissue. Wound measures 3.2 (cm) x 2.8 (cm) x 0.1 cm ., created by Nurse B. Physician notes that stated: 2/17/18, by Doctor NN, Patient is seen today for recheck primarily of her pressure ulcers . Now recall that family is very involved in her care and they prefer to see patient sitting up they feel that her lying down is not good for her but unfortunately the pressure ulcers are all from the way she is sitting and for too long . Plan: . I have advised nursing that patient cannot be up in her chair for more than 2 hr. (hours) at a stretch and told them to please advise family that is a physician order [REDACTED]. I understand that they want her up more often but she just cannot until the pressure ulcers mend. Physician order [REDACTED]. NN)! On 2/28/17 at 9:50 AM, an observation was made of Resident #53 in their wheelchair with a hoyer sling under the Resident. The Resident was near the nurses station. On 2/28/17 at 12:20 PM, an observation was made of Resident #53 in a common area near the nurses station. The Resident was in their wheelchair with a Hoyer sling under the Resident. CNA (Certified Nursing Assistant) F, who was assigned care of the Resident, was queried regarding Resident #53 being up in their wheelchair. The CNA stated, I get her up for breakfast then she will lay down after lunch. The CNA was queried about the time period of when the Resident is to be up in their wheelchair and stated, She is on a doctor's order two hours up and two hours down. When queried what time the CNA had assisted Resident #53 into the wheelchair, the CNA stated, I got her up for breakfast, around 9:15 today. When queried if the Resident had been up since the time the CNA had assisted the Resident before breakfast, the CNA stated, Yes. When revealed to the CNA that the Resident had been up in the wheelchair for three hours, the CNA stated, I don't know if she has eaten yet. I will find out and put her back to bed. A review of the Resident Care Guide (a guide for the care of the Resident for direct care staff to refer to when providing care) that was in the Resident's room and reviewed with the CNA, stated, Special needs: not to be up in chair for more than 2 hr/day. When CNA F was queried regarding the two hours per day, the CNA was unsure. On 2/28/17 at 2:00 PM, a review of Resident #53's care plan for the problem listed as Pressure Ulcer stated, Resident is at risk for alteration in skin integrity r/t thin, fragile skin, incontinence, advanced cognitive impairment, [MEDICAL CONDITION], anxiety, DM (diabetes), needs assist with ADLs (Activities of Daily Living), hx (history) of [MEDICAL CONDITION], hx shingles. Braden Score: 12 (Score of 12 or less represents high risk for development of pressure ulcers). Sacral (stage III) and left ischium pressure injury (unstageable). Redness to rt (right) ischium. Edited: 2/27/2018, Edited By: (Nurse B). An Approach (a care plan intervention) stated, Not to be up in chair for more than 2 hours per physician. Created: 2/20/2018, Created By: (Nurse B). On 3/1/17 at 10:20 AM, an interview was conducted with the Wound Care Nurse B regarding Resident #53's pressure ulcers to the sacral region and the left ischium. Wound documentation was reviewed with Nurse B. The Nurse reviewed the interventions in place prior to and after development of the wounds. Nurse B stated one of the interventions was Not to be up for more then two hours. When the Nurse was queried about the 3 hour time span that Resident #53 was up in the wheelchair on 2/28/18, Nurse B state, Typically she is in bed between meals. I'm not sure why she wasn't, its right there on her care plan. I will definitely follow up on what happened but that doesn't fix what happened yesterday. A review of the facility care plan entitled, Prevention of Pressure Ulcers, stated, . The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate . Risk Factor-Chair-fast. Avoid use of wheelchairs with sling seats for prolonged periods . Risk Factor-Lowered Mental Awareness. Choose preventive actions appropriate to individual risk factors and adjust for cognitive impairment of the resident. For example, if the person is chair-fast, refer to the specific interventions for that risk factor, adjusting for any limitations in resident's understanding of instructions or ability to participate in preventive actions.

This citation pertains to intake MI 252 and MI 265. Based on observation, interview and record review the facility failed to prevent sexual abuse in 1 of 3 residents (Resident #1) reviewed for abuse in a total sample of 3 residents resulting in Resident #1 being sujected to sexual abuse, and placed in immediate jeopardy to psychosocial and mental health safety based on the reasonable person standard. The facility was placed in Immediate Jeopardy (IJ) as a result of the facility's failure to protect one resident (Resident #1) from sexual abuse by a visitor (Visitor C) who was observed being intimate with Resident #1 on 11/14/15 at approximately 5:30 PM and admitted on [DATE] at approximately 12:00 PM that he had received oral sex from Resident #1 the evening before. The facility failed to immediately protect, investigate and report to the police and state agency an allegation/suspected abuse. Resident #1 was not protected following this observation and the sexual abuse on this occurrence was not reported to the law enforcement and state agency until 14 hours after the event. On 11/18/15 at 5:25 PM the Nursing Home Administor (NHA) A was notified of Immediate Jeopardy that began on 11/14/15 at approximately 5:30 PM, due to the facility's failure to protect Resident #1 from sexual abuse, immediately protect, investigate, report to the law enforcement and state agency. On 11/19/15 at 1:50 PM, the Immediate Jeopardy was removed when the surveyor verified the following: (Element #1): Corrective action 1. 11-15-15 @ 6:55am ADON notified of allegation of abuse by charge nurse. 2. 11-15-15 @7:05am ADON notified facility Administrator and DON. 3. 11-15-15 @ 7:15am facility Social workers notified to report to the facility due to allegation. 4. 11-15-15 @ 7:50am charge nurse completed a head-to-toe assessment with female CNA present. No harm, injury, or distress was noted to the resident. 5. 11-15-15 approximately 8:10am ADON arrived at the facility, momentarily, DON, and Social Workers arrived at the facility. Investigation initiated, interviewed the charge nurse and housekeeper (witnesses) via speaker phone. 6. 11-15-15 Administrator arrived. 7. 11-15-15 @ 9:30am immediately after staff interviews SW conducted an interview and well-being assessment with Resident #1. 8. 11-15-15 9:15am DON reviewed facilities Abuse policy and Elder Justice Act policy, no changes needed. 9. 11-15-15 @ 10am initiated an all staff in-service r/t the facilities Abuse Policy/reporting process and Elder Justice Act policy. 40% of staff were in-serviced prior to the submitting the 24hr State report. All remaining staff in-servicing was completed by 11-17-15 by 5pm, with the exception of 11 employees off work for FMLA, vacation, or not working. And will not return to work until in-servicing is completed. 10. 11-15-15 approximately 11am SW notified Adult Protective Services and reported the resident's allegations and account of the event. 11. 11-15-15 @ 11:20am ADON called 911 and reported the allegation. 12. 11-15-15 @ 11:55-12:00pm Administrator, DON ,ADON present during Social workers interview with Visitor C and Visitor C's family member. Both were informed that 911, APS, and State of MI was notified and he was not allowed into the facility. If so the staff would notify 911. 13. 11-15-15 County Sheriff Department arrived. ADON & SW informed officer of the allegations and interview findings with Resident #1 and Visitor C. 14. 11-15-15 @ 12:50pm the DON notified Resident #1's primary physician. 15. 11-15-15 the officer initiated her interviews. 15. 11-15-15 SW left message for Resident #1's DPOA at 9:15am, 11:45am & 2:00pm spoke with DPOA and he agreed to come to the facility at 3:00pm. DPOA arrived at 3:00pm and was informed of allegations. 16. 11-15-15 SW placed a memo out to alert staff that Visitor C is not to enter the facility along with the process to follow and call 911. 17. 11-15-15 State of MI notification was submitted. 18. 11-16-15 Nurse practitioner was in to assess and see Resident #1. No distressed was noted per progress note. 19. 11-16-15 @ 10am SW visited and assessed Resident #1's psychosocial well-being. No distress noted resident was smiling frequently, made good eye contact, was friendly and denied feeling sad, depressed or anxious. 20. 11-16-15 SW consulted with County Behavioral Health OBRA supervisor r/t trauma counseling. They recommended to monitor Resident #1 d/t her cognitive deficit, and no recall of the incident, felt that counseling may exacerbate the situation by re-introducing the trauma and informed SW there will be a cost. 21. 11-16-15 residents DPOA contacted. 22. 11-16-15 SW notified psychiatrist. 23. 11-16-15 DON notified the facility medical director 24. 11-16-15 @ 12:17pm initiated 15 minute checks on Resident #1. 25. 11-17-15 1:1 distant oversight was initiated to monitor the residents behaviors, mood and interactions with others for 48 hrs during 1st and 2nd shift and is currently ongoing. 26. 11-17-15 SW informed DPOA of # 20 and he felt counseling was not needed. Informed we would monitor and inform of any changes or need for counseling. 27. 11-18-15 @ 10:30am psychiatrist was in to assess Resident #1. 28. 11-18-15 @ 11:05am initiated every shift charting to monitor and document Resident #1's mood and behaviors and to note any changes in baseline. Element #2 the facility identified 3 residents that Visitor C visited while at the facility. SW interview all 3 residents. · 11-15-15 @ 2:30pm resident in M16B- voiced no concerns r/t his visits · 11-15-15 @ 2:28pm resident in M10B - voiced no concerns r/t his visits · 11-11-15 @ 2:35pm resident in 10A- voiced no concerns r/t his visits. Element # 3 Measures put in place to prevent re-occurrence 1. Visitor C was banned from coming into the facility, 11-15-15 a memo was placed out to alert the staff. 2. Continue to in-service all new staff upon hire, quarterly and as needed until resolved r/t to the facilities Abuse policy/reporting process and Elder justice Act. 3. Department Head and supervisors to complete random weekly interviews on all shifts for 3 months r/t facilities Abuse policy/reporting process and elder justice act. Element # 4 Monitoring 1. Initiate monthly QA for 3 months or until resolved r/t the facilities Abuse policy/reporting process and Elder justice Act. Element #5 Corrective Action date is 11-18-15 Although the Immediate Jeopardy was removed on 11/19/15 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 for abuse and reporting and sustained compliance had not been verfied by the state agency. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected that Resident #1 was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS, dated [DATE], for Brief Interview for Mental Status (BIMS), reflected a score of 15 out of 15 which indicated that Resident #1 was cognitively intact. During an interview and observation on 11/18/15 at approximately 11:15 AM, Resident #1 was seated in a wheelchair in her room. Resident #1 did not recall the incident on 11/14/15 nor was she able to answer specific questions regarding Visitor C . During an interview on 11/18/15 at 12:15 PM, the NHA A stated that Resident #1 was recently declared incompetent and provided the Physician Certification of Resident's Capability for record review. The Capability form reflected two different physician signatures dated 10/26/15 and 11/3/15 and checked the area to indicate Incapable of understanding his/her rights and responsibilities. The form also reflected the BIMS score of 15 and poor judgement and insight. Review of Durable Power of Attorney (DPOA) for Health Care Designation record reflected that Resident #1's family member H was appointed Resident #1's DPOA. During an interview on 11/18/15 at approximately 11:00 AM, Housekeeper (HK) D stated that on 11/14/15 between 5:00 and 6:00 PM, she passed Resident #1's room in the hall, she heard voices, and thought Resident #1 was talking with a Certified Nurse Aid (CNA). HK D stated I knocked and stepped in. HK D stated, I heard kissing noises, like wet kissing, lip smacking, I heard Visitor C voice and saw his feet up on Resident #1's bed. The privacy curtain was pulled down near the foot of the bed and I could tell Visitor C was laying on his right side and Resident #1 was sitting in her wheel chair right up near him .The window blind behind Resident #1 was open, it was dark and the room light was on so I could see their reflection in the window. I was shocked when I saw it. I never thought I'd walk in on something like that. I've never come across any resident or visitor doing that .I knew Visitor C had visited her just about daily in her room . HK D stated that she left the room and went to get Licensed Practical Nurse (LPN) E and told her what she had seen and heard in Resident #1's room. HK D stated, We both returned to the room and watched them in the reflection of the window. We didn't hear anything besides their voices but did see Visitor C sit up on the bed and he moved up Resident #1 with his hands, gave Resident #1 a hug and then stood and buttoned or adjust his pants. HK D stated, LPN E seemed nervous and shocked .she made the comment that they (Resident #1 and Visitor C) seemed closer lately. HK D stated, Visitor C wheeled Resident #2 (another female resident) in her wheelchair to therapy earlier that day and I thought that was odd because Resident #2 is newer here and he is not a family member or a friend of hers. During an interview on 11/18/15 at 1:45 PM, LPN E stated (when she and HK D entered the room), I saw Visitor C tuck his shirt in or adjust his pants and Resident #1 put some gum or candy into her mouth. Visitor C then left the room to go to his wife's room and I went to the dining room to assist with feeding. When asked if she notified anyone regarding the incident, LPN E stated, No, and I have received a discipline for it. I should have called my supervisor right away. Review of the nurses notes dated 11/14/15 at 5:44 PM authored by LPN E reflected, A housekeeper upon knocking and entering res (Resident #1) room heard what sounded like res kissing another res husband. Writer was called to res room to address the situation. Writer was told by housekeeper she observed through reflection of window another res husband laying on res bed and getting possibly intimate with res. Writer upon entering room possibly saw through reflection of window the other res husband (Visitor C) adjusting his pants up and buttoning them while standing . During an interview on 11/18/15 at approximately 10:00 AM the Assistant Director of Nursing (ADON) F stated that she received a call from LPN G at approximately 7:00 AM on 11/15/15 (approximately 14 hours after the incident) and was made aware of the nursing note that LPN E had made about the suspected/allegation of sexual abuse. ADON F stated that the administration met with Visitor C at approximately 12:00 PM on 11/15/15 and Visitor C admitted that he had received oral sex from Resident #1 the evening before (11/14/15). Visitor C additionally admitted to hugging, kissing and touching Resident #1's breast. ADON F stated the police were notified of the incident. (# )

This citation pertains to MI 831. Based on interview and record review, the facility failed to provide the necessary supervision for a resident with a known risk of falls to prevent a fall and failed to document, identify, and implement interventions for behavioral factors that could potentially contribute to a fall for one resident (#100) out of four residents reviewed for falls resulting in a head injury and hospitalization . Findings include: According to the Resident Admission Record, dated 8/31/2015, Resident #100 was a [AGE] year old female admitted to the facility on [DATE] and discharged to a hospital on [DATE] at 10:19 am. The [DIAGNOSES REDACTED].#100's Resident Admission Record, dated 8/31/2015 included heart disease, chronic pain, lung disease, diabetes, and high blood pressure. According to the Resident Care Plan #11, dated 7/11/2015 with an update on 7/22/2015, Resident #100 was at high risk for falls because of debility, decreased range of motion, and decreased balance. One of the approaches to prevent falls listed on Resident Care Plan #11 was the use of a tab alert, added to the care plan 8/24/2015. A tab alert is a small alarm box that is activated when the string clipped to clothing pulls the tab from the alarm box and sounds the alarm. This alerts staff that the resident has changed position. Resident Care Plan #5B, dated 6/24/2015 with an update on 7/3/2015, indicated that Resident #100 was transferred with a mechanical lift. An interview with the Restorative Nurses on 10/28/2015 at 2:30 pm, Licensed Practical Nurse (LPN) Staff D, and LPN Staff E. LPN Staff D stated that the job responsibilities of Restorative Nurse included reviewing all resident falls with an interdisciplinary team that included a therapist and developing interventions and approaches to add to resident care plans to prevent future falls. LPN D stated that any resident who had an intervention for fall prevention of an alarm should not be left unattended in a bathroom. LPN D stated that at the very least, a staff member should remain just outside the bathroom door to allow privacy for the resident while being able to provide supervision. According to an Unusual Occurrence Form, dated 8/29/2015, Resident #100 had been heard yelling from behind the closed door of her room. The Unusual Occurrence Form revealed that Resident #100 had been found on the floor of her bathroom, that no alarm was sounding, and Resident #100 had a golf-ball sized hematoma to the back of the left side of her head. During an interview with Registered Nurse (RN) staff F on 10/29/2015 at 12:30 pm, he stated that he had been the first staff member to respond to the yelling of Resident #100 on 8/29/2015. RN F stated that Resident #100 had been alone in her room when she was found on the floor and that he had been unaware that she was in the bathroom unattended. RN F said that Resident #100's alarm had not been attached to her. RN F stated that the Certified Nursing Assistant (CNA) who he discovered had assisted Resident #100 to the bathroom, had reported off to another CNA and had gone off duty and left the building. RN F stated that Resident #100 should not have been left alone in the bathroom and that if she had asked for privacy in the bathroom, the CNA should have left the bathroom door cracked open and should have stayed in the room. During an interview with the RN Assistant Director of Nursing, Staff C on 10/28/2015 at 4:15 pm, she stated that she had prepared a follow up report regarding the incident with Resident #100. According to the documentation of RN Staff C's report, dated 9/9/2015, Resident #100 had refused to wear the tab alarm on the day of the incident and had a history of [REDACTED].#100 had a history of [REDACTED]. During the interview with the LPN Restorative Nurse, Staff E on 10/29/2015 at 2:30 pm, she stated that she had been told that Resident #100 had refused to wear the tab alarm and that Resident #100 had thrown the alarm at staff members. LPN Staff E stated that she had asked staff where they had documented Resident #100's refusal to wear the alarm and had never found the documentation. LPN Staff E said that no care plan interventions had been put in place related to Resident #100's refusal of the alarm. According to the Resident Progress Notes, dated 8/30/2015 at 9:52 am, Resident #100 was very hard to arouse on that morning, the morning after the incident, and complained of uncontrollable aching an pain in back of R lower skull. The documentation included that two masses were felt in that area and that Resident #100 also had pain in her left shoulder and knee. According to the progress note, the physician was contacted and Resident #100 was transferred to the hospital emergency room for testing for internal bleeding and fractures. During an interview with RN Staff C on 10/28/2015 at 4:15 pm, she stated that Resident #100 had not been readmitted to the facility following her transfer to the hospital on [DATE]. ( )

This citation pertains to MI# 120 Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practical well-being for 1 (#101) of 4 sampled residents, from a total sample of 9 residents, resulting in an immediate jeopardy for Resident #101 when facility staff failed to follow facility policy for an unconscious choking adult, after Resident #101 was observed to be unconscious in the dining room with no respirations or pulse. Facility staff failed to follow facility policy for an unconscious choking adult by attempting back blows, while the resident was sitting up in her wheelchair in the dining room. Facility staff delayed treatment by pushing Resident #101 in her wheelchair from the dining room to the resident's room, lifting the resident into bed and, only then, beginning cardiopulmonary resuscitation. Resident #101 was transferred to the hospital and subsequently died . Findings include: Observation on [DATE] at 9:15 AM of the facility main dining room located between the East and West nursing units revealed that there was no suction equipment for immediate use in case of a choking resident. The dining room was located an estimated 106 feet from Resident #101's room located on the North West unit. Record review of Resident #101's minimum data set (MDS) revealed an [AGE] year-old female with brief interview of mental status (BIMs) score of 13 cognitively intact. Resident #101 had an order for [REDACTED]. Record review of Resident #101's complete medical chart, including the thinned/back filed records, revealed a nutrition risk assessment dated [DATE] that noted the resident eats food too fast and chokes. Resident #101 had a swallow evaluation done on [DATE] by a speech therapist with the reason for referral as nursing staff referred secondary to choking on foods. Speech therapy was ordered with short term goals of resident will use safe swallow strategies with assist. Long term goal was to tolerate most appropriate diet without signs or symptoms of aspiration or choking. Speech therapy discharge note dated [DATE] revealed care givers were educated on safe swallow strategies (e.g. alternate bites and sips). Discharge recommendation was to continue using strategies for safe swallow. Record review of Resident #101's 'Dysphagia Instructions' form dated [DATE] revealed swallow strategies of alternate solids and liquids, take 1 teaspoon bites/sips, eat and drink slowly. In an interview on [DATE] at 1:20 PM, the current Speech Therapist (ST) #7 stated that she hired into the facility in 2012 and reviewed the speech evaluation documentation done on [DATE] by the previous ST. ST #7 reviewed the speech therapy progress notes dated [DATE] through [DATE] which revealed safe swallow strategies of alternate solids and liquids and indicated that care givers were educated, but did not indicate who was educated. ST #7 reviewed the last speech therapy discharge note dated [DATE] which listed a goal of 'use safe strategies'. Record review of Resident #101's physician orders [REDACTED]. Record review of Resident #101's nutritional progress note dated [DATE] quarterly review noted that the resident had a chewing impairment, but no swallowing problems. Record review of Resident #101's Nutrition care plan dated [DATE] did not identify chewing impairment or safe swallow strategies of alternating solids or liquids. Record review of Resident #101's facility unusual occurrence form and investigation form, dated [DATE] at 8:30 AM, revealed that the Licensed Practical Nurse (LPN) #11 was called to room W106 where resident was sitting on edge of wheelchair knees bent and almost touching floor in bathroom, in front of the toilet. Wheelchair locked, tenner shoes on, gait (belt) around waist, and Certified Nursing Assistant (CNA) unable to lift resident by herself. Assistance provided lifting resident into proper position in wheelchair by (mechanical) lift. LPN #11 documented the resident self-propelled to dining room and oxygen at 2 liter nasal cannula at 93% saturation. The back side of the investigation form revealed that the LPN #11 noted that Resident #101 had weakness and was unable to bear weight. Resident 101's transfer status was noted to be SBA (stand by assist). Record review of facility unusual occurrence form, dated [DATE], at 8:55 AM revealed that Resident #101 had an emesis in the main dining room and then went unresponsive, was returned to her room, suctioned a large amount of scrambled eggs and afinger sweep was performed. No pulse, no breathing, CPR (cardiopulmonary resuscitation) started. Record review of facility 'Conscious and unconscious choking' policy (revised [DATE]) revealed if the unconscious victim is not moving or breathing, give 2 rescue breaths. If the rescue breaths do not make the chest clearly rise reposition the airway by tilting the head farther back and try 2 rescue breaths again. If rescue breaths still do not make the chest raise give 5 chest thrusts. Place the heel of the hand on the center of the chest. Place the other hand on top of the first hand and compress 1 ? inches to 2 inches. Each chest thrust should be a distinct attempt to dislodge the object. Record review of facility investigation dated [DATE] revealed that Resident #101 was sitting at a table in the main dining room eating breakfast, had a small emesis, and went unresponsive at the table. Resident #101 was returned to her room, placed in bed on a back board and had a large amount of scrambled eggs suctioned from her mouth. A finger sweep removed more food. No pulse was noted, CPR was started and the AED applied. The investigation report noted that facility staff was unable to obtain vital signs during the situation. In an interview on [DATE] at 12:19 PM, with the dietary person #8, revealed that he was not a CNA but a food service person and that CNA #9 was in the room. Dietary person #8 stated he was the only dietary person in the dining room and that he was bussing tables when he heard Resident #101 coughing while eating. Dietary person #8 stated that Resident #101 was coughing for a minute or so, then he saw Resident #101 put her hand to her mouth and chest then stopped coughing. Dietary person #8 stated that he looked back over at Resident #101 and she was slumped over in her wheelchair. In an interview on [DATE] at 11:45 AM, CNA #8 revealed that it was at the end of the breakfast meal when Resident #101 was sitting at a table by herself. CNA #8 stated that she was pushing residents out the door into the hall and that Resident #101 was coughing and sounding like her usual phlegmy cough when she eats. CNA #8 stated that Resident #101 would eat fast and as soon as she would set the plate in front the resident, Resident #101 would say 'Thank you' three or more times, then Resident #101 would start to eat and eats rapidly, so fast that she would have a mouth full and take another bite, sometimes CNA #8 stated that she had to tell Resident #101 to slow down. CNA #8 stated that she yelled down the hallway to tell Licensed Practical Nurse (LPN) #11 that Resident #101 sounded funny and LPN #11 started toward the dining room. CNA #8 stated that she was watching Resident #101 as the nurse was coming, but before the nurse came, Resident #101 threw up in her clothing protector then looked at CNA #8 and Resident #101's head went limp and forward into her chest and her whole body went limp. CNA #8 stated that LPN #11 came to the dining room, looked at Resident #101 and told CNA #8 to go get more help. CNA #8 stated that she yelled down the hallway. Registered Nurse (RN) #5 came into the dining room and attempted back thrusts/blows and nothing came out. CNA #8 stated that they (LPN #11, RN#5 and LPN#3) decided to take Resident #101 to her room (down the hall) and that she followed the resident to her room. CNA #8 stated that she did not recall seeing Resident #101 have oxygen on during the meal or seeing oxygen on the resident until she was in her room [ROOM NUMBER]. In an interview on [DATE] at 9:30 AM, Licensed Practical Nurse (LPN) #11 revealed that before breakfast Resident #101 was in her bathroom sitting at edge of wheelchair and couldn't get herself transferred (care planned for self-transfers) to the toilet. LPN #11 stated that it took three staff to transfer and reposition her in the wheelchair because Resident #101 was like dead weight. LPN #11 stated that staff had to use a mechanical lift to lift the resident up to do peri care and slide the resident back into her wheelchair. LPN #11 stated that Resident #101 was able to self-propel to the main dining room and that she was later getting to the dining room than normal. LPN #11 stated that she was in the hallway talking with CNA #8 and looking into the dining room through a window in the hallway when Resident #101 went limp, face forward with chin to chest, as she was going into talk with the resident. LPN #11 stated that Resident #101 didn't talk or grunt, was limp with chin to chest, head down, and with no pulse. LPN #11 stated that she checked the radial pulse and that there was no pulse and the resident's eyes were closed. LPN #11 stated that RN #5 was coming down the hall, he came into the dining room did a couple of back pats, and a little egg dribbled out. LPN #11 stated that she and RN #5 proceeded to talk to Resident #101 and then decided to take Resident #101 back to her room. LPN #11 stated that Resident #101 was limp and unresponsive in the dining room. LPN #11 stated that they had CNA #19 grab Resident #101's pant legs while sitting up in the wheelchair and that they pushed Resident #101 back to her room. LPN #11 stated that it was immediate that Resident #101 went unresponsive and blue not gray. LPN #11 stated that Resident #101 was a fast eater with large bites, didn't swallow well and had no teeth at all. LPN #11 stated that Resident #101 did not have any teeth in at the time of the incident because she didn't have any dentures, partials or any teeth at all. LPN #11 stated that she did not see Resident #101 have an emesis (vomit) or hear her coughing. LPN #11 stated that RN #5 patted Resident #101's back in the dining room while she was up in the wheelchair leaning forward, with her chin to her chest, but nothing came out. Record review of LPN #11's nursing notes dated [DATE] at 8:30 AM for Resident #101 revealed that the nurse was called into the bathroom to assist transfer of resident. Resident #101 was awake and alert sitting at edge of wheelchair seat with knees bent towards floor and the Resident #101 was unable to bear weight. Assist of three CNA's and two nurses to reposition resident into wheelchair. Resident was incontinent of urine, placed in (mechanical) lift and placed into wheelchair and that the resident self-propelled to the morning meal. Record review of Resident #101's nurse note dated [DATE] at 8:55 AM, written by LPN #11, revealed the nurse was called to the dining room where it was noted that resident vomited eggs. It was observed resident going unresponsive, head bent toward chest and not breathing. Back thrust given and removed from dining room to room, placed on back board, suctioned large amount of scrambled eggs. CPR started, not breathing on own, given respiratory assistance via ambu-bag, code blue called. EMS arrived at 9:15 AM. In an interview on [DATE] at 10:08 AM, RN #5 revealed that he was walking down the hall when someone called him into the dining room where staff didn't know what to do. RN #5 stated that Resident #101 was sitting at a table in her wheelchair with food in her mouth and down her shirt leaning forward, not breathing, completely blue with twitching of her hands at her sides, and she was limp. RN #5 stated that he checked a radial pulse and that there was no pulse. RN #5 stated that he instantly thought she was choking. RN #5 stated that he was the first nurse in the dining room followed by LPN #11. RN #5 stated that he started back blows and that a little bit came out, not really anything and that she was still blue. RN #5 stated that he could not get Resident #101 to breathe and that she was unresponsive. RN #5 stated that Resident #101 was blue in color when he walked into the dining room and went unresponsive. RN #5 stated that they needed to get Resident #101 lay down somehow, but that she was a larger/heavy sized lady. RN #5 stated that they wheeled Resident #101 down the hall to her room, had to lift the resident over into the bed and place the back board to start chest compressions and cardiopulmonary resuscitation (CPR). RN #5 stated that they did see some eggs in her mouth and then did a mouth sweep. RN #5 stated that staff suctioned the resident and that the suction tubing plugged up with chucks of eggs. RN #5 stated that he had worked the west hall units prior and that Resident #101 was known to eat fast with large rapid bites causing coughing. RN #5 stated that Resident #101 was known to staff to eat fast large bites. RN #5 stated that there was no oxygen used in the dining room and that the resident had no teeth. In an interview on [DATE] at 10:25 AM, with LPN #3 who was the facility in-service director and weekend charge nurse, revealed that she was sitting in her office during the breakfast time when she heard CNA #8 holler down the hall needing a nurse. LPN #3 stated that Resident #101 was unresponsive in the dining room when she came into the dining room and RN #5 was giving back blows to Resident #101. LPN #3 stated that the resident was ashen or gray in color with head tilted down with RN #5 patting her back. LPN #3 stated that Resident #101 was sitting in a wheelchair and that she did not see anything come out. LPN #3 stated that she hollered for the East hall nurse to call a code blue. LPN #3 stated that it was her decision to move Resident #101 to her room, rather than use the floor because they were in the main dining room with windows. LPN #3 stated that they took the resident down the hall 100 yards to her room and transferred her to her bed which had a back board in place. LPN #3 stated that she did not remember oxygen being used in the dining room. LPN #3 stated that she didn't remember seeing one used and that Resident #101 has oxygen on the back of her wheelchair. LPN #3 stated that she had seen Resident #101 every day and that the resident wears oxygen when she needs it, but didn't see it on her. LPN #3 stated that once the resident was in her room, put in bed and compressions started, and the AED (Automatic External Defibrillator) was applied, she got the suction equipment ready and removed chunks of eggs from Resident #101's mouth that would plug up the suction tubing. LPN #3 stated that EMS (Emergency Medical Services) came and put in an airway and gave [MEDICATION NAME], and got a blood pressure before they transported her to hospital. In an interview on [DATE] at 11:25 AM, CNA #19 revealed that she worked on [DATE] as the activity aide in the dining room during the breakfast meal. CNA #19 stated that Resident #101 was in the dining room sitting at table facing the door and eating. CNA #19 stated that she was taking residents back to their rooms. CNA #19 stated that she was coming back toward the dining room when CNA #8 stated, "Get the nurse, (LPN #11) "because (Resident #101) wasn't acting right. CNA #19 stated that she was standing at the glass window, saw Resident #101 was sitting up in wheelchair, eyes open and eggs dropped out of her mouth, so CNA #19 hollered for LPN #11, she said just a minute, LPN #11 was pushing a lift down the hall and pushed it into a room and then started toward the dining room and went in. CNA #19 stated that she was stopped by another resident when she heard LPN #11 saying "(Resident #101), (Resident #101), wake up" that's when CNA #19 went into the dining room. CNA #19 stated that someone went out to get another nurse and RN #5 came. CNA #19 stated that she picked up Resident #101's legs and walked backwards down the hall while nurses pushed the wheelchair to Resident #101's room down the hall. CNA #19 stated that Resident #101 did not have oxygen on in the dining room. Record review of EMS (Emergency Medical Services) run sheet for Resident #101 dated [DATE] revealed: Staff stated the patient was eating when she began to choke and ultimately became unresponsive; patient was wheeled back to her room in wheelchair per staff when she went into [MEDICAL CONDITION]. Patient was moved from wheelchair to bed, a backboard was placed under her and CPR was initiated by personnel on scene at skilled nursing facility. The run sheet noted that an airway was placed and the resident was transported to the hospital. Record review of Resident #101's hospital chief complaint report dated [DATE] revealed the patient had a known history of [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]. Record review of Resident #101's hospital critical care consult dated [DATE] noted the resident resided in a nursing home where she was having breakfast and was witnessed choking on her breakfast and subsequently went into [MEDICAL CONDITION]. The resident was intubated in the emergency room where there was witnessed food material including material from eggs. Noted impression and recommendation included: 1. [MEDICAL CONDITION] with high peak airway pressure secondary to abdominal distention likely with transmission of abdominal pressure to [MEDICATION NAME] pressure. 2. [MEDICAL CONDITION] secondary to choking on food with upper airway obstruction. Record review of Resident #101's 'Certificate of Death' dated [DATE] revealed cause of death to be acute [MEDICAL CONDITION]. In an interview of [DATE] at 10:30 AM, with the facility attending physician #16, who stated that he was also the county medical examiner, revealed that Resident #101 choked on eggs and had a prolonged down time (unresponsive) due to airway blockage. Observation on [DATE] at 1:50 PM of the alcove hallway located between the East and West units, revealed that the facility had a portable crash cart and suction equipment that could have been taken into the dining room when Resident #101 became unresponsive. Record review of facility cardiopulmonary resuscitation (CPR) learning material from the American Red Cross 2011 handbook covered choking (conscious and unconscious). Review of the handbook pages ,[DATE] instructed for a conscious choking adult to give 5 back blows and 5 abdominal thrusts. If the victim becomes unconscious lower the victim to the ground (floor) and provide care for the unconscious choking victim which noted to ensure that the victim is on a firm, flat surface, such as the floor........ Record review of Facility 'Choking-conscious and unconscious' reviewed date of [DATE] revealed that back blows are given for conscious choking adults. For the unconscious choking adult rescue breaths and tilting the head backwards followed by 2 more rescue breaths and then chest thrust should be a distinct attempt to dislodge the object. The Nursing Home Administrator (NHA) was notified on [DATE] at 12:40 PM of the Immediate Jeopardy that began on [DATE] at 8:55 AM, due to the facility's failure to provide quality care of Resident #101, who was noted to be unresponsive with no pulse and no respirations while in the dining room, was wheeled down the hall and placed in bed before suction or compressions began. This deficient practice places all additional residents, identified as having chewing difficulties, at risk for serious harm and injury. On [DATE] at 3: 30 PM, the state surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. On [DATE], the facility reviewed and updated 'Conscious and Unconscious Choking' policy. 2. On [DATE] at 1:15 PM the facility started in-servicing nurses on the revised 'Conscious and Unconscious Choking' policy. 46 out of 59 nurses were in-served as of [DATE] at 1:50 PM. The remaining nurses will not be allowed to work until policy is reviewed. 3. On [DATE] facility started to review resident care plans for appropriate interventions in place for 36 residents identified with swallowing difficulties. 4. On [DATE] the facility identified 36 out of 125 residents with swallowing difficulties. 5. To prevent re-occurrence the facility will continue to in-service new and old employees on 'Conscious and Unconscious Choking' policy and plan to be completed on [DATE]. 6. Monitoring: On [DATE] the facility initiated a monthly QA on 'Conscious and Unconscious Choking' policy and conduct Code Blue drills and continue until resolved. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at isolated scope and a severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to not all staff have been in-serviced and sustained compliance has not been verified by the state agency. #

This citation pertains to MI# 120 Based on observation, interview and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (#102) of 4 sampled residents from a total sample of 9 residents, resulting in Resident #102 sustaining a fall in the bathroom causing injury. Findings include: Observation on [DATE] at 9:00 AM of the Manor North unit revealed that room #1 and #3 were joined by a bathroom between the rooms with a door on each side. The bathroom had handicap grab bars on both sides of the toilet and long the back. Record review of Resident #102's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old female with brief interview of mental status (BIMs) score of 14 cognitively intact. Record review of Resident #102's admitting physician orders [REDACTED]. There was no order for safety alarms noted. Record review of Resident #102's Hospital 'Inter Agency Referral Form' fax dated [DATE] revealed that Resident #102 needed assist of 1 with toilet transfers and ambulation. Record review of Resident #102's 'Fall Risk Assessment' dated [DATE] revealed a score of 8. Record review of Resident #102's 'Safety devises and Transfer' form on [DATE], still located in room #1 behind the room door by Licensed Practical Nurse (LPN) #12, who is also a restorative nurse, revealed assist of one in bathroom. Record review of Resident #102's 'High risk for falls' care plan updated [DATE] revealed the resident needed assist with ADL's (Activity of Daily Living) as evidence by decreased balance and unsteady gait. Approaches included ensure resident wears proper foot wear and monitor frequently. Record review of Resident #102's 'ADL (Activity of Daily Living) care plan updated [DATE] revealed the resident was care planned related to weakness as evidence by decreased balance, unsteady gait and shortness of breath with exertion. Record review of 'Ineffective Breathing Pattern' care plan dated [DATE] revealed Resident #102 was care planned due to inability to maintain adequate rate and depth of respirations as evidence by dyspnea, SOB (shortness of breath), oxygen saturation below 90%, medical [DIAGNOSES REDACTED]. Plan approach noted to administer oxygen as ordered. Record review of Resident #102's 'Unusual Occurrence Form' dated [DATE] at 9:55 AM revealed that a Certified Nurse Assistant (CNA) called for assistance stating that the resident fell . The resident was in the doorway of the bathroom on the floor as nurse entered. The resident was initially responsive. Assessing the resident she stated "I think I hurt my hip". Nurse started to assess residents right hip approximately one minute later after fall and at that time the resident's facial expression went flat and body limp. Hematoma noted superior to the right temple with a diameter of approximately 4 cm and protruding approximately 2 cm. Code blue called as soon as resident was unresponsive. Pupils were constricted and unresponsive as well. A non-rebreathe mask at 8 liters placed right away. Resident's pulse was weak and breathing sporadic. Ambulance was in house at 10:05 AM. Resident's family was notified and gave permission to transport to hospital. In an interview on [DATE] at 10:50 AM, with CNA #6 revealed she was in the adjoining room (RM #3) when she heard an alarm going off. CNA #6 stated that Resident #102 had a chair alarm to her wheelchair and that she heard it sound and the bathroom door was closed. CNA #6 stated that she was helping another resident (#104) change her colostomy bag when she heard the alarm sound so she put down the colostomy and went to the bathroom and checked Resident #102 who was sitting on the toilet. CNA #6 stated that she moved Resident #102's wheelchair out into her bedroom so that she wouldn't get up without her and closed the bathroom door and went back to the other resident (#104) to assist with the colostomy. CNA #6 stated that she heard some rumbling around in the bathroom, went to open the door and Resident #102 was leaning forward and fell on the floor. CNA #6 told the state surveyor that she did not see the fall that it happened fast and that the resident fell on her hip and side. CNA #6 stated that she did not see what Resident #102's head hit or struck. CNA #6 stated that she ran out into the hall to get a nurse. CNA #6 stated that Registered Nurse (RN) #4 was told that the resident fell and that they went back into the room. CNA #6 stated that they were trying to pick the resident up to put her in bed when RN #4 had to call a code blue when Resident #102 went unresponsive with her eyes open. CNA #6 was asked why she did not apply a gait belt to Resident #102 and stay to supervise a resident with an alarm while toileting and CNA #6 stated that she did not transfer the resident and that she did not help her so she didn't put a gait belt on the resident and that she didn't stay in the bathroom because "the resident did it herself". In an interview on [DATE] at 11:15 AM, with Resident #102's roommate (Resident #103), revealed that she was sitting up in her wheelchair and that Resident #102 took herself to the bathroom but that the oxygen tubing didn't reach the bathroom. Resident #103 stated that physician #15 came in to the room and told Resident #102 to use her oxygen in the bathroom and that Resident #102 told the physician that it didn't reach and that was a week before the fall. Resident #103 stated that she could see into the bathroom through the door hinge crack and saw Resident #102 on the floor and the CNA (#6) telling her to get up. Resident #103 stated that she didn't hear Resident #102 fall, but heard the staff telling the resident to wake up. Resident #103 stated that she did not see Resident #102's oxygen tubing going into the bathroom. In an interview on [DATE] at 11:09 AM, with RN #4 revealed that he was the regular nurse for Manor hall and was sitting at the nursing station when CNA #6 stated that "we have a fall" and RN #4 went to Room #1. RN #4 stated that he walked in to the room and saw Resident #102 sitting up in bathroom doorway with her back against the door jamb facing out to the hallway. RN #4 stated that he squatted down and asked Resident #102 if she was hurt, and that she said 'I think I hurt my hip' and reached toward her right hip. RN #4 stated that he was asking her about hip pain when the resident's eye's glassed over, had a flat affect on her face and went limp, slumped to the floor. RN #4 stated that Resident #102 was talking and breathing when he went into the room and then became unresponsive. RN #4 stated that there was no gait belt on the Resident #102 when he entered the room, no oxygen used, and no alarms, and had on regular socks on, not grippe socks. RN #4 stated that he called a code blue and placed a non-rebreather mask (oxygen) at 8 liters on Resident #102 because of sporadic gasping respirations. RN #4 stated that checked the resident's pupils that were unresponsive. RN #4 stated that he noted a hematoma to the right side of head above temporal area of 2 cm x 4 cm in size that protruded 2 cm outward like a big goose egg. Emergency Medical services (EMS) came and helped get the resident into bed. RN #4 stated that CNA #6 told him that Resident #102 transferred herself onto the toilet and she heard her alarm go off, so CNA #6 went into the bathroom turned the alarm off, pushed the wheelchair back into the bedroom and then she closed the bathroom door and continued to work on another residents colostomy. RN #4 stated that CNA #6 left Resident #102 alone in the bathroom, who had an alarm, with no gait belt placed and she closed the bathroom door. RN #4 stated that he had to do a discipline on CNA #6 for not using a gait belt or using oxygen during transfer. RN #4 stated that there was no oxygen on Resident #102 when she was in the bathroom or on the floor. RN #4 stated that Resident #102 was oxygen dependent. RN #4 stated that he did not know until after he had disciplined CNA #6 that she had left Resident #102 alone in the bathroom and that she did not tell RN #4 at the time of the fall. RN #4 stated that he took CNA #6 back to the bathroom to demonstrate what had happened and that's when CNA #6 stated that she left he resident alone in the bathroom and had pushed her wheelchair out into the bedroom and closed the bathroom door. RN #4 stated that CNA #6 could not tell him what Resident #102 hit her head on or her hip during the fall. RN #4 stated that Resident #102 had on regular socks, not grippe socks with no grip to them. Record review of Resident #102's nurse notes dated [DATE] added [DIAGNOSES REDACTED]. Record review of facility 'Using Transfer Belts' (undated) policy provided by the facility revealed that transfer belts make moving residents who need assistance much safer and noted that even if a resident loses consciousness, the belt can enable you to lower the person safely to the floor. Record review of facility 'Personal Alarms' policy revised dated [DATE] revealed that the facility used a variety of devices to enhance the fall prevention program, thereby minimizing the risk of fall a potential injury to residents. The fall risk committee and restorative department make the final decision for use. Personal alarms my include tab alert, tab alert with yellow snapper, bed sensor, chair sensor, and alarmed belt to wheelchair. Item #5 noted: Ensure resident need are met when devices are in use. In an interview on [DATE] at 12:50 PM, with LPN #20, who was the restorative director, revealed that all residents had a fall care plan and were considered a fall risk. LPN #20 did not know that Resident #102 had an alarm on her wheelchair nor did she know who assessed the resident and placed the alarm without care planning the resident for alarm. In an interview on [DATE] at 12:30 PM, RN #17 revealed that she was the assistant director of nursing (ADON) and that Resident #102's fall was unavoidable and that the facility could not have prevented her fall. RN #17 stated that fall alarms are recommended by the therapy department or restorative assesses and recommends alarms, and then staff (CNA's or nurses) can place alarms. RN #17 stated that Resident #102's alarm was not care planned and that she did not know who put the alarm on the resident, and that there was no written assessment for use of alarm, and that no one knew why Resident #102 had one. RN #17 stated that CNA's do walking rounds and are to check alarms, but that the facility had no documented proof because the walking rounds sheets are shredded. RN #17 stated that she did the investigation on Resident #102's fall and that it was not reported to the state agency because the facility knew how the fall occurred. Record review of CNA #6 'Progressive Discipline' form dated [DATE] revealed documentation of: Resident must always be transferred with a gait belt, unless otherwise stated on care plan. Residents on continuous oxygen must remain on oxygen at all times. Resident was transferred to bathroom without gait belt and oxygen. Resident fell resulting in head injury, further disciplinary action may follow. The document was signed by RN #4 and CNA #6. Record review of the EMS run sheet dated [DATE] revealed that per the RN, the patient fell by bathroom door onto floor and hit the side of her head 10 minutes prior to arrival and is now unresponsive. Per RN this was not a witnessed fall. Per RN, patient never went pulseless or apneic so they did not initiate CPR............patient regained consciousness and was able to answer yes to paramedic of having a headache........During transport patient went pulseless and apneic, asystole confirmed. #

This citation pertains to MI# 707 Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for 1 (#101) of 4 sampled residents, from a total sample of 4 residents, resulting in resident #101 having an elevated blood sugar and dehydration requiring transfer to the hospital for treatment. Findings include: Observation on 1/2/13 during the entrance tour of the facility revealed that Resident #101 no longer lived at the facility. Observation on 1/2/13 at the noon meal and on 1/3/13 at the morning meal revealed that residents on the north east unit in the Florida dining room were assisted or fed by staff members. Record review of Resident #101's minimum data set ((MDS) dated [DATE] revealed a [AGE] year old female with cognitive skills for daily decision making as severely impaired never or rarely made decisions. Functional status of eating assessed as total dependent on staff for meals. Record review of Resident #101's nutrition care plan (last review date 10/25/12) revealed that the resident was at risk for dehydration as evidenced by the use of diuretic ([MEDICATION NAME]) and the use of cathartics ([MEDICATION NAME]). Approaches (interventions) included: Monitor for sign/symptoms of dehydration (dry mucus membranes, skin turgor, ect...), determine possible cause of weight changes, report significant weight changes to physician, registered dietitian and family. Record review of Resident #101's physician monthly orders dated 12/1/12 revealed a [AGE] year old female with [MEDICAL CONDITION], diabetes, age-related [MEDICAL CONDITION]. The physician orders [REDACTED]. Record review of resident #101's nurse notes dated 11/2/12 written by the wound care nurse noted: Shearing to coccyx, stage II pressure ulcer measured at 1.3 X 1.3 (centimeter) and that a she left a message for the dietitian and faxed a note to the physician. Record review of facility 'Food acceptance records' policy dated 7/20/12 revealed that purpose of the food acceptance record (FAR) was to monitor the resident's pattern of intake for the purpose of planning appropriate care. The FAR would be maintained for any resident who had a pressure ulcer of stage II or greater. The roster of residents requiring FARs will be maintained by the registered dietitian and communicated to the unit charge nurse. Record review of Resident #101's nutritional status review note dated 10/25/12, revealed a quarterly review note that the resident was on a pureed diet with necture thick liquids related to chewing and swallowing impairment. Skin was noted to be intact. Weights were noted on 10/24/12 139.8#, down 4.5%in 30 days , down 9.2% in 90 days, and down 13.5% in 180 days. In an interview on 1/3/13 at 10:00 AM, Registered Dietitian (RD) revealed that she reviewed Resident #101's closed medical record with the state surveyor and that there were no food acceptance records (FARs) noted for Resident #101 for the months of November or December 2012. The RD stated that there was no record of if or how much of her meals and snacks were being taken/ingested by the resident. The RD stated that the facility used to do FARs on every resident but had changed the policy to only certain residents that were to be tracked. The dietitian stated that a FAR should have been in place for Resident #101, but clearly was not. In a second interview on 1/3/13 at 10:50 AM, the RD revealed that the facility used variance sheets in which the nurses fill out when a resident has a weight loss greater than 3 pounds in a week or 5 pounds in a month. The RD reviewed Resident #101's weight record which revealed a weight loss over 3 pounds on 10/8/12 and a loss of over 3 pounds on 11/18/12 and continued weight loss each week after. The RD stated that Resident #101 would have qualified several times for tracking and that it was missed. The RD stated that there were no (not any) variance sheets for Resident #101. The dietitian stated that the nursing staff had spoken to the dietary manager and that supplement was added. The RD stated that Resident #101 had more troubles with [MEDICAL CONDITION] and that a speech evaluation was done in August 2012 with a down grade in diet to pureed with necture thick liquids. Record review of Resident #101's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of Resident #101's nurse notes dated 12/10/12 at 6:50 AM revealed Resident #101's blood sugar check was reported at 512, rechecked and had gone up 527. The nurse noted that she called the on call physician and an order for [REDACTED]. There was no note of checking mucus membranes or skin turgor. There were no vital signs noted for that time. Record review of nurse note dated 12/10/12 at 7:40 AM noted that Resident #101's blood sugar was rechecked and that the meter read "HI" over 600. The nurse noted that she notified the physician and that an order was given and insulin to scale. The family member was notified. There was no note of checking mucus membranes or skin turgor. There were no vital signs noted for that time. Record review of nurse note dated 12/10/12 at 9:00 AM noted blood sugar recheck of 475. Resident vital signs were noted as BP 92/50, T 99.2, P 110, R 19. Resident noted to have legs elevated and to be given sips of a shake. Family noted at facility. Further nurse note at 10:50 AM revealed BP 88/44, P 112, R 19, T 96.5, blood sugar recheck 544 with insulin given to scale and then the resident was transferred to hospital at 11:30 AM via ambulance. In an interview on 1/2/13 at 12:12 PM, Registered Nurse (RN) #6 revealed that she reviewed her nurse notes and came into work at 6:30 AM on 12/10/12 and received report from the night shift nurse that Resident #101's blood sugar was 512, and then she herself went to recheck it at 6:50 AM and got 527 and that the resident was diaphoretic but did not have a temperature. RN #6 stated that she called the physician and gave insulin as ordered and then ended up sending the resident to the hospital. RN #6 stated that staff had to feed Resident #101 with a baby spoon because the resident did not open her mouth very wide and that the resident would eat well for a few days and not eat. RN #6 stated that Resident #101 would pinch her mouth shut and not open it somedays. In an interview on 1/3/12 at 11:20 AM, the facility medical director revealed that the facility had a procedure of sub Q hydration if the resident is not taking oral fluids. Record review of hospital emergency room records dated 12/10/12 noted acute dehydration, [MEDICAL CONDITION] and elevated blood sugars. The emergency room record noted that the resident blood pressure responded to IV fluids. #

This citation pertains to MI 172 Based on observation, interview and record review the facility failed to provide supervision and prevent a burn from hot liquid in 1 of 7 sampled residents (Resident #101), from a total sample of 7 residents, resulting in an Immediate Jeopardy when Resident #101, who had been identified as requiring a cup with a lid for hot beverages, sustained a second degree burn to the back of her left thigh after being served hot chocolate in a cup with no lid by Certified Nurse Assistant (CNA) #4 on 8/3/12 at approximately 6:05 p.m. This deficient practice placed 100 Residents, identified as needing covered cups for hot liquids, at risk for serious harm and/or injury. Findings include: Review the Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old female with brief interview for mental status score of 10 which indicated moderately impaired decision making skills, cues and supervision required. The MDS indicated Resident #101 needed supervision with oversight, encouragement, cueing, and set up with eating. Resident #101 was assessed as having limitation that interfered with daily functions or placed the Resident at risk for injury due to lower extremity impairment on both sides. Resident #101 had an active [DIAGNOSES REDACTED]. Record review of the Admission History and Physical dated 7/29/12 revealed Resident #101 had contractures (resistant to stretching/stiff) of her knees, generalized muscle atrophy (wasting), and a decreased ROM (range of motion). Review of the 'Therapy Screen for use of Hot Liquids' form dated 7/26/12 revealed Resident #101 was deemed to be unsafe drinking hot liquids without a covered cup. Review of the "Safety Assessment for Resident Handling of Hot Liquids' form dated 7/26/12 revealed Resident #101 was not safe to handle hot liquids and covered cups were initiated. Review of Resident #101's nutrition care plan dated 7/26/12 revealed that covered cups for hot liquids were initiated. Record review of the Unusual Occurrence form dated 8/3/12 at 6:05 PM, revealed that Resident #101 was eating in the Lakeview dining room when she received a cup of hot chocolate. It was noted that Resident #101 took a drink and sat it down on the table and bumped it with her hand resulting in a spill. The liquid ran down into Resident #101's chair and under her left leg. Record review of the Facility Investigation report dated 8/9/12, revealed that Resident #101 spilled a hot beverage on 8/3/12 at 6:05 PM in the dining room after CNA #4 had served Resident #101 a cup of hot chocolate without a lid and Resident #101 bumped the cup of hot chocolate. The report indicated that the hot chocolate spilled onto Resident #101 clothing protector, covering her chest and lap, and pooled on the left side of her wheelchair and left leg. The report indicated the hot chocolate spill was soaked up by the CNA and that Registered Nurse (RN) #3 and Licensed Practical Nurse (LPN) #6 assessed Resident #101's left thigh and observed pink/reddened area with no blistering. A cool compress of a wet towel was applied and Resident #101 declined to leave the dining room and denied any discomfort. Review of the Nursing Note dated 8/3/12, revealed at 6:05 PM, Resident #101 was in the dining room when the spill occurred and cold compress were applied and removed at 7:40 PM to re-inspect the area. The note indicated Resident #101 had a 12 centimeter (cm) X 8 cm blistering red wound to her upper, posterior (back) left leg. An order was obtained for Silvadene cream to be applied to the affected area. In an interview on 8/13/12 at 2:10 PM, CNA #4 stated, "The kitchen was running late. The Lakeview Residents are alert and oriented, complaining that dinner was late. Kitchen (staff) came down late, they didn't bring hot drinks early; usually the bring them 30 minutes prior to serving food. I was rushing and I over-looked the tray tracker slips (dietary information slips). It was on her's (Resident #101) to use cup covers for her, and I didn't. It was my fault". CNA #4 stated that she gave Resident #101 hot chocolate with no lid. CNA #4 stated that she was not watching Resident #101 with the hot chocolate, but getting food trays ready at the kitchen counter when another resident (Resident #104) started to yell "she spilled or burned". CNA #4 revealed that she went to Resident #101 and lifted her pants away from the top of her leg, got the nurse, and the nurses took over. CNA #4 stated that CNA #5 came to help, and they rolled the pant leg up and saw a pink/red mark. CNA #4 reported that she and CNA #5 tried to soak up the spill. CNA #4 stated that no one got Resident #101 up out of the chair and that she stayed to finish the meal 20-30 minutes more. In an interview on 8/15/12 at 1:00 PM, Resident #104 stated, "I saw it, started yelling to get help. The lady grabbed her cup and spilled it........on to her pants and into her chair. I believe she stayed in the dining room and finished her dinner". Record review of the nurse notes dated 8/1/12 revealed that Resident #101 was total dependence for transfers (from surface to surface), had an unsteady gait , and required a Hoyer (mechanical) lift. Written narrative charting revealed: 'Per husband, Resident (Resident #101) does not voice her complaint of pain often and will deny pain when asked'. In an interview on 8/13/12 at 4:25 PM, RN #3 stated, "I was called into the dining room after the spill had occurred. CNA's were cleaning up the liquid with paper towels. I left to go to the linen cart down on the north end to bring a towel back to the dining room, I got it wet and wrung it out. The CNA's had (Resident #101's) pants pulled up to the thigh area. There was a clean clothing protector in place between the pants and skin. I put cool towel in place of the clothing protector. I saw redness on Resident #101's skin.......When I went to get the towel, I told LPN #6 about the spill and she came with me to the dining room.......Resident #101 stayed a finished her meal, I guess 20-30 minutes. I only put the towel on it then went back to doing my stuff." In an interview on 8/13/12 at 4:30 PM, LPN #6 revealed that she was sitting at the nursing station desk when RN #3 came down the hall and said that someone was burned. LPN #6 stated that she followed RN #3 to the Lakeview dining room where Resident #101 was sitting in her wheelchair away from the table with her pant leg up and noted redness on her left thigh area. LPN #6 reported that RN #3 applied a wet compress to Resident #101's leg. LPN #6 stated that she asked Resident #101 to return to her room and that she declined. LPN #6 stated that Resident #101 was left in the dining room to finish her meal after the spill approximately 20-25 minutes to eat her dinner. LPN #6 stated that she left Resident #101 in the dining room and returned to the nursing station. LPN #6 stated that she told Resident #101's nurse, LPN #7, that she had a burn. LPN #6 stated that about 8:00 PM she was in talking to Resident #101's roommate when she had Resident #101 turnover and noted there was redness and blisters on her thigh. LPN #6 stated she let LPN #7 know about the redness and blisters. In an interview on 8/14/12 at 2:15 PM, LPN #7 reported that she was feeding other Residents in a different dining room when the incident with Resident #101 occurred. LPN #7 stated that she came back to the nursing station on the north east unit and was notified of the spill on one of her Residents, that it was under control, and that RN #3 had handled it. LPN #7 stated that she did not see the Resident #101 in the dining room, but that Resident #101 was brought down the hall to her in her wheelchair, but did not know what time. LPN #7 stated that at some point she put Resident #101 in bed rolled her over and looked and saw nothing on the left leg. LPN #7 stated that a half hour later she was told it had blistered by LPN #6. LPN #7 stated that she thinks that she did not roll Resident #101 over far enough to see the blisters. LPN #7 stated she measured the burn to be 12 cm X 8 cm with blistering 4 cm in diameter, red with blistered areas. LPN #7 stated that no staff got Resident #101 out of the wheelchair after the spill until she put Resident #101 to bed. LPN #7 stated that Resident #101's pants were still wet, but that there was no puddle. LPN #7 stated "I first saw the wound at 7:30 PM when I laid Resident #101 down, it was red, but I didn't see blisters. I went back at 8:00 PM when LPN #6 saw it". During an interview and observation on 8/13/12 at 9:30 AM, Resident #101 was noted to be a two person Hoyer lift for transfers from wheelchair to bed. Resident #101 was asked about the hot chocolate incident on 8/3/12 and stated that she went to pick up the cup and it spilled, going down her leg. Resident #101 stated that "it burned me real good". Review of the Occupational Therapy Evaluation dated 7/26/12 revealed Resident #101 was evaluated at 3 of 5 for upper left and right extremity strength which indicated movement possible against gravity, but not against resistance. In an interview on 8/14/12 at 2:35 PM, Resident #101's spouse (Spouse #1) stated, "Saturday (8/11/12) I saw it, when the physician looked at it (burn). It was red with blisters that had opened so it has to stay covered. I believe she spilled it (hot liquid) and it ran down her leg and pooled under her. The staff didn't get her up out of the wheelchair and that's where it burned her on the back of the leg". In a second interview on 8/14/12 at 2:38 PM, Resident #101 stated, "I wasn't gotten up out of the chair, it was wet under me. I did finish my meal before I was taken to my room. I don't know how long it took. Yes, a wet cloth was put on it once in dining room". During an observation on 8/13/12 at 10:15 AM, LPN #12 (wound care nurse) completed a dressing change to Resident #101's left posterior thigh area. Observation of the thigh revealed a red/pink area estimated to be 2 cm X 4 cm. Review of Resident #101's physician progress notes [REDACTED]. The physician noted second degree burn (partial thickness) of lateral aspect of the left thigh. On 8/16/12 at 8:36 AM, Administrator #1 and DON #2 were notified of an Immediate Jeopardy identified on 8/3/12 at 6:05 PM, when Resident #101, who had been identified as requiring a cup with a lid for hot beverages, sustained a second degree burn to the back of her left thigh after being served hot chocolate in a cup with no lid. On 8/16/12 at 11:20 AM, the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. On 8/3/12, Resident #101 was assessed and a cool compress was applied to the left thigh while in the dining room. Excess liquid was cleaned off and Resident #101's pants were pulled away from her skin. 2. On 8/3/12, the physician was notified and new order to apply silvadene cream twice daily to affected area on left leg and cover with dry dressing until healed. 3. On 8/3/12, every shift charting was initiated to monitor Resident #101. Resident #101 continues on therapy caseload for therapy activities, neuro, transfer, and mechanical lift. Occupational therapy caseload for neuro-muscular re-education, self-care, wheelchair management and training. 4. On 8/3/12, CNA #4 received a verbal discipline for not following the Residents care plan. 5. On 8/8/12, the Hot Liquid policy was reviewed and updated. 6. On 8/7/12, the facility performed chart audits to verify adherence to the facilities Hot Liquid Policy. 7. On 8/6/12, 8/8/12, 8/10/12 and 8/15/12 all staff in-services were completed regarding the Hot Liquid Policy. 8. On 8/7/12 observation/audits were initiated and to be completed by registered dietitian or certified dietary manager or designee weekly for 3 months, then monthly for 3 months. 9. Continuing 8/8/12, in-servicing for all new employees on facility Hot Liquid Policy/Covered cups will occur. Although the Immediate Jeopardy was removed on 8/8/12, the facility remained out of compliance at the scope of isolated and severity of actual harm that is not Immediate Jeopardy due to the State Agency had not yet verified sustained compliance.