Every finding on record at Cass County Medical Care Facility

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings include:On 5/5/26 at 9:48 AM, an initial tour of the walk-in cooler found a large bowl of tartar sauce dated 4/8 to 5/8, when asked if this is made in house, Certified Dietary Manger (CDM) DD stated, yes. Further review of the cooler found an open package of hot dogs with no legible date to indicate discard, an open package of sliced turkey dated 4/28 to 5/3, and a chunk of ham dated for discard on 5/2. On 5/5/26 at 10:52 AM, a tour of the Nutrition Kitchen found a container of individual prune pudding cups dated 4/10 to 5/10. When asked if this was an item made in house, CDM DD stated it was. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .On 5/5/26 at 10:12 AM, observation of the clean utensil drawers found an accumulation of crumbs and debris in the back of the drawers containing whisks and spatulas. A further review of this area found dried food accumulation on a grey mechanical scoop stored with clean utensils. On 5/5/26 at 10:18 AM, observation of the slicer found some accumulation of dried meat debris on the backside bottom and top portions of the blade and back components of the slicer. An interview with CDM DD found that the slicer had not been used today and it only gets used once or twice a week. On 5/5/26 at 10:20 AM, observation of the production area utensil drawer found an accumulation of crumb debris in the back of the drawer. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 5/5/26 at 10:38 AM, observation of the three-compartment sink area found an overhead spray laying on the running boards of the sink. The overhead spray was found in a manner where it would rest below the overflow rim of the sink, creating a plumbing cross connection from potable and wastewater. According to the 2022 FDA Food Code section 5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).On 5/5/26 at 10:48 AM, observation of the wall mounted spray in the dish room found a Y valve on the faucet hose bib and the hose left on leaving the faucets internal vacuum breaker under constant pressure of which it is not rated to handle. Sign above the faucet states to turn off the water when not in use. According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.On 5/5/26 at 10:40 AM, observation of the dish machine found that the rinse pressure gauge was missing its glass cover piece and would not give consistent readings between cycles of the dish machine. The machine states it needs 20 pounds per square inch (PSI) during the rinse cycle, and the gauge was reading anywhere from 25 to 45 PSI when the rinse was triggered. According to the 2022 FDA Food Code section 4-501.113 Mechanical Warewashing Equipment, Sanitization Pressure. The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch).On 5/5/26 at 10:41 AM, an interview with CDM DD found that they don't have the means to ensure proper temperature of the dish machine by having an irreversible registering temperature indicator.According to the 2022 FDA Food Code section 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing. (A) In manual WAREWASHING operations, a TEMPERATURE MEASURING DEVICE shall be provided and readily accessible for frequently measuring the washing and SANITIZING temperatures. (B) In hot water mechanical WAREWASHING operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL surface temperature.On 5/5/26 at 2:30 PM, a revisit of the kitchen walk in cooler found a full, six-inch-deep quarter pan, on a cart covered in saran wrap. An interview with CDM DD found that the pan contains the soup of the day that is made every morning and used for lunch and dinner. CDM DD went on to state that due to limiting how long the soup is on hot hold, staff start a cooling process for the soup after lunch so that they can reheat it back up for dinner. At this time, the temperature of the soup was found to be 132F after being placed in the walk-in cooler around 1:00 PM. According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

Based on observation, interview, and record review the facility failed to ensure oxygen orders were followed consistently for 3 (Residents #57, #53, and #25) of 3 residents reviewed for respiratory care resulting in residents receiving incorrect oxygen concentrator (a medical device that delivers purified/concentrated oxygen) flow rates (volume of oxygen delivered per minute and often expressed in liters per minute) and the potential for breathing difficulties.Findings include:Resident #57:Review of Resident #57's admission record, dated 5/7/26, revealed she was an [AGE] year old female with pertinent diagnoses that included chronic obstructive pulmonary disease (COPD; lung disease that makes it difficult to breathe), acute (sudden/short-term) and chronic (develop gradually/persist over a long period) respiratory failure (condition in which the lungs cannot provide enough oxygen) with hypoxia (low oxygen levels), dyspnea (shortness of breath/difficulty in breathing) and dependence on supplemental oxygen.Review of Resident #57's oxygen order, dated 8/25/2025, stated, Oxygen: Run at 2 L/min (liters per minute; supplemental oxygen flow rate) via NC (nasal cannula; oxygen tubing) continuous.Review of Resident #57's oxygen care plan included an intervention, dated 10/18/2022, which stated, OXYGEN SETTINGS: O2 (oxygen) via Nc (nasal cannula) @ (at) 2L continuous.During an observation on 05/05/2026 at 10:53 AM, Resident #57 was seated upright in her wheelchair in her room with her oxygen tubing on. The oxygen concentrator was on and running at a flow rate of 4 liters per minute. Resident #53 reported her oxygen flow rate was supposed to be 2 liters per minute.During an observation on 05/05/2026 at 2:12 PM, Resident #57 was seated upright in her wheelchair near her doorway with a portable oxygen concentrator on the back of her wheelchair. The device was on, providing oxygen to the resident, and the device's screen displayed it was set to a level of 3.During an interview on 05/06/2026 at 3:06 PM, Director of Nursing (DON) B confirmed the number (which could range from 1 through 6) on the portable oxygen concentrator's display/screen in the top right-hand corner translated to liters per minute. DON B confirmed if the screen displayed 3 that meant it was providing oxygen at a flow rate of 3 liters per minute. During an observation on 05/06/2026 at 8:15 AM, Resident #57 was asleep in bed with her oxygen tubing on. The oxygen concentrator was on and running at a flow rate of 4 liters per minute.During observations and interviews on 05/06/2026 at 12:01 PM, Resident #57 was in her room with oxygen tubing on. The oxygen concentrator was on and running at a flow rate of 4 liters per minute. Certified Nurse Aides T and CC confirmed Resident #57's oxygen concentrator was set at a flow rate of 4 liters per minute. Licensed Practical Nurse (LPN) G arrived in Resident #57's room on 05/06/2026 at 12:02 PM and confirmed the oxygen concentrator should have been set to 2 liters per minute and not 4 liters per minute. LPN G confirmed that Resident #57 would not have changed her own oxygen concentrator settings and didn't know who set the oxygen flow rate incorrectly.Resident #53:Review of Resident #53's admission record, dated 5/7/26, revealed she was a [AGE] year old female with pertinent diagnoses that included vascular dementia (impaired cognitive function when blood vessels in the brain are damaged/blocked) and asthma (disease that effects inflammation, swelling, and narrowing of the airways in the lungs).Review of Resident #53's oxygen order, dated 6/25/2024, stated, Oxygen: Run at 2L/min via n/c (nasal cannula) continuous. Review of Resident #53's oxygen care plan included an intervention, dated 11/2/2023, which stated, OXYGEN SETTINGS: O2 via Nc @ 2L (Liter; liter per minute) continuous.During an observation and interview on 05/05/2026 at 11:22 AM, Resident #53 was lying in bed with her oxygen tubing on. The oxygen concentrator was on and running at a flow rate of 3 liters per minute. Resident #53 reported her oxygen flow rate was supposed to be 2 liters per minute.During observations on 05/05/2026 at 2:14 PM and 05/06/2026 at 8:08 AM, Resident #53 was asleep in bed with her oxygen tubing on. The oxygen concentrator was on and running at a flow rate of 3 liters per minute. During an interview on 05/06/2026 at 12:02 PM, LPN G confirmed that Resident #53 would not have changed her oxygen concentrator settings.During an observation and interview on 05/06/2026 at 12:11 PM, Resident #53 was lying in bed with her oxygen tubing on. The oxygen concentrator was on and running at a flow rate of 3 liters per minute. LPN G confirmed Resident #53's oxygen concentrator flow rate was set incorrectly, and Resident #53 was supposed to receive oxygen at a flow rate of 2 liters per minute.Resident #25:Review of Resident #25's admission record, dated 5/7/26, revealed she was an [AGE] year old female with pertinent diagnoses that included chronic obstructive pulmonary disease, asthma, and chronic respiratory failure with hypoxia.Review of Resident #25's oxygen order, dated 11/11/2025, stated, Oxygen: Run at 2L/min via NC at HS (abbreviation of a Latin term meaning at bedtime) and PRN (as needed).Review of Resident #25's oxygen care plan included an intervention, dated 11/10/2023, which stated, OXYGEN SETTINGS: O2 via NC @ 2L at HS and PRN.During an observation and interview on 05/05/2026 at 12:10 PM, Resident #25 was lying in bed with her oxygen tubing on. The oxygen concentrator was on and running at a flow rate of 2.5 liters per minute. Resident #25 reported her oxygen flow rate was supposed to be 2 (liters per minute), she wore her oxygen at night and as needed, and she didn't touch or adjust her oxygen concentrator. During an observation on 05/06/2026 at 8:04 AM, Resident #25 was asleep in her bed with her oxygen tubing on. The oxygen concentrator was on and running at a flow rate of 2.5 liters per minute. During an interview on 05/06/2026 at 12:02 PM, LPN G confirmed that Resident #25 would not have changed her oxygen concentrator settings.During an observation on 05/07/2026 at 7:59 AM, Resident #25 was awake lying in bed with her oxygen tubing on. The oxygen concentrator was on and running at a flow rate of 2.5 liters per minute.Review of the facility's Oxygen Use, Storage, and Safety policy, reviewed/revised 3/2026, stated, .Oxygen tubing and supply will be set up according to physician orders and manufacture's/supply company directions .New tubing with tank and/or concentrator will be used when first setting up oxygen therapy per physician order for liters/minute .

Based on observation, interview, and record review, the facility failed to ensure a resident was assessed to be appropriate for self-administration of an inhaler for 1 resident (Resident #34) of 1 resident reviewed for self-administration of medications resulting in the inhaler being left unsecured in resident room, resident self-administering the inhaler without staff assessment, and the potential for negative outcomes from taking too much of the medication. Findings include: Resident #34 (R34)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R34's initial admission date to the facility was on 2/7/2023 with pertinent diagnoses including chronic obstructive pulmonary disease (lung disease) and chronic respiratory failure with hypoxia (low blood oxygen levels). Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R34 was cognitively intact. During an observation and interview on 5/5/2026 at 11:54 AM, R34 was lying in bed and an inhaler was observed on his bedside table with a tissue underneath it. R34 stated that he was done using the inhaler and the nurse was coming to get it.Review of R34's physician order revealed Incruse Ellipta (Umeclidinium Bromide) Inhalation (prescription bronchodilator; relaxes airway muscles) Aerosol (suspension of particles in a gas; usually air) Powder Breath Activated 62.5 MCG/ACT (micrograms per actuation; dosage measurement). 1 inhalation, inhale orally one time a day related to chronic obstructive pulmonary disease. Order date: 12/22/2024. Start date: 12/23/2024. Review of R34's chart revealed no self-administration assessment for medication was completed.Review of R34's care plan revealed no care plan for self-administration of medication. During an interview on 5/5/2026 at 2:41 PM, Licensed Practical Nurse (LPN) H stated there were no residents on 200 Hall (where R34 resided) that can self-administer medications. When asked about R34's inhaler left at his bedside, LPN H said he could use the inhaler by himself. LPN H reported that she usually left it at his bedside since he knew how to use it and to rinse his mouth with water afterwards and then said, Don't worry, he is okay.During another interview on 5/6/2026 at 9:07 AM, R34 stated that the nurse left the inhaler by his bedside so he could take it when he was ready and she had done it many times before. During an interview on 5/6/2026 at 2:02 PM, Director of Nursing (DON) B and Registered Nurse (RN) P stated that there weren't any residents in the facility that could self-administer medications. RN P stated that LPN H stated that R34 wanted her to leave the inhaler at his bedside so he could take a puff on his own time. When asked if an inhaler was an order and considered a medication and whether a self-administration of medication assessment should have been completed, DON B said Yes. RN P stated that it was done and when this surveyor asked when, RN P' said today. When discussing that there was no documentation in the chart on R34 being able to self-administer medications, DON B stated it should have been completed.During an interview on 5/7/2026 at 8:32 AM, LPN J stated that there were no residents on 200 Hall that could self-administer medications. LPN J said she always stood at R34's bedside when he took the inhaler since it was a medication and it couldn't be left at the bedside. Review of the Self-Administration of Medications Policy dated 1/2025 revealed . Procedures: A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognition (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process. C. For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition. D. The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each medication authorized for self-administration, the label contains a notation that it may be self-administered.

Based on observation, interview, and record review, the facility failed to follow-up and offer prompt dental services for 1 resident (Resident #6) of 1 resident reviewed for dental care resulting in Resident #6 experiencing bleeding gums, plaque buildup (sticky film of bacteria that causes cavities, gum disease and bad breath if not removed daily) and poor dental hygiene. Findings include: Resident #6 (R6)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R6's initial admission date to the facility was on 1/24/2020 with pertinent diagnoses including cerebral infarction (stroke), hemiplegia affecting right dominant side (paralysis affecting right arm, leg, face) and chronic periodontitis (slow-progressing, infectious, and inflammatory gum disease causing destruction of the tissues and bone supporting the teeth leading to tooth loss if not treated). Brief Interview for Mental Status (BIMS) reflected a score of 11 out of 15 which indicated R6's cognition was moderately impaired. During an observation and interview on 5/5/2026 at 11:33 AM, R6 was noted to have no upper teeth and her lower teeth were brown and black. R6 was able to communicate with a thumbs up or down signal and when this surveyor asked if she wanted the surveyor to look into dental services she gave a thumbs up. During an interview on 5/5/2026 at 11:34 AM, Licensed Practical Nurse (LPN) H stated that R6's husband said R6 had plaque on her teeth and he didn't want her to see a dentist and she agreed with whatever he decided. Review of R6's physician order revealed May see dentist, podiatrist, optometrist, and/or audiologist as desired. Order date 2/5/2020. Dental referral for bleeding gums. Order date 10/2/2025. Review of R6's progress note dated 10/2/2025 and completed by [NAME] Clerk (WC) W revealed Spoke with residents (R6) husband today in regards to dental referral for bleeding gums, he was on board with her going and being seen at (name omitted) Special Dental Care Office. Explained to (R6's husband) that this would be a consult for the first appointment and we will keep open communication on any recommendations/procedures to come forward for this potential visit.Review of R6's progress note dated 3/19/2026 and completed by WC W revealed Called (dental clinic receptionist-name omitted) this morning to follow up on this referral. He said he will be back later today and he was unable to take my call at that time. Review of the outside dental consult for R6 dated 3/26/2026 revealed . Doctor's note summary: Room visit. Patient non-verbal. She had complete layer of tartar (hardened, mineralized plaque that sticks strongly to teeth and cannot be removed by brushing or flossing alone), could not see the lower teeth. She would need to see outside (dentist) to clean them and evaluate. recommend resident (R6) be brought to the dental clinic at their next visit.Review of R6's progress note dated 4/30/2026 revealed . bottom right lower teeth continues with discolored and dark. During an interview on 5/6/2026 at 4:14 PM, Director of Social Services (DSS) S stated that R6 was signed up to receive dental services and her husband was her power of attorney (legal document that allows a person to appoint someone they trust to manage their medical and financial affairs if they are unable to do so). DSS S stated when the ancillary services (supportive services offered to residents in the facility including dental, vision, auditory, podiatry services) dentist visited the facility and filled out recommendations, the facility physician signed the note and it went to WC W who scheduled follow-up appointments. During an interview on 5/6/2026 at 4:19 PM, WC W stated that they received a dental referral a while ago for R6 due to her bleeding gums and needing her teeth to be extracted at University of Michigan's dental clinic. WC W reported that University of Michigan appointments were on hold for 6-8 months because they were way behind. WC W was asked if the facility tried to find an alternate place for R6 to get her teeth extracted and she stated it could only be done at University of Michigan. WC W stated that she didn't schedule the ancillary services dentist recommendations/referrals and that would be DSS S. During another interview on 5/7/2026 at 8:10 AM, DDS S stated that she wasn't aware of the dental recommendations from 3/26/2026 until this surveyor brought it to her attention on 5/6/2026. DSS S reported that the dentist typically followed up with her after seeing residents in the facility but the dentist didn't follow-up like usual this time. During an interview on 5/7/2026 at 8:19 AM, Registered Nurse (RN) P stated that WC W got referrals from ancillary services and then WC W scheduled appointments and gave the notes to the Unit Managers who then gave it to the physician to review. RN P said the physician then decided what to do and if orders were needed. RN P stated even with R6's recommendation to have an outside cleaning she would have to go to the University of Michigan. During an interview on 5/7/2026 at 9:19 AM, Family Member (FM) GG stated that the facility was supposed to send her to University of Michigan dental clinic to have her teeth extracted due to her bleeding gums which was causing her pain and he wasn't sure what happened. FM GG said that she needed to have a good cleaning to remove plaque on her gums first and then once that was removed, they could extract the teeth and he didn't know what was going on with that either. FM GG stated that he tried calling the facility a few times to ask about follow-up and no one had called him back. Review of the Dental Services Policy dated 3/2026 revealed Policy Explanation and Compliance Guidelines: 2. Residents and/or resident representatives, during the admission process, are notified of dental services available under 360care (ancillary support services provided to residents in the facility that include dental, vision, auditory, podiatry services) and of the potential charges that may apply in the case of routine or emergency dental care provided by outside resources. a. CCMCF ([NAME] County Medical Care Facility) will assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan 4. CCMCF will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location 9. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record

This citation pertains to Intake #2641076Based on interview and record review the facility failed to revise a person-centered care plan timely for 1 (Resident #101) of 3 residents reviewed for care plan revisions, resulting in the potential for unmet care needs. Findings include:Resident #101Review of an admission Record revealed Resident #101 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Cerebral infarction due to thrombosis of the right posterior cerebral artery (stroke on the right side of the brain due to a blood clot resulting in left side weakness).Review of Order Summary for Resident #101 revealed Name Omitted Hospice service to eval and tx (evaluate and treat) with a start date of 10/15/25.Review of Health Status Note for Resident #101 dated 10/15/25 revealed .seen by hospice nurse this shift.Review of Care Plan for Resident #101 revealed .Focus/goal/interventions.I wish for hospice services.intervention: coordinate care with hospice staff including changes in care needs. Initiated on 10/21/25.In an interview on 10/21/25 at 11:45 AM, Registered Nurse/Unit Manager (RN/UM) T reported Resident #101's hospice care plan was added today and when queried, RN/UM T reported care plans should be entered within the next business day or as soon as possible. RN/UM T reported that Director of Social Services (DSS) X was responsible for care plans related to hospice services. In an interview on 10/21/25 at 12:32 PM, DSS X reported she will initiate hospice care plans related to the coordination of services, she would not create clinical interventions for hospice care. DSS X reported Resident #101 readmitted to the facility with hospice services in place, she did not coordinate the service, and she would not create the care plan unless she coordinated the hospice services.In an interview on 10/21/25 at 12:46 PM, Minimum Data Set/Registered Nurse (MDS/RN) O reported she created Resident #101's hospice care plan today when she reviewed her record, noted the order for hospice services and realized there was not a care plan for hospice services in place. MDS/RN O reported that DSS X was the one that should create hospice care plans.In an interview on 10/21/25 at 12:01 PM, Director of Nursing (DON) B reported her expectations were that specific care plans, such as hospice services, were created sooner rather than later in the resident's care plan.

This citation pertains to Intake #2641076Based on observation, interview, and record review the facility failed to maintain adequate supervision to ensure the safety of 1 (Resident #100) of 3 residents reviewed for safety, resulting in Resident #100 experiencing a fall that resulted in a left side pubic rami fracture (a fracture of the pelvis bone). Findings include:Resident #100Review of an admission Record revealed Resident #100 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Repeated falls, dizziness, and weakness.Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 10/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #10 was moderately cognitively impaired. (BIMS score 8-11 indicates moderate cognitive impairment).Review of Care Plan for Resident #100 revealed Focus: I am at high risk for falls and injury.cognitive loss, general weakness, poor needs/safety awareness, self-initiation of care tasks without assistance.Interventions: Educate/encourage call light use, encourage activities that promote exercise, physical activity for strengthening and improve mobility, ensure proper, well maintained-footwear, therapy referral all initiated on 7/25/25.Review of Morse Fall Scale-2 dated 7/25/25 for Resident #100 revealed .high risk for falling. due to: history of falling, multiple diagnoses, impaired gait (walking ability), and overestimates or forgets limits.Review of facility investigation revealed Registered Nurse (RN) L observed Resident #100 ambulating in his room with his walker in the process of losing his balance and falling backward.RN L witnessed Resident #104 land on his bottom on the floor.Resident #100 was transferred to the local emergency department for evaluation and treatment on 10/10/2025.In a telephone interview on 10/20/25 at 12:16 PM, RN L reported she observed Resident #100 ambulating in his room with his walker, and while she was observing him, the front wheels of his walker came off the floor, he was falling backward, and she watched him hit his head on the footboard of the other bed in the room and land on his bottom on the floor. RN L reported Resident #100 was never moved from the floor and was sent to the hospital for evaluation. RN L reported Resident #100 was diagnosed with a fracture of his pelvis bone while at the hospital. RN L reported that Resident #100 ambulated independently numerous times when he was in his room, he would also self-transfer from his wheelchair to his recliner chair. RN L stated I don't think there was any intervention I could have done because I thought he was independent in his room with his walker.In an interview on 10/20/25 at 10:20 AM, CNA Q reported Resident #100 was impulsive and would self-transfer from his wheelchair into his recliner chair. CNA Q reported Resident #100 would occasionally use his call light but when he pushed it, he was already on his way out of the chair and to the bathroom. CNA Q reported Resident #100 was a one person assist with transfers for safety and balance, but he does not need physical assistance to get up or down. CNA Q reported Resident #100 was toileted before and after meals and the standard was every 2 hours. CNA Q stated we know he will self-transfer, so we follow him to his room after meals to assist with transfers.On 10/20/25 at 12:01 PM, Resident #100 was observed transferring himself from his wheelchair into his recliner chair in his room. Resident #100 stood from his wheelchair in a crouched position, pivoted to his left, and flopped into the recliner chair. At 12:03 PM CNA Q entered Resident #100's room and stated to this surveyor He did it himself didn't he?In an interview on 10/20/25 at 1:08 PM, CNA P reported Resident #100 did not use his call light much before he fell, he would just get up on his own and he would be taking off to the bathroom without us, and we would have to run to catch up with him. CNA P reported that Family Member (FM) DD would remind Resident #100 to wait for the girls to help him.In an interview on 10/20/25 at 1:16 PM, FM DD reported that Resident #100 would go when he needed to go and he would occasionally use his call light, but not all the time.Review of Kardex (a documentation system used to organize and reference key patient information) dated 10/10/25 for Resident #100 revealed ADLS (activities of daily living).toilet transfer I require the assistance of 1 staff member, toileting program: toileting per standard protocol.Safety/Monitoring.Educate/encourage use of call light, ensure proper, well-maintained footwear.In an interview on 10/20/25 at 1:35 PM, CNA W reported offering to assist a resident to the bathroom every 2 hours was standards of care and what should be done for all residents. On 10/20/25 at 3:16 PM, Resident #100's room call light was activated; CNA K and CNA M were both present in the hallway. CNA M walked past this surveyor, the mobile phone from her pocket was heard announcing Room Number (Resident #100's room number) calling . CNA M continued past Resident #100's room and entered another room with CNA K. At 3:27 PM, Resident #100's room call light was still active, CNA K and CNA M exited another resident's room into the hallway, and both walked past Resident #100's room and did not answer the activated call light. At 3:29 PM, CNA P answered Resident #100's room call light. Resident #100's room call light was observed active for 13 minutes before it was answered.In an interview on 10/20/25 at 3:40 PM, RN V reported every staff member carried a mobile phone that was linked to the call light system. RN V reported staff members logged into the system with their assigned hall at the start of the shift and every person assigned to the hall would receive all call light activation notifications. RN V reported call light activations were displayed on a monitor at the nurse's station.In an interview on 10/21/25 at 8:50 AM, CNA H reported Resident #100 was independent when he admitted , was impatient, and when he needed something, he needed it right now and would not wait; he would get up and go and many times we would find him already in the bathroom. In an interview on 10/21/25 at 9:10 AM, Director or Therapy (DOT) R reported Resident #100 had been assessed to be stand by assistance (SBA) and supervision for transfers when he was discharged from therapy services on August 7, 2025. DOT R reported SBA means staff needs to be next to the resident and able to physically assist if needed and supervision means direct observation of the resident during the transfer. DOT R reported Resident #100 was not assessed to be independent at any time during his stay.In an interview on 10/21/25 at 9:30 AM, Physical Therapist Assistant (PTA) I reported he had observed Resident #100 ambulating independently in his room with his walker to the bathroom and was unsure if the nursing department had changed Resident #100's status to independent in his room. PTA I reported the therapy department had not assessed Resident #100 to be independent during his stay.In an interview on 10/21/25 at 9:36 AM, Therapy Manager TM CC reported Resident #100 was never assessed as independent, he was SBA and supervision for safety. TM CC reported Resident #100 would do what he wanted and would get up and walk.In an interview on 10/21/25 at 11:45 AM, Registered Nurse/Unit Manager (RN/UM) T reported Resident #100 would self-transfer in his room. RN/UM T reported staff was aware of Resident #100 self-transferring, but it was not well documented in his record. RN/UM T reported there was no documentation of self-transferring in Resident #100's care plan.In an interview on 10/21/25 at 12:01 PM, Director of Nursing (DON) B reported Resident #100 was impulsive and we did not take credit for the things we did to try to mitigate his impulsivity. DON B reported there was no documentation regarding Resident #100's self-transferring and impulsiveness to get up on his own in his record. DON B reported we did not take credit for what we did.Review of Resident #100's record revealed no noted documentation of impulsive behavior nor any noted documentation regarding Resident #100's self-transferring or independent ambulation. Review of facility policy Accidents and Supervision with a reviewed date of 8/2025 revealed .to ensure the resident environment remain as free of accident hazards as possible.Identification of hazards and risks.This information is to be documented and communication across disciplines.examining data to identify specific hazards and risks to develop targeted interventions to reduce potential for accidents.Implementation: using specific interventions to try to reduce a resident's risk from hazards in the environment.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions and ensure proper labeling and dating of foods in the kitchen and the resident refrigerator in the activity room, resulting in the potential to spread food borne illness to all residents that consume food from the kitchen and residents that store food in the activity room refrigerator. Findings include: During the initial kitchen tour on 3/23/2025 at 9:41 AM, 1 spout on the coffee machine had lime buildup around the spout (white crusty and flakes around it). During another visit to the kitchen on 3/24/2025 at 9:31 AM, the same spout was observed to still have lime buildup around it. Certified Dietary Manager (CDM) TT stated that it should have been cleaned the day before and they must have missed it. During the initial kitchen tour on 3/23/2025 at 9:52 AM, Dietary Aide (DA) FFF accompanied this surveyor and the following items were observed: The ice-cream freezer had 3 individual bowls of hand dipped ice cream in them with no label and dates and ice cream was splattered on the bottom of the freezer. The following items were observed in the dietary aides reach in dessert refrigerator: 6 pear and 2 peach individual bowls with an expiration date of 3/22/2025. 1 big plastic container with chicken noodle soup with an expiration date of 3/22/2025. 1 big plastic container of tomato soup with an expiration date of 3/21/2025. The following items were observed in the aides reach in refrigerator: 7 individual 12-ounce (oz) cups of specialty drinks with no label and date. 6 individual 12 oz cups of chocolate milk and 4 individual 12 oz cups of white milk with no label and date. 35 individual 8 oz cups with either iced tea or milk with no label and date. The following was observed in the dry storage room: A big plastic bag of orzo (pasta) was not sealed, had no label and date and was lying in a box and spilling into it. A plastic bag of flour was not sealed, had no label and date and was lying in a box spilling into it. The following was observed in the cook's refrigerator: 1 styrofoam carryout container with salad in it with no label and date. 1 quart milk carton, not closed with no label and date. A sandwich plastic bag with mozzarella cheese, not sealed and no label and date. The bottom of the refrigerator was dirty with crumbs on the bottom. During an interview on 3/23/2025 at 10:22 AM, DA FFF stated that there should have been labels and dates on the food items that were not labeled and dated, food items should be sealed and food should be tossed past the expiration date. During the full kitchen tour on 3/24/2025 at 9:31 AM with DM TT the following was observed: In the main kitchen area, a shallow pan with breading for fish with saran wrap was not sealed and didn't have a label and date. The resident refrigerator in the activities room contained an open gallon milk jug with a best by date of 3/22/2025, and cheese slices in a sandwich bag did not have a label and date. During an interview on 3/24/2025 at 10:30 AM, CDM TT stated that labels and dates should be on perishable food items in the kitchen and the resident refrigerator in the activity room and said staff is aware of what they should do. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, 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. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . Review of the Date Marking for Food Safety Policy with a review date of 1/2025 revealed Policy Explanation and Compliance Guidelines for Staffing 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. 5. The discard date or date may not exceed the manufacturers use-by-date or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.) 6. The head cook or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed.

This citation contains two Deficient Practices Statements, A & B. Deficient Practice Statement A. Based on interview and record review the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents who reside in the facility. Findings include: Review of the facility Water Management Plan book on 3/24/25 at 4:00 pm, revealed no documentation regarding a team of staff members who meet to discuss water management, no test results, and no risk assessment that had been completed. In an interview on 3/24/25 at 5:00 pm, Maintenance Director (MD) DD reported he was not aware of a team related to water management in the building. In an interview on 3/24/25 at 5:05 pm, Nursing Home Administrator (NHA) A reported the team for water management should include maintenance director, director of nursing, and herself. In an interview on 3/25/25 at 10:51 am, MD DD reported he was new to the position, about six months, and he did recall when he first started, he was introduced to the water management plan, and the binder, but did not understand what needed to be done related to the water management plan. MD DD reported the facility has city water and the water supply was tested by the county and that he had never completed any kind of water testing in the facility. MD DD reported he had not conducted any evaluation on the water system in the building, he had not evaluated any areas of potential risk, and he had no established control measures to monitor water in the building. Review of facility policy Water Management Program with a review date of 4/2024 revealed .to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens .in the facilities water system .1. A water management team has been established to develop and implement the facility's water management program including facility leadership, the infection preventionist, maintenance employees, safety offices, risk and quality management staff and the director of nursing .2. The maintenance director maintains documentation that describes the facility's water system . 3. A risk assessment will be conducted by the water management team annually .5. Based on the risk assessment control points will be identified .6. Control measures will be applied to address potential hazards at each control point .7. Testing protocols and control limits will be established for each control measure .8. The water management team shall regularly verify that the water management program is being implemented as designed . Deficient Practice Statement B. Based on observation, interview, and record review the facility failed to maintain infection control practices as evidenced by 1). Incorrect use of personal protective equipment (PPE) in an enhanced barrier precaution setting for 2 (Resident #1 and Resident #46) of 2 residents reviewed for enhanced barrier precautions (EBP) PPE use during catheter care, dressing, repositioning and transferring; and 2). Proper hand hygiene by staff during meal service in the dining room resulting in the potential for introduction of infection, cross-contamination, and disease transmission. Findings include: Resident #1 Review of an Admission Record revealed Resident #1 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: paraplegia (paralysis of the lower part of the body), neuromuscular dysfunction of the bladder (loss of control of the bladder), and retention of urine (inability to empty the bladder). Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 1/29/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #1 was cognitively intact. (BIMS score 13-15 indicates no cognitive impairment). In an observation on 3/24/25 at 8:45 am, signage was noted on Resident #1's room door indicating that enhanced barrier precautions were to be used when providing care, including catheter care. Review of the Order Summary for Resident #1 revealed .Enhanced barrier precaution with a start date of 1/6/2025. Review of a current Care Plan for Resident #1 revealed Focus .I require enhanced barrier precautions .r/t (related to) my supra pubic catheter/urine . Interventions- enhanced barrier precautions (don (put on) glove and gown) with all care involving suprapubic (catheter inserted directly through the skin into the bladder) (urine) .such as device care to decrease the risk of cross contamination and risk for active infection . with an initiation date of 9/25/2023 . In an observation on 3/24/25 at 8:51 am, Certified Nurse Assistant (CNA) K was observed in Resident #1's room, at her bed side, with a graduated cylinder (a triangle shaped plastic container to collect urine from a drainage bag) preparing to empty Resident #1's catheter drainage bag. CNA K was then observed placing the graduated cylinder on the floor and holding Resident #1's catheter bag in her left hand while she unclamped the drain tube with her right, positioned the drain tube into the graduated cylinder and allowed for the urine to drained from Resident #1's catheter drainage bag. CNA K then emptied the graduated cylinder into the toilet in the bathroom. CNA K was not wearing a gown during this process as indicated by the EBP signage present on Resident #1's door to her room. In an interview on 3/24/25 at 9:22 am, CNA K reported that EBP were to be used for residents who had wounds and that it did include Resident #1. CNA K reported Resident #1 was in EBP and she should have been wearing a gown when she emptied Resident #1's catheter drainage bag. In an interview on 3/24/25 at 2:37 pm Wound Nurse/Infection Preventionist (WN/IP) C reported that EBP were to be used when the staff was come into contact with the potential infection site, opening, or line when providing care. WN/IP C reported EBP should be used when providing catheter care and emptying a catheter drainage bag. In an interview on 3/24/25 at 2:41 pm, Director of Nursing (DON) B reported that her expectations were that if a resident was in enhanced barrier precautions, the staff were using the correct PPE when providing care. Review of facility policy Enhanced Barrier Precautions with a revised date of 02/2024 revealed .maintain and implement infection control measures/processes/procedures that will help control the spread of infection .an order for enhanced barrier precautions will be obtained for residents with any of the following .indwelling medical devices (i.e. urinary catheter .) implementation of enhanced barrier precautions will include: Make gowns and gloves .for high contact resident care activities .bathing, providing hygiene . dressing, transferring .providing device care or use .urinary catheter .masks should be available for activities involving possible risk of splashing/spraying . Review of Centers for Disease Control and Prevention (CDC) dated March 20, 2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or 2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Effective Date: April 1, 2024 . 41424 Resident #46: Review of an Admission Record for Resident #46 revealed the resident was a male with pertinent diagnoses which included osteomyelitis (infection in a bone) in a active wound, urinary tract infection and sepsis (life threatening complication of infection). Review of Care Plan dated 02/02/2023 for Resident #46, revealed the focus, .require assistance with ADL's (Activities of Daily Living) r/t (related to) contractures of BLE (bilateral lower extremities), immobility, abnormal labs, and chronic disease processes . with the intervention .TRANSFERS: I require a full body mechanical lift for transfer with 2 assist .BED MOBILITY: I require assistance of 1-2 staff members to turn and reposition in bed .DRESSING: I require assistance of 1 staff member with dressing . Review of Care Plan dated 9/10/24 for Resident #46, revealed the focus, .I require Enhanced Barrier Precautions AND I am at increased risk of MDRO (Multidrug-Resistant Organism) acquisition r/t my urine, wound, and midline line. DX: Chronic Osteomyelitis, COPD (Chronic Obstructive Pulmonary Disease), hx (history) Klebsiella (bacteria that can cause health care associated infections spread through person to person contact and can be dangerous if it enters other parts of the body other than the nose, throat, skin and intestinal tract) . with the intervention .Institute Enhanced Barrier Precautions (Don (to put on) gloves and gown) with all care involving my wound Osteomyelitis R (right) Ischium (sit bones where you sit) and urine (MDRO) such as, bathing, wound dressing changes, to decrease risk of cross contamination and risk for active infection. If there is a chance of bodily fluid splashing, please wear a mask . During an observation on 03/24/25 at 09:44 AM, Shower Aide (SA) II entered Resident #46's room to re-position him in the bed. SA II was behind the head of the bed and pulled Resident #46 up in his bed, she placed his pillows back under his arms and she asked if he wanted his wedges under his hips and he said he wanted them on both sides. SA II placed the wedges on the side of the resident. She repositioned the pillows between his legs for comfort. SA II did not don a gown when she repositioned him or when she placed the pillows and wedges. During an observation on 03/24/25 at 12:20 PM, Resident #46 was being assisted with care by CNA K At 03/24/25 at 12:35 PM, CNA Q had come to the room, she moved the hoyer over to the side of the bed, she moved the wheelchair over to the privacy curtain, she washed her hands after moving the chair over and then donned gloves. CNA K and CNA Q were observed to not be wearing gowns. On 03/24/25 at 12:37 PM, CNA Q lowered the bed, both had gloves on but no gowns, they had removed his oxygen, and he was lying flat in the bed. CNA K had tucked in the tubing to the plastic bag hanging on the side of the oxygen concentrator. CNA K removed his pillows from both sides of him. The blue wedges were noted at the foot of his bed. Resident #46 was flat in the bed, but his legs were positioned to the left of his body, he was turned at the waist in that direction. CNA K rolled him towards the wall and CNA Q and CNA K tucked the sling under him. And then both CNA's rolled him back, flat in the bed. CNA Q moved to the foot of the bed and held his legs and then placed the sling between his legs. CNA K and CNA Q proceeded to adjust the sling and placed the loops on the hooks of the machine. CNA Q was gently raising the lift and Wound Nurse C entered the room and informed them he needed to be transported in a different chair and went to obtain the chair. Transport Aide F had entered the room at this time as well. CNA K did not remove her gloves while attempting to put together the broda chair footrest. CNA K and CNA Q guided the hoyer over to the broda chair, CNA K guided his legs, supporting them and slowly lowered him into the broda chair. CNA K and CNA Q raised the hoyer back up and CNA K held the back bottom of the sling to guide him back in the seat of the broda chair. CNA K placed the blue wedges on each side of Resident #46's hip/side area, had to readjust him in the chair. CNA K readjusted the back of the broda chair, so he was reclined more, she still had on her gloves from earlier in the care process. On 03/24/25 at 12:55 PM, Transport Aide F placed the plastic bag with his oxygen tubing for him on his lap area, went to grab gloves and placed his nasal cannula on his face. CNA K was putting his tennis shoes on his feet. On 3/24/25 at 12:57 PM, CNA Q placed the hoyer into the bathroom and exited the room. CNA K had her gloves on still and proceeded to make his bed and adjusted his blankets again while he was in the chair prior to him leaving to attend his appointment. During this observation, neither CNA had donned a gown as required when transferring/repositioning a resident who was on EBP. In an interview on 03/25/25 at 11:46 AM, Certified Nursing Assistant (CNA) D reported the enhanced barrier precautions sign was on the doorway and it informed the staff what activities they were to wear a gown and gloves, like with a catheter bag, wounds, PICC (peripherally inserted central catheter) lines or any type of care that would require hands on care. CNA D reported this was done to protect the resident from us and any germs the staff would have. Dining: During an observation on 03/23/25 at 11:49 AM, in the main dining room, Dietary Aide (DA) AA brought a resident her meal, set it up for her, used the resident's fork and cut up the fried fish in smaller bites, and went back into the kitchen, opened the doors to the carts and then went to the back of the kitchen in the freezer scooped out a cup of ice cream and brought it back to the resident without performing hand hygiene without performing hand hygiene in between. During an observation on 03/23/25 11:52 AM, DA AA was observed heading into the kitchen from the dining room, adjusted her apron, she then went and grabbed a plate of toast for a resident dropped it off to them, returned to the kitchen grabbed a plate for another resident and handed the plate to Activity Aide (AA) XX and proceeded back in the kitchen and grabbed a plate for another resident and dropped it off at her table without performing hand hygiene in between. During an observation on 03/23/25 at 11:59 AM, DA AA was observed serving Resident #10's meal, provided her with the salt and went back to the kitchen into the freezer, grabbed ice cream without performing hand hygiene in between. During an observation on 03/23/25 at 12:00 PM, DA AA was observed exiting the dining room and entered the kitchen. DA AA grabbed the plate for Resident #15 and went over to his table to drop it off and headed back into the kitchen without performing hand hygiene at all during this observation. During an observation on 03/23/25 at 12:12 PM, DA OO brought a cup of ice cream to AA HH and went back into the kitchen, then she was observed walking in the kitchen tossed a dirty serving spoon into the sink, went to the other side of the kitchen, grabbed chocolate milk for a resident, and brought it to them in the dining room. DA OO did not perform hand hygiene during this observation. In an interview on 03/23/25 12:13 at PM, DA OO reported hand hygiene would be performed when they handle a dirty plate and if they had dirty hands. DA OO reported hand hygiene would be performed when you would give items to one resident prior to giving to the next resident. DA OO reported there was hand sanitizer on the table for staff to use to sanitize their hands. It was noted there was no hand sanitizer over by the drink machines and ice cream machine on the other side of the kitchen. During an observation on 03/23/25 at 12:16 PM, DA AA entered the kitchen from the dining room, brought in two mugs used for coffee, then went back to the door of the kitchen organized the dessert plates on the cart, went over to the table with hand sanitizer, took a drink from her water bottle, and exited the kitchen to the dining room. No hand hygiene was performed during this observation. In an interview on 03/25/25 at 10:16 AM, DA W reported when a staff member exited the kitchen and delivered food to a resident and entered back into the kitchen the staff member should sanitize their hands. In an interview on 03/25/25 at 11:46 AM, Certified Nursing Assistant (CNA) D reported in the dining room hand hygiene would be performed between serving food, performing set-up for a resident, and when the staff assisted a resident with meals. In an interview on 03/25/25 12:05 PM, Dietary Manager (DM) TT reported hand hygiene would be done prior to serving a resident their meal and after before serving another resident their meal. DM TT reported this was done as not to contaminate the residents with other's germs. In an interview on 03/25/25 at 11:26 AM, Director of Nursing (DON) B reported during orientation staff were educated on hand hygiene and personal protective equipment (PPE) use. DON B reported the staff demonstrated on return hand hygiene and the donning of PPE. DON B reported the staff were educated on the types of isolation and what the needs were for PPE when providing care for the resident. DON B reported hand hygiene was required after touching self/clothing, environment, after touching the resident, prior to entry and upon exit from a resident's room. DON B reported when meals were delivered to a resident, hand hygiene should be performed prior to handling another resident's meal.

Based on observation, interview, and record review, the facility failed to provide an environment that promoted a dignified dining experience for 4 residents (Resident #15, #10, #49, & #40) of 4 residents reviewed for dignity, resulting in feelings of disappointment with the dining experience. Findings include: During an observation on 03/23/25 at 11:37 AM, dining service had started, and residents were being served roast beef, broccoli, French fries or baked beans. On 03/23/25 at 11:46 AM, this writer observed there were multiple residents seated throughout the dining room who had not received their lunches. Noted no particular order for meal tray delivery. In an interview on 03/23/25 at 11:47 AM, Certified Nursing Assistant (CNA) U reported a resident who was not served had ordered a special meal and those take longer to cook. CNA U asked Dietary Aide (DA) AA where the resident's food was as the other residents at the table had their meals already. In an interview on 03/23/25 at 11:56 AM, this writer requested from Activity Aide (AA) XX who were the multiple residents still waiting for their lunches. AA XX reported Resident #15, Resident #49, Resident #10, and Resident #40. This writer observed the other residents seated at the tables with those residents were already served their lunches and were eating or close to finished with the meal. Resident #15: Review of an Admission Record revealed Resident #15 was a male with pertinent diagnoses which included dementia, diabetes, paralysis on his right side, kidney disease, and stroke. During an observation on 03/23/25 at 12:00 PM, Dietary Aide (DA) AA was observed exiting the dining room and entered the kitchen, waited in line for a plate of food for Resident #15. DA AA grabbed the plate for him and headed over to his table and delivered his meal. Resident #49: Review of an Admission Record revealed Resident #49 was a male with pertinent diagnoses which included malnutrition, dysphagia (difficulty in swallowing foods or liquids, arising from the throat or esophagus), and cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language). During an observation on 03/23/25 at 12:02 PM, Resident #49's meal was brought to him by AA XX. Resident #10: During an observation on 03/23/25 at 12:04 PM, DA OO was observed bringing a plate to the dining room for Resident #10. Resident #40: During an observation on 03/23/25 at 12:06 PM, Resident #40 received her meal brought to her by AA XX. In an interview on 03/24/25 at 09:12 AM, Resident #40 reported she gets to the dining room early and was one of the first ones there and her ticket goes to the bottom. Resident #40 stated that's the way it is and reported it would be nice to eat her lunch with the other ladies she sat at the table with. Using the reasonable person concept, though Residents #10, #15, and #49 had decreased ability to verbally express their own thoughts due to their medical diagnoses, any reasonable person would likely feel a sense of frustration, loss of self-worth, and emotional distress. In an interview on 03/25/25 12:05 PM, Dietary Manager (DM) TT reported she had the dietary staff bring out soup, side salad, or cottage cheese to the residents so they would have something in front of them to keep them occupied while waiting for their food. DM TT reported as there were two cooks on 03/23/25, the alternate meals for residents should not have taken 15-20 minutes to be served to them after their table mates had been served. DM TT reported we had enough staff to ensure those who have the alternate meal would not wait that long for their meals.

Based on observation, interview, and record review, the facility failed to provide assistance with getting out of bed for dependent residents in 1 of 3 residents (Resident #8) reviewed for ADL (Activities of Daily Living) care, resulting in the potential for residents to not meet their highest practical level of well-being. Findings include: Resident #55 Review of an Admission Record revealed Resident #55 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: down syndrome. Review of a Minimum Data Set (MDS) assessment for Resident #55, with a reference date of 3/6/24, under Functional Abilities and Goals section GG revealed that Resident #55 was dependent on staff for eating and transferring out of bed. Review of Resident #55's Skin Care Plan revealed, .at high risk for skin breakdown .need to sit upright after meals .Date initiated: 3/13/24. Interventions: .Please assist be back to bed if I have been in my chair for more than 2 hours at a time. Date initiated: 3/9/24. Please only have resident up with meals, but no longer than 2 hours in chair at a time. Date initiated: 3/13/24 . In Resident #55's ADL care plan there was nothing related to getting out of bed. During an observation on 04/23/24 at 10:30 AM Resident #55 was lying in her bed wearing a gown from the home. There was signage of the door indicating Contact Precautions. During an observation on 04/23/24 at 12:59 PM Resident #55 was lying in her bed with the head of bed (HOB) at 45-90 degrees, and she was still wearing a gown, and had just finished eating lunch. Resident #55 did not get out of bed for lunch. During an observation on 04/24/24 at 11:37 AM Resident #55 was in her bed with the HOB at 30 degrees, and wearing a gown from the home. During an observation on 04/24/24 at 01:06 PM Resident #55 was in her bed and Certified Nursing Assistant (CNA) LL was assisting her with lunch. In an interview on 04/24/24 at 01:12 PM, CNA LL reported that Resident #55 does not get out of bed for meals anymore. During an observation on 04/24/24 at 02:15 PM Resident #55 was lying in her bed wearing a gown from the home. In an interview on 04/25/24 at 11:30 AM, CNA EE reported that Resident #55 would not be getting out of bed for lunch. During an observation on 04/25/24 at 11:30 AM in Resident #55's room, CNA EE and CNA RR were giving Resident #55 a bed bath, and put a clean gown from the home on her. In an interview on 04/25/24 at 11:55 AM, CNA RR reported that Resident #55 was not getting out of bed for lunch, because she was only allowed to be up in her chair for 1 hour and she was isolated to her room because she had C. Diff (Clostridioides difficile: a highly contagious bacteria that causes an infection of the bowels). In an interview on 04/25/24 at 11:57 AM, Infection Preventionist (IP) Z reported that Resident #55 could be up in her chair for 2 hours at a time, and she could still go to the dining room for meals, even though she was positive for C. Diff. IP Z reported that staff should know this information because they had just been educated them recently about it.

Based on interview and record review, the facility failed to allow and accommodate resident choice to spend time outdoors by themselves in 1 of 18 residents (Resident #6) reviewed for self-determination, resulting in the potential for residents not meeting their highest practicable level of well-being. Findings include: Resident #6 Review of an Admission Record revealed Resident #6 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 2/7/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #6 was cognitively intact. In an interview on 04/23/24 at 01:05 PM, Resident #6 reported that she enjoyed being outside in the fresh air, but that she was not allowed to go outside unless someone from activities was with her. Resident #6 reported that when she admitted to the home, she was told that she could come and go as she wished, but now she had been told that she can only leave the home with family or staff. Resident #6 reported that she made all her own decisions, and did not have a power of attorney (POA), and did not want a staff member supervising her while she was outside. Review of Resident #6's Admission Record revealed, Self-Medical Decision Maker, Responsible Party for billing. Review of Resident #6's Care Plan revealed, .I enjoy outdoor sports .I enjoy being outside when the weather permits. Please offer to take me outside on nice days. Date initiated: 11/28/23 . Review of Resident #6's Activities Assessment from admission, dated 4/12/23 revealed, .enjoys playing sports (tennis, pool, baseball), and really enjoys being outside . In an interview on 04/24/24 at 11:25 AM, Receptionist M reported that no residents are allowed to go outside by themselves. Receptionist M reported that some residents are allowed to go into the courtyard along with someone from activities. In an interview on 04/24/24 at 03:57 PM, Certified Nursing Assistant (CNA) QQ reported that she does not take any residents outside, and that Resident #6 always says that she's waiting for her family, so that she can go outside. In an interview on 04/24/24 at 03:58 PM, Activity Aide (AA) BB reported that the home does not allow any residents to go outside by themselves, and does not offer residents to go outside until the weather is warm. In an interview on 04/24/24 at 03:46 PM, Social Services Director (SSD) U reported that residents must have a staff member with them at all times when they are outside. SSD U reported that Resident #6 is her own decision maker and there would be no reason that she should need someone to go outside with her. SSD U reported that the home had not ever thought about allowing residents to go outside on their own. In an interview on 04/25/24 at 09:50 AM, Resident #6 reported that staff had discussed with her yesterday about being able to go outside on her own now, and that she planned on spending time outside that afternoon.

Based on observation, interview, and record review, the facility failed to properly maintain standard infection control practices during incontinence care for 2 of 18 residents (Resident #55 & #58) reviewed for infection control, resulting in the lack of hand hygiene and improper glove use, and the potential for the development and transmission of communicable diseases and cross-contamination of C. Diff (Clostridioides difficile: a highly contagious bacteria that causes an infection of the bowels). Findings include: Resident #55 Review of an Admission Record revealed Resident #55 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: down syndrome. Review of Resident #55's Physician Orders indicated orders for Contact Precautions. During an observation on 04/25/24 at 11:30 AM in Resident #55's room, CNA EE and CNA RR were giving Resident #55 a bed bath. Both CNA's were wearing gowns and gloves and providing direct care to the resident. Both CNA's changed their gloves multiple times during care, and did not perform any type of hand hygiene before donning clean gloves from the glove box on the wall near the entrance of the room. Both CNA's removed their gloves in the room and washed their hands for approximately 10-15 seconds in resident bathroom. In an interview on 04/25/24 at 11:57 AM, Infection Preventionist (IP) Z reported that Resident #55 tested positive for C. Diff (Clostridioides difficile: a highly contagious bacteria that causes an infection of the bowels) last week. IP Z reported that CNA's are expected to perform hand hygiene after removing soiled gloves and before donning clean gloves to ensure there is no cross contamination from dirty to clean. IP Z reported that staff were recently educated about C. Diff. and the importance of proper PPE (personal protective equipment) use. Resident #58 Review of an Admission Record revealed Resident #58 was originally admitted to the facility on [DATE], with pertinent diagnoses which a stroke. Review of Resident #58's Physician Orders indicated orders for Enhanced Barrier Precautions (EBP). During an observation on 04/24/24 at 11:57 AM in Resident #58's room, CNA JJ and CNA RR were providing incontinence care to the resident who had a large BM (bowel movement). Both CNA's donned gloves and gowns, and began by changing the resident's gown. The BM was noted to be a large loose consistency. CNA RR was holding Resident #58 by her shoulder and hip to keep her positioned on her side, while CNA JJ used multiple washcloths to clean the residents backside. CNA JJ ran out of washcloths, removed her gloves and walked out the door into the hall, calling for assistance and more wash clothes. CNA JJ had removed her soiled gloves, touched the door knob, obtained clean washcloths, then donned clean gloves and resumed with incontinence care; CNA JJ did not perform any type of hand hygiene. With soiled gloves on, CNA JJ obtained clean bed linens, positioned them on the bed, and assisted to position Resident #58 onto her other side to continue washing the resident's bottom. There was a large wound dressing just above the anus, which had BM noted on it. CNA JJ gathered additional washcloths to clean Resident #58 front side and urinary catheter; CNA JJ was still wearing soiled gloves. CNA JJ then removed her gloves and walked out into the hall again to call for the nurse to assist with applying a medicated powder to the resident's abdominal folds. CNA JJ did not perform hand hygiene, and donned clean gloves. Registered Nurse (RN) O came into the room, wearing gloves and did not have a gown on, when she leaned on the resident's bed to observe the resident's skin, while CNA RR shook powder over the residents abdomen. RN O then reattached the resident's brief and assisted CNA JJ to boost Resident #58 up in the bed. In an interview on 04/24/24 at 12:33 PM, CNA JJ was unable to explain proper hand hygiene during in continence care, and/or when to change gloves. In an interview on 04/25/24 at 12:01 PM, IP Z reported that Resident #58 was currently on EBP due to chronic wounds. IP Z reported that staff are expected to wear gloves and a gown when providing direct care to Resident #58, and when in the resident's personal space for a prolonged period of time. IP Z reported that staff should perform hand hygiene every time they removed soiled gloves, when going from dirty to clean areas during baths or incontinence care, and before donning gloves.

Based on observation, interview and record review, the facility failed to implement interventions to prevent skin breakdown for residents at risk for pressure ulcers, for 1 of 5 residents (Resident #69) reviewed for pressure ulcer prevention, resulting in the potential for the development of an avoidable pressure ulcer, infection, and overall deterioration in health status. Findings include: Review of an Admission Record revealed Resident #69 was a male with pertinent diagnoses which included glaucoma, chronic pain, pain in right hip, low back pain, severe protein calorie malnutrition, adult failure to thrive, disc degeneration lumbar region, and muscle weakness. Review of Care plan revised on 3/26/24, revealed the focus, .I am at risk for skin breakdown per my Braden assessment due to vision loss, general weakness, indwelling Foley use, potential shearing, medication use, abnormal labs, and chronic disease processes. I was admitted with open area to left great toe and am at risk for poor wound healing and/or unavoidable skin breakdown due to the above factors. DX: Prostate CA, BPH, anemia, HTN A-fib, glaucoma, PVD, chronic pain, malnutrition . with the interventions . Heel protector boots on while in bed as I allow .Standard turning & repositioning program except with sleep initiative which is defined as 0000-0400 .Skin Observation per protocol .Monitor and report signs of skin breakdown to Nurse . Review of Order Summary dated 3/27/24, revealed, .Apply betadine to toes on L foot every shift for skin prevention . Review of Order Summary dated 3/26/24, revealed, .Skin Observation Tool every day shift every Tuesday .Alert wound nurse/Unit manager of any new skin concerns . Review of Order Summary dated 4/7/24, revealed, .Monitor open areas to L foot every shift for s/s (signs & symptoms) infection every day shift for skin prevention . Review of Plan of Care Note dated 4/8/24 at 8:52 AM, revealed, .(Resident #69) is assessed as at risk for skin breakdown per Braden assessment, was admitted with open are to left great toe, and has preventive measures in place . Review of Health Status Note dated 4/14/24 at 12:45 PM, revealed, .He is compliant with care today as long as staff is explaining everything. He is blind L eye and visually impaired R eye .Betadine is applied to residents toes on L foot . Review of Health Status Note dated 4/17/2024 at 3:11 PM, revealed, .Resident is currently in his room and resting in bed .dependent on staff for total ADL care .Betadine is applied to toes on L foot per orders . Review of Health Status Note dated 4/17/2024 02:59 AM, revealed, .Resident is currently resting in bed .Betadine applied to toes with no s/s of worsening noted . During an observation on 04/23/24 at 10:56 AM, Resident #69 was observed lying in his bed, supine position, with his eyes closed. In an interview on 04/23/24 at 11:07 AM, Licensed Practical Nurse (LPN) N reported Resident #69 had wounds on the tops of his three toes on his left foot and they were treated with betadine. In an interview on 04/24/24 at 09:25 AM, Resident #69 reported his toes were painful and they didn't appear to be healing, and you can look at them and see why they are painful. During an observation on 04/24/24 at 09:25 AM, observed Resident #69 lying in his bed with his right foot right up against the foot board of the bed with his right knee bent, the left leg was bent at the knee and laid to the side with his left foot arch touching the calf area of his right leg. The left foot had a wound to the tip of the left great toe appearing as the toenail was lifting off the toe, the second toe had a scabbed area to the top of the first knuckle and a small spot without a scab, third toe had a scabbed area to the knuckle, and the fourth toe had multiple scabbed areas spread across the top of the toe. His right great toe had an open area where the scab had fallen off the tip of his toe, second toe had an open area on the base of the toe nail on the left side of it and on the right side of it, the third toe had an scabbed appearing area on the knuckle area, the fourth toe had damage to the base of the toenail and was black in appearance. The toenails on both of his feet did need to be trimmed. When queried on how tall Resident #69 was, he replied he was 6'4 tall. Resident #69's top of his head was approximately 2.5 inches from the end of the mattress at the head of the bed. The resident's head of the bed was at an approximate 45 degrees. Resident #69 did not have the prescribed blue heel boot protectors on either foot. Review of Resident #69's medical record revealed no documentation of the declination of the heel protector boots. Review of Admit/Readmit Screener dated 3/26/24, .Section C: Skin Integrity: Details/Comments: Multiple scab areas/bruising x4 extremities .L big toe small pea sized open area at end of big toe .Pacemaker and foley in place . Review of Braden Scale for Predicting Pressure Sore Risk dated 3/26/24, revealed a score of 18 which indicated the resident was At risk for pressure ulcers. During an observation on 04/24/24 at 12:26 PM, Resident #69 was lying in his bed, he did not have the blue heel protector boots on and both of his knees were bent upwards to prevent his feet from being pressed up against the head board. The head of his bed was approximately 30 degrees. In an interview on 04/24/24 at 12:28 PM, Certified Nursing Assistant (CNA) C reported Resident #69 did get assistance with his meals if he requests it. CNA C proceeded to enter Resident #69's room and spoke to him to see if he needed assistance with his meal. CNA C reported to the resident she was lowering his bed so she could adjust him in the bed to pull him up more in the bed and asked him to reach for the headboard and she would pull him up. CNA C repositioned the resident and placed the rolling tray table over the bed and informed the resident of where each item was located on his meal plate and tray. CNA C informed the resident where the call light was and guided his hand to show him. During an observation on 4/24/24 at 3:57 PM, Resident #69 was lying in his bed on his back and he had his legs bent at the knees and leaned over towards the left facing the wall. The head of the bed was approximately 45 degrees. His feet were at the end of the mattress touching the foot board. In an interview on 04/25/24 at 09:58 AM, Registered Nurse (RN) O reported when a skin assessment was completed the nurse would notify the wound nurse of any new wounds or changes to existing wounds and obtain treatment recommendations. In an interview on 04/25/24 at 10:03 AM, Maintenance I reported the maintenance department would be notified by a work order completed by staff. Maintenance I reported the request was on paper and after it was submitted the department had two days to respond to it unless it was deemed emergent. In an interview on 04/25/24 at 10:07 AM, Maintenance I reported Resident #69 had a standard bed which was 6 feet long, but all of their beds were convertible. Maintenance I reported there were two hand screws with twist handles, pull those out, adjust the bed and relock them. Maintenance I reported the head and food of the bed both extend outward approximately 12 inches. Maintenance I reported as he looked at Resident #69's positioning that the bed was not at a comfortable length for him but nursing would have had to initiate a work order for them to be aware of Resident #69's comfortableness and positioning in the bed. In an interview on 04/25/24 at 12:23 PM, Licensed Practical Nurse (LPN) FF reported the nurse would complete the skin observation form in the medical record and if there was any concerns or changes, they would notify the wound nurse, ensure there were treatments in place and contact the appropriate contacts. LPN FF observed the photos of Resident #69's feet and reported those appeared to be pressure wounds which could have been caused by the linens on the bed or from being pressed against something. LPN FF reported the betadine was used to dry out wounds. In an interview on 04/25/24 at 11:56 AM, LPN N reported with skin concerns it would depend on the condition but would notify the wound nurse, add to alert charting to monitor the wound/skin condition, and obtain orders for treatment. LPN N reported Resident #69 preferred to have his feet tucked up and he had slight contractures to his legs. In an interview on 04/25/24 at 12:18 PM, Resident #69 stated, I don't think the sores on my toes are getting any better, can't be getting better if they are still putting medication on them, plus they hurt him and that treatment isn't working. The resident was up dressed and seated in his wheelchair. This writer asked Resident #69 if he could straighten out his legs, Resident #69 proceeded to outstretch his left leg and then his right leg completely. In an interview on 04/25/24 at 09:48 AM, Wound Care Nurse (WCN) F reported when the resident was admitted the wound care nurse would complete the initial admission skin check assessment for the new resident. When queried whether she was aware of the extent of skin concerns for Resident #69 she reported he was not on her rotation and she had not seen him. WCN F reviewed the medical record of Resident #69 and reviewed the skin assessments completed since admission and stated, 4/2/24: no skin issues, groin redness .4/9/24: no new skin issues .4/16/24: no new skin issues .and 4/23/24: no new skin issues. This writer and WNC F proceeded to Resident #69's room to make observations of his wounds on his bilateral toes. During an observation and interview on 04/25/24 at 09:53 AM, WNC F reported after she observed Resident #69's toes, he should have been on her rotation and would be on her rotation and would be seen by the wound provider. WNC F reported the wound looked like they would be pressure ulcers based on their appearance and reported she would complete a referral to the wound provider, who came to the facility to see residents, for them to see Resident #69.

Based on observation, interview, and record review, the facility failed to provide individualized activities based on resident preferences, needs, and abilities for 3 of 18 Residents (Resident #65, Resident #69, and Resident #63) reviewed for activities, resulting in feelings of boredom, and a potential for loneliness, social withdrawal, and depressed mood. Findings include: Resident #65 Review of an Admission Record revealed Resident #65 was a [AGE] year-old male, originally admitted to the facility on [DATE] with pertinent diagnoses which included: aphasia (language disorder affecting verbal communication), and hemiplegia (paralysis on one side of the body) following a cerebral infarction (stroke). Review of a Minimum Data Set (MDS) assessment for Resident #65, with a reference date of 11/23/23 revealed Resident #65 had unclear speech and could not complete a Brief Interview for Mental Status. Section F of the MDS revealed Resident #65 indicated it was very important to him to go outside to get fresh air when the weather was good, somewhat important to pursue his favorite leisure activities, listen to music, and do things with groups of people. Resident #65 felt it was not important at all to pursue religious activities. Review of a Care Plan for Resident #65, with a reference date of 11/24/23 revealed a focus/goal/interventions as follows: Focus: I am an independent person, I would like to be invited to activities, and I enjoy keeping busy .Goal: Resident will maintain involvement in cognitive stimulation, social activities as desired .Interventions: all staff converse with me .encourage ongoing family involvement .I enjoy reading crime books .please go over activities calendar with me . Review of an Activity Assessment for Resident #65 dated 11/10/23 revealed Resident #65 enjoyed traveling, working, learning new things, and reading crime novels. Section C of the assessment revealed Resident #65 wished to participate in activities, including group activities and independent activities but did not want individual visits. Section D indicated that activities did not need to be modified to address a communication deficit. In an interview on 4/24/24 at 1:12pm, Resident #65 used yes/no responses and gestures to communicate. Resident #65 indicated he wanted to get outside more often, would enjoy listening to crime novels on audio books, and would like to listen to rap and rhythm and blues music in his room. When asked if he felt bored frequently, Resident #65 nodded his head up and down to indicate yes. Resident #65 attempted to verbally respond to questions, but his vocal quality was poor and unintelligible. In an interview on 4/23/24 at 12:14pm, Family Member (FM) NN reported Resident #65 did not enjoy the types of activities provided by the facility. RM NN reported Resident #65 enjoyed being outside and loved listening to Rap and Rhythm and Blues music. In an interview on 4/23/24 at 12:27pm, Family Member/Power of Attorney (FM/POA) MM reported she visited Resident #65 approximately 3 times a week and had not seen him attend any group activities. FM/POA reported Resident #65 cried during some of her visits and. FM/POA MM reported Resident #65 enjoyed trivia games, playing cards, listening to rap and rhythm and blues music, and spending time outside. FM/POA MM reported she was worried about Resident #65 losing his abilities and becoming depressed due to his lack of activity. FM/POA MM reported she was assist Resident #65 in pursuing coloring during her visits but he needed someone to encourage him and set it up in order for him to actively participate. In an interview on 4/24/24 at 1:34pm, Community Enrichment Director (CED) OO reported Resident #65 had not been doing a whole lot regarding his involvement in activities. When further queried about what interventions were in place for residents who were not attending group activities, LED OO reported Life Enrichment staff came by and chatted with them. In an interview on 4/24/24 at 2:20pm, Certified Nursing Assistant (CNA) LL reported Resident #65 slept a lot throughout the day and would often be in bed for the night before the evening meal was served. CENA LL reported Resident #65 did not participate in many activities, seemed withdrawn, and primarily seemed to look forward to mealtime. When further queried, CENA LL stated it wouldn't surprise me if he's depressed because he sleeps so much. In an interview on 4/25/24 at 10:20am, Community Enrichment Aide (CEA) PP reported she was assigned to Resident #65's hallway on this date, and that Resident #65 had not been involved in many activities since his admission. When queried about Resident #65's interests, CEA NN stated He really likes church. In an interview on 4/25/24 at 9:53am CED OO reported he was unsure how many activities Resident #65 had been involved in during the last 3 months. CED OO reported it would require a lot of digging to track each residents monthly group activity attendance due to the current documentation process. CED OO reported it was important to be able to track each resident's involvement to ensure the activities program was meeting each person's needs/interests. CED OO reported the facility did offer card games every evening, but he was unsure if Resident #65 had attended. CED OO reported the facility had not offered Resident #65 any devices that would allow him to listen to music or use audio books in his room. Review of activity logs dated February, March, April 2024 revealed Resident #65 participated in 1 exercise group and 2 outdoor visits during the 84-day period. During an observation on 4/23/24 at 1:21pm, Resident #65 laid in bed on his back, curtains were drawn, and the room was dark. Resident #65 appeared to be asleep. During an observation on 4/23/24 at 3:02pm, Resident #65 laid bed on his side, curtains were drawn, and the room was dark. Resident #65 appeared to be asleep. During an observation on 4/24/24 at 11:06am, Resident #65 was lying in bed, awake, his television was on, but he was not watching it. During an observation on 4/24/24 at 1:40pm, Resident #65's curtains were drawn, room darkened, and he sat in his wheelchair, awake with his back turned toward his television. During an observation on 4/24/24 at 2:15pm, Resident #65 laid on his back, in his bed, and appeared to be asleep. During an observation on 4/25/24 at 10:19am, Resident #65 sat in front of a large window at the end of the hallway and looked out the window. Review of The Boredom of Solitude published 4/21/23 by Psychology Today, [NAME] Danckert Ph.D., [NAME], Ph.D, revealed Loneliness is a complex experience, one that can heighten our sense of vulnerability .which leads to elevated stress . and just like boredom, loneliness has been associated with poor mental health, challenges to cognitive function, and even cognitive decline in the elderly .perceived lack of meaning will color things as being boring. So, to solve loneliness, like solutions to boredom, we can't simply reach for any kind of interaction. We need things that are meaningful to us. Review of a facility policy, Community Enrichment, with a reference date of 2/24 revealed a statement: Facility sponsored group, individual and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will .enhance the resident's sense of well-being, belonging, and usefulness .reflect a resident's interests and age .reflect choices of the resident . 41424 Resident #69: Review of an Admission Record revealed Resident #69 was a male with pertinent diagnoses which included glaucoma, chronic pain, pain in right hip, low back pain, severe protein calorie malnutrition, adult failure to thrive, disc degeneration lumbar region, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #69, with a reference date of 4/1/24 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated Resident #69 was cognitively intact. Review of Care plan revised on 4/2/24, revealed the focus, .I prefer independent activities, I would also like to be invited to group activities as well . with the intervention .All staff to converse with me while providing care. I am from (local city), I have three children, I have been married for over [AGE] years, and I enjoy jazz music .I am a religious person. Please invite me to religious based groups .I enjoy spending time outside. Please offer to take me outside when the weather is nice .I enjoy watching sports (baseball and football). Please remind me if there are any games on TV . Review of MDS assessment for Resident #69, with a reference date of 4/1/24 revealed, .Section GG: .Chair/bed-to-chair transfer: Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity . Review of Activities Assessment - Initial/Annual/SC dated 3/29/24 at 2:38 PM, revealed, .A. Past Activity Interests/Service .[NAME] likes baseball, football, and enjoys being outside a lot .previous occupation Gas Manufacturing .Education Level: High school graduate .Military service .b. yes .dd. branch- Army .ee. Specific Era: Vietnam .Religious Affiliation: aa. Protestant .1. Does the resident wish to participate .Yes .2. Does the resident wish to participate in group activities .Yes .5. Does resident like independent activities (i.e. reading, puzzles, etc.)? .Yes .D. Limitations/Special Needs: 4. Activities should be modified to address visual deficit .Yes .6. [NAME] Resident #69 has almost no vision, will need help to locate and grab things . Review of medical record for Resident #69 revealed no Activity notes and/or Activity Participation notes. In an interview on 04/24/24 at 09:34 AM, Resident #69 reported he had low vision and he can't read anything. He reported he had his vision as a child and then when he got older her lost his vision. Resident #69 reported when he was at home his wife would read the Bible to him. Resident #69 reported since he was not able to see it was difficult for him to participate in activities. Resident #69 reported the facility had not offered to have an audiobook version of the Bible for him. There was no noted radio in the room. Reviewed the March 2024 Activity Calendar revealed on .3/28/24 at 1030 Prayer and Worship, 3/28/24 at 200 Bible Study, and 3/2924 at 1030 Men's Club . Review of the A Hall Activity Logs for March 2024 revealed Resident #69 was marked as participating in the activity Room Visit on 3/27/24, 3/29/24, 3/30/24, and 3/31/24 and independent activity Music/TV/Radio on 3/27/24, 3/28/24, and 3/29/24-3/31/24, and the independent activity Visitors on 3/31/24, and the activity Social Dining on 3/27/24. Noted no documentation to indicate if Resident #69 had been invited or encouraged to attend group activities. Reviewed the April 2024 Activity Calendar noted the activity Bible Study was scheduled every Tuesday at 10:30 AM, Prayer and Worship was scheduled every Thursday at 10:30 AM, Men's Group was scheduled every other Friday at 10:30 AM starting on 4/12/24, Church Services were scheduled every Sunday. Note: No activities scheduled geared towards sports or outdoor activities for April 2024. Reviewed the April 2024 Activity Calendar noted the activity 4/2/24: Ice Cream Social, 4/6/24: Corn hole, 4/11/24: Resident Council, 4/13/24: Exercises, 4/15/24: Popcorn Social, 4/19/24: Snack and Chat, and 4/10/24: Karaoke. Review of the A Hall Activity Logs for April 2024 revealed Resident #69 was marked as participating in the activity Room Visit on 4/1/24 - 4/4/24, 4/6/24 - 4/8/24, 4/10/24 - 4/13/24, 4/15/24 - 4/17/24, 4/19/24 - 4/23/24 and the independent activity Music/TV/Radio on 4/1/24 - 4/4/24, 4/6/24 - 4/8/24, 4/10/24 - 4/13/24, 4/15/24 - 4/17/24, 4/19/24 - 4/23/24, the independent activity Visitors on 4/10/24, 4/15/24, 4/20/24, the activity Social on 4/2/24, the activity Bingo on 4/23/24. Noted no documentation to indicate if Resident #69 had been invited or encouraged to attend group activities. Review of activity logs dated March and April 2024 revealed Resident #69 participated in 1 social group activity, 1 bingo activity, and 1 social dining activity during the previous 29-day period. During an observation on 04/23/24 at 10:56 AM, Resident #69 was observed lying in his bed, supine position, with his eyes closed. During an observation on 04/23/24 at 11:15 AM, Resident #69 was observed lying in his bed with the television on low. During an observation on 04/23/24 at 12:08 PM, Resident #69 was observed lying in his bed with the rolling beside table next to him with a couple of snacks on it, with the television on low volume. During an observation on 04/24/24 at 09:25 AM, Resident #69 was observed lying in his bed supine position. The television was on at a low volume. During an observation on 04/24/24 at 12:26 PM, Resident #69 was observed lying in his bed with his lunch on the rolling table over his lap area. In an interview on 4/24/24 at 3:57 PM, Resident #69 was asked if he attended the all month birthday celebration which happened today and he reported he wasn't aware of it. In an interview on 04/25/24 at 12:18 PM, Resident #69 reported he liked to watch sports, jazz music, really like baseball and the Tigers were his team. Resident #69 reported he had been to a few Tigers games before. In an interview on 4/24/24 at 4:17 PM, Community Enrichment Director (CED) OO reported he was at a seminar a few weeks ago and had the activity staff start implementing whether the resident accepted or declined the invitation to attend an activity prior to that it was not done. When queried if Resident #69 had attended any group activities, CED OO reported the resident had not been at the facility very long but he did come to Bingo yesterday. CED OO reported if Resident #69 wanted someone to help him with the chips at Bingo or if he wanted someone to read the Bible to him, they could do that for him but indicated this had not been offered to Resident #69. CED OO indicated he would like to have his staff document activities in the electronic medical record as there was a lot of paper to compile for tracking activity participation. CED OO reported he asked Resident #69 when he was admitted if he wanted a radio in his room and the resident declined but he did not reapproach. 36221 Resident #63 Review of an Admission Record revealed Resident #63 was a male, with pertinent diagnoses which included autism, depression, and a developmental disorder. Review of a Minimum Data Set (MDS) assessment, with a reference date of 3/27/24, revealed Resident #63 had a short-term memory problem, and some difficulty with daily decision making in new situations. Review of an Activities Assessment for Resident #63, dated 7/6/23, revealed .(Resident #63) enjoys playing music, drawing, reading magazines, and working on various forms of artwork .Does the resident wish to participate in activities while in the home? Yes .Does the resident wish to participate in group activities? Yes .Does the resident wish 1:1 with staff? No . Review of a current Care Plan for Resident #63 revealed the focus .I enjoy independent activities (reading and listening to music), and I may attend activities with some encouragement . initiated 7/14/23, with interventions which included .All staff to converse with me while providing care .I am Christian, and I enjoy listening to country and Christian music .I am a religious person. Please offer to take me to bible study on days it is offered . initiated 7/14/23, and .I enjoy being outside or in the sun. Please offer to take me outside when weather permits or offer to put a chair in the sun for me . initiated 8/9/23. Review of an Activity Note for Resident #63, dated 1/4/24, revealed .(Resident #63) is not receptive to attending activities or room visits too much, but he enjoys company when he is open to it . Review of a Care Conference note for Resident #63, dated 1/17/24, revealed .Dietary reported that (Resident #63) has gained weight which isn't a problem as long as he becomes more active. Activities will encourage him in that area . Review of a Behavior Note for Resident #63, dated 4/19/24, revealed .(Resident #63) had 3 noted behaviors in this review period of agitation, mood changes, restless, uncooperative, and withdrawn. Noted increase from previous month. Non pharmacological interventions were .involve in activities . In an observation on 4/23/24 at 10:51 AM, Resident #63 was noted in bed in his room. Resident #63 was awake, watching television. In an observation on 4/23/24 at 12:21 PM, Resident #63 was noted sitting on the edge of the bed in his room, drumming his hands on the tray table. In an observation on 4/23/24 at 2:54 PM, Resident #63 was noted sitting in his armchair in his room, with the television on. In an observation on 4/24/24 at 9:25 AM, Resident #63 was noted in bed in his room, laying on his left side facing the wall. Noted his television was on, with the volume low. In an interview on 4/24/24 at 9:43 AM, Family Member SS reported Resident #63 enjoys music, plays the drums, and often strums on his acoustic guitar. Family Member SS reported Resident #63 also enjoys coloring. Family Member SS reported with Resident #63, his participation depends on how he is approached, and stated .He is really good at saying no . Family Member SS reported he believes Resident #63 would be interested in group activities, and hopes facility staff .keep trying . to encourage his participation. In an observation on 4/24/24 at 11:36 AM, Resident #63 was noted in bed in his room, laying on his right side with his eyes closed. In an observation on 4/24/24 at 12:17 PM, Resident #63 was noted in bed in his room, laying on his right side with his eyes closed. Noted his television was on, with the volume low. In an observation on 4/24/24 at 3:41 PM, Resident #63 was noted in bed in his room, laying on his left side facing the wall. Noted a guitar in Resident #63's room, leaning against the far wall. In an interview on 4/24/24 at 3:45 PM, Certified Nursing Assistant (CNA) Y reported Resident #63 does not do much during the day, and spends most of his time in bed. CNA Y stated Resident #63 .comes alive at night . and will sometimes spend time with staff at the nurses desk, playing his guitar or coloring. In an observation on 4/25/24 at 9:50 AM, Resident #63 was noted in bed in his room, laying on his left side facing the wall. Noted his television was on, with the volume low. In an interview on 4/25/24 at 9:55 AM, CNA TT reported Resident #63 will occasionally be up all day strumming on his guitar, and then other days spends the majority of the day in bed. CNA TT reported she has not observed Resident #63 in any group activities. CNA TT reported Resident #63 sometimes enjoys going with staff to the cafeteria to get a pop. Review of the B Hall Activity Logs for February 2024 revealed Resident #63 was marked as participating in the activity Room Visit on 2/7/24, 2/11/24, 2/12/24, 2/17/24, 2/19/24-2/22/24, and 2/24/24-2/29/24, the independent activity Music/TV/Radio on 2/11/24, 2/12/24, 2/16/24, 2/17/24, and 2/19/24-2/29/24, the activity Social on 2/7/24, 2/14/24, 2/18/24, 2/20/24-2/23/24, and 2/29/24, the activity Music/Singing on 2/14/24 and 2/18/24, and the independent activity Crafts on 2/18/24. Noted no documentation to indicate if Resident #63 had been invited or encouraged to attend Religious or Outdoors activities. Review of the B Hall Activity Logs for March 2024 revealed Resident #63 was marked as participating in the activity Room Visit on 3/1/24-3/15/24, 3/17/24, 3/19/24-3/21/24, and 3/23/24-3/31/24, the independent activity Music/TV/Radio on 3/1/24-3/24/24 and 3/26/24-3/31/24, the independent activity Visitors on 3/5/24 and 3/24/24, the activity Music/Singing on 3/8/24 and 3/27/24, the activity Social on 3/11/24, 3/16/24, 3/17/24, 3/27/24, and 3/30/24, the activity Movies/TV (TV Room) on 3/16/24, and the independent activity Crafts on 3/20/24. Noted no documentation to indicate if Resident #63 had been invited or encouraged to attend Religious or Outdoors activities. Reviewed the April 2024 Activity Calendar. Noted the activity Bible Study was scheduled every Tuesday at 10:30 AM, Thursday 4/18/24 at 2:00 PM, and Thursday 4/25/24 at 2:00 PM. Review of the B Hall Activity Logs for April 2024 revealed Resident #63 was marked as participating in the activity Room Visit on 4/1/24-4/9/24, 4/13/24-4/14/24, and 4/16/24-4/23/24, the independent activity Music/TV/Radio on 4/1/24-4/10/24, 4/13/24-4/14/24, and 4/16/24-4/22/24, the independent activity Visitors on 4/3/24, the activity Education on 4/5/24, the activity Social on 4/6/24, 4/8/24, 4/10/24, 4/14/24, 4/16/24, 4/17/24, 4/21/24, and 4/22/24, and the activity Pets/Birds on 4/14/24. Noted no documentation to indicate if Resident #63 had been invited or encouraged to attend Religious or Outdoors activities. In an interview on 4/25/24 at 11:15 AM, Community Enrichment Director OO stated in regard to Resident #63 .He is a very unique individual. He clicks with a few of my employees. Other times (Resident #63) is quick to push someone out . Community Enrichment Director OO reported Resident #63 sometimes comes out in the hallway to play music on his guitar, and stated .most of the time we only get him to do room visits . Community Enrichment Director OO reported documentation under the activity Social indicates the resident was participating in some type of social behavior, such as talking to another resident or staff in the hallway. Community Enrichment Director OO reported Social does not necessarily indicate a scheduled or group activity. Community Enrichment Director OO reported a Room Visit is typically 20-30 minutes long, and the content of this activity depends on resident preferences. Community Enrichment Director OO reported the activity Music/TV/Radio indicates that a resident was participating in this type of activity independently in their room. Community Enrichment Director OO reported Resident #63 does not attend religious activities. Community Enrichment Director OO reported Resident #63 should still be invited to attend group activities. Community Enrichment Director OO reported in regard to activity documentation, activity staff recently switched to documenting A for accept or D for decline on the activity logs, beginning 4/12/24, to show which activities the residents were invited to.

Based on observation, interview, and record review, the facility failed to maintain the dignity of one resident (#46) of 18 residents reviewed for dignity, by denying the resident the right to use personal belongings of choice in her room. This deficient practice resulted in decreased ability to pursue an independent activity of choice, and feelings of frustration and disappointment. Findings include: Resident #46 Review of a facility policy titled Resident Personal Belongings with a review date of 4/24 revealed: It is the policy (facility name omitted) to protect the resident's right to posses personal belongings .for their use while in (facility name omitted) . will support the resident's right to .use personal possessions to promote a homelike environment . Review of an Admission Record revealed Resident #46, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: major depressive disorder and occipital neuralgia (condition in which the occipital nerves are inflamed causing headaches/blurred vision, neck pain). Review of a Minimum Data Set (MDS) assessment for Resident #46, with a reference date of 4/10/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #46 was cognitively intact. Section B revealed Resident #46 wore glasses. During an observation on 4/23/24 at 3:17pm, a 40 television sat in a box on the floor near Resident #46's shelving unit. The head of Resident #46's bed was against the wall on the right side of the room. A small television was mounted on the wall opposite of Resident #46's bed, in a recessed area with shelving. The distance from Resident #46's head of her bed to the television was approximately 15 feet. In an interview on 4/23/24 at 3:18pm, Resident #46 reported her daughter her a larger television to use in her room because the facility's television was too small for her to use. Resident #46 reported she was told she could not use the 40 television in her room because the wall mounted brackets that held the facility's television would only accommodate a 32' television. Resident #46 reported she offered to purchase larger brackets herself if the facility would install them and was told that was not an option. During an observation on 4/24/24 at 4:08pm, Resident #46 sat at the edge of her bed, resting her arms on her bedside table, staring straight ahead in her darkened room. During an observation 4/25/24 at 10:21am, Resident #46 sat at the edge of her bed, resting her arms on her beside table, staring straight ahead. In an interview on 4/24/24 at 3:59pm, Social Services Director (SSD) U reported the facility had no specific restrictions regarding the personal belongings residents used in their rooms unless they posed a safety hazard. SSD U reported the facility refused to allow Resident #46 to use the 40 television her daughter purchased for her because the television would not fit above the shelving in the room. When further queried, SSD U reported the facility had not explored other options for mounting the television, changing the location of the television bracket, running additional cable to the television. In an interview on 4/24/24 at 4:04pm, Social Services Assistant S reported the facility would provide Resident #46 with a 34 television but would not allow her to use the 40 television. In an interview on 4/24/24 at 4:09pm, Resident #46 she could not enjoy watching television on the smaller television the facility provided because she could not see it well, and had developed headaches after watching it for short periods of time. Resident #46 reported in her own home, prior to coming to the facility, she had a larger television and never developed headaches while watching it. Resident #46 reported her daughter measured the space where the facility television was mounted and found the opening to be 40 wide by 48 diagonal which would accommodate the larger television. Resident #46 reported facility made no attempt to resolve the issues involving mounting the television on the wall and she was told it was at the discretion of the maintenance department regarding her use of a larger television. In an observation on 4/24/24 at 4:16pm, the measurements of the television space in Resident #46's room were confirmed to be 40 wide, >40 high, by 48 diagonal. The 40 television measured approximately 38 wide by 20 high.

This citation pertains to intake #MI00143146 Based on interview and record review the facility failed to assess, monitor, and treat a resident with a skin tear in 1 resident (Resident #101) of 3 residents reviewed for quality of care, resulting in an Resident #101 having a skin tear not cared for for 4 days and signs and symptoms of a wound infection due to lack of care. Findings include: Review of an Admission Record revealed Resident #101 had pertinent diagnoses which included: unspecified dementia, general anxiety disorder, reduced mobility, and urinary tract infection. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 1/3/24 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #101 was severely cognitively impaired. Review of Physician Orders for Resident #101 revealed .monitor skin tear to right upper thigh every shift for worsening or s/s (signs and symptoms) of infection until resolved started on 2/22/24 at 07:00 AM and Cleanse skin tear to right upper thigh with NS and cover with a dry dressing daily until resolved. Review of Progress Note from provider dated 2/22/24 revealed .reason for visit skin issue . chief complaint skin wound injury . right thigh skin tear .SKIN: right thigh skin tear noted .assessment: right thigh skin tear . Plan: Ensure proper wound care . Review of Progress Notes for Resident #101 dated 2/25/24 revealed .continue to monitor skin tear on R (right) thigh. No s/s (sign and symptoms) infection noted . Review of Progress Notes for Resident #101 dated 2/26/24 revealed No s/s of infection to right thigh, will continue to monitor . Review of Treatment Administration Record (TAR) for Resident #101 revealed documentation indicated the order for cleanse skin tear on right upper thigh with NS and cover with dry dressing daily until resolved. One time a day; and monitor skin tear to right upper thigh every shift for worsening or s/s of infection until resolved every shift; both orders were noted to be documented as completed on each of the shifts on the dates 2/23/24, 2/24/24, 2/25/24, and 2/26/24. No documentation was noted to indicate that the orders were not complete. Review of Staff Schedule for the dates of 2/23/24 through 2/26/24 revealed 8 licensed nurses had been assigned to care for Resident #101 during those dates. Review of TAR for Resident #101 for the dates of 2/23/24, 2/24/24, 2/25/24, and 2/26/24 revealed 8 licensed nurses had documented the completion of the order to monitor Resident #101's skin tear to the right upper thigh and 4 licensed nurses had documented completion of the ordered daily dressing change. Review of Progress Note for Resident #101 dated 2/27/24 at 07:00 revealed . skin tear to right thigh noted. Yellowish/green drainage noted on dressing. Dressing changed. Cleansed with NS, applied TAO (triple antibiotic ointment) and covered with a dry dressing . placed in dr. book for rounds in AM r/t (related to) increased drainage. Review of handwritten communication note dated 2/27/24 revealed CNA's (certified nurse assistant) called the nurses to change resident dressing to right thigh. Observed the dressing was dated for 2/22/24 .Order is in for it to be changed daily. It has been signed out all 4 days as done . wound is a lot bigger with green drainage . During an interview on 3/20/24 at 6:50 AM., CNA D reported that on 2/22/24 Resident #101 was found to have a skin tear on her right upper thigh. CNA D reported that a dressing was applied to the skin tear by the nurse on 2/22/24. CNA D reported the nurse was notified on 2/27/24 that the dressing on Resident #101's right upper thigh needed to be changed. CNA D reported that the dressing present on Resident #101's right thigh on 2/27/24 was dated as 2/22/24 at 2:20 AM. CNA D reported that Resident #101 verbalized pain during the dressing change on 2/27/24. CNA D reported that the wound appeared slimy with pus and green colored drainage, and the dressing was wet with green/yellow puss and drainage. CNA D reported that the dressing on Resident #101's right leg appeared to not have been changed for 4 days. Purulent drainage (pus or exudate) is a symptom of infection. This thick, milky fluid oozes from a wound that isn ' t healing properly. It contains a mixture of dead cells and bacteria, as well as white blood cells, which rush to the site at the first sign of injury. Pus from an infected wound might be white, yellow, green, pink or brown in color. Changes in purulent drainage color or odor usually mean the infection is getting worse. Left untreated, a wound with purulent drainage can turn into a chronic wound (also called a non-healing wound). This refers to a wound that doesn ' t heal within eight weeks. This type of infection can spread to other areas of your body, causing increased pain and a range of health complications .The best way to reduce your risk of purulent drainage is to clean and dress the wound properly. (https://my.clevelandclinic.org/health/symptoms/purulent-drainage) During an interview on 3/20/24 at 6:09 AM., LPN H reported that on 2/27/24 the CNA notified her that Resident #101's dressing on her right thigh needed to be changed. LPN H reported that the dressing, dislodged from the wound area and was dated for 2/22/24 at 02:20 AM. LPN 'H reported that on 2/27/24 the dressing was noted to have green drainage, a foul odor, and the skin tear on Resident #101's right thigh appeared to be spread open with drainage present. LPN 'H reported that the dressing appeared to have not been changed in 4 days when it should have been changed daily. During an interview on 3/20/24 at 7:46 AM., RN G reported that she applied a dressing to Resident #101's right upper thigh on 2/22/24 for a skin tear. RN G reported that the edges of the skin tear were well approximated (closely touching) and there was no noted blood or drainage on 2/22/24. RN G reported she completed a skin observation tool, an incident report, a progress note, and orders to change the dressing and monitor the wound daily. RN G reported she notified the manager, the provider, and family member about the injury. RN G reported that she was notified on 2/27/24 by the CNA that Resident #101's dressing needed to be changed. RN G reported that the dressing that was present on #101's right thigh was the same dressing she had applied on 2/22/24. RN G reported she verified there was an order in place to change the dressing daily and noted documentation in the TAR that the dressing change had been completed daily since the order was started on 2/22/23. RN G reported that the wound edges were no longer well approximated, and there was green/yellow drainage noted. RN G reported that the findings were noted in the doctor's book for increased drainage and as a request for a doctor's visit, and the findings were reported to the unit manager. During an interview on 3/19/24 at 4:23 PM., Unit Manager (UM) I reported that Resident #101 did have a skin tear on her right upper thigh. UM I reported that the dressing was changed daily, there was no concern with the dressing change being completed and that the wound had not healed prior to Resident #101 passing away on 3/15/24. During a second interview on 3/20/24 at 10:29 AM., UM I reported that Resident #101 obtained a skin tear on 2/22/24 and there was an order for monitoring the wound every shift and an order for a daily dressing change. When asked, UM I confirmed that concerns that Resident #101's dressing changes were not being completed as ordered were brought to her attention on 2/27/24. UM I reported that she assessed Resident #101's wound by pealing back the dressing and visualizing the wound and there was no drainage present. UM I reported she asked the wound nurse to monitor Resident #101's wound. UM I reported Resident #101 was not added to the providers rounding list to be seen since the wound had no drainage when she assessed it (after the dressing had already been changed). UM I reported that she did not document her assessment of Resident #101's wound. UM I reported that she discussed the concerns for Resident #101's dressing changes not being completed with the management team and a one-to-one education was provided to one nurse. UM I reported that there was no documentation regarding the concern, the discussion, or the one-to-one education she provided. UM I reported that she did not complete an investigation into the concern for Resident #101's dressing changes not being done.

This citation pertains to intake #MI00143146 Based on interview and record review the facility failed to provide services that meet professional standards of nursing practice related to assessing, monitoring and providing wound care dressing changes for 1 resident (Resident #101) of 3 residents reviewed for professional standards, resulting in ineffective monitoring, dressing changes not completed as ordered, inaccurate documentation, and Resident #101 having a skin tear not cared for for 4 days with signs and symptoms of a wound infection. Findings include: Review of an Admission Record revealed Resident #101 had pertinent diagnoses which included: unspecified dementia, general anxiety disorder, reduced mobility, and urinary tract infection. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 1/3/24 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #101 was severely cognitively impaired. Review of Incident Note dated 2/22/24, 02:20 AM revealed . Resident has a new 5 cm skin tear to her right upper thigh .cleansed skin tear with NS (normal saline), patted dry, and covered with dry dressing .on call manager, provider, and family notified .new order to monitor skin tear till resolved and cleanse daily . Review of Midnight Census report as used for rounding requests for providers dated 2/22/24 revealed . Resident #101 was listed for an acute visit for a skin tear on the right thigh . Review of Progress Note from provider dated 2/22/24 revealed .reason for visit skin issue . chief complaint skin wound injury . right thigh skin tear .SKIN: right thigh skin tear noted .assessment: right thigh skin tear . Plan: Ensure proper wound care . Review of Physician Orders for Resident #101 revealed .monitor skin tear to right upper thigh every shift for worsening or s/s (signs and symptoms) of infection until resolved started on 2/22/24 at 07:00 AM and Cleanse skin tear to right upper thigh with NS and cover with a dry dressing daily until resolved. Review of Midnight Census report as used for rounding requests for providers dated 2/23/24 revealed Resident #101 was listed for an acute visit for a new skin issue and crossed out and indicated addressed 2/22. Review of Progress Notes for Resident #101 dated 2/25/24 revealed .continue to monitor skin tear on R (right) thigh. No s/s (sign and symptoms) infection noted . Review of Progress Notes for Resident #101 dated 2/26/24 revealed No s/s of infection to right thigh, will continue to monitor . Review of Progress Note for Resident #101 dated 2/27/24 at 07:00 revealed . skin tear to right thigh noted. Yellowish/green drainage noted on dressing. Dressing changed. Cleansed with NS, applied TAO (triple antibiotic ointment) and covered with a dry dressing . placed in dr. (doctor) book for rounds in AM r/t (related to) increased drainage. Review of handwritten communication note dated 2/27/24 revealed CNA's (certified nurse assistant) called the nurses to change resident dressing to right thigh. Observed the dressing was dated for 2/22/24 .Order is in for it to be changed daily. It has been signed out all 4 days as done . wound is a lot bigger with green drainage . Review of Treatment Administration Record (TAR) for Resident #101 revealed documentation indicated the order for cleanse skin tear on right upper thigh with NS and cover with dry dressing daily until resolved. One time a day; and monitor skin tear to right upper thigh every shift for worsening or s/s of infection until resolved every shift; both orders were noted to be documented completed on each of the shifts on the dates 2/23/24, 2/24/24, 2/25/24, and 2/26/24 by the nurses working that shift. During an interview on 3/20/24 at 6:50 AM., CNA D reported that on 2/22/24 Resident #101 was found to have a skin tear on her right upper thigh. CNA D reported that a dressing was applied to the skin tear by the nurse on 2/22/24. CNA D reported the nurse was notified on 2/27/24 that the dressing on Resident #101's right upper thigh needed to be changed. CNA D reported that the dressing present on Resident #101's right thigh on 2/27/24 was dated as 2/22/24 at 2:20 AM. CNA D reported that Resident #101 verbalized pain during the dressing change on 2/27/24. CNA D reported that the wound appeared slimy with puss and green colored drainage, and the dressing was wet with green/yellow puss and drainage. Purulent drainage (pus or exudate) is a symptom of infection. This thick, milky fluid oozes from a wound that isn ' t healing properly. It contains a mixture of dead cells and bacteria, as well as white blood cells, which rush to the site at the first sign of injury. Pus from an infected wound might be white, yellow, green, pink or brown in color. Changes in purulent drainage color or odor usually mean the infection is getting worse. Left untreated, a wound with purulent drainage can turn into a chronic wound (also called a non-healing wound). This refers to a wound that doesn ' t heal within eight weeks. This type of infection can spread to other areas of your body, causing increased pain and a range of health complications .The best way to reduce your risk of purulent drainage is to clean and dress the wound properly. (https://my.clevelandclinic.org/health/symptoms/purulent-drainage) During an interview on 3/20/24 at 6:09 AM., LPN H reported that on 2/27/24 the CNA notified her that Resident #101's dressing on her right thigh needed to be changed. LPN H reported that the dressing, dislodged from the wound area and was dated for 2/22/24 at 02:20 AM. LPN 'H reported that on 2/27/24 the dressing was noted to have green drainage, a foul odor, and the skin tear on Resident #101's right thigh appeared to be spread open with drainage present. During an interview on 3/20/24 at 7:46 AM., RN G reported that she applied a dressing to Resident #101's right upper thigh on 2/22/24 for a skin tear. RN G reported that the edges of the skin tear were well approximated (closely touching) and there was no noted blood or drainage on 2/22/24. RN G reported she completed a skin observation tool, an incident report, a progress note, and orders to change the dressing and monitor the wound daily. RN G reported she notified the manager, the provider, and family member about the injury. RN G reported that she was notified on 2/27/24 by the CNA that Resident #101's dressing needed to be changed. RN G reported that the dressing that was present on #101's right thigh was the same dressing she had applied on 2/22/24. RN G reported she verified there was an order in place to change the dressing daily and noted documentation in the TAR that the dressing change had been completed daily since the order was started on 2/22/23. RN G reported that the wound edges were no longer well approximated, and there was green/yellow drainage noted. RN G reported that the findings were noted in the doctor's book for increased drainage and as a request for a doctor's visit, and the findings were reported to the unit manager. Review of Staff Schedule for the dates of 2/23/24 through 2/26/24 revealed 8 licensed nurses had been assigned to care for Resident #101 during those dates. Review of TAR for Resident #101 for the dates of 2/23/24, 2/24/24, 2/25/24, and 2/26/24 revealed 8 licensed nurses had documented the completion of the order to monitor Resident #101's skin tear to the right upper thigh and documented completion of the ordered daily dressing change. Review of Staff Schedule for the dates of 2/23/24 through 2/26/24 revealed that RN L was scheduled to work with Resident #101 on two days during the hours of 7 am and 7 pm. Review of TAR for Resident #101 for the dates of 2/23/24 through 2/26/24 revealed that RN L documented she completed the daily dressing change to her right upper thigh on the two days she worked. During an interview on 3/19/24 at 4:06 PM., RN L reported that Resident #101 had a skin tear on her right inner thigh and the dressing was changed daily on the day shift and she did not recall any drainage. RN L reported she did not recall any time during a shift she worked when she was unable to complete the scheduled dressing change for Resident #101. During a telephone interview on 3/20/24 at 9:03 AM., RN L reported that an order to monitor a wound or dressing the nurse needs to look for changes and document if there are any. RN L reported that to monitor a dressing the nurse would make sure the dressing was clean, dry, and intact. RN L reported that dressings should be dated and timed when changed and during monitoring if the date is old that dressing should be changed. RN L stated that if a dressing had an old date, she would automatically change it. RN L reported that she recalls Resident #101 having a dressing to her right upper thigh but did not recall a time when she didn't change the dressing as ordered. Review of Staff Schedule for the dates of 2/23/24 through 2/26/24 revealed that RN J was scheduled to work with Resident #101 on one day during the hours of 7 am and 7 pm. Review of TAR for Resident #101 for the dates of 2/23/24 through 2/26/24 revealed that RN J documented she completed the daily dressing change to her right upper thigh on the one day she worked. During an interview on 3/20/24 at 8:20 AM., RN J reported that Resident #101 had a skin tear on her right upper thigh and the dressing was to be changed daily. RN J reported that dressing change documentation occurred on the TAR, and it should include when a dressing change was not completed. RN J reported that she did not have a day she documented completing Resident #101's dressing change and it did not occur. During an interview on 3/19/24 at 4:23 PM., Unit Manager (UM) I reported that Resident #101 did have a skin tear on her right upper thigh. UM I reported that the dressing was changed daily, there was no concern with the dressing change being completed. During a second interview on 3/20/24 at 10:29 AM., UM I reported that Resident #101 obtained a skin tear on 2/22/24 and there was an order for monitoring the wound every shift and an order for a daily dressing change. When asked, UM I confirmed that concerns that Resident #101's dressing changes were not being completed as ordered were brought to her attention on 2/27/24. UM I reported that she assessed Resident #101's wound by pealing back the dressing and visualizing the wound and there was no drainage present. UM I reported she asked the wound nurse to monitor Resident #101's wound. UM I reported Resident #101 was not added to the providers rounding list to be seen since the wound had no drainage when she assessed it. UM I reported that she did not document her assessment of Resident #101's wound. UM I reported that she discussed the concerns for Resident #101's dressing changes not being completed with the management team and a one-to-one education was provided to one nurse. UM I reported that there was no documentation regarding the concern, the discussion, or the one-to-one education she provided. UM I reported that she did not complete an investigation into the concern for Resident #101's dressing changes not being done. The Professional Standard of Quality for documentation of the resident's health care in a medical record is the information must be true and complete. Under no circumstances should erroneous records be removed from the overall record and new pages submitted. (Fundamentals of Nursing, Concepts, and Practice. Mosby. [NAME], P.A., [NAME], A.G., 1985) According to the Nursing's Social Policy Statement (American Nurses Association, 2003, pg. 2), Society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality in performance is at the heart of this relationship. It goes on to state (pg. 11), Professional nursing .is accountable for ensuring that its members act in the public interest in the course of providing the unique service society has entrusted to them.

Based on observation, interview, and record review, the facility failed to prevent the development and /or worsening of pressure ulcers in 2 of 2 residents (R56 and R31) reviewed for pressure ulcer prevention, resulting in the worsening of a sacral pressure ulcer and deep tissue injury for R56 and the development of pressure ulcers for R31. Findings include: Resident #56: Review of an Admission Record revealed Resident #56 was a female with pertinent diagnoses which included pressure ulcer of sacral region stage 2, down syndrome, adult failure to thrive, need for assistance with personal care, kidney failure, and incontinence without sensory awareness. Review of current Care Plan for Resident #56, revised on 12/31/22, revealed the focus, .I am at high risk for skin breakdown per my Braden assessment. I was admitted with an unstageable pressure injury to the sacrum and acquired a DTI (deep tissue injury) to my right ischial with the potential for further skin breakdown r/t cognitive loss, communication deficits, incontinence, immobility . with the intervention .Turn & reposition every 2 hour in bed and chair (1/12/23) .Monitor and report signs of skin breakdown to Nurse (12/17/22) .Apply- Skin Protectant to bilateral buttocks (12/16/22) .Administer treatments as ordered and monitor for effectiveness (12/18/22) .Skin observation 3x weekly per protocol (1/12/23) .Heel protector boots when in bed (2/15/23) .Please only have resident up with meals, but no longer than 2 hours in chair at a time (3/7/23) and Please assist me back to bed if I have been in my chair for more than 2 hours at a time . Review of Admission Report Sheet/Hand Off Form dated 12/16/23, revealed, .Skin Condition: Coccyx .Treatments/Dressing orders: Mepilex . Review of Doctor Visit/Chart Review dated 12/20/23 at 10:24 AM, revealed, .Assessment and Plan: 4. Stage 2 PU (pressure ulcer) - local wound care measures. Does not reposition self. Will need offloading and monitoring . Review of Health Status Note dated 12/23/2022 7:38 PM, revealed, .Note Text: Resident's wounds noted on admission assessed by Wound Care Coordinator (WCC) RN. Sacrum: Unstageable pressure ulcer to medial sacrum measuring 2.4 x 1.4 X 0.1 cm with wound bed tissue consisting of 70% yellow slough tissue and 30% red granulation tissue. Wound edges well-defined and without tunneling, undermining, or epibole (wound edge curling). Peri-wound tissue WNL without erythema, heat, or induration. R. Ischium: previously noted deep tissue injury evolved into a stage II pressure injury measuring 2.1 x 2.4 x 0.1cm. Wound bed consists of 100% red granulation tissue. Wound edges ill-defined but without undermining, tunneling, or epibole. Peri-wound tissue WNL without erythema, induration, or heat .Recommend treatment with leptospermum honey to both wounds and covering with the sacral wound with a optifoam sacral dressing every three days to promote autolytic debridement. The ischial wound will also be covered with an optifoam dressing every three days . Review of Skin/Wound Note dated 12/26/2022 at 3:31 PM, revealed, .Resident's wounds reassessed during wound rounds. Unstageable wound to sacrum measures 1.8 x 1.0 x 0.1cm with wound bed tissue consisting of 80% yellow slough tissue and 20% red granulation tissue. Wound edges well-defined and without undermining, tunneling, or epibole. Peri-wound tissue without erythema, induration, or heat. The deep tissue injury to the resident's left ischial tuberosity (bony protrusion which takes the body's weight during sitting) has evolved into a stage II pressure injury measuring 0.9 x 0.8x 0.1cm with wound bed consisting of 100% red granulation tissue. Wound edges WNL without undermining, tunneling, or epibole. Peri-wound tissue without erythema, induration, or heat observed .Recommend continuing with current treatment orders . Review of Health Status Note dated 12/30/2022 at 03:14 PM, revealed, .Resting in bed with eyes closed at this time .Skin pale pink, warm, and dry. Extreme dry skin on chest and bottom of both feet with peeling, chest skin receiving medication treatment. Has two areas with intact drsg. in place, one on thigh and one over coccyx . Review of Order dated 1/2/23, revealed, .Keep resident's head of bed to 30 degrees or less except when eating/drinking and 30 minutes after PO intake . Review of Order dated 1/9/23, revealed, .Wound Consult . Review of Order dated 1/11/23, revealed, .Skin Observation Tool: every day shift every Mon, Wed, Fri Alert Wound Nurse/Unit Manager of any new skin concerns . Review of Order dated 1/12/23, revealed, .Monitor Sacrum (PI) two times a day for s/s of worsening or infection . Review of Skin/Wound Note dated 1/2/2023 at 09:31 AM, revealed, .Resident's wounds reassessed by WCC RN .The unstageable pressure injury to the resident's sacrum measures 1.7 x 1.3 x 0.1cm. No exudate noted upon dressing removal. Wound bed consists of 70% yellow slough tissue and 30% red granulation tissue. Wound edges are circular in configuration and they are without undermining, tunneling, or epibole. Peri-wound tissue WNL and without erythema, induration, or heat. Recommend increasing frequency of dressing changes to sacrum to twice daily. The head of the resident's bed should be kept to 30 degrees or lower except when the resident is eating/drinking and 30 minutes afterwards to reduce shearing forces to the wound bed. Will also add liquid protein supplementation daily . Review of Skin & Wound Evaluation dated 1/2/2023, revealed, .Sacrum: Pressure Ulcer, Unstageable .Wound Measurements: 1.7x 1.3x 0.1CM .Granulation: 30% wound filled .Slough: 70% wound filled .Surrounding Tissue: Denuded: loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate, or friction .Progress: Deteriorating . Review of Skin & Wound Evaluation dated 1/2/2023, revealed, .Pressure: Stage: Deep Tissue Injury .Left Ischial Tuberosity . Note: No other data. Review of Skin & Wound Evaluation dated 1/7/2023, revealed, .Pressure: Stage: Unstageable: Obscured full-thickness skin and tissue loss .Sacrum .Measurements: 3.0 x 2.0 x 2.0 CM .Epithelial: 0% of wound covered .Granulation: 10% of wound filled .Slough: 80% of wound filled .Eschar: 10% of wound filled .Exudate: Light, Purulent (sign of infection, made up white blood cells trying to fight the infection, it's white, yellow, or brown fluid, and there may be an unpleasant smell to the fluid) .Open lesion .Left Ischial Tuberosity .Measurements: .7 x .8 x .1 CM .Granulation: 90% of wound filled .Slough: 0% of wound filled .No infection noted. Wound appears to be a shearing injury. Triad cream applied as dressing . Review of Skin & Wound Evaluation dated 1/9/2023, revealed, .Pressure: Unstageable .Due to Slough and/or eschar .Sacrum .Measurements: 3.0 x 2.8 x 1.5 CM .Slough: 100% wound filled .Exudate: Light, Serous (thin, watery fluid produced in response to local inflammation) .Surrounding Tissue: Denuded: loss of epidermis caused by exposure to urine, feces, body fluid, wound exudate, or friction .Erythema: Redness of the skin: may be intense bright red to dark red or purple . Review of Skin & Wound Evaluation dated 1/23/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: None entered .Slough: 100% wound filled .Exudate: Light, Serous . Surrounding Tissue: Erythema: Redness of the skin - may be intense bright red to dark red to purple .Progress: Deteriorating . Review of Doctor Visit/Chart Review dated 1/23/23 at 4:07 PM, revealed, .Late Entry: Visit per (Wound Provider) services (Wound provider) MD .Change in treatment to be made .Primary Nurse apprised . Review of Treatment Administration Report (TAR) for January 2023, revealed, .Sacrum: Cleanse with NS (normal saline) or wound cleanser. Apply leptospermum honey to wound bed. Cover with bordered gauze dressing. In the morning for Unstageable Pressure Injury .Start date: 1/18/23 .D/C date: 1/24/23 . For dates: 1/20/23 and 1/23/23 the order was not implemented and not denoted on the report. Review of Treatment Administration Report (TAR) for January 2023, revealed, .Skin Observation Tool every day shift every Mon, Wed, Fri. Alert Wound Nurse/Unit Manager of any new skin concerns .Start date: 1/11/23 at 07:00 AM . For date, 1/20/23 the order was not implemented and not denoted on the report. Review of medical record revealed, Resident #56 was in isolation from 1/31/23 to 2/11/23 due to testing positive for COVID-19. Review of Skin & Wound Evaluation dated 2/1/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 1.6 x 1.2 x 1.9 CM .Epithelial 10% wound covered .Granulation: 10% wound filled .Slough: 80% wound filled .Other: Bleeding, Pink or Red .Exudate: Light, Serous . Review of Health Status Note dated 2/5/2023 at 10:47 PM, revealed, .Remains in Enhanced respiratory isolation for + COVID on 1/31. Resting in bed with eyes open. Communication per typical with looks, movement, and occasionally a word or two. Accepted offered evening snack. Skin pale pink, warm, and dry. Resp. even and unlabored. No cough heard. VS stable . Review of Doctor Visit/Chart Review dated 2/7/2023 at 6:34 PM, revealed, .Note Text: (Wound Provider) PA from (Wound Care Provide Business Name) wound care here to see resident . Review of Skin & Wound Evaluation dated 2/9/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 2.8 x 2.3 x 1.5 CM . Granulation: 10% wound filled .Slough: 90% wound filled .Surrounding Tissue: Erythema: Redness of the skin - may be intense bright red to dark red to purple .Progress: Deteriorating . Review of Skin & Wound Evaluation dated 2/16/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 2.7 x 1.8 x 1.9 CM .Slough: 100% wound filled . Review of Skin & Wound Evaluation dated 2/21/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 4.2 x 1.9 x 3.1 CM . Eschar: 100% .Exudate: Light, Serous .Surrounding Tissue: Erythema: Redness of the skin - may be intense bright red to dark red to purple . Review of Treatment Administration Report (TAR) for February 2023, revealed, .Monitor Sacrum (PI) two times a day for s/s of worsening or infection .Start Date: 1/12/2023 . For date, 2/26/23 the order was not implemented and not denoted on the report. Review of Skin & Wound Evaluation dated 3/2/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 1.7 x 1.4 x 1.5 CM . Slough: 90% .Exudate: Light, Serous .Surrounding Tissue: Erythema: Redness of the skin - may be intense bright red to dark red to purple . Review of Skin/Wound Note dated 3/7/2023 at 3:04 PM, revealed, .Resident currently in bed, alert and oriented to self .Coccyx wound cleansed with normal saline, santyl and optiform applied .Right gluteal fold red, blanchable and center is unstageable injury .Optiform applied to site . Doctor Visit/Chart Review 3/7/2023 6:23 PM, revealed, .Note Text: (Wound Care Provide Business Name) wound visit per (Wound Provider) PA . Review of Skin & Wound Evaluation dated 3/7/2023, revealed, .Pressure .Deep Tissue Injury - Persistent non-blanchable deep red, maroon, or purple discoloration .In-House Acquired .New .Measurements: 2.2 x 2.0 x 1.6 CM . Review of Skin & Wound Evaluation dated 3/7/2023, revealed, .Pressure .Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 3.0 x 2.1 x 1.9 CM . Slough: 50% wound filled .Eschar: 50% wound filled .Exudate: Serous . Review of Skin Tool Audit completed on 3/8/23 at 1:27 PM, revealed, .(Resident #56) .Location: Sacrum .Type: Pressure .Stage: Unstageable .admitted with: Y (yes) .(Resident #56) .Location: R (right) hip .Type: Pressure .Stage: SDTI (deep tissue injury) .admitted with: N (no) .Noted: 3/7/23 . Review of Health Status Note dated 3/8/2023 at 2:34 PM, revealed, .DTI (Deep tissue injury) to right buttocks treatment continues, slight purple red in color, skin prep applied . Review of Order dated 3/8/23, revealed, .Sacral Unstageable pressure injury: Cleanse wound with normal saline or wound cleanser, apply 0.125% Dakin's gauze in wet to moist fashion, cover with bordered gauze one time a day for Sacral unstageable pressure injury AND as needed for Sacral unstageable pressure injury . Review of Order dated 3/8/23, revealed, .Monitor Rt Ischial for s/s of worsening or infection two times a day for DTI (deep tissue injury) . Review of Order dated 3/8/23, revealed, Apply Sureprep to bilateral Hips (Ischial)two times a day .two times a day for Right Ischial DTI, left hip preventive . Review of Braden Scale for Predicting Pressure Sore Risk dated 3/10/23, revealed, .Score: 14.0 .Moderate Risk . Review of Skin & Wound Evaluation dated 3/14/2023, revealed, .Pressure .Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 3.4 x 2.8 x 1.7 CM .Granulation: 20% wound filled .Slough: 90% wound filled .Exudate: Light, Serous .Surrounding Tissue: Erythema: Redness of the skin - may be intense bright red to dark red to purple .Progress: Stalled . Review of Wound Assessments dated 3/14/23, revealed, .Wound #1 Sacral is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3.1cm length x 1.7cm width x 0.6cm depth, with an area of 5.27 sq cm and a volume of 3.162 cubic cm. There is a small amount of sero-sanguineous drainage (liquid drainage which contains blood) noted which has no odor. The patient reports a wound pain of level 1/10. The wound is improving .The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. The temperature of the periwound skin is WNL. Periwound skin does not exhibit signs or symptoms of infection Wound #2 Right Ischial is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple decoloration Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2.1cm length x 1.6cm width with no measurable depth, with an area of 3.36 sq cm . There was no drainage noted. The patient reports a wound pain of level 0/10. The wound is deteriorating The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. The temperature of the periwound skin is WNL. Periwound skin does not exhibit signs or symptoms of infection .General Notes: Portion of wound with intact serous (fluid) filled blister . Review of Treatment Administration Report (TAR) for March 2023, revealed, .Santyl Ointment 250 UNIT/GM (Collagenase) Apply to per additional directions topically in the morning for Unstageable Pressure Injury .Sacrum: Cleanse with NS only. Apply to Santyl to wound bed with approximately a nickels width thickness. Cover with bordered gauze dressing .Start Date: 1/27/2023 .D/C Date: 3/8/2023 . For date, 3/3/23 the order was not implemented and not denoted on the report. During an observation on 03/20/23 at 01:04 PM, Resident #56 was [NAME] back to her room and left seated in her chair. In an interview on 03/20/23 02:34 PM, CNA QQ reported the facility was thinking her pressure ulcers on her bottom were from the resident's chair. In an interview on 03/20/23 at 02:51 PM, Registered Nurse (RN) J reported Resident #56 had two areas, one on her sacrum and one on her coccyx. RN J stated, .She has got a few areas on her bottom .She likes to sit up and watch people and we think that from her being seated in her chair for long periods of time it was not helping that wound, it was getting worse .Had to curb that down and get her back to bed, after meals will have her get placed in bed to off load . Review of NAR Note dated 3/21/2023 at 12:44 PM, revealed, .NAR team monitoring r/t dx PCM, low BMI, compromised skin integrity, dysphagia, and UTI .Skin: Per wound physician note 3.14.23 PU sacral improving, PU R ischial deteriorating. Skin and Wound Eval 3.15.23 DTI pressure not set, PU sacrum improving, open lesion resolved .Recommend: increase additional fluids 120 ml QID (4 times a day), eval for swallow study to advance texture/liquid consistency. Continue monitor PRN and respect res choice . During an observation on 03/21/23 at 01:09 PM, Resident #56 was observed lying in her bed with the head of her bed at approximately 80 degrees. In an interview on 03/22/23 at 10:50 AM, CNA H reported Resident #56 mostly gets up on first shift. CNA H reported when she comes in for second shift and she was up in her chair, we lay her down. CNA H reported she had a time limit of how long she can be in her chair now. In an interview of 03/22/23 at 11:12 AM, Unit Manager (UM) R reported the skin audit were completed weekly, nurse would notify the UM if there was a new wound. UM would observed the wound and if it was an actual wound the resident would be referred to the wound provider who comes to the facility every Tuesday. UM R reported that was when the measurements were taken of the wound as well as photographs of the wound. In an interview on 03/22/23 at 11:15 AM, UM Z reported the skin audits were completed this morning. In an interview on 03/22/23 at 1:00 PM, Nursing Home Administrator (NHA) A reported, Wound Tracking - the facility has been working on (before we lost our wound nurse) the whole wound process. How the Braden translates to actual care. The facility has kind of done an algorithm. We had also worked on wound types and so forth. The unit managers keep a line listing of skin issues. It helps them track what all needs to happen with them. NHA A reported we do at least weekly skin observations. Based on the Braden, the nursing staff may do more frequent observations, as well as, the shower aides work with the nurse on those. NHA A reported the facility had an alert in (electronic medical record) - as a communication tool. The facility had a wound care team, and (Outside wound provider) that comes in weekly, and if there was a new wound that the outside provider needed to see, it was communicated either by verbalization or notes. Review of policy, Pressure Injury Risk assessment dated ,d+[DATE], revealed, .Procedure: 1.Pressure injury risk assessments will be conducted by a licensed or registered nurse on admission/re-admission, weekly times four weeks, then quarterly, and as needed. Assessments may also be conducted after a change of condition or after any newly identified pressure injury .2.Standardized pressure injury risk assessments will be conducted, using a validated risk assessment tool or scale. Braden Scale has been designated as the standardized tool .a. Each item will be scored individually (i.e. moisture, mobility, nutrition) .b. Individual scores will be added to obtain an overall score .c. Consider at risk according to the parameters set by the validated tool .3. Each item on the standardized risk assessment will be considered, individually, to ensure risk factors are addressed appropriately, regardless of the total risk score .4. The tool will be used in conjunction with assessment of other risk factors not captured by the risk assessment tool. (i.e. presence of a pressure injury, prior stage 3 or 4 pressure injury, hypoperfusion states, peripheral vascular disease, diabetes, smoking, restraint use, spinal cord injury, end-of-life/palliative care) .5. Residents determined as at risk for developing pressure injuries will have interventions documented in plan of care based on specific factors identified in the risk assessment .7. Training on the completion of the pressure injury risk assessment will be provided to licensed staff as needed . 41027 During an observation on 03/22/23 at 08:54 A.M., CNA KK was observed exiting Resident #56's room with a breakfast tray. Resident #56 was observed lying in bed with the HOB (head of bed) at approximately 90 degrees, slouched down and leaning to the left, and her head was off of the pillow. During an observation on 03/22/23 at 09:39 A.M., Resident #56 was lying in bed in the same position as the previous observation. In an interview on 03/22/23 at 09:43 A.M., CNA KK reported that Resident #56 had been checked and changed recently, and that CNA KK would be laying her down soon. During an observation on 03/22/23 at 10:10 A.M. Resident #56 was lying in bed in the same position as previous observations and CNA KK was in the room preparing to reposition Resident #56. CNA KK removed Resident #56's incontinence brief and turned Resident #56 onto her left side, this revealed pink discolored skin with deep creases from the brief and mattress, covering the entire surface of Resident #56's buttocks. There was a large bandage covering Resident #56's sacral area, and it was partially detached and soiled around the bottom edge of the bandage. CNA KK reported that she would let the nurse know that the bandage needed to be replaced. Resident #56's right hip was observed with darker red skin, and a small open wound, that was not covered with a bandage. At 10:16 A.M. Registered Nurse (RN) J entered the room and removed the soiled bandage that covered Resident #56's sacral area, which revealed a deep open wound, with a small amount of slough (dead tissue) noted in the wound bed. When the wound care was finished, CNA KK positioned Resident #56 onto her left side. 38384 R31 According to the Minimum Data Set (MDS dated [DATE], R31 scored 7/15 (moderately cognitively impaired) on his BIMS (Brief Interview Mental Status), received a formal assessment for pressure ulcer risk which determined he was at risk, with diagnoses that included stroke, and hemiplegia (partial paralysis). Review of R31's Order Summary revealed, 2/16/2023- Skin Observation Tool every day shift every Thursday. Alert Wound Nurse/Unit Manager of any new skin concerns. 3/15/2023 Skin protectant to left heel every shift for skin prevention every shift for skin prevention. Cleanse R (right) heel with wound cleanser, pat dry. Apply xerofoam dressing and bordered gauze. Change dressing daily until healed one time a day for skin treatment. Review of R31's Care Plan at Risk for Skin Breakdown 2/16/2023 reported this focus due to the resident's Braden assessment r/t (related to) cognitive loss, communication deficits, general weakness, poor awareness of needs, and acute/chronic illnesses including diabetes and stroke. The goal was to maintain intact skin. To meet this goal, interventions included monitoring and reporting signs of skin breakdown to the resident's nurse. Review of R31's Kardex (resident care guide for CNA pulled from care plan) reported Skin Prevention to monitor and report signs of skin breakdown to nurse. During an interview and observation on 3/21/23 at 1:19 PM Registered Nurse (RN) X and Licensed Practical Nurse (LPN) BB prepared supplies to perform a wound dressing change on R31's right heel. When RN X asked resident if he was in pain, R31 stated, They (feet) burn everyday like on fire, I don't see any difference with new medication they are giving me. RN stated, You are on Gabapentin. RN stated, I told the Social Worker (SW) that (R31) may need new shoes. It looks to me like the back of his shoes are rubbing his heel and causing the wound. The orders are to change the dressing QD (every day) in the morning and PRN (as needed). RN X removed the dressing, stating, It is coming off so it needed changing anyway. Observed with the RN a small amount of serosanguineous (blood and clear yellow liquid) drainage on the bandage. The wound was round approximately 2.5 cm (centimeters) in width and length with a small open area in the middle. The RN dated the dressing 3/21/23 placed a towel as a barrier underneath his feet, donned clean gloves, cleaned the wound, applied the petroleum-based pad and covered it with the large bandage. During an interview on 3/21/23 at 1:32 PM SW Y stated, (R31), I did not know (R31) had a wound on his right heel. (RN X) did not talk to me about his shoes possibly rubbing on his heel to cause the wound. Observed on 3/22/2023 at 10:05 AM R31 sitting in room in a wheelchair watching television wearing gripper socks to both feet. During an interview and record review on 3/22/2023 at 10:15 AM Unit Managers (UM) R and W, and Director of Nursing (DON) B reviewed R31's medical records. UM R stated, (R31) has in his care plan under skin integrity, he is to wear blue protective boots while in bed. DON B stated, The nurses are doing wound care right now because the facility wound nurse left (employment) about two weeks ago. She managed all the wounds. Now, the nurses are to measure wounds weekly. Reviewed R31's medical record with UM R and W which did not reveal any measurements for the wound on the right heel. UM W stated, I audit weekly to see if the nurses have done the weekly skin/wound assessments. UM R stated, (R31) was reported as having a dry skin crack on his right heel on March 13 (2023). It was about 0.1 cm. It has not been reported as open. Review of R31's Skin Observation Tool dated 3/8/2023 reported Yes to new skin issues as redness to right heel Review of R31's Progress Note 3/10/2023 at 2:22 (2:22 AM) revealed, Health Status Note . Skin prep to right heel . Review of R31's Progress Note 3/15/2023 02:40 (AM) revealed, Health Status Note . Opti foam in place to right heel . Review of R31's Progress Note 3/15/2023 14:05 (2:05 PM) revealed, Health Status Note .R (right) heel skin treatment dc' d (discontinued) with new orders to apply xerofoam and cover with bordered gauze dressing. Skin protectant to L (left) heel for skin prevention. Staff will continue to monitor .

Based on interview and record review the facility failed to ensure residents received care in accordance with professional standards of nursing practice for 1 of 18 residents (Resident #40) resulting in the worsening and infection of a cyst. Findings include: Review of an Admission Record revealed Resident #40 was a male with pertinent diagnoses which included diabetes, weakness, anxiety, restlessness & agitation, reduced mobility, dementia, and lipomatous neoplasm of skin and subcutaneous tissue of right arm (fatty tumor located just below the skin), and cyst. Review of current Care Plan for Resident #40, revised on 3/13/23, revealed the focus, .I have been diagnosed with skin infection r/t (related to) cyst (middle upper chest) . with the intervention .Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness .Observe and report signs of cellulitis: Localized pain, redness, swelling, tenderness, drainage, fever, chills, malaise, tachycardia, hypotension .Observe and report signs of sepsis: fever, lassitude or malaise, change in mental status, tachycardia, hypotension, anorexia, nausea, vomiting, diarrhea, headache, lymph node tenderness/enlargement .Tx (treatment) per MD orders . Review of electronic correspondence provided on 3/22/23 at 1:30 PM, Unit Manager Z reported, .8/16/2022 (Previous Provider) states in a monthly visit, left chest wall mass-seems to be a cyst, non-infected. Will have alert charting to see whether it becomes red, painful or starts to drain. If so, can refer him to CFC to have it drained. Otherwise for now just monitor .10/25/2022 (Previous Provider) states in a monthly visit, left chest mass mass-seems to be a cyst, non-infected. Will have alert charting to see whether it becomes red, painful, or starts to drain. Review of Skin/Wound Note dated 3/6/23 at 2:06 PM, .Cyst on left side of chest has some redness around it and no drainage . Review of Doctor Visit/Chart Review dated 3/6/23 at 5:27 PM, revealed, .ACUTE VISIT .the patient is being seen today by (Provider Name) for complains of left chest cyst. Cyst is hard, immobile, not tender and measures 5x3 CM .Assessment: Left cyst chest .Plan: Continue monitoring . Review of Health Status Note dated 3/13/23 at 1:49 PM, revealed, .Cyst on left chest warm, pink/red, size has remained unchanged since Friday, 3/10; now appears with visible with head; tender to touch . Review of Health Status Note dated 3/14/2023 at 00:15 AM, revealed, .Easily aroused for po ABT for cellulitis on middle upper chest. Area swollen and appears to be slightly more swollen but remains dark pink to red in color. It is the same temperature as surrounding skin. No discomfort and (Resident #40) said, No when asked about pain in this area. I explained about infection and swelling . Review of Health Status Note dated 3/14/2023 at 11:36 AM, revealed, .Cyst on left chest warm, pink/red, size has remained unchanged since Friday, 3/10; now appears with visible white heads; tender to touch. VS WNL with the exception of temp 99.3; scheduled acetaminophen given - effective. No s/e, s/s of ABT noted . Review of Vitals Note dated 3/14/23 at 12:10 PM, revealed, .TEMPERATURE WARNING: 99.3 .High of 99.0 exceeded . Review of Skin Tool Audit completed on 3/14/23 at 1:27 PM, revealed, .(Resident #40) .Location: Lt. Upper Chest .Type: Cyst .Treatment Order: N (no) .Monitor Order: Y (yes) . Review of Health Status Note dated 3/15/23 at 00:48 AM, revealed, .Remains on antibiotic for cyst to upper chest, area red and raised with two small white pus pockets present in center . Review of Skin/Wound Note dated 3/15/2023 at 7:48 PM, revealed, .Resident alert and oriented. Chest abscess red and swollen but resident continues to tolerate ABX .ABD (abdominal gauze pads) applied over abscess to catch any drainage if needed . Review of Health Status Note dated 3/16/2023 at 11:34 PM, revealed, .Skin pink, warm, and dry. Lump on upper middle chest covered with dry dressing. (Resident) reports the area itches at times. Continues on ABT for cellulitis on chest at this time. Temperature 99.0 . Review of Health Status Note dated 3/17/2023 at 1:43 PM, revealed, .Cyst on left chest covered with bandage; oozing with yellow drainage, open red areas and yellow pustules (bulging patch of skin contains fluid or pus); tender to touch. VS WNL; scheduled acetaminophen for pain. No s/e (side effects), s/s (signs or symptoms) of ABT (antibiotic) noted . Review of Health Status Note dated 3/18/2023 at 00:57 AM, revealed, .Resting in bed with eyes closed but aroused easily for po ABT and dressing change. Skin pink, warm, and dry. Lump on upper middle chest has three open areas measuring .5cmX.5cm,.5cmX.5cm (both on left side of lump) and 1.2cmX1.2cm (on right side of lump).dressing had moderate amount of purulent drainage and slight amount of dark pink drainage. Area remained dark red in color and swollen but surrounding skin pink and intact. (Resident #40) called out with removal of old dressing and during procedure to cleanse area but closed eyes and quieted once new dressing placed over the area. Continues on ABT (antibiotic) for cellulitis on chest at this time. Afebrile . Review of Health Status Note dated 3/18/2023 at 11:22 AM, revealed, .Cyst on left chest covered with bandage; oozing with yellow drainage, open red areas and yellow pustules; tender to touch. VS WNL; scheduled acetaminophen for pain. No s/e (side effects), s/s (sign or symptoms) of ABT (antibiotic) noted . Review of Skin/Wound Note dated 3/19/2023 at 1:09 PM, revealed, .Resident alert and oriented to self .Resident up in wheelchair and continues to take his abx for the cyst on his upper chest .Cyst on upper chest continues to drain purulent drainage (a sign of infection, it is a white, yellow, or brown fluid, might be slightly thick, made up of white blood cells trying to fight infection, there may be an unpleasant smell to the fluid) at this time .Dressing changed and resident tolerated it well . Review of Social Service Note dated 3/20/2023 at 3:17 PM, revealed, .(Resident #40) is tearful and stating, I'm hurting .(Resident #40) voiced, I just want to go Review of Orders dated 3/20/23, revealed, .Referral to General Surgery for cyst extraction . In an interview on 03/21/23 at 12:53 PM, Resident #40 was observed lying in his bed. Resident #40's wife reported a nurse tried to pop the spot on his chest, she thought it was a blackhead, but it wasn't. R#40's wife reported it was a growth filled with fluid, (Resident #40) was taking medications for it. R#40's wife thought the facility referred him to (local hospital) to see a wound doctor. During an observation on 03/21/23 at 02:44 PM, observed dressing change for Resident #40. Observed bandage dated 3/20/23 with initials of nurse who completed dressing change on 3/20/23 at 7:08 PM. RN D prompted Resident #40 on how she was proceeding with the dressing change. Observed removal of previous dressing, Resident #40 was very painful, grimacing/wincing and calling out in pain. Resident #40 was observed to be painful in the areas surrounding the golf ball sized cyst as well. Resident #40 was observed to reach to grab something with his hands on the side of the bed. Resident #40's skin on and around the cyst was very red and inflamed, a dark reddish color and the dressing showed purulent drainage on the gauze. When RN D proceeded to clean the wound, Resident #40 was observed to be very painful, grimacing/wincing in pain. RN D stated to Resident #40, .No, no more .All done . Resident #40 was grabbing at side of the bed. RN D proceeded to place the new dressing, and Resident #40 grimaced/winced in pain. RN D reported Resident #40 had broken out in a rash and a new course of antibiotics was prescribed, she reported today was the last day of 10 days of the two previously prescribed antibiotics. RN D reported the resident did receive Tylenol prior to the dressing change. In an interview on 03/22/23 at 10:43 AM, CNA H reported Resident #40's wife told her the nurse popped it. CNA H reported she did that a couple of weeks ago and since then it has gotten big and really red. CNA 'H reported the cyst did not bother him, he had no complaints until now. CNA H stated, .It is bothering him since the nurse did what she did with it .Have to be careful when getting him dressed or touch in that area .It really hurts him .She doesn't work at the facility anymore .Heard she was terminated . In an interview on 03/22/23 at 02:10 PM, CNA FF reported the cyst had been there a long time. CNA FF stated, .I came in for my shift and I took his shirt off and saw it, I asked what happened to chest. (Resident #40's) wife reported the nurse took a needle to it, popped it and it smelled really, really bad . CNA FF' reported the cyst was painful and he did clutch his chest when it was bothering him, even when no one was touching it. CNA FF reported it is upsetting as it was not bothering him until she did that. CNA FF reported the nurse does not work here anymore. In an interview on 3/22/23 at 11:21 AM, Unit Manager Z reported the cyst was first noted last August and it remained stable until recently .when it got infected . When queried on how the cyst became infected, UM Z stated, .There was a floor nurse who was not here for very long .She worked first shift .She had no orders to do anything to the cyst only to just monitor the cyst .There was no investigation conducted in to her actions .Was not aware the nurse tried to pop or aspirate the cycst until after the fact when it was placed on the doctor's board on Monday, 3/6/23 .Unsure of when the incident occurred . UM Z reported monitoring was to look for redness and if it was painful .Prior to that day, there was no issue for months and months . In an interview on 3/22/23 at 11:27 AM, Unit Manager R reported the nurse had tried to aspirate it with a needle .The nurse used term blackhead, she never talked to other nurse about cyst indicating what she saw or what she had done .(Resident #40) never had pain until that happened .Couple of antibiotics started on 3/10/23 .(Resident #40 got a rash and received Benadryl .He was switched to another antibiotic to continue until he goes to surgery appointment on 4/4/23. When queried if the nurse documented on her actions in a progress note, the response was No .The cyst was currently draining fluid and due to the drainage indicating the cyst was open .the resident should be on enhanced barrier precautions. When queried if resident was currently on enhanced barrier precautions, UM R reported he was not.

Based on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity in 1 (Resident #33) of 18 residents reviewed for dignity, resulting in the likelihood of feelings of humiliation, embarrassment, and loss of self-worth, and a negative psychosocial outcome for the residents impacting their quality of life. Findings include: According to https://journals.lww.com/ regarding call light use, It is one of the few means by which patients can exercise control over their care on the unit. When patients use the call light, it is usually to summon the nurse .Patients expect that when they push the call light button, a nursing staff member will answer or come to them. Resident #33: Review of an Admission Record revealed Resident #33 was a female with pertinent diagnoses which included multiple sclerosis, muscle weakness, muscle spasm, history of urinary tract infections, contracture, unsteadiness on feet, and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #33, with a reference date of 1/18/23 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated Resident # 33 was cognitively intact. Review of current Care Plan for Resident #33, revised on 4/22/22, revealed the focus, .I require assistance with ADL's r/t (related to) general weakness, impaired mobility, and incontinence. DX: MS, muscle spasms, contractures . with the intervention .Transfer: I require assistance of 2 staff members to transfer. Sit to Stand Mechanical Lift - PRN .I require a scheduled toileting/prompted program every 2 hours . In an interview on 03/20/23 at 02:04 PM, Resident #33 reported she activated her call light at approximately 09:00 AM in the mornings and stated, .It takes 09:30 to 10:00 AM before someone responds to take me to the bathroom but then it is too late .I have a brief on in just in case .Waiting hours and hours and by then there is nothing I can do .I use the bathroom if taken in time . In an interview on 03/22/23 at 09:46 AM, Resident # 33 stated, .Waiting for assistance depends on the day and time of day .The staff are busy all the time .Staff know that if I am using the call light to call for assistance, I need to use the bathroom .The staff know this and they come prepared with the sit to stand or get the hoyer, if needed . Review of Resident Rights and Responsibilities Policy revised on 2/2023, revealed, .1. Resident Rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .2. Iv. The right to receive the services and /or items included in the plan of care .5. Self-determination .b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident .

This citation pertains to intake #: MI 581 Based on observation, interview, and record review, the facility failed to revise care plan interventions to prevent falls in 1 of 13 residents (Resident #8) reviewed for falls, resulting in a fall with an acute right orbital (eye socket) fracture and left rib fractures. Findings include: Review of the facility policy Care Planning last revised 9/17 revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .2. Comprehensive Care Plans .c. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. d. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. E. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: i. The attending physician. ii. A registered nurse with responsibility for the resident. iii. A nurse aide with responsibility for the resident. iv. A member of the food and nutrition services staff. V. The resident and/or the resident's representative, to the extent practicable. Most include an explanation in the medical record .f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. g. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive assessment (Admission, Annual or Significant Change) per current RAI guidelines. H. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. i. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. Review of the facility policy Fall Prevention & Management last revised 5/2020 revealed, POLICY: It is the policy of the (facility) to provide a safe environment for our residents. We will assess each resident for the potential for falls, provide appropriate care for anyone who has fallen and address issues related to any fall that occurs involving a resident. The (facility) promotes a culture of safety .ASSESSMENT UPON ADMISSION/READMISSION .3. A fall assessment will be completed quarterly with the Minimum Data Set Assessment (MDS) and with any significant change in condition. The care plan and Kardex will be reviewed and updated to reflect any changes .Standard Protocols: a. Implement Universal environmental interventions that decrease the risk of resident falling, including, but not limited to: i. A clear pathway to the bathroom and bedroom doors .c. Monitor for changes in resident's cognition, gait, ability to rise/sit, and balance .Additional Protocols: Provide additional interventions as directed by the resident's assessment, including but not limited to .iv. Medication regimen review . Review of the Fundamentals of Nursing revealed, 4. Review patient's medications for use of antidepressants, anticonvulsants, antipsychotics, hypnotics (especially benzodiazepines), anxiolytics, diuretics, antihypertensives, [MEDICATION NAME], anti-Parkinson drugs, hypoglycemics, muscle relaxants, [MEDICATION NAME], and laxatives. Also assess for polypharmacy (i.e., over six medications, duplicate medications, drugs inappropriate for condition) Effects of certain medications and use of multiple medications increase risk for falls and injury. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #8 Review of a Face Sheet revealed Resident #8 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 7/8/20 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #8 was moderately cognitively impaired. Review of the Functional Status revealed that Resident #8 was independent with bed mobility and locomotion on unit and required supervision with no setup or physical help from staff for transferring or toileting. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 8/12/20 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #8 was moderately cognitively impaired. Review of the Functional Status revealed that Resident #8 required supervision with one person physical assist for bed mobility, transferring, walking in room, and toileting. (Indicating Resident #8 had a decrease in her functional status from 7/8/20 to 8/12/20.) Review of Resident #8's Morse Fall Scale dated 7/6/20 revealed a score of 15 indicating Resident #8 was a Low Risk for Falling. Review of Resident #8's Electronic Health Record revealed no additional assessments for falls following her COVID-19 diagnosis. Review of Resident #8's Care Plan revealed, AMBULATION: I am able to ambulate independently in room with 4WW (4 wheeled walker) Date Initiated: 02/14/2019 Resolved Date: 09/21/2020. Review of Resident #8's Therapy Screen dated 6/15/20 revealed, 3. Current transfer assessment .Independent. MOBILITY 1. Mode of locomotion a. Self ambulatory .Ambulation support a. Independent. Review of Resident #8's Therapy Screen dated 9/3/20 revealed, 3. Current transfer assessment .Stand by Assistance (SBA). MOBILITY 1. Mode of locomotion a. Self ambulatory .Ambulation support b. Stand by Assistance (SBA). Review of Resident #8's Physical Therapy Evaluation & Plan of Treatment: dated 8/10/20 revealed, .Assessment Summary-Clinical Impressions: Pt (patient) is an [AGE] year old long-term resident of this facility with a recent dx (diagnosis) of Covid-19 resulting in some increased difficulty with mobility requiring PT (Physical Therapy) to address .Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: further decline in function and falls. Review of Resident #8's Occupational Therapy Evaluation & Plan of Treatment dated 8/7/20 revealed, .Assessment Summary-Clinical Impressions: Client exhibits a decline due to [DIAGNOSES REDACTED].Risk Factors: Due to the documented physical impairments and associated functional deficits the patient is at risk for: falls and anxiety. During an interview on 10/06/2020 at 12:56 P.M., Physical Therapy Assistant (PTA) EE reported that at the time of Resident #8's last assessment in September she was a Stand By Assist for transferring and ambulation. PTA EE reported a Stand By Assist requires staff to be present during transferring and/or ambulation but does not require touching the resident. PTA EE reported that the Occupational Therapist documented that Resident #8 was independent in the bathroom and could do her own pericare but would need supervision to and from the bathroom. PTA EE reported that when there is a change in the residents needs it is reported to the unit managers and the unit managers update the care plans. Review of Resident #8's Doctor Visit dated 9/4/20 revealed, SUBJECTIVE: This patient has [MEDICAL CONDITION] (lung disease), [MEDICAL CONDITIONS], anxiety, dementia. Medications reviewed. PHYSICAL EXAM: Female. Heart regular. Some distress due to respiratory difficulties. She is on several medications for her breathing. Positive for anxiety, SOB (shortness of breath) .PLAN: 2.5 mg [MEDICATION NAME] ([MEDICATION NAME]) q 6 hours PRN (every 6 hours as needed) to help with air hunger as she reports to have SOB despite that she is on oxygen therapy and [MEDICAL CONDITION] medications. Monitor. Consider increasing [MEDICATION NAME] to 5 mg if she is able to tolerate low dose. Review of Resident #8's September Medication Administration Record [REDACTED].Start Date 08/11/2020. Review of Resident #8's September Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED].M., 9/7/20 at 10:03 A.M. and 9:30 P.M., 9/9/20 at 9:25 P.M., on 9/11/20 at 05:03 A.M. and 6:15 P.M., and on 9/12/20 at 04:10 A.M. (Interaction of [MEDICATION NAME] and [MEDICATION NAME] can cause an increase of sedation and drowsiness.) Review of Resident #8's Communication Note dated 8/4/2020 at 10:31 P.M. revealed, (Name Omitted), (Resident #8's) daughter and POA (Power of Attorney) was notified by phone of COVID-19 test result - positive for (Resident #8). and currently she is stable. I explained that she will be moved tomorrow to the isolation unit and she would be notified . Review of Resident #8's Health Status Note dated 8/25/2020 at 06:01 (AM) revealed, Resident alert and oriented X1 (to person). Increased confusion noted . Review of Resident #8's Doctor Visit dated 8/25/2020 at 08:09 (AM) revealed, Chart review per Dr. (name omitted). Nurse (initials omitted) reports (Resident #8) has frequency, cloudy, foul urine with increased confusion. Also, positive urine dip obtained. New order received for Bactrim (antibiotic) .for UTI (Urinary Tract Infection) . Review of Resident #8's Health Status Note dated 8/26/2020 at 03:08 (AM) revealed, Resident is alert and oriented per usual. Increased confusion noted. Review of Resident #8's Behavior Note dated 9/11/2020 at 21:34 (9:34 PM) revealed, Resident had confusion, with restlessness and delusions. Resident took oxygen off and wanted to look outside for her husband. It was explained to resident that her O2 (oxygen) was decreasing and she needed her oxygen. Resident was redirected several times and assisted with putting oxygen back on. When resident had O2 off her SPO2 (oxygen level) was 87% on room air. Resident was offered, toileting, snacks and fluids which were refused. Resident was assisted to bed at 2000 (8:00 PM) and has been laying in bed with eyes closed. Safety measures are in place with call light within reach. Review of Resident #8's Health Status Note dated 9/12/2020 at 07:56 (AM) revealed, Resident has been confused all shift, frequent trips to toilet with dark cloudy smelly urine noted and yelling for help . Review of Resident #8's Incident Note dated 9/12/2020 at 20:33 (8:33 P.M.) revealed, This writer was passing med at the end of the hall while the blue light (emergency light) went off, running to the room and found res (resident) lying on her right at the rest room door, a pool of blood on the floor. Nose bleeding noted, bruise to left shoulder, skin tear to right elbow. Res is very confused, no answering question properly . Review of Resident #8's Incident Note dated 9/15/2020 at 14:51 (2:51 PM) revealed, IDT (interdisciplinary team) met and reviewed documentation. The team discussed how to proceed with plan of care and appropriate interventions. Staff reports that she (Certified Nursing Assistant 'CNA') was providing care to (Resident #8's) roommate (CNA) could hear that (Resident #8) was in the bathroom per her normal routine and then heard a scream then a smack. Staff member states she turned on the emergency light and the nurse entered the room. Nurse interview indicates upon post fall assessment, (Resident #8's) pajama bottoms halfway down her left buttocks on one side placing her at risk for falling. Nurse voiced (Resident #8) had been at baseline throughout her shift prior to this occurrence. It appears (Resident #8) tripped/slipped on low hung pants causing her to lose balance and come in contact with bathroom appliances and floor. Safety interventions in place. Nursing staff will reassess safety precautions upon readmission to this facility. Care plan reviewed. IDT will meet as needed. Review of Resident #8's Incident Report dated 9/12/20 at 8:14 P.M. revealed, At 1315 (1:15 P.M.), this writer was passing med at the end of the hall while the blue light went off, running into the room and found res lying on her right side at the rest room door, head toward room door, pajama pants half down buttocks on left side/pulled up on right, oxygen tubing in place but slightly under nostrils, blood on the floor from her face. Nose bleeding noted, bruise to left shoulder, skin tear to right elbow. Res is very confused status [REDACTED]. Full set of VS (Vital Signs) taken, kept res comfortable but not moving and wait until the ambulance come. Daughter (name omitted) and son (name omitted) notified. NM (Nurse manager) (Name omitted) and on call MD Dr. (name omitted) notified. (Resident #8) did not present with any urinary frequency or confusion during shift and was functioning at baseline. Safety measures in place per care plan .Predisposing Physiological Factors (Confused), (Current UTI), (Recent change in Medication/New), (Recent change in Cognition), (Recent Illness), and (Weakness/Fainted) .Predisposing Situation Factors (Ambulating without Assist), (Recent Room Change), (Using Walker), and (Using Wheeled Walker). Review of Resident #8's Hospital Record dated 9/12/20 revealed, (CT Scan Result) Blowout [MEDICAL CONDITION] inferior orbital wall (eye socket) .Possible nondisplaced [MEDICAL CONDITION] wall of the right maxillary sinus .(CT Scan Result) There are fractures of the anterior (front) left first, second, and third ribs. During an interview on 9/30/2020 at 1:55 P.M., Licensed Practical Nurse (LPN) I reported that she had been the nurse for Resident #8 on the date of Resident #8's fall and had also been caring for her prior to the fall. LPN I reported that since Resident #8 had COVID-19 in August she had noticed an increase in Resident #8's confusion and weakness. LPN I reported that Resident #8 was independent in her room. During an interview on 10/6/20 at 9:27 A.M., Registered Nurse (RN) DD reported that Resident #8 had had an increase in confusion and weakness since her COVID-19 diagnosis. RN DD reported that Resident #8 would have increased anxiety which would cause her to be unsteady on her feet. During an interview on 10/07/2020 at 9:30 A.M., LPN FF reported that Resident #8 would transfer herself back and forth to the bathroom and her care plan indicated she was able to do so independently. LPN FF reported that after Resident #8 was diagnosed with [REDACTED].#8 was more confused and confused more often. LPN F stated, So many times I thought (Resident #8's) going to fall (because of her oxygen tubing) but she would always move the oxygen tubing (out of the way.) During an interview on 10/07/2020 at 11:50 A.M., Director of Nursing (DON) B reported that she was not made aware of the therapists concerns and changing Resident #8 from Independent to a Stand By Assist. During an interview on 10/7/2020 at 10:53 A.M., Certified Nursing Assistant (CNA) N reported that Resident #8 had had an increase in confusion and weakness since her [DIAGNOSES REDACTED].#8 was care planned to be independent in her room.

Based on observation, interview, and record review, the facility failed to prevent facility acquired deep tissue pressure injury and provide pressure ulcer preventative care and treatment consistent with professional standards of practice for 2 out of 13 residents (Resident #1 and #27) reviewed for the risk of and/or the development of pressure injuries, resulting in the development of an avoidable deep tissue pressure injury for Resident #1 and the potential for skin breakdown and overall deterioration in health status for both residents. Findings include: Review of a facility policy Skin: Assessment, Prevention, and Wound Management last revised 12/2018 revealed, Policy: to provide guidelines for skin assessments, measures to help maintain skin integrity, and management for impaired skin integrity. Procedures: Nursing will follow the national pressure ulcer advisory panel (NPUAP) terms and definitions with PU (pressure ulcer)/PI (pressure injury) assessment, prevention and treatment. All procedures will be followed through by the wound nurse/nurse supervisor upon admission/readmission/newly observed non-pressure or pressure wounds. Procedure: 1. Within eight hours of admission/readmission, weekly, after skin incident, and with significant change in status. The wound nurse/nurse supervisor will perform a head to toe skin assessment. The findings of the assessment will be documented in the residence medical record. 2. The CNA (Certified Nursing Assistant) will observe skin on all residents during care and report any new skin issues to the nurse supervisor. The nurse supervisor will assess the areas and report skin issues to the wound nurse. 3. The CNA/shower aid will perform a thorough skin observation with showers/baths and complete the CNA shower alert form then sign and hand off the form to the nurse supervisor. The nurse supervisor will review the form and assess any skin issues noted and report skin issues to the wound nurse, and document any findings in the medical record. 4. The wound nurse/nurse supervisor will perform a thorough head to toe skin assessment weekly on all residents and document in the residence medical record. Prevention: 1. Within eight hours of admission/readmission the wound nurse/nurse supervisor will complete a Braden evaluation with head to toe skin assessment, then weekly for the first four weeks after admission, monthly and when there is a change in residence condition or skin incident. 2. Based on the Braden evaluation and a resident admission assessment. The wound nurse/nurse supervisor will develop a resident specific care plan for pressure prevention, pressure injury or pressure ulcer. 3. The wound nurse/nurse supervisor will update the care plan with resident specific interventions as needed . Review of Fundamentals of Nursing (Potter and Perry) 8th edition revealed, Positioning interventions reduce pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces .patient's need repositioning on a schedule of at least every 2 hours . Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 1196-1197 According to the MDS 3.0 RAI Manual, October 2017, DEEP TISSUE INJURY: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may precede the development of a Stage 3 or 4 pressure ulcer even with optimal treatment. Deep tissue injuries may sometimes indicate severe damage. Identification and management of deep tissue injury (DTI) is imperative. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Resident #1 Review of an Admission Record revealed Resident #1 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 9/23/20 indicating Functional Status revealed that Resident #1 required maximum assistance from 2 or more persons for bed mobility. Review of MDS assessment on 9/28/20 revealed Resident #1 was at risk for pressure ulcer and had 0 unhealed pressure ulcers. Review of Resident #1's Careplan revealed, Focus: I am at risk for skin breakdown r/t (related to) end of life care comfort care measures, memory loss, general weakness, and end of life. Date Initiated: 09/23/2020. Goal: I will maintain intact skin within the limits of disease process and end of life care. Date Initiated: 09/23/2020. Interventions/Tasks: Provide gentle turn and reposition frequently. Date Initiated: 10/01/2020. Skin protectant to buttocks, heels and bony prominences every shift. Date Initiated: 09/23/2020. Monitor and report signs of skin breakdown to Nurse. Date Initiated: 09/23/2020. During an observation on 09/30/20 at 02:41 P.M., Resident #1 was lying on his back side in his bed, with the Head of the bed (HOB) at 30-45 degrees. No pillows observed aiding in repositioning. During an observation on 10/01/20 at 10:43 A.M., Resident #1 was lying on his back side in his bed with the HOB at 45 degrees. No pillows observed aiding in repositioning. During an observation on 10/01/20 at 01:44 P.M., Resident #1 was lying on his back in his bed with the HOB at 45 degrees. No pillows observed aiding in repositioning. During an observation on 10/2/20 at 10:11 A.M., Resident #1 was lying on his back in his bed with the HOB at 45 degrees, flat pillow observed tucked under left trunk. During an interview on 10/02/20 at 10:22 A.M., Licensed Practical Nurse (LPN)/Wound Nurse (WN) W reported that Resident #1 is currently comfort care for end of life and stated, .we do PRN (as needed) suctioning and keep him comfortable . During an interview on 10/02/20 at 10:25 A.M., Certified Nursing Assistant (CNA) R reported that she would be providing care and repositioning for Resident #1 soon. During an observation on 10/02/20 from 11:24 A.M., Resident #1 was lying on his back side in his bed with the HOB at 45 degrees and a flat pillow observed tuck under his left trunk as previously observed at 10:11 A.M. During an interview on 10/02/20 at 11:49 A.M., regarding when Resident #1 would be provided care, CNA R stated, .I have not been in there yet .two of us need to be in there .and the other girl is on break . During an observation on 10/02/20 at 12:15 P.M., Resident #1 observed lying in his bed, on his back side, with HOB at 45 degrees and a flat pillow observed on his left side. During an observation on 10/02/20 at 12:24 P.M., Resident #1 observed lying in his bed, on his back side, with HOB at 45 degrees and a flat pillow observed on his left side. During an observation on 10/02/20 at 1:02 P.M., Resident #1 observed lying in his bed, on his back side, with HOB at 45 degrees and a flat pillow observed on his left side. During an observation on 10/02/20 at 1:22 P.M., Resident #1 observed lying in his bed, on his back side, with HOB at 45 degrees and a flat pillow observed on his left side. During an observation on 10/02/20 at 1:25 P.M., CNA R and CNA CC entered Resident #1's room to perform care. Flat pillows were observed and removed from the right and left side of Resident #1's trunk. CNA CC stated, .these pillows are flat and don't do anything . Observed staff perform an upper body bed bath and then position Resident #1 on his left side to wash his back side. Observation of a large white and pink foam dressing (approximately 5 x 5) covering the entire coccyx area. CNA CC stated, .I've never seen a dressing like that .I can't even put the barrier cream on . Observation of bandage revealed that there was not a date indicating when the bandage was applied. During an interview on 10/2/20 at 1:50 P.M., LPN/WN W reported that she was not aware of Resident #1 having a dressing on his bottom and there were no current orders treatment. LPN/WN W stated, .it sounds like something the hospital would have put on him .he came back to the facility last week .I will look in to it . During an interview on 10/02/20 at 02:30 P.M., LPN O and CNA CC were present. LPN O reported that Resident #1 does not have orders for a dressing on his bottom and is currently only receiving a barrier cream treatment and stated , .the CNA applies the cream .we just verbally verify that it is done . CNA CC then stated, .we can't put a cream on .his whole bottom is covered by a patch . LPN O reported that she was not aware that Resident #1 had a dressing on his bottom. Review of Resident #1's Treatment Administration Record (TAR) from September 2020 and October 2020, as of 10/2/20 at 2:47 P.M., did not reveal orders for a dressing to be applied to the coccyx. Review of Resident #1's Orders dated 10/1/20 revealed, .Skin protectant to buttocks every shift. every shift for preventative . Note that these orders did not indicate a dressing to the coccyx. During an interview and observation on 10/02/20 at 02:36 P.M., Resident #1 was in his bed re-positioned on his right side by LPN/WN W. Observed a large white and pink foam dressing on Resident #1's bottom. LPN/WN W attempted to remove the dressing, and when she touched the dressing it detached from Resident #1's skin without any effort from LPN/WN W. Red skin with deep red wrinkles observed over entire coccyx and purple linear area of discoloration approximately 4 inches long outlining the shape of the dressing was observed on Resident #1's left buttock. LPN/WN W stated, .I think he is getting some deep tissue injury there .I am concerned that the dressing shifted and caused creasing of his skin . LPN/WN W reported that this specific dressing was not one that is kept in stock at the facility and therefore was unable to provide a precise identification for the dressing. LPN/WN W reported that since there was no date or initials on the dressing, and no documentation in the record, she would need to talk to staff to determine when the dressing was applied. During an interview on 10/02/20 at 02:57 P.M., LPN D reported that Resident #1 had returned from the hospital with a preventative dressing on his bottom and it was still in place the next day when she received report and stated, .dressing are initialed and dated when we apply them and there was no date on the one he came back with . LPN D reported that she worked last night and stated, .the girls didn't report anything to me (regarding Resident #1) .he has orders for cream which the CNA's apply .I was not in the room when they applied it . During an interview on 10/02/20 at 03:41 P.M., LPN/WN W reported that she removed a foam dressing covering Resident #1's coccyx when he returned from the hospital on [DATE] and stated, .at that time there were no issues .the deep tissue injury was not there then . During an interview on 10/02/20 at 03:32 P.M., LPN S reported that she was assigned to Resident #1 when he readmitted from the hospital on [DATE] but did not visualize his bottom during his re-admission assessment. Attempts were made on 10/6/20 and 10/7/20 to interview LPN/WN W regarding follow up to indicate when the dressing (that was discovered on 10/2/20) was applied to Resident #1's bottom. During an interview on 10/07/20 at 11:32 A.M., Director of Nursing (DON) B reported on behalf of LPN/WN W and stated, we were unable to determine who put the dressing on (Resident #1) or when it was applied. Review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 9/23/20 at 16:21 (4:21 P.M.) revealed, Moderate Risk: 14 .Sensory perception: Slightly limited .Moisture: Rarely moist .Activity: Chairfast .Mobility: Very limited .Nutrition: Very poor .Friction & Shear: Potential problem. Review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 9/30/20 at 19:53 (7:53 P.M.) revealed, High Risk: 10 .Sensory perception: Very limited .Moisture: Occasionally moist .Activity: Bedfast .Mobility: Very limited .Nutrition: Very poor .Friction & Shear: Problem. During an interview on 10/07/20 at 11:41 A.M., DON B reported that the nurses are using the Braden Scale tool as documentation of the resident's skin assessment. DON B reported that skin assessments are completed once a month, unless the CNA's report a new skin concern. DON B reported that Resident #1's Braden Scale tool documents did not accurately reflect the residents risk for pressure sores. DON B reported that a skin assessment should be performed and the findings documented by the nurse, but at this the facility does not currently have a policy for more than once a month. Resident #27 Review of an Admission Record revealed Resident #27 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #27, with a reference date of 8/12/20 revealed a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #27 was cognitively impaired. Review of the Functional Status revealed that Resident #27 required extensive assistance of one person for mobility in bed. Review of Resident #27's Careplan revealed, FOCUS: I am at moderate risk for skin breakdown related to cognitive loss, vision loss, immobility, incontinence, disease processes, prolonged periods in bed .Date Initiated: 12/26/2018. Goal: My skin will remain free from breakdown thru the next review date. Date Initiated: 12/26/2018. Interventions/Tasks: Apply skin protectant every shift. Date Initiated: 12/26/2018. Apply zinc paste to buttock Q (every) shift for prevention. Date Initiated: 10/01/2020. Apply [MEDICATION NAME] to R (right) side of buttock shearing Q shift until resolved. Date Initiated: 10/01/2020 .Turn & re-position every hour. Date Initiated: 08/23/2019. FOCUS: I am at risk for skin breakdown due to Braden score, preference to remain in bed, immobility, and incontinence. Date Initiated: 08/03/2020. Goal: I will have intact skin, free of redness, blisters or discoloration by/through review date. Date Initiated: 08/03/2020. Interventions/Tasks: .Skin protectant to buttocks every shift Date Initiated: 08/03/2020. During an observation on 09/30/20 at 12:03 P.M., Resident #27 was observed lying in her bed, on her back with HOB at approximately 45 degrees, with her lunch tray on the table over her bed. During an observation on 9/30/20 at 2:20 P.M., Resident #27 was observed lying in her bed on her back with HOB at approximately 45 degrees. During an interview on 10/01/20 at 10:12 A.M., CNA Z reported that Resident #27 does not get out of bed and has not for the past year and stated, .she is one that we turn hourly and monitor for pressure ulcers . During an observation on 10/01/20 at 10:12 A.M., Resident #27 was observed lying in her bed, on her back, with a pillow observed on the left side of the bed and the HOB at approximately 20 degrees. During an interview and observation on 10/01/20 at 11:27 A.M., Resident #27 was lying in her bed, CNA HH was performing a bed bath and incontinence care. CNA HH positioned Resident #27 on her left side and removed a soiled brief. Observation of Resident #27's buttocks revealed, a small open area approximately the size of a dime located on Resident #27's left coccyx area. Observation of CNA HH rubbing a white cream directly on the open area, and no cream on the rest of Resident #27's buttocks. CNA HH finished care and positioned Resident #27 on her right side, using a pillow and placing it under her left hip. Note that this was the same position that Resident #27 was in during the previous observation. During an interview on 10/1/20 at 11:27 A.M., CNA HH reported that the open area on Resident #27's coccyx was not a new issue and stated, .I try to put a little barrier cream on her spot .it's barely anything .she does not get cream anywhere else on her bottom . Review of Resident #27's Orders on 10/7/20 at 11:22 A.M. revealed, .Apply [MEDICATION NAME] to R (right) side of buttock Q (every) shift. every shift for shearing area Verbal Active 10/01/2020 Apply skin protectant to heels, buttocks, and bony prominences every shift. every shift for skin care Phone Active 02/21/2020 . Hourly repositioning provided every shift for skin prevention Verbal Active 08/18/2020. During an observation and interview on 10/07/20 at 09:56 A.M., Resident #27 was lying in her bed and was observed to be repositioned on her left side by CNA Z. CNA Z pointed to the area on Resident #27's left buttock and stated, we are using the white barrier and a zinc ointment .the spot was considered a shearing . Review of Resident #27's Skin/Wound Note dated 10/1/2020 at 14:27 (2:27 P.M.) revealed, Res (resident's)buttocks is assessed, noted is a small area to R (right) side of buttock that is blanch-able with depth less than 0.1 Area is undefined and presents as shearing. Res voices no discomfort. Reminder of the importance of turning and repositioning provided. New order received for [MEDICATION NAME] Q (every) shift until resolved. Will continue with preventative plan of skin protectant as res prefers to spend long periods of time in bed. NOTE: this document references the skin/wound location incorrectly as right side of buttock. Review of Resident #27's Skin/Wound Note dated 10/5/2020 at 16:30 (4:30 P.M.) revealed, Buttocks is assessed. ALl skin is intact with out concern. Shearing area is resolved. Continue with zinc past Q shift for prevention . During an interview on 10/07/20 at 12:15 P.M., DON B provided CNA Shower Alert Forms for Resident #27 and reported that the CNA's should note on these sheets any skin concerns. Review of the form dated 9/29/20 did not indicate any areas of concern on the body diagram. Review of the form dated 10/1/20 indicated a skin concern on Resident #27's middle coccyx, noted by a circle drawn on the body diagram by the CNA. Note: this document referenced the location of the skin concern incorrectly on the middle coccyx.

This citation pertains to intake #: MI 581 Based on observation, interview, and record review, the facility failed to review and revise a comprehensive, individualized plan of care for 3 of 13 residents (Resident #8, #46, and #45) reviewed for care plans, resulting in Resident #8's fall with fractures and the potential for impaired physical, mental, and psychosocial well-being. Findings include: Review of Fundamentals of Nursing (Potter and Perry) 8th edition revealed, If the patient's status has changed and the nursing [DIAGNOSES REDACTED]. An out of date or incorrect care plan compromises the quality of nursing care. Review and modification enable you to provide timely nursing interventions to best meet the patient's needs .It is necessary to revises related factors and the patient's goals, outcomes, and priories. Date any revisions. Revise specific interventions that correspond to the new nursing [DIAGNOSES REDACTED]. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 257-258 Review of the facility policy Care Planning last revised 9/17 revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .2. Comprehensive Care Plans .c. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. d. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. E. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: i. The attending physician. ii. A registered nurse with responsibility for the resident. iii. A nurse aide with responsibility for the resident. iv. A member of the food and nutrition services staff. V. The resident and/or the resident's representative, to the extent practicable. Most include an explanation in the medical record .f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. g. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive assessment (Admission, Annual or Significant Change) per current RAI guidelines. H. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. i. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. Resident #8 Review of a Face Sheet revealed Resident #8 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 7/8/20 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #8 was moderately cognitively impaired. Review of the Functional Status revealed that Resident #8 was independent with bed mobility and locomotion on unit and required supervision with no setup or physical help from staff for transferring or toileting. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 8/12/20 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #8 was moderately cognitively impaired. Review of the Functional Status revealed that Resident #8 required supervision with one person physical assist for bed mobility, transferring, walking in room, and toileting. (Indicating Resident #8 had a decrease in her functional status from 7/8/20 to 8/12/20.) Review of Resident #8's Morse Fall Scale dated 7/6/20 revealed a score of 15 indicating Resident #8 was a Low Risk for Falling. Review of Resident #8's Care Plan revealed, AMBULATION: I am able to ambulate independently in room with 4WW (4 wheeled walker) Date Initiated: 02/14/2019 Resolved Date: 09/21/2020. Review of Resident #8's Therapy Screen dated 6/15/20 revealed, 3. Current transfer assessment .Independent. MOBILITY 1. Mode of locomotion a. Self ambulatory .Ambulation support a. Independent. Review of Resident #8's Therapy Screen dated 9/3/20 revealed, 3. Current transfer assessment .Stand by Assistance (SBA). MOBILITY 1. Mode of locomotion a. Self ambulatory .Ambulation support b. Stand by Assistance (SBA). Review of Resident #8's Physical Therapy Evaluation & Plan of Treatment: dated 8/10/20 revealed, .Assessment Summary-Clinical Impressions: Pt (patient) is an [AGE] year old long-term resident of this facility with a recent dx (diagnosis) of Covid-19 resulting in some increased difficulty with mobility requiring PT (Physical Therapy) to address .Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: further decline in function and falls. Review of Resident #8's Occupational Therapy Evaluation & Plan of Treatment dated 8/7/20 revealed, .Assessment Summary-Clinical Impressions: Client exhibits a decline due to [DIAGNOSES REDACTED].Risk Factors: Due to the documented physical impairments and associated functional deficits the patient is at risk for: falls and anxiety. During an interview on 10/06/2020 at 12:56 P.M., Physical Therapy Assistant (PTA) EE reported that at the time of Resident #8's last assessment in September she was a Stand By Assist for transferring and ambulation. PTA EE reported a Stand By Assist requires staff to be present during transferring and/or ambulation but does not require touching the resident. PTA EE reported that the Occupational Therapist documented that Resident #8 was independent in the bathroom and could do her own pericare but would need supervision to and from the bathroom. PTA EE reported that when there is a change in the residents needs it is reported to the unit managers and the unit managers update the care plans. Review of Resident #8's Incident Note dated 9/12/2020 at 20:33 (8:33 P.M.) revealed, This writer was passing med at the end of the hall while the blue light (emergency light) went off, running to the room and found res (resident) lying on her right at the rest room door, a pool of blood on the floor. Nose bleeding noted, bruise to left shoulder, skin tear to right elbow. Res is very confused, no answering question properly . Review of Resident #8's Incident Note dated 9/15/2020 at 14:51 (2:51 PM) revealed, IDT (interdisciplinary team) met and reviewed documentation. The team discussed how to proceed with plan of care and appropriate interventions. Staff reports that she (Certified Nursing Assistant 'CNA') was providing care to (Resident #8's) roommate (CNA) could hear that (Resident #8) was in the bathroom per her normal routine and then heard a scream then a smack. Staff member states she turned on the emergency light and the nurse entered the room. Nurse interview indicates upon post fall assessment, (Resident #8's) pajama bottoms halfway down her left buttocks on one side placing her at risk for falling. Nurse voiced (Resident #8) had been at baseline throughout her shift prior to this occurrence. It appears (Resident #8) tripped/slipped on low hung pants causing her to lose balance and come in contact with bathroom appliances and floor. Safety interventions in place. Nursing staff will reassess safety precautions upon readmission to this facility. Care plan reviewed. IDT will meet as needed. Review of Resident #8's Incident Report dated 9/12/20 at 8:14 P.M. revealed, At 1315 (1:15 P.M.), this writer was passing med at the end of the hall while the blue light went off, running into the room and found res lying on her right side at the rest room door, head toward room door, pajama pants half down buttocks on left side/pulled up on right, oxygen tubing in place but slightly under nostrils, blood on the floor from her face. Nose bleeding noted, bruise to left shoulder, skin tear to right elbow. Res is very confused status [REDACTED]. Full set of VS (Vital Signs) taken, kept res comfortable but not moving and wait until the ambulance come. Daughter (name omitted) and son (name omitted) notified. NM (Nurse manager) (Name omitted) and on call MD Dr. (name omitted) notified. (Resident #8) did not present with any urinary frequency or confusion during shift and was functioning at baseline. Safety measures in place per care plan .Predisposing Physiological Factors (Confused), (Current UTI), (Recent change in Medication/New), (Recent change in Cognition), (Recent Illness), and (Weakness/Fainted) .Predisposing Situation Factors (Ambulating without Assist), (Recent Room Change), (Using Walker), and (Using Wheeled Walker). Review of Resident #8's Hospital Record dated 9/12/20 revealed, (CT Scan Result) Blowout [MEDICAL CONDITION] inferior orbital wall (eye socket) .Possible nondisplaced [MEDICAL CONDITION] wall of the right maxillary sinus .(CT Scan Result) There are fractures of the anterior (front) left first, second, and third ribs. During an interview on 10/07/2020 at 9:30 A.M., LPN FF reported that Resident #8 would transfer herself back and forth to the bathroom and her care plan indicated she was able to do so independently. LPN FF reported that after Resident #8 was diagnosed with [REDACTED].#8 was more confused and confused more often. LPN F stated, So many times I thought (Resident #8's) going to fall (because of her oxygen tubing) but she would always move the oxygen tubing (out of the way.) During an interview on 10/07/2020 at 11:50 A.M., Director of Nursing (DON) B reported that she was not made aware of the therapists concerns and changing Resident #8 from Independent to a Stand By Assist. During an interview on 10/7/2020 at 10:53 A.M., Certified Nursing Assistant (CNA) N reported that Resident #8 had had an increase in confusion and weakness since her [DIAGNOSES REDACTED].#8 was care planned to be independent in her room. During an interview on 10/07/2020 at 12:18 P.M., DON B reported care plans are reviewed weekly in the care plan meetings. DON B reported that the Unit Managers and the Floor Nurses are responsible for updating the care plans as needed for any change in condition or new intervention. Resident #46 Review of a Face Sheet revealed Resident #46 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #46, with a reference date of 9/16/20 revealed a Staff Assessment for Mental Status score of 3 indicating Resident #46 was severely cognitively impaired. Review of the Functional Status revealed that Resident #46 required extensive assist of 2 people for bed mobility and transferring. Review of Section M Skin Conditions revealed Resident #46 was at risk for developing pressure ulcers/injuries. Review of Resident #46's Care Plan revealed, I am at a moderate risk for skin impairment, and pressure ulcer development r/t (related to) comfort care immobility and unaware of safety risk. Date Initiated: 06/13/2019 .Pressure Reducing Chair Pad Date Initiated: 06/13/2019. Review of Resident #46's Braden Scale for Predicting Pressure Sore Risk dated 9/10/20 revealed Resident #46 was a moderate risk of developing a pressure ulcer/injury. During an observation on 10/2/20 at 12:27 P.M., Resident #46 was up in her gerichair and did not have a pressure reducing chair pad in place. During an observation on 10/6/20 at 9:30 A.M., Resident #46 was up in her gerichair and did not have a pressure reducing chair pad in place. During an observation on 10/07/20 at 9:02 A.M., Resident #46 was up in her gerichair and did not have a pressure reducing chair pad in place. During an interview on 10/07/2020 at 11:30 A.M., CNA II reported that Resident #46 did not have a pressure reducing chair pad placed in her gerichair. Resident #45 Review of a Face Sheet revealed Resident #45 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 9/9/20 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated Resident #45 was cognitively impaired. Review of Behaviors-Rejection of Care revealed that the behavior did not exists. Review of Resident #45's Careplan revealed, FOCUS: I require assistance with ADL's .Date Initiated: 6/09/2020. Interventions/Tasks: .I am independent with exercises in the hall, including grabbing the handrail for sit to stand exercises Date Initiated: 09/18/2020 .I am independent for transfers. Date Initiated: 06/09/2020 .AMBULATION: I am independent to ambulate with my four wheeled walker in my room. Date Initiated: 06/09/2020. During an observation and interview on 10/01/20 at 11:15 A.M., Resident #45 was sitting in his easy chair in his room. Resident #45 attempted without success to transfer himself into his wheelchair and stated, .My legs don't wanna hold me up anymore .it's been getting worse and worse since I've been back over here .I used to be able to get my self around .I don't even know why I have that walker anymore .they don't walk me since I've been over here . Resident #45 reported that he had resided on different hall while he was in quarantine for COVID-19 and therapy staff walked him up and down the halls everyday. Resident #45 reported that he likes to go outside once a day and stated, .I go by myself in my wheelchair now .I used to walk with my walker .I can't do it anymore .I wish I could . Resident #45 reported that he would like to have therapy again, and stated, .I haven't had anyone work with me since I've been on this side . During an interview on 10/02/20 at 10:41 A.M., Therapy Director (TD)EE reported that Resident #45 was discharged from therapy a few weeks ago and stated, .it would be our expectation that the CNA's would continue to walk with him so that he stays independent and then refer back to us if there is a decline . Review of a MDS dated [DATE] revealed a Functional Status which indicated the following for Resident #45: Transfer: activity only occurred once or twice .one person physical assist, Walk in room: activity did not occur .ADL activity itself did not occur, Walk in corridor: activity did not occur .ADL activity itself did not occur. During an interview on 10/02/20 at 11:05 A.M., Resident #45 reported that no one has worked with him on this unit and stated, .I used to use that walker all over on the other side of the facility, but not at all over here .they used to come in and work with me in the bed .they don't come here anymore with those weights or anything there was a lady that worked with me with weights and a little game on the other side. Resident #45 went on to say, I haven't walked in the halls .my legs have stopped working since I've been over here .when I was in the other side I used my walker 2-3 times a day walking the length of the hall .but not over here .just my wheelchair. Resident #45 reported that the facility removed his alarm monitors from his bed and chair and stated, I guess they don't think I need them anymore because I don't get up . During an interview on 10/02/20 at 11:15 A.M., CNA CC reported that Resident #45 is not independent in his room and stated .you are supposed to be in the room .he shouldn't be transferring by himself .he is limited assist . During an interview on 10/02/20 at 11:46 A.M., CNA R reported that Resident #45 expects help to get dressed and stated, .a few months ago he was doing it on his own . CNA R reported that Resident #45 needs assistance to transfer and does not use his walker. CNA R reported that she has not walked Resident #45 in the hall and stated, .he was walking a couple months ago . During an observation on 10/06/20 at 09:14 A.M., Resident #45 was observed in his room, sitting in his easy chair, while HA V read scripture to him. Observation of Resident #45's walker parked on a low shelf near the door. No observation of staff offering to walk Resident #45 in the hall. During an interview on 10/06/20 at 09:16 A.M., CNA K reported that Resident #45 does not use his walker independently in his room. During an interview on 10/07/20 at 12:27 P.M., CNA X reported that Resident #45's is able to pull himself up to standing with the bar during a shower and stated, .I have noticed him not being able to stand for as long recently .

This intake pertains to MI 957. Based on observation, interview, and record review, the facility failed to support use of indwelling bladder (Foley) catheter in 2 of 3 sampled residents (Resident #101 and Resident #103) reviewed for Foley catheter, from a total sample of 3 residents, resulting in Resident #101 having a preventable urinary tract infection [MEDICAL CONDITION] with hospitalization and Resident #103 receiving a Foley catheter without the evidence of a clinical condition. Findings include: According to the State Operations Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, pp. 244-245. "Urinary Incontinence requires that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. Some residents are admitted to the facility with indwelling catheters that were placed elsewhere (e.g., during a recent acute hospitalization ). The facility is responsible for the assessment of the resident at risk for urinary catheterization and/or the ongoing assessment for the resident who currently has a catheter. When a resident is admitted to the facility with a Foley catheter a comprehensive assessment should be developed to address the use of the Foley catheter. A comprehensive assessment should address those causes that influence the resident to the use of an indwelling urinary catheter. The assessment of continence/incontinence is based upon interdisciplinary review. The comprehensive assessment should include underlying factors supporting the medical justification for the initiation and continuing need for catheter use, determination of which factors can be modified or reversed (or rationale for why those factors should not be modified), and the development of a plan for removal." Resident #101 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS revealed Resident #101's ability to make daily decisions was severely impaired and he was extensively dependent on one to two facility staff members for bed mobility, dressing, transfers, bathing, hygiene, and toilet use. Review of the Physician Phone Order dated 1/27/14 at 4:03 p.m., revealed Resident #101 had an order for [REDACTED]. Review of the physician progress notes [REDACTED]. "He has a Foley catheter. At his stage he is beginning to get a little bit better. He is however a large man and we will need to continue the catheter until he is able to do a little bit better." Review of the Indwelling Urinary Catheter Care Plan dated 1/25/14, revealed Resident #101 "will have catheter care managed appropriately without signs of urinary tract infection." The Care Plan revealed approach "administer medications as ordered and evaluate and document and report effectiveness and any adverse side effects. Assess for signs and symptoms of UTI Burning, pain with urination, urgency, frequency, bladder cramps/spasms, low back pain, flank pain, malaise, nausea, vomiting, pain tenderness over the bladder, chills fever, foul odor of urine, concentrated urine, blood in urine, confusion. Monitor labs per order. Assess the drainage every shift. Record the amount, type, color, odor. Observe for leakage. Change catheter per MD order. Keep catheter system a closed system as much as possible. Monitor and ensure Foley in anchored to leg at all times. Monitor vital signs PRN. Report presence of fever...." Review of Care Conference dated 2/7/14 at 4:00 p.m., revealed Family Member "A" asked about the catheter-"why is it still in?" Review of Physician Phone Order dated 3/2/14 (no time), transfer Resident #101 to the Hospital for evaluation. Review of the Hospital History and Physical dated 3/2/14 (no time), revealed Resident #101's chief complaint was lower abdominal pain, distress, and urinary tract infection. The Hospital History and Physical revealed that Resident #101 looked to be in distress from pain at the time of the exam. The Hospital History and Physical revealed that Resident #101's white blood cell count was high at 14.54 indicating he had an infection (4.00-11.00 normal), had a catheter associated urinary tract infection, and was started on antibiotics and cultures for Staphylococcus. The Hospital History and Physical revealed Resident #101's "per Registered Nurse (RN), they have trouble taking the Foley catheter out. It seems to be nonfunctioning. We will get urology involved for placement of this possibly new catheter." Review of the Radiology Report dated 3/2/14 at 8:03 a.m., revealed Resident #101 had a CT of his abdomen, the impression was "1. Abnormally distended urinary bladder with thickened walled and abnormal [MEDICAL CONDITION] changes in the surrounding fat and mild stranding in the presacral space. Findings may be related to severe [MEDICATION NAME] (bladder inflammation). A Foley catheter is present. If this is not clamped, it is probably nonfunctioning." Review of the Hospital Discharge Summary dated 3/12/14, revealed Resident #101's discharge [DIAGNOSES REDACTED]...2. Malfunctioning Foley catheter on admission likely from bladder outlet obstructions..." In an interview on 3/21/14 at 9:00 a.m., Medical Doctor (MD) "D" reported that Resident #101 was lethargic when he first saw him and that he used the [DIAGNOSES REDACTED]." MD "D" reported that ultimately Resident #101 did develop a UTI due to the Foley catheter after admission resulting in hospitalization . In an interview on 3/20/14 at 1:20 p.m., Registered Nurse (RN) "D" reported that MD "D" wanted Resident #101 to keep the Foley catheter "due to residents size and being post [MEDICAL CONDITION]." In an interview on 3/20/14 at 11:40 a.m., Director of Nursing (DON) "C" reported that Resident #101"s Foley catheter was left in when he was first admitted because Medical Doctor "D" felt he had [MEDICAL CONDITION] with [MEDICAL CONDITION]. DON "C" reported that when the subject of removing the Foley catheter was brought up on 2/17/14, MD "D" felt it was not a good time to trial the Foley catheter removal. In an interview on 3/20/14 at 4:00 p.m., Certified Nursing Assistant (CNA) "D" that reported Resident #101's Foley catheter always did not have as much fluid out as he took in and sometime it was dark and had a foul odor. CNA "D" reported that the output was put in the computer and reported to the nursing staff. In an interview on 3/20/14 at 4:05 p.m., CNA "E" reported that Resident #101's Foley catheter for the last 2 weeks prior to him being hospitalized had low output. CNA "E" reported that the urine output was low and she had checked the pad to verify the Foley was not leaking and checked to see if family was emptying the Foley. CNA "E" reported that the nurse was aware of the low output and that the urine was dark and that at time that there were clots of blood coming out in the Foley catheter. In an interview on 3/24/14 at 4:57 p.m., Licensed Practical Nurse (LPN) "C" reported that Resident #101's urine output was not cloudy it was yellow, but that she did not empty the Foley catheter, the CNA's did and they never informed her of a problem that would make her look at the Foley catheter. Resident #103 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #103 was a [AGE] year old female admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS revealed Resident #103's ability to make daily decisions was cognitively intact and she was extensively dependent on one to two facility staff members for bed mobility, dressing, transfers, bathing, hygiene, and toilet use. Review of the Physician Phone Order dated 2/24/14 at 5:00 p.m., revealed that Resident #103 was to have a post void residual bladder scan every shift x 7 days, for incomplete bladder emptying. Review of the Bladder Scan Results dated 2/24/14 at 1932 (7:32 p.m.) 120 ml, 2/25/14 at 5:14 a.m. 64 ml, 2/25/14 at 1359 (1:59 p.m.) 39 ml, 2/25/14 at 2047 (8:47 p.m.) 273 ml, 2/26/14 at 5:20 am 158 ml, 2/26/14 at 1507 (3:07 p.m.) 171 ml, 2/27/14 at 10:51 a.m. 58 ml. The scans were conducted a total of 4 days. Review of the Bladder Standing Order, revealed that if there was no void in 8 hours a resident could be Straight Catheterize if bladder scan was greater than 350 cc. Review of Physician Phone Order dated 2/27/14 at 1500 (3:00 p.m.), revealed Foley catheter for decreased output for Resident #103. Review of the Physician Phone Order dated 2/27/14 at 2100 (7:00 p.m.), revealed that Resident #103's post void residual bladder scan was discontinued due to Foley catheter insertion. Review of the Facility Foley Catheter Care Plan dated 3/28/14, revealed Foley catheter due to decreased output, short term goal was that Resident #103 would have complete bladder emptying. In an interview on 3/21/14 at 1:00 p.m., DON "C" reported that the Foley catheter was placed in Resident #103 because of fluid retention and weight gain and they wanted to monitor output. In an interview on 3/21/14 at 11:25 a.m., CNA "J" reported that Resident #103 had a Foley catheter placed because she was not urinating. In an observation on 3/19/14 at 10:40 a.m., this Surveyor observed peri care on Resident #103 while in her room and noted that the Foley catheter was no longer in place. #

Based on observation, interview and record review the facility failed to implement their own policy and procedure for abuse and protect residents from the potential for further abuse to occur ( did not remove a alleged perpetrator from duties) in 1 of 16 sampled residents (Resident #2) and 1 of 2 supplemental residents (Resident #17) reviewed for abuse, from a total of 16 sampled residents, resulting in an Immediate Jeopardy when, on 4/25/13, Resident #2 informed facility staff of an allegation of verbal abuse by Certified Nurse Aide (CNA) "C" and Resident #17 reported (dates not specified by resident) allegations of verbal, mistreatment and fearfulness of CNA "C" and the facility administrator did not implement the facility abuse policy to potentially prevent further abuse incidents from occurring. These deficient practices placed all 22 residents who resided on the "B" hall at risk for serious harm and/or injury. Findings include: Review of the facility policy and procedure for "Abuse, Neglect, Mistreatment and Misappropriation of Resident Property", dated 11/2011, revealed on page #7 under "Protection of Resident during Investigation" #1, "...Any employee suspected of abuse, neglect, mistreatment or misappropriation of property will be suspended pending the outcome of the investigation..." On page #5 under "Reporting of Incidents, Investigations and Facility Response to the Results of Investigations" #2, "...The Administrator or designee will immediately conduct a thorough in-house investigation and do the following: A. Complete an incident report and submit it to the State agency as soon as possible but not more than 24 hours from the time of the discovery of the alleged incident... B. Notify the State agency of the investigative finding within five (5) working days of of the incident... C. During, and subsequent to its investigation, the facility will take protective and corrective actions to protect residents from current abuse, neglect or misappropriation and prevent further incidents..." Resident #2 Review of the written statement dated 4/25/13 written by Certified Nurse Aide (CNA) "Y" regarding Resident #2 revealed that, "...the first time I call, the aide on nights is nice to me the first time but she brings another aide in my room. But the next few times I call she is extremely rude and cruel and sometimes she yells at me..." Resident #2 further stated that to CNA "Y" that the aide was "...kinda tall with dark hair..." CNA "Y" reported the allegation to Registered Nurse (RN) "L" at 6:50 pm. At 6:55 pm RN "L" interviewed Resident #2 who stated "...last night the first call was ok and then she acted like I was bothering her..." Resident #2 could not identify the aide at the time, according to the statement by RN "L", however RN "L" documented in her written statement that Resident #2 was crying and visibly upset and stated "...I'm afraid to put my light on at night now..." RN "L" notified the facility Administrator "A" and Director of Nursing (DON) "B" at 7:00 pm on 4/25/13. According to the Face Sheet (undated) Resident #2 was an [AGE] year old female, admitted to the facility on [DATE]. Review of the Physician's orders dated 8/2013 revealed, Resident #2 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that was cognitively intact. During an interview on 8/26/13 at 3:00 pm, Resident #2 stated "...in April 2013 two CNA's (did not know who they were) were rude and made fun of me..." Resident #2 also stated that one of the CNA's (she did not know who) said to her "...why couldn't you have gotten up earlier?..." Resident #2 stated that "...I did speak with the "head nurse" (did not state the name of the nurse), but nothing came out of it..." During the interview, Resident #2 was visibly upset and had a frightened expression on her face when talking about the incident from April 2013. During a second interview and observation on 8/28/13 at 3:50 pm, Resident #2 stated, "...I might be afraid to say. I could get into trouble. I told my daughter about it..." In an interview on 8/26/13 at 3:55 pm, DON "B" reported that she was aware that Resident #2 was not "...happy to be here and has made some comments about staff...". DON "B" also stated that she has not completed any investigations regarding Resident #2 and the allegation from April 25, 2013 and that the "...administrator handles most of those investigations...". In an interview on 8/27/13 at 1:20 pm with the Assistant Administrator "E", he stated that he was aware of Resident #2's allegation from April 25, 2013 and that Resident #2 could not identify the CNA. Assistant Administrator "E" further stated they recently terminated a CNA (CNA "C") that worked the B hall (where Resident #2 resided) due to "...several residents had asked to not have her take care of them..." ( ) Resident #17 Review of the Face Sheet and the Minimum Data Set ((MDS) dated [DATE] revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #17 had a Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact. In an interview on 8/29/13 at 3:50 p.m., Resident #17 stated CNA "C", "...treated me mean. She snatched my clothes and did not talk nice to me. Just recently, she left. It was not too long ago. She had worked here for a long time. I didn't talk to much about her and afraid she would get back to me. I requested her not to work with me. She would take her time assisting me to the toilet. Usually I always wet my pants then. I ate at 5:00 p.m., and would get back to my room by 6:00 p.m. Then I would wet myself. I reported it to the nurses many times. I never made it to bed until 11:00 p.m. (when she worked). Normally I go to bed about 9:00 p.m. She doesn't work with me anymore." Resident #17 reported she was fearful and didn't want to say much because she was fearful of retaliation. Resident #17 defined retaliation as "they won't talk to you or help you, so I requested her to not work with me anymore." ( ) Review of an employee file for CNA "C" revealed multiple documents regarding resident and family complaints about care and demeanor received by CNA "C" on 4/8/13, 4/29/13 and 8/15/13. In addition, review of an "Employee Warning Notice" dated 8/16/13 revealed that CNA "C" was terminated from her employment at the facility on 8/16/13 due to, "...Multiple instances with residents and staff regarding a negative approach and quality of care..." In an interview on 8/28/13 at 11:15 am Administrator "A" reported that she knew the follow-up to the incident reported by Resident #2 on April 25, 2013 was not thoroughly investigated and that "...the documentation could have been better..." Administrator "A" stated that the social worker at the time (no longer employed at the facility), Assistant Administrator "E", DON "B" and herself met and discussed the reported allegation and verbally investigated it to determine that no abuse could be substantiated. When Administrator "A" was asked why the allegation of verbal abuse was not reported to the State agency, according to their facility policy and procedure she stated "...based on their investigation she didn't feel it needed to be reported..." Administrator "A" was unable to produce evidence of an investigation. In a second interview on 8/29/13 at 3:00 pm Administrator "A" reported that she did not complete a thorough investigation, nor suspend CNA "C" after she became aware of allegations that CNA "C" was providing rough care, residents being fearful of her, was not friendly and gruff in her nature. Administrator "A" stated she was aware that CNA "C" had a "...rough demeanor and was gruff but I couldn't remove her just because of that. We don't have anything (on an investigation) because we didn't do an abuse investigation..." On 8/30/13 at 12:26 pm Administrator "A" was notified that the the facility was placed in Immediate Jeopardy as a result of the facility's failure to implement their own abuse policy and thoroughly investigate, report, and protect residents from the potential for further abuse to occur. On 9/3/13 at 11:30 am, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On 8/28/13, the Director of Nursing and the Social Worker interviewed 16 of 16 interviewable residents on the "B" hall to determine if any residents experienced treatment they felt was abusive or inappropriate. There were no reports of abuse or inappropriate treatment. 2. On 8/29/13, remaining 62 interviewable resident statements were reviewed. The 1 resident who reported potential abuse and the 8 who reported "feeling rushed" had investigations in process and were under review and reported to the State Agency as appropriate. 3. On 8/29/13, the Administrator "A", Assistant Administrator "E" and DON "B" received training provided by the facility nurse consultant as to the reporting requirements and the elements of a thorough investigation when there is an allegation of abuse. 4. On 8/29/13, 8 of 9 Department Directors were provided in-servicing on the abuse material provided by the nurse consultant. The one Deparment Director not present will receive the education prior to returning to work. 5. On 8/29/13, 112 of 123 employees were interviewed to determine if any had witnessed any abuse and if so, had it been reported to the Administrator. 6. Beginning 8/29/13, the Administrator will report to the State Agency any allegation of abuse discovered during the interviews. 7. On 8/30/13, te Administrator developed guidance for investigations and trained the Assistant Administrator and Director of Nursing as to the steps for a thorough investigation. 8. Beinning 8/30/13, the Social Worker and Activity Director will interview 10% of the interviewable residents weekly to identify potential unreported allegations of abuse. This will continue until 100% compliance is achieved for 12 consecutive weeks. Reviewed the form that the will be utilized. 9. Beginning 8/30/13, all facility staffs began mandatory in-servicing on abuse, types of abuse, the process for removal of an alleged perpetrator from the facility, and identification of the Abuse Coordinator. No facility staffs will be allowed to work prior to receiving the education. 10. As of 8/30/13, all potential incidents of abuse and resulting investigations will be reviewed by the Quality Improvement Committee. Although the Immediate Jeopardy was removed on 8/30/13, the facility remained out of compliance as a scope of no actual harm, with the potential of more than minimal harm that is not immediate jeopardy and severity of pattern due to the fact that not all facility staff had received the education and sustained compliance had not yet been verified by the State Agency. ( ) The following interviews were conducted which pertained to employee to resident and resident to resident abuse situations with instruction to identify the protocol/expectations of the facility abuse training program. Employees reported the following: In an interview on 8/27/13 at 8:00 a.m., Housekeeping Assistant "H" reported if abuse had occurred with an employee/resident, she felt they should be terminated but was unsure how the process with investigation proceeded and if the aide would be removed from the current assignment until relief could be obtained. Housekeeping Assistant "H" verified after she reported an incident to the nurse or her supervisor, then the next call is to Administrator "A". In an interview on 8/27/13 at 9:10 a.m., Restorative Aide "I" reported that all abuse is reported to Administrator "A" as soon as the resident was determined to be safe. In an interview on 8/28/13 at 8:00 a.m., Housekeeping Director "K" reported it was not her decision if an employee to resident situation occurred as to the outcome of the employee. If the employee was not in nursing, then it would be a nursing and administrator issue. Housekeeping Director "K" reported she would always make sure a resident was safe and would intervene. Housekeeping Director "K" reported all allegations are reported to the Director of Nursing "B" or Administrator "A". In an interview on 8/28/13 at 8 :30 a.m., Unit Manager, Registered Nurse (RN) "L" stated that if an employee was involved with a resident potential abuse situation, after making sure the resident was safe, "I would probably send the employee home. I would definitely report it to our Administrator." RN "L" stated, "I am not totally sure of the suspension process." In an interview on 8/28/13 at 9:30 a.m., Certified Nursing Assistant (CNA) "M" reported with an employee to resident occurrence, she would make sure a resident was safe, but was not aware of the reporting process. CNA "M" stated, "I would definitely tell the Administrator, but I don't know the process if an employee is suspended, or fired." In a telephone interview on 8/28/13 at 11:15 a.m., Beautician "N" reported if an abuse situation was reported to her in the beauty shop, her immediate reaction would be to report to Administrator "A" and Director of Nursing "B". She stated, "I can't really say how the employee situation is handled but I do know it has to be investigated before the employee can work again." In a telephone interview on 8/30/13 at 6:10 p.m., RN "W" reported as a previous Unit Manager at the facility, if an employee to resident situation occurred, it was her responsibility to contact Director of Nursing "B" as soon as it had been determined a resident was safe. RN "W" reported that she had never written an investigation or allegation document with resident complaints when she was the Unit Manager. RN "W" reported that she had always informed Director of Nursing "B". RN "W" reported she had spoken with Resident #17 in the past about care issues and of employee care issue complaints. RN "W" reported the concerns were always forwarded to Director of Nursing "B" and the next step was then to Administrator "A". ( )

Based on observation, interview and record review the facility failed to thoroughly investigate and report to the State agency, allegations of staff to resident abuse in 1 of 16 sampled residents (Resident #2) and 1 of 2 supplemental residents (Resident #17) reviewed for abuse, from a total of 16 sampled residents, resulting in an Immediate Jeopardy when, on 4/25/13, Resident #2 informed facility staff of an allegation of verbal abuse against Certified Nurse Aide (CNA) "C" and Resident #17 (dates not specified by resident) reported allegations of verbal, mistreatment and fearfulness of CNA "C" and the facility administrator did not investigate or report the incidents to potentially prevent further abuse incidents from occurring. These deficient practices placed all 22 residents who resided on the "B" hall at risk for serious harm and/or injury. Findings include: Review of the facility policy and procedure for "Abuse, Neglect, Mistreatment and Misappropriation of Resident Property", dated 11/2011, revealed on page #3, under "Identification" #2 "...An incident report for suspected or actual abuse, neglect, mistreatment or misappropriation of property will be initiated immediately..." On page #5 under "Reporting of Incidents, Investigations and Facility Response to the Results of Investigations" #2, "...The Administrator or designee will immediately conduct a thorough in-house investigation and do the following: A. Complete an incident report and submit it to the State agency as soon as possible but not more than 24 hours from the time of the discovery of the alleged incident... B. Notify the State agency of the investigative finding within five (5) working days of of the incident..." Resident #2 Review of the written statement dated 4/25/13 written by Certified Nurse Aide (CNA) "Y" revealed that Resident #2 reported, "...the first time I call, the aide on nights is nice to me the first time but she brings another aide in my room. But the next few times I call she is extremely rude and cruel and sometimes she yells at me..." Resident #2 further stated that to CNA "Y" that the aide was "...kinda tall with dark hair..." CNA "Y" reported the allegation to Registered Nurse (RN) "L" at 6:50 pm. At 6:55 pm RN "L" interviewed Resident #2 who reported, "...last night the first call was ok and the she acted like I was bothering her..." Resident #2 could not identify the aide at the time, according to the statement by RN "L", however RN "L" documented in her written statement that Resident #2 was crying and visibly upset and stated "...I'm afraid to put my light on at night now..." According to the document, RN "L" notified Administrator "A" and Director of Nursing (DON) "B" at 7:00 pm on 4/25/13. According to the Face Sheet (undated) Resident #2 was an [AGE] year old female, admitted to the facility on [DATE]. Review of the Physician's orders dated 8/2013, revealed Resident #2 had [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that she was cognitively intact. In an interview on 8/26/13 at 3:00 pm, Resident #2 stated, "...in April 2013 two CNA's (did not know who they were) were rude and made fun of me..." Resident #2 also stated that one of the CNA's (she did not know who) said to her "...why couldn't you have gotten up earlier?..." Resident #2 stated, "...I did speak with the "head nurse" (did not state the name of the nurse), but nothing came out of it..." During the interview, Resident #2 was visibly upset and had a frightened expression on her face when talking about the incident from April 2013. In an interview on 8/26/13 at 3:55 pm, DON "B" reported that she was aware that Resident #2 was not "...happy to be here and has made some comments about staff...". DON "B" also stated that she has not completed any investigations regarding Resident #2 and the allegation from April 25, 2013 and that the "...administrator handles most of those investigations..." During a second interview and observation on 8/28/13 at 3:50 pm, Resident #2 stated "...I might be afraid to say. I could get into trouble. I told my daughter about it..." In an interview on 8/27/13 at 1:20 pm with the Assistant Administrator "E", he stated that he was aware of Resident #2's allegation from April 25, 2013 and that she could not identify who the CNA was that was involved in the incident. Assistant Administrator "E" stated that they recently terminated a CNA (CNA "C") that worked the B hall (where Resident #2 resides) due to "...several residents had asked to not have her take care of them..." ( ) Resident #17 Review of the Face Sheet and the Minimum Data Set ((MDS) dated [DATE] revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #17 had a Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact. In an interview on 8/29/13 at 3:50 p.m., Resident #17 stated CNA "C", "...treated me mean. She snatched my clothes and did not talk nice to me. Just recently, she left. It was not too long ago. She had worked here for a long time. I didn't talk to much about her and afraid she would get back to me. I requested her not to work with me. She would take her time assisting me to the toilet. Usually I always wet my pants then. I ate at 5:00 p.m., and would get back to my room by 6:00 p.m. Then I would wet myself. I reported it to the nurses many times. A person named Ann talked to me once about my concerns. I never made it to bed until 11:00 p.m. Normally I go to bed about 9:00 p.m. She doesn't work with me anymore and has been gone for awhile now." Resident "17" reported she was fearful and didn't want to say much because she was fearful of retaliation from CNA "C". Resident "17" defined retaliation as "they won't talk to you or help you, so I requested her to not work with me anymore." ( ) Review of an employee file for CNA "C" revealed multiple documents regarding resident and family complaints about care and demeanor received from CNA "C" on 4/8/13, 4/29/13 and 8/15/13. In addition, review of an "Employee Warning Notice" dated 8/16/13 revealed that CNA "C" was terminated from her employment at the facility on 8/16/13 due to, "...Multiple instances with residents and staff regarding a negative approach and quality of care..." In an interview on 8/28/13 at 11:15 am Administrator "A" reported that she knew the follow-up to the incident reported by Resident #2 on April 25, 2013 was not thoroughly investigated and that "...the documentation could have been better..." Administrator "A" stated that the social worker at the time (no longer works at the facility), Assistant Administrator "E", DON "B" and herself met and discussed the reported allegation and verbally investigated it to determine that no abuse could be substantiated. When Administrator "A" was asked why the allegation of verbal abuse was not reported to the State agency, according to their facility policy and procedure she stated "...based on their investigation she didn't feel it needed to be reported..." In an interview on 8/29/13 at 3:00 p.m. Administrator "A" reported that she did not complete a thorough investigation, nor suspend CNA "C" after she learned that CNA "C" had allegations of rough care, residents being fearful of her, was not friendly and gruff in her nature. Administrator "A" stated she was aware that CNA "C" had a "rough demeanor and was gruff but I couldn't remove her just because of that. We don't have anything (an investigation) because we didn't do an abuse investigation." On 8/30/13 at 12:26 pm, Administrator "A" was notified that the the facility was placed in Immediate Jeopardy as a result of the facility's failure to thoroughly investigate and report allegations of abuse to the State agency. On 9/3/13 at 11:30 am, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On 8/28/13, the Director of Nursing and the Social Worker interviewed 16 of 16 interviewable residents on the "B" hall to determine if any residents experienced treatment they felt was abusive or inappropriate. There were no reports of abuse or inappropriate treatment. 2. On 8/29/13, remaining 62 interviewable resident statements were reviewed. The 1 resident who reported potential abuse and the 8 who reported "feeling rushed" had investigations in process and were under review and reported to the State Agency as appropriate. 3. On 8/29/13, the Administrator "A", Assistant Administrator "E" and DON "B" received training provided by the facility nurse consultant as to the reporting requirements and the elements of a thorough investigation when there is an allegation of abuse. 4. On 8/29/13, 8 of 9 Department Directors were provided in-servicing on the abuse material provided by the nurse consultant. The one Deparment Director not present will receive the education prior to returning to work. 5. On 8/29/13, 112 of 123 employees were interviewed to determine if any had witnessed any abuse and if so, had it been reported to the Administrator. 6. Beginning 8/29/13, the Administrator will report to the State Agency any allegation of abuse discovered during the interviews. 7. On 8/30/13, te Administrator developed guidance for investigations and trained the Assistant Administrator and Director of Nursing as to the steps for a thorough investigation. 8. Beinning 8/30/13, the Social Worker and Activity Director will interview 10% of the interviewable residents weekly to identify potential unreported allegations of abuse. This will continue until 100% compliance is achieved for 12 consecutive weeks. Reviewed the form that the will be utilized. 9. Beginning 8/30/13, all facility staffs began mandatory in-servicing on abuse, types of abuse, the process for removal of an alleged perpetrator from the facility, and identification of the Abuse Coordinator. No facility staffs will be allowed to work prior to receiving the education. 10. As of 8/30/13, all potential incidents of abuse and resulting investigations will be reviewed by the Quality Improvement Committee. Although the Immediate Jeopardy was removed on 8/30/13, the facility remained out of compliance as a scope of no actual harm, with the potential of more than minimal harm that is not immediate jeopardy and severity of pattern due to the fact that not all facility staff had received the education and sustained compliance had not yet been verified by the State Agency. ( ) The following interviews were conducted which pertained to employee to resident and resident to resident abuse situations with instruction to identify the protocol/expectations of the facility abuse training program. Employees reported the following: In an interview on 8/27/13 at 8:00 a.m., Housekeeping Assistant "H" reported if abuse had occurred with an employee/resident, she felt they should be terminated but was unsure how the process with investigation proceeded and if the aide would be removed from the current assignment until relief could be obtained. Housekeeping Assistant "H" verified after she reported an incident to the nurse or her supervisor, then the next call is to Administrator "A". In an interview on 8/27/13 at 9:10 a.m., Restorative Aide "I" reported that all abuse is reported to Administrator "A" as soon as the resident was determined to be safe. In an interview on 8/28/13 at 8:00 a.m., Housekeeping Director "K" reported it was not her decision if an employee to resident situation occurred as to the outcome of the employee. If the employee was not in nursing, then it would be a nursing and administrator issue. Housekeeping Director "K" reported she would always make sure a resident was safe and would intervene. Housekeeping Director "K" reported all allegations are reported to the Director of Nursing "B" or Administrator "A". In an interview on 8/28/13 at 8 :30 a.m., Unit Manager, Registered Nurse (RN) "L" stated that if an employee was involved with a resident potential abuse situation, after making sure the resident was safe, "I would probably send the employee home. I would definitely report it to our Administrator." RN "L" stated, "I am not totally sure of the suspension process." In an interview on 8/28/13 at 9:30 a.m., Certified Nursing Assistant (CNA) "M" reported with an employee to resident occurrence, she would make sure a resident was safe, but was not aware of the reporting process. CNA "M" stated, "I would definitely tell the Administrator, but I don't know the process if an employee is suspended, or fired." In a telephone interview on 8/28/13 at 11:15 a.m., Beautician "N" reported if an abuse situation was reported to her in the beauty shop, her immediate reaction would be to report to Administrator "A" and Director of Nursing "B". She stated, "I can't really say how the employee situation is handled but I do know it has to be investigated before the employee can work again." In a telephone interview on 8/30/13 at 6:10 p.m., RN "W" reported as a previous Unit Manager at the facility, if an employee to resident situation occurred, it was her responsibility to contact Director of Nursing "B" as soon as it had been determined a resident was safe. RN "W" reported that she had never written an investigation or allegation document with resident complaints when she was the Unit Manager. RN "W" reported that she had always informed Director of Nursing "B". RN "W" reported she had spoken with Resident #17 in the past about care issues and of employee care issue complaints. RN "W" reported the concerns were always forwarded to Director of Nursing "B" and the next step was then to Administrator "A". ( )

This cite pertains to MI 249 Based on observation, interview, and record review, the facility failed to follow manufacturer's guidelines for equipment use (use of caster wheel locks) in 1 of 3 sampled residents (Resident #101), from a total sample of 3 residents, resulting in a fall which caused Resident #101 pain and distress. Findings include: Review of the Face Sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact. The MDS revealed Resident #101 required limited assistance of 1 person for transfers and was independent in her wheelchair for locomotion on the unit. The MDS revealed Resident #101 had impairment on both sides of her upper body (left and right arms). Review of the Fall Risk assessment dated [DATE] revealed Resident #101 had "decreased muscular coordination", "balance problems", "loss of limb movement", "3 or more falls in the last 3 months" and required the use of a wheelchair. Review of the Care Plan Activities of Daily Living dated 3/26/12 revealed Resident #101 required "extensive assistance related to poor upper extremity range of motion, right arm fracture (broken bone), left arm rotator cuff tear (shoulder injury)" and had interventions, updated on 4/5/12, to assist resident with bed mobility, transfer, dressing, and bathing (whirlpool bath, shower or bed bath). Review of the Manufacturer's Operating Instructions for whirlpool bathtub dated 1/26/10 (posted next to the whirlpool tub in the shower room) revealed "when transferring the resident onto or off of (whirlpool) chair, the front casters must be locked." Review of Manufacturer's Operating Instruction for whirlpool bathtub revealed under "#2 transfer resident into tub...lock front locking casters by stepping down on brake lock." Review of the Operating Instructions revealed "failure to heed the above warnings could result in injury to the resident or operator." Review of Manufacturer's Whirlpool tub Specifications, Layout, Rough In, Installation and Adjustment Instructions dated 12/4/06 revealed, under "general warnings", to "be sure (whirlpool) chair carrier is securely latched to tub with wheels locked while transferring residents." Per the Facility Incident Report dated 5/11/12 at 8:30 P.M. Resident #101 was taken to the shower room in the whirlpool chair. Resident #101 had a whirlpool bath and after the bath was moved (in the whirlpool chair) to the exit of the whirlpool tub. A Certified Nurse Assistant (CNA) #11 attempted to move Resident #101 from the whirlpool tub onto the whirlpool chair. The chair did not lock, went sideways, and Resident #101 slipped off the chair, to her right, under the support arm that is attached to the chair. The CNA #11 assisted Resident #101 to the floor and emergency medical services took Resident #101 to the hospital. Resident #101 was diagnosed by emergency department staff as having a sprained right shoulder. An observation on 6/5/12 at 11:00 A.M., revealed a whirlpool tub with tub rails on the inside lower left and right side of the whirlpool. The whirlpool chair consisted of a lower carrier with 2 front locking caster wheels and 2 rear wheels. The lower carrier supports the upper chair section with rails for a gliding movement when locked into the tub rails. The two sections (upper and lower) lock together for transport of a resident. When the tub door is opened, the lower carrier locks the chair rails into the tub rails. The rails allowed the upper chair section to slide into the whirlpool tub. The lower carrier is then unlocked and removed and the tub door is closed. When bathing is completed the tub door is opened and the lower carrier is locked into position (chair rails and tub rails locked together) and the upper chair section slides on the rails and back onto the lower carrier. The lower carrier and upper chair are locked together and the resident could be moved in the whirlpool chair. In an interview on 6/6/12 at 10:50 A.M., CNA #11 stated, on 5/11/12, she had taken Resident #101 to the shower room in the whirlpool chair. CNA #11 stated Resident #101 was given her whirlpool bath and emptied the whirlpool tub of water. CNA #11 stated "it (upper chair) got stuck" on the rails in the whirlpool tub. CNA #11 stated there was "about an inch gap between the track and the chair (lower carrier)." CNA #11 stated she pushed Resident #101 and the chair back into the tub and attempted to slide the upper chair out again (with Resident #101 in the upper chair). CNA #11 stated when doing this Resident #101 slid onto the floor. CNA #11 stated she "kind of helped her (Resident #101) down" and her (Resident #101) arm (right arm) was caught in the chair. CNA #11 stated "the brakes (caster wheels) were not locked because the "it (whirlpool chair lower section) locks to the tub." An observation and interview on 6/6/12 at 11:15 A.M. revealed CNA #12 using the whirlpool chair in the shower room. CNA #12 stated "you don't lock the wheels when it (whirlpool chair) 'clicks' (into the whirlpool tub) into the rails because it's (whirlpool chair) latched." CNA #12 was observed transferring an un sampled resident into the whirlpool tub with the front caster wheels not in the locked position. In an interview on 6/6/12 at 12:05 P.M., Director of Quality/Risk Management #15 was asked by Surveyor how the CNA's are trained to use the whirlpool tub? Director of Quality/Risk Management #15 stated "we pair them off with a CNA and they are checked off by a nurse." Director of Quality/Risk Management #15 stated the staff were taught how to operate, clean, take care of residents in the tub (whirlpool bath), and getting them (residents) in and out of the tub (whirlpool bath). Director of Quality/ Risk Management #15 stated "spot checks" were done by herself to ensure proper transfer techniques were performed by the staff. These "spot checks", as stated by the Director of Quality/Risk Management #15, were not documented unless there was a problem. Review of Physician's Progress note dated 5/15/12 at 9:20 A.M., revealed Resident #101 had a sling placed as needed due to fall and injury of right shoulder. Review of the Hospital Discharge Summary dated 5/12/12 at 1:02 A.M. revealed Resident #101 had "moderate pain" in right shoulder on admission to the emergency department and "received Dilaudid (narcotic pain medication) and an x-ray taken was negative for fracture (no broken bone)". Review of Nurses Progress Notes dated 5/16/12 at 7:28 A.M., revealed Resident #101 had "10/10 pain in right shoulder. Resident #101 was given oral pain medication. The oral pain medication lowered Resident #101's pain to "7/10" which was "acceptable to resident (#101)." Review of Nurses Progress Notes dated 5/16/12 at 10:21 P.M., revealed Resident #101 "was crying at 8:30 P.M. with complaint of right arm and shoulder pain." Review of Medication Administration Record dated 5/16/12, un-timed, revealed Resident #101 was given Percocet (oral pain medication) for pain. Review of Nurses Progress Notes dated 5/20/12 at 4:08 A.M., revealed Resident #101 "had right shoulder pain that exceeded 10/10 on the pain scale" and Resident #101 stated scheduled pain medication "was not helping." Review of Physician's Progress Notes dated 5/29/12 at 3:17 P.M., revealed Resident #101 had poor pain control and "will increase Fentanyl (narcotic pain medication) to 50 micrograms every 3 days." Review of Medication Administration Record dated 5/30/12 - 6/5/12 revealed Resident #101 was given a Fentanyl patch 50 micrograms every 3 days as ordered for pain. Review of Nurses Progress Notes dated 6/4/12 at 2:55 P.M., revealed "resident (#101) continues to sleep better with the increase in fentanyl patch." In an observation and interview on 6/5/12 at 11:00 A.M., Resident #101 seated in her wheelchair. Resident #101 did not have a sling on her arm and stated her right arm still hurt. In an interview on 6/5/12 at 11:10 A.M., Resident #101 stated, on 5/11/12, CNA #11 had taken her to the shower room in the special chair (whirlpool chair). Resident #101 stated she was put in the whirlpool tub and completed her bath. Resident #101 stated when she (CNA #11) "took me out the wheels (on the whirlpool chair) wouldn't lock and the bars (tub rails and chair rails) didn't lock." Resident #101 stated CNA #11 tried to slide the upper chair from inside the whirlpool tub to the lower carrier. Resident #101 stated CNA #11 "kept pushing me until I fell out (onto the floor)." Resident#101 stated her right arm was caught on the side arm rest (of the whirlpool chair) and was "pulled". Resident #101 stated the lower carrier was only attached to the whirlpool tub on one side and CNA #11 did not assist her (Resident #101) at all when she fell to the floor. Resident #101 stated she "loved it (whirlpool tub) but not no more. I won't use that again (whirlpool tub)... I'm just too scared to go in it again."

Complaint Intake Numbers: MI 896, MI 294, & MI 295 Based on observation, interview and record review the Facility failed to follow care plan interventions and failed to conduct walking rounds timely and failed to provide adequate supervision to prevent accidents (falls) for 3 of 3 residents in the sample (#101, #102 & #103) resulting in injuries (#101-fractured humerus, #102-fractured hip & #103-bruises & laceration requiring sutures). Findings include: Resident #101 Per the Incident Report and investigation file dated 11/07/11 at 7:20 a.m. Resident #101 was found partially seated on her wheelchair with her knees on the mat next to her bed and with her left arm behind her. Resident #101 was crying out "My arm! My arm!" In a statement dated 11/08/11 Nurse Aide #30 stated on 11/07/11 she "pulled" Resident #101's left arm which was "stuck behind her back" to the "correct position" and lowered Resident #101 to the floor. Per the emergency room Physician's Note dated 11/07/11 and an x-ray of Resident #101's left arm dated 11/07/11 she sustained a displaced fracture to her upper left arm; a sling was applied and she was returned to the Facility the same day. Per the Minimum (MDS) data set [DATE] Resident #101's [DIAGNOSES REDACTED]. Per Resident #101's Fall Risk Prevention Care Plan "Start Date 3/31/2010" the approach dated 8/18/2011 instructed staff to place a soft mat next to the bed when Resident #101 was in bed but to "remove from the floor when in wheelchair." Per the investigation statement dated 11/11/11 Resident #101's "care plan states that the soft mat next to the bed is to be picked up when resident is not in the bed (to avoid the resident falling on or over the mat when attempting to self transfer). The mat was documented as being on the floor when the resident returned to her room, possibly causing the resident to slip/fall and land on her knees..." In a telephone interview on 11/29/11 at 8:34 a.m. RN #14 said on 11/07/11 she observed Resident #101 lying in a fetal position on the floor next to the mat which was unfolded and positioned on the floor parallel with the bed. RN #14 said Nurse Aide #30 was sitting on the floor next to Resident #101. RN #14 said Nurse Aide #30 told her the personal fall alarm sounded and upon entering the room she saw Resident #101 "sitting on the edge of her wheelchair with her left arm behind her back. She said she 'repositioned' the arm to the front and assisted (Resident #101) to the floor. (Nurse Aide #30) said (Resident #101)'s arm was 'kinda like pinned' behind her." In a telephone interview on 11/30/11 at 2:57 p.m. Nurse Aide #30 said she worked the third shift that ended at 7:30 a.m. on 11/07/11. Nurse Aide #30 said approximately 15 minutes before the incident in question occurred she saw Resident #101 dressed and in her wheelchair in the corridor moving in the direction of the dining room. Nurse Aide #30 said she was not assigned to care for Resident #101 or her roommate and did not go into their room during her shift until she heard the personal fall alarm sounding. Nurse Aide #101 said Resident #101 was "hanging" by her left arm which was "twisted" behind her. Nurse Aide #30 said Resident #101's knees were bent but not touching the floor and other than her left arm, no part of Resident #101's body was on the wheelchair. Nurse Aide #30 said Resident #101's toes were in contact with the floor but it was her left arm which was still on the wheelchair that was holding her up. Nurse Aide #30 said Resident 101 and her wheelchair were "far from the bed" because the floor mat was between Resident #101 and her bed. Nurse Aide #30 said the floor mat was unfolded and flat on the floor and positioned parallel to the bed as it would have been had Resident #101 been in bed. Nurse Aide #30 said Resident #101's bedside floor mat was supposed to be up from the floor when Resident #101 was not in bed. Nurse Aide #30 said she ran in front of Resident #101 and supported Resident #101's body with her own body. Nurse Aide #30 said she rocked back bringing Resident #101 with her and lowered her to the floor while simultaneously supporting Resident #101's twisted left arm with her right hand. Nurse Aide #30 said she brought Resident #101's left arm forward. Nurse Aide #30 said at that time Nurse Aide #10 entered the room and Nurse Aide #30 told her to call the nurse and activate the emergency light and then she (Nurse Aide #30) left the room to "get the vitals machine." Nurse Aide #30 said the chair alarm was still sounding at that time and she did not know who silenced the alarm. In a telephone interview on 11/29/11 at 10:18 a.m. Nurse Aide #16 said he was in charge of Resident #101's care on the midnight shift that ended at 7:30 a.m. on 11/07/11. Nurse Aide #16 said at approximately 7:00 a.m. he provided morning care for Resident #101 which included transfer to the wheelchair, activation of her fall alarm, and folding up the mat from alongside her bed. Nurse Aide #16 said he was in the habit on leaning the folded mat against the "bottom one-third" of the mattress. Nurse Aide #16 said the mat was "limp" and often the mat did not remain standing but "slid down"to rest against the bed while a bookcase near the bed stopped the slide. Nurse Aide #16 said the mat never unfolded when it slid down. Nurse Aide #16 said on 11/07/11 at approximately 7:20 a.m. he heard Resident #101's fall alarm sound and asked Nurse Aide # 10 who was in the same room helping another resident to respond to the alarm. Nurse Aide #16 said when Nurse Aide #10 opened the bedroom door he heard Resident #101 screaming, "something like 'Help me! It hurts!'" In an interview on 11/28/11 at 2:35 p.m. Nurse Aide #10 said she was in charge of Resident #101's care on the day shift on 11/07/11. Nurse Aide #10 said she did not visualize Resident #101 during "walking rounds" which were conducted at the change of shifts with the out-going and the in-coming nurse aides but was told by Nurse Aide #30 that Resident #101's personal fall alarm was on and in working condition. Nurse Aide #10 said she saw the floor mat on the floor next to Resident #101's bed during walking rounds and did not see Resident #101 in her bed or in her room at that time. Nurse Aide #10 said she did not pick up the mat because she expected Nurse Aide #30 to do so before she left the room. Nurse Aide #10 said a short time later she saw Resident #101 self-propelling her wheelchair in the corridor in the direction of Resident #101's room. Nurse Aide #10 said she (Nurse Aide #10) then entered the room across the hall and began providing care for another resident with the bedroom door closed without ensuring Resident #101's floor mat was taken up or that her personal fall alarm was on and in working order. Nurse Aide #10 said she heard "screams" through the closed door but did not hear a fall alarm sound. Nurse Aide #10 said she responded to the "screams" and saw Resident #101 lying in a fetal position on the floor of her room near her bed with the mat open and flat and in position parallel to the bed. Nurse Aide #10 said the floor mat was between Resident #101 and the bed. Nurse Aide #101 said Resident #101's head was at the foot of the bed and her feet at the head of the bed and her wheelchair was near her feet. Nurse Aide #10 said Nurse Aide #30 was already in attendance next to Resident #101 who was "screaming" that her left arm hurt. In a telephone interview on 11/29/11 at 8:34 a.m. RN #14 said the expectation was the out-going and incoming nurse aides would visualize all residents assigned to their care who were identified as "at risk for falls" during walking rounds at the change of shift and ensure all safety devices were in place and in working order. In the telephone interview on 11/29/11 at 10:18 a.m. Nurse Aide #16 admitted he did not conduct "walking rounds" with Nurse Aide #10 on 11/07/11 before Resident #101 fell . Nurse Aide #16 said he was "busy providing care" to residents and "didn't have the chance" to do rounds. In the interview on 11/28/11 at 2:35 p.m. Nurse Aide #10 admitted she did not visualize Resident #101 and check that her personal fall alarm was in place and in working order at the start of her shift on 11/07/11. Nurse Aide #10 said, "I should have." In the telephone interview on 11/30/11 at 2:57 p.m. Nurse Aide #30 denied she was in Resident #101's room providing care to the roommate as related by Nurse Aide #10 and denied telling Nurse Aide #10 that Resident #101's alarm was on and working. Nurse Aide #30 repeated she was not assigned to care for Resident #101 or her roommate on the shift that ended at 7:30 a.m. on 11/07/11. Nurse Aide #30 said she did not conduct walking rounds with the on-coming shift for Resident #101 because neither Resident #101 nor her roommate were under her care on the shift that ended at 7:30 a.m. on 11/07/11. In a telephone interview on 11/29/11 at 12:10 p.m. Nurse Aide #17 said she was told by Nurse Aide #18 that Resident #101 had unfolded and positioned the mat alongside her bed and then "crawled over it" to get into bed on multiple occasions. In a telephone interview on 11/29/11 at 12:44 p.m. Nurse Aide #18 said she had witnessed Resident #101 unfold the floor mat and put in on the floor parallel with her bed. Nurse Aide #18 denied saying Resident #101 would "crawl over" the mat and get into her bed. Nurse Aide #18 said Resident #101 was found "sitting in her chair" after she had unfolded the mat and placed it next to (and on some occasions on top of) her bed. In the telephone interview on 11/30/11 at 2:57 p.m. Nurse Aide #30 stated Resident #101 was physically unable to unfold the floor mat and place it alongside her bed. Nurse Aide #30 said she had never seen or heard from others that Resident #101 unfolded and placed the mat alongside her bed. In an observation on 11/28/11 at 9:45 a.m. Resident #101 was asleep in her bed which was positioned next to the wall and had a floor mat parallel to it. A sling and strap was visible on Resident #101's left arm. ( ) Resident #102 Per the Incident Report dated 11/27/11 at 8:05 a.m. Resident #102 was found lying on her bedroom floor with blood on the floor; there was an "abrasion" on her head and her right leg was "painful and shorter than her left leg." Resident #102 was stabilized on the floor, 9-1-1 was called, and she was transported to the hospital. Per the hospital emergency room Physician's Notes dated 11/27/11 and x-rays dated 11/27/11 Resident #102 had a laceration to her head and a fractured hip. She was admitted for surgical repair of the hip and was not present in the Facility during the investigation. Per the Minimum (MDS) data set [DATE] Resident #101's [DIAGNOSES REDACTED]. Per Resident #102's Fall Risk Care plan dated 6/21/11 an intervention to apply a personal fall alarm while she was in bed was added on 9/24/11. In a statement dated 11/27/11 Nurse Aide #13 stated the personal fall alarm was not attached and was not sounding off when she entered Resident #102's room on 11/27/11 and saw her lying on the floor. In a telephone interview on 11/29/11 at 8:17 a.m. Nurse Aide #13 said she responded to the nurses' call light which she discovered was activated by Resident #102's roommate and saw Resident #102 lying on the floor. Nurse Aide #13 said Resident #102 was wearing pajamas and her bed was unmade thus she believed Resident #102 had not been gotten up for the day and had fallen from the bed. Nurse Aide #13 said the personal fall alarm was not sounding and was not attached to Resident #102. Nurse Aide #13 said the personal fall alarm box with the string still attached was on Resident #102's bed. Nurse Aide #13 said Resident #102's roommate told her she did not see Resident #102 fall as the privacy curtain was pulled and blocked her view, but she heard the fall. Nurse Aide #13 said the Roommate said "she hit pretty hard." In an interview on 11/28/11 at 10:10 a.m. Resident #102's Roommate (out of sample Resident #A) said on 11/27/11 the privacy curtain was pulled shut when she "heard her fall. I turned the light on" to call the nurse. In a telephone interview on 11/29/11 at 1:02 p.m. Nurse Aide #20 said she was "assigned" to care for Resident #102 on the day shift on 11/27/11. Nurse Aide #20 said the first time she visualized Resident #102 on 11/27/11 was when other staff members told her Resident #102 had fallen. Nurse Aide #20 said she had conducted "modified walking rounds" at the change of shift on the morning of 11/27/11. Nurse Aide #20 said she did not see Resident #102 or check her alarm at the start of her shift and thus did not know if Resident #102's personal fall alarm was attached and in working order prior to the fall. Nurse Aide #20 said she knew Resident #102 was still abed at the time of the fall as she had "not gotten there yet" to perform morning care. In a telephone interview on 11/29/11 at 8:28 a.m. RN #14 said she responded to the "blue code" emergency call and found Resident #102 lying on the floor in her room with a nurse aide "trying to keep her calm. RN #14 said Resident #102 was wearing gripper socks, pajama pants and a white T-shirt that had blood on it. RN #14 said the bed was unmade and she "did not see an alarm on her." RN #14 said both the off-going and the on-going shift aides were responsible to ensure alarms were in place and in working order at the change of shift. Attempts to reach Nurse Aide #19 who was assigned to care for Resident #102 on the midnight shift that ended at 7:30 a.m. on 11/27/11 were unsuccessful. ( ) Resident #103 11/04/11 Per the Incident Report dated 11/4/11 Resident #103 was observed "running" with her walker near the Nurses' Station, "ran into linen closet by A-wing, then continued down A-wing hallway, hit wall by double door then fell down." Attempts to interview Nurse Aide #23 who was documented as the witness to this incident and ask her why she did not stop Resident #103 while she was "running" near the Nurses' Station and before she "ran into" the linen closet, "hit the wall" continued running and fell down were unsuccessful. In a telephone interview on 11/29/11 at 3:30 p.m. LPN #28 said Nurse Aide #23 told her she "tried to stop her. She said she was going after her but she went so fast" Nurse Aide #23 was unable to catch Resident #103 before she fell . Per the statement signed by Nurse #28 dated 11/04/11 Resident #103 complained of back pain and was sent to the hospital where x-rays were done and no injuries were found; Resident #103 returned to the Facility at 10:45 p.m. 11/21/11 7:30 p.m. Per the Incident Report dated 11/21/11 at 7:30 p.m. Resident #103 was "running with walker, hit foot of bed first then fell forward and hit head into roommate's bed." Per the hospital emergency room notes dated 11/21/11 Resident #103 sustained a contusion to her forehead; a CT scan of her head showed no acute injuries and she was sent back to the Facility. Per the Nurses' Notes dated 11/21/11 Resident #103 returned from the hospital at 10:30 p.m. 11/21/11 11:40 p.m. Per the Incident Report dated 11/22/11 (sic) at 11:40 p.m. and the Nurses' Notes dated 11/22/11, on 11/21/11 at 11:40 p.m. "10 minutes" after Resident #103 returned from the hospital she was found on the floor in her room. No new injuries were discovered at that time. In a telephone interview on 11/29/11 at 3:30 p.m. LPN #28 said when Resident #103 returned from the hospital on [DATE] at 10:30 p.m. (not 11:30 p.m.) she "looked at" Resident #103's bruise on the left side of her forehead, asked her if she had any pain (Resident #103 said 'No.') and gave Resident #103 a drink of soda upon her request. LPN #28 said Resident #103 "said she wanted to get up. I told her she had to wait till the girls could come down. Then I left (Resident #103's room). She was still dressed (in street clothes). The aides were coming in to get her ready for bed but they were doing (change of shift) rounds too." LPN #28 said she did not institute any new fall prevention interventions when Resident #103 returned from the hospital as she was "doing rounds too." LPN #28 said minutes later Nurse Aide #27 came to the desk and reported Resident #103 was found on the floor of her room. In a telephone interview on 11/29/11 at 4:25 p.m. Nurse Aide #27 said Resident #103 returned from the hospital on the night of 11/21/11 "after 11:00 p.m. I get there at 11:00 p.m. and I was there when the hospital called and said they were sending her back." Nurse Aide #27 said she was not given any instructions by the nurses regarding special safety precautions to take to prevent Resident #103 from falling again. Nurse Aide #27 said the reason she went to Resident #103's room was because she was given the task to take all vital signs for required residents and knew that someone who had just returned from the hospital "needed vital" signs taken she went to Resident #103's room. Nurse Aide #27 said she found Resident #103 on the floor. Nurse Aide #27 said, "I did not leave her side. I put the emergency call light on. The nurses came to her room. I did not go to get a nurse." 11/27/11 Per the Incident Report dated 11/27/11 at 5:10 p.m. Resident #103 was "observed in the hallway walking fast, leaning forward on walker, lost control of walker, fell forward and hit floor. When staff observed resident walking fast-instructed resident to slow down." In a telephone interview on 11/29/11 at 10:01 a.m. Maintenance Staff #25 said on 11/27/11 he was working at the nurses' station and saw Resident #103 "going around the nurses' desk. It is a circle. She was crowding the front of the the walker. Leaning over it." When asked to clarify #25 said Resident #103's body was so far into the walker that her body was up against the front bars of the walker "as if she was trying to walk right through it. She was bent over from her mid-back/waist. She had her elbows bent quite a bit. She was leaning with her head out in front about a foot or so." #25 said, "When she went around (the Nurses' Station) the first time it was OK. Her speed was OK. She tends to go too fast at times. But she was kinda rubbing the wall. The second time she was a little faster and rubbing the walker wheels on the baseboard. I mentioned this to (two staff persons present in the Nurses' Station). Then (Resident #103) veered off and sped up and lost her balance." Per the Nurses' Notes dated 11/27/11 Resident #103 sustained a head laceration which was bleeding; she was stabilized on the floor; 9-1-1 was called; and she was taken to the hospital by ambulance. Resident #103 returned from the hospital at 9:30 p.m. with sutures in her forehead. Per the hospital emergency room notes dated 11/27/11 a CT of the head and an x-ray of Resident #103's right hip revealed no acute injuries. In a telephone interview on 11/29/11 at 3:25 p.m. LPN #28 said on 11/27/11 Resident #103 "had been pacing on the day shift. They gave her a different walker." LPN #28 said she was paged to the scene and saw Resident #103 lying on the floor bleeding from the right side of her head. LPN #28 said she and other staff members stabilized Resident #103 on the floor and sent her to the hospital by ambulance. LPN #28 said, "She came back with that bruise on her right hip, bruises on her right shoulder and sutures in her right forehead." In an observation on 11/28/11 at 9:50 a.m. Resident #103 was in bed with Nurse Aide #11 seated at her side. Nurse Aide #11 said she was assigned to provide one-to-one supervision to Resident #103 and was not allowed to leave her alone for one second. Resident #103's face was swollen; there were multiple bruises in a range of colors from dark purple to green to yellow on her face cheeks, eyes, and forehead; a dressing was taped to her left forehead and purple bruises were visible on her right wrist. Resident #103 said her right hip hurt. Nurse Aide #11 removed the blanket and revealed a dark purple bruise with an area in the center of greenish yellow color extended from above Resident #103's right hip down to her mid-thigh. Resident #103 said, "They gave me a new walker and I couldn't control it." A walker with tennis balls covering the rear wheels was standing next to Resident #103's closet. Resident #103 said that was the walker she used when she fell "last night." During the observation on 11/28/11 at 9:50 a.m. Resident #103's roommate (off-sample Resident #B) said "she fell in my room twice about a week ago on 2 different days. Last night she fell after dinner. She had that new walker. They said she picked up the walker and ran into the wall. She hurt the hip here-in this room. She fell on to the bottom part of my bed. They came right in. She crawled to the door and called for help." Attempts to interview the other staff persons who were named as being on the scene were unsuccessful. ( )