Every finding on record at Christian Park Health Care Center

This citation pertains to complaint #3053535Based on interview and record review, the facility failed to ensure the safe wheelchair transportation of one resident (R4) of three residents reviewed for accidents and environmental hazards. This deficient practice resulted in actual harm when the resident's leg slipped from the wheelchair footrest during transport, causing hyperextension of the knee, an inoperable femur fracture due weight and respiratory status, chronic pain, and confinement to bed.Findings include:Resident #4 (R4)Review of R4's Minimum Data Set (MDS) assessment dated [DATE], revealed R4 was admitted to the facility on [DATE]. R4 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition.An interview was conducted with R4 on 7/14/26 at 3:00 p.m. R4 stated a Certified Nurse Aide (CNA) was propelling his wheelchair down the hall to take him to therapy. Resident #4 reported, I told the nurse's aide to slow down because I could feel my foot slipping off the footrest. She did not slow down, and my foot came off the footrest and went underneath the wheelchair. I heard a loud snap - it just popped. R4 further stated that the incident caused immediate and severe pain, adding, I knew my leg was broken.R4 reported being transported to the hospital, where diagnostic imaging confirmed a fracture (femur-leg bone above the knee) of the lower extremity. R4 explained surgical intervention was not an option and stated, Now all I do is lie in this bed. I was working with therapy to get stronger so I could go home, but now all I can do is lie here. This injury has really set me back.Regarding the ongoing effects of the injury, R4 reported persistent, severe pain despite prescribed analgesic medication, stating, My leg constantly throbs, and the pain medication doesn't touch it. At the time of the interview, the resident rated the pain as 9.4 on a 10-point scale and expressed significant emotional distress, stating, I am so sad and depressed.An observation of R4's leg was conducted on 7/14/26 at 3:12 p.m. R4's leg was externally rotated as he lay in bed with an ace wrap dressing below his knee to his ankle.Review of the discharge paperwork from the emergency department (ED) dated 6/8/26 read in part Primary diagnosis: Closed fracture of distal end of right femur .Review of progress notes revealed the following:6/9/26 Nurse reported pt (patient) returned yesterday from ER (emergency room) with report of fracture to distal end of right femur. It (sic) now c/o (complained of) pain, had a norco (pain medication) while in ER but was not continued on pain medication from ER discharge.6/11/26 Notified [physician's name] office and spoke with LPN (Licensed Practical Nurse) about [R4} is stating that he was in a lot of pain after this nurse had administered his oxycodone.6/16/26 Xray transport scheduled for 6/17.R4 refused to go last week due to the amount of pain in the recent fracture.orthopedics to see him and decide what comes next.Review of physician documentation dated 6/17/26 read in part x-rays of the knee.There does appear to be some slight shift of the fracture compared to prior films.Review of progress notes revealed the following:6/22/26 .PCP (primary care physician) in for acute visit [physician ordered] .6/30/26 for x-ray of recent RLE (right lower extremity) fracture.6/29/26 .new order from [orthopedic physicians name] .for x-ray of the Rt (right) knee.6/30/26 .Resident will be transferred to [hospital name].for evaluation of right leg fracture and possible surgical intervention.7/1/26 .resident returned from hospital per ambulance; No hospital will to accept him at this time.he is not a candidate for surgery at this time.Review of orthopedic consult dated 7/1/26 read in part, Noted this type of fracture is very difficult to fix and especially at 3 weeks out would likely need a total knee replacement.Review of a physician progress note dated 7/3/26, read in part .Closed minimally displaced fracture of distal end of right femur without routine healing worsening displacement.fracture is worsening, now displaced from initial x-ray. Today [R4's} leg appears to be slightly inward rotated.patients' leg has not been splinted since date of injury, likely causing displaced fracture.pain is not well controlled due to very poor respiratory status.Review of physician documentation dated 7/8/26 read in part, .Will continue with ace wrap.at facility and recommended bedrest x12 weeks.During an interview on 7/14/26 at 3:17 p.m., the Director of Nursing (DON) reported, The wheelchair pedal malfunctioned and went off to the side of the chair. [R4's] leg hyperextended and the resident was sent to the hospital. As a result of the incident the x-ray revealed a fracture. It is now too painful for him to get out of bed, so he has been in bed since the return from the hospital. He was attending therapy to regain strength to his legs and feet. Therapy is no longer working with him since the incident. He was sent out to the orthopedic surgeon, and the surgeon has elected not to perform surgery. The Certified Nurse Aides (CNA's) that were working with him that morning were [CNA C and CNA F]A phone interview was conducted on 7/14/26 at 3:25 p.m., and CNA C reported, He wanted to get up that day.[CNA F and Registered Nurse (RN) H] were assisting him to get out of bed with the lift.The wheelchair leg rest moved away from the wheelchair when CNA F and I were in the room. I thought I put it back in place and thought the latch was hooked, though it still moved a little.I pushed him down the hallway. Then suddenly he yelled and asked me to stop. He said his leg went back under the wheelchair and I pulled the wheelchair back. He complained of pain and I went to get the nurse. He went to the hospital. He has not been out of bed since and has been in pain. His leg is rotated outwards ever since that happened.During an interview on 7/14/26 at 3:38 p.m., Licensed Practical Nurse (LPN) D reported, I was charting at the nurse station by the 500 hall and saw the wheelchair leg rest swung out to the side and his leg twisted under his chair.He hollered out in pain.A follow up interview with the DON was conducted on 7/14/26 at 3:46 p.m., and the DON reported, The ace wrap is used to try to keep his leg straight.The ace wrap is supposed to be placed from his mid-thigh to just above his ankle.it will take time to heal this break.this injury really has set him back.An interview was conducted on 7/14/26 at 4:00 p.m., with Rehab Director E. Rehab Director E reported I was working with him prior to the incident on transfers, wheelchair mobility, reportioning, and strengthening.his strength and repositioning was improving.An interview was conducted on 7/15/26 at 7:55 a.m., and CNA F reported, [R4] has two chairs in his room. One is for appointments and the other is for use in the nursing home. He had an appointment that day, so we put him in his appointment chair.CNA C was still in training and I worked with her that day.His feet do not fit right on the foot rests.but we were in a hurry that day to get him up for his appointment.His foot came off the pedal and the foot rest had swung out to the side.His leg was twisted under the chair and CNA C backed the chair up and the RN came.he went to the hospital and now has a broken leg.I had heard after the incident that the pedal was broken but Central Supply Director A would know.I don't know if it has ever gotten fixed.the communication around here isn't the greatest.An interview was conducted on 7/15/26 at 8:24 a.m., with Central Supply Director A who reported, The wheelchair pedal was broken on his wheelchair that he uses in the facility, and a new one was ordered and came in prior to the incident with [R4]. The pedals are used interchangeably with his appointment chair.During an interview on 7/15/26 at 8:58 a.m., with Rehab Director E. Rehab Director E reported, the wheelchair pedals that I had Central Supply Director A' order could not be used with his appointment chair.I have not heard if the wheelchair pedals for his appointment chair are broken.I am not sure where that chair is currently. During a follow-up interview at 9:36 a.m., Rehab Director E reported, I don't know what happened the day of the incident.all I can think of it was operator error and the CNAs did not latch the pedal into place.During a follow up interview on 7/15/26 at 11:17 a.m., CNA F reported We used the appointment chair that day.it's the chair with smaller wheels. I was told he had an appointment.I heard later that there was an issue with the chair pedals latching.we don't hear when equipment is broke or when it gets fixed.During an interview on 7/15/26 approximately 12:00 p.m., nursing Home Administrator (NHA) and the Director of Nursing (DON) acknowledged that R4 sustained a fracture during transportation in the facility.

This citation pertains to complaint intake #3010662.Based on interview and record review, the facility failed to notify the state agency of a resident-to-resident altercation to the State Agency (SA) for two Residents (#1 and #5) of five residents reviewed for abuse. Findings include: Resident #1 (R1)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 1/14/26. R1 scored 15/15 on the Brief interview for Mental Status (BIMS) reflective of intact cognition.Resident #5 (R5)Review of MDS assessment dated [DATE], revealed admission to the facility on [DATE]. R5 scored 15 of 15 on the BIMS assessment reflective of intact cognition.During a phone interview on 5/28/26 Certified Nurse Aide (CNA) E reported, On the evening of May 1st I was charting on the hallway where I was working and [R1] had entered the room where [R5] was receiving personal care from another CNA and opened the privacy curtain and exposed the resident.During an interview on 5/28/26 at 2:20 p.m., the Director of Nursing (DON) reviewed the progress notes for R1and reported, This is the first time I have read the charting.no one told me about this incident.During an observation and interview on 5/28/26 at 2:30 p.m., R5 reported, There was one night.a few weeks ago, when a man burst into my room when a CNA was changing my nightgown. He pulled the privacy curtain open about 2 feet.I had no nightgown on at the time and was lying in bed naked and facing him.I tried to cover my breasts so he could not see me.I was so embarrassed and felt so exposed. I don't want him to come into my room ever again. I am a private person, and I don't want a man seeing me like that.(resident observed with tears in her eyes while talking about the incident) the curtain was closed for a reason.I am afraid of what he might do is he comes back I here.I know who he is and she then named R1.During an interview on 5/28/26 at 4:00 p.m., the Nursing Home Administrator (NHA) reported, I was not aware of R1 going into R5's room while she was receiving personal care.I don't know what we can to do make our staff report to us when there is an incident.our residents have the right to feel safe in their home.Review of policy titled Abuse Prohibition Policy last revised 9/9/22, read in part .The staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation.to the Administrator {NHA} and DON immediately.the administrator.will notify.any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury; all others not later than 24 hours).Review of policy Incidents and Accidents for Residents last revised 7/8/25, read in part .incident or Accidents involving a resident will be documented and reported so as to meet regulatory requirements.when an incident or accident is discovered, the employee making the discovery will immediately notify his/her direct supervisor.if the event requires immediate action from the Administrator.the Administrator will be notified immediately.The Administrator or Director of Nursing must report an Incident and accident to the State Agency.

Based on observation, interview, and record review, the facility failed to implement a complete infection control program as evidenced by failure to:Effectively mitigate outbreaks of COVID-19 and Influenza A resulting in widespread dissemination of infection disease throughout the facility.Properly disinfect and store multiple-resident use glucometers and individual insulin pens following use.Maintain clean and sanitary medication carts, andProperly clean and sanitize resident bed pans for 5 of the 5 residents in the facility that use bed pans.This deficient practice resulted in the harm when COVID-19 and Influenza A outbreaks in January and February 2026, respectively, spread throughout all Halls of the facility, infecting 25 Residents with one death for COVID-19, infecting 10 Residents with one death for Influenza A, and a decreased quality of life. Findings include: 1. Outbreak Mitigation Failure/Infection Control Surveillance and Tracking/Timely Implementation of Contact Precautions. During an interview on 4/8/2026 at 11:00 a.m., Licensed Practical Nurse (LPN) U, was observed donning Personal Protective Equipment (PPE) prior to entering R69's room which was posted for Contact Precautions. When asked why R69 was under contact precautions, when the Resident (R69) the transmission-based precautions (TBP) had not been posted the previous day when this Surveyor entered R69's room, LPN U was unsure of the answer. During an interview on 4/8/26 at approximately 11:02 a.m., when asked why R69's room was not posted for Contact Precautions Infection Preventionist (IP) H stated, [R69] is on (contact precautions) because she has a MDRO (multi-drug-resistant organism) in her urine. When asked why contact precaution signage was not posted outside of R69's room the previous day, IP H stated, That is because I didn't see it (MDRO) documentation (from the hospital) and didn't put the signage up. IP H said the Contact Precaution signage had been put up that morning (4/8/26) but should have been posted the previous day (4/7/26). During an interview on 4/8/26 at 11:31 a.m., the Director of Nursing (DON) was asked when the results from R69's urine culture results were noted by the facility. The DON said R69 went out to the hospital on 4/1/26, the urine culture was done in the hospital on 4/1/26 and she (R69) came back the same day (4/1/26) with the culture results. The DON stated, I would think someone would have checked the culture when she came back. When asked who she would have expected to check those culture results, the DON said [IP H]. The DON confirmed IP H was not out of the building (on 4/1/26 )and acknowledged that no contact precaution signage was posted outside R69's room until 4/8/26. Review of the Infection Control Binder on 4/9/2026 at 7:58 a.m., revealed the following, in part: The April 2026 section of the binder contained no documentation, including no line listing of infections (including documentation for R69 who was currently in contact precautions), and no infection mapping within the facility. During an interview on 4/9/26 at 8:42 a.m., the Director of Nursing (DON) reviewed the Infection Control binder, and confirmed no documentation was present for April 2026 section of the binder. The line listing for April was empty. The March 2026 section had a line listing with infection mapping that appeared to have been completed at the end of the month. The February 2026 section included a line listing detailing a facility Influenza A outbreak beginning including 10 facility residents with onset dates beginning 2/16/26 through 2/20/26. Resident #93 (R93) acquired Influenza A on 2/18/26 and died in the facility on 2/22/26. The February 2026 line listing revealed the Influenza A outbreak began on the 200 Hall within the facility and spread to both the 400 and 500 Halls on 2/20/26 and 2/18/26 respectively. No Outbreak Summary was present for review. The January 2026 section included a COVID-19 outbreak line listing detailing the spread of COVID-19 within the facility to 25 facility residents with onset dates of 1/7/26 through 1/27/26. The COVID-19 outbreak began on the 500 Hall and spread to the 200 Hall on 1/10, the 400 Hall on 1/19, the 300 Hall on 1/23/26. Resident #93 (R93) contracted COVID-19 on 1/16/26 and died in the facility on 1/19/26. No COVID-19 Outbreak Summary was present for review. During an infection control interview on 4/9/26 at 8:45 a.m., the DON, DON N (from a corporate sister facility) and Infection Preventionist (IP) H were asked about the lack of April 2026 infection control documentation. IP H acknowledged the infection control mapping was not completed for April 2026, and said the mapping gets done at the end of the month, not in real time. When asked about the absence of [R69] on the April 2026 line listing, the DON and IP H acknowledge R69 should have been placed on the line listing on 4/1/26, based on urine culture results received that day (4/1/26). IP H acknowledged all the residents on the infection control line listings received antibiotics. IP H confirmed tracking of issues such as nausea and vomiting were not routinely documented on the line listing. During an interview on 4/9/2026 at 9:13 a.m., IP H confirmed they had not prepared or completed an Influenza A outbreak summary for February 2026. When asked about the outbreak of Influenza A, IP H said the outbreak began on 2/17/26 when two or more residents within the facility contracted Influenza A. During an interview on 4/9/2026 at 9:16 a.m., IP H confirmed 25 residents within the facility contacted COVID-19 during the January 2026 outbreak for COVID-19. IP H said the hallway double doors were not closed during the COVID-19 outbreak in an attempt to contain the outbreak from spreading from the 500 Hall (first COVID-19 positive resident) to all of the other halls. DON N, present during the interview, when asked why the Hall doors would have been closed, stated, You can close the (Hallway) doors to decrease the spread (mitigate spread of infectious disease). IP H reported the following COVID-19 details: No outbreak investigation summary was completed for the January 2026 COVID-19 outbreak, infection mapping was completed at the end of the outbreak, communal dining and activities continued throughout the outbreak and staff positive for COVID-19 were not tracked as they worked within the facility for source tracking of the virus. IP H and DON H said they had received a CDC recommendation from the local public health department to leave communal dining open. During an interview on 4/9/2026 at 9:46 a.m., when asked why the hallway double doors were not closed to mitigate the spread of both COVID-19 and Influenza A outbreaks in January and February 2026, respectively, IP H stated, I did not consider closing the doors, even though someone said, ' . you know [previous IP T] always closed the doors (with an outbreak) . During an interview on 4/9/26 at 12:15 p.m., a repeat interview was conducted with IP H, the DON, and DON N. When asked about the hallway doors remaining open during infectious disease outbreaks in January 2026 and February 2026, IP H stated, .(we) used to close the doors. I didn't even think about it. IP H acknowledged the hallways doors were wide open between all the hallways, and the facility did not restrict communal dining. We did not restrict communal dining. When asked if IP H, DON N, or the DON had read the local public health departments article provided via email that recommended leaving communal dining in place, all three said they had not read the article. IP H said she was told not to close the doors because it was considered a restraint by administrative staff. Review of the Center for Disease Control (CDC) Viral Respiratory Pathogens Toolkit for Nursing Homes, received by the facility via email on 1/16/26 at 4:37 p.m. from their local public health department, revealed the following, in part: .When an infection due to a respiratory virus is suspected in a resident or HCP, it is important to take rapid action to prevent the spread to others in the facility . Residents placed in Transmission-Based Precautions for acute respiratory infection should primarily remain in their rooms except for medically necessary purposes. If they must leave their room, they should practice physical distancing and wear a facemask for source control. The resident should be removed from Transmission-Based Precautions as soon as they are deemed no longer infectious to others . Investigate potential spread . Perform active surveillance to identify any additional ill residents or HCP using symptom screening and evaluating potential exposures. If transmission is limited to specific units, consider limited quarantine of those units (e.g., restricting those units from group activities or communal dining with residents from other units). Take additional measures if initial interventions fail Consult with the local or state public health department about additional interventions. Consider establishing cohort units for residents with confirmed infections. Dedicate HCP to care for residents in cohort units and Minimize HCP movement from areas of the facility where residents are having illness to areas not affected by the outbreak. Limit group activities and communal dining. Consider limiting the use of communal areas where residents or HCP might congregate over multiple units or facility wide . Review of the email from the local public health department to the IP H, dated 1/16/26 at 4:37 p.m., revealed the following, in part: .If you feel you have executed all the initial steps to control spread and are still seeing cases, then you are supposed to move on to the additional measures. Under the additional measures, it suggests considering limiting the use of communal areas. Because only you know the extent you have taken to control spread and whether you feel they are working, Public Health would never tell you that you have to suspend communal dining. However, if you feel it would be helpful, we will support your decision. From our conversation, I did think that you felt suspending communal dining would make a difference at this time . During an interview on 4/9/26 at 12:30 p.m., the Nursing Home Administrator (NHA) said the double doors on all Halls were not closed during the January 2026 COVID-19 and February 2026 Influenza A outbreaks. Review of the facility Outbreak Investigation policy, last revised 10/17/23, revealed the following, in part: . An outbreak is typically one or more of the following: A single case of an infection that is highly communicable (such as COVID-19). Trends that are ten percent (10%) higher than the historical rate of infection for the facility that may reflect an outbreak or seasonal variation and therefore warrant further investigation. Occurrence of three (3) or more cases of the same infection over a specified length of time in the same unit as defined by the local/state health department . PREPARE: 1. Part of routine education of staff should include description of what an outbreak is, their roll in an outbreak and methods of prevention such as: a. Hand hygiene. B. Following appropriate precautions as directed during an event . F. Control measures that may be implemented during an outbreak such as isolation or quarantine . h. The need for nursing staff to monitor for clusters of infection and to report suspected cluster of infection to the Infection Control or their manager . IDENTIFY .f. Develop a line listing .Develop a map to identify clusters or trends of signs and symptoms of potential infection and confirmed cases of infection in residents or staff .CONTAIN, CONTROL AND PREVENT MORE CASES . 4. Other measures may include isolating individuals who are ill from those who are not, discontinuing group activities, discontinuing main dining room services . ADJUST: 1. If control measures are followed but remain ineffective, er-evaluate and modify as needed including possible closure of a unit or the facility to new admissions or transfers out (except in medical emergency), restrict movement of staff between units, restrict visitors, vendors and non-essential staff. RESOLVE:1. When there have been no new cases for at least 72 hours, you may consider the outbreak resolved. 2. Strict quarantine and control measures may be lifted .ANALYZE DATA .1. Compile data gathered during the outbreak and analyze for possible improvement opportunities in identification and management of disease. 2. Determine actions that were effective and actions that were ineffective and possible reasons for the disease. 3. Develop a written report of the outbreak details including an epidemiologic curve, attack rates, risk factors identified, actions that were taken, and control measures that were effective or ineffective. 4. Identify possible strategies that could be implemented to prevent future outbreaks or improve the process. 2. Disinfection of Multiple Use Resident Equipment and Insulin Pens During an observation and interview on 4/8/26 at approximately 11:00 a.m., LPN U prepared a glucometer (used for multiple residents' blood glucose assessments) and an insulin pen for insulin administration to R69. LPN U placed the insulin supplies on a small rectangular tray. The foam tray was placed on R69's overbed table while the glucometer was used to verify the Resident's blood glucose level, and the insulin pen was used to administer 18 units of Glargine insulin to R69. Upon exit from R69's contact precaution room on 4/8/2026 at 11:23 a.m., LPN U was observed as they removed the small white tray from R69's room and placed the tray directly on top of the 400 Hall medication cart, with no barrier present. A new, clean tray was used to place the used (considered dirty) glucometer on, and a bleach disinfectant wipe was folded around the glucometer. LPN U did not wipe (clean) the exterior surfaces of the glucometer, which was then placed on the white, foam tray. LPN U asked this Surveyor if the insulin pen needed to be disinfected (after being in R69's contact precaution room) and stated, We usually don't clean them (insulin pens) before we put them back in the medication cart. Review of the [Name Brand] Blood Glucose Monitoring System User's Guide, copyright 2024, revealed the following disinfection instructions: Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter .so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease-causing agents are destroyed on the meter . surface . 1. Wash hands with soap and water and dry thoroughly. 2. Inspect for blood, debris, dust or lint anywhere on the meter . 4. To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below .(included [Name Brand Healthcare Bleach Germicidal and Disinfectant Wipes) .Wipe all external areas of the meter .including both front and back surfaces until visibly clean .Allow the surface of the meter . to remain wet at room temperature for the contact time listed on the wipe's directions for use. 5. Wipe meter dry or allow to air dry . During an interview on 4/8/2026 at 12:31 p.m., when asked about disinfection of multiple resident use glucometers (measures blood glucose levels) and resident-specific insulin pens IP H said glucometers were disinfected with a [Name Brand] disinfectant wipe that has a three (3) minute kill time (required for effectiveness of disinfectant), and glucometers and the insulin pens should have been wiped (wet all surfaces) prior to wrapping the wipe around the items for the required kill time. IP H confirmed any disposable items (such as a small foam tray for medical supplies) taken into a contact precaution room should be discarded prior to exit from the room and agreed that all insulin pens taken into a resident's room should be disinfected prior to being placed back into a medication cart. IP H acknowledged failure to implement the above procedures would reflect a control of infection control principles. During an interview on 4/9/2026 at 9:41 a.m., IP H agreed with the infection control concerns related to disinfection of glucometers and insulin pens. 3. Clean, Sanitary Medication Cart During a medication pass observation on 4/8/2026 8:41 a.m., a [Name Brand] concentrated, liquid protein medical food designed to manage wounds, pressure injuries, and protein-energy malnutrition bottle was covered with multiple spills from the top of the bottle when removed from the 300 Hall medication cart for administration to Resident #70 (R70). The dosage was poured into a 30 ml (milliliter), plastic medication cup; the cover replaced on the [Name Brand] liquid protein medical food liquid; and the bottle was placed back into the 300 Hall medication cart with all of the sticky, yellowish liquid dripping down the sides. During an observation on 4/9/26 at 7:30 a.m., RN S retrieved the [Name Brand] concentrated liquid protein medical food designed to manage wounds, pressure injuries, and protein-energy malnutrition from the 300 Hall medication cart. The bottle was inside a black, plastic holder with the sticky, yellowish liquid observed dripping from multiple sides of the bottle top. When the DON and IP H were asked to observe the bottle and comment on whether the condition of the [Name Brand] concentrated liquid protein container was acceptable storage within the medication cart. The DON stated, No, is it not acceptable. I will take it and clean it up. IP H stated Oh God. when she saw the condition of the bottle. 4. Properly clean and sanitize bedpans On 4/7/2026 at 1:45 PM in interview with Certified Nursing Assistant (CNA) B stated that bed pans were taken to the soiled linen room and rinsed out with the water nozzle at the hopper and then placed in a clean garbage bag and taken back to the resident's room and placed in the closet. On 4/7/2026 at 1:50 PM the Director of Nursing (DON) was asked to provide in writing and upload the number of residents that are on bed pans, along with the facility policy for cleaning and sanitizing reusable medical equipment. On 4/7/2026 at 2:08 PM in an interview with CNA C she stated that clean bedpans are put into a clean garbage bag in the room. When she goes to work with a resident that needs a bed pan, she puts down a clean garbage bag on the floor of the room, removes the bedpan from under the resident and places it on the garbage bag. She then takes the bed pan with the garbage bag underneath it and dumps it in the resident toilet in that room. She uses water from the sink in the resident restroom to rinse out the bed pan and said there is no soap or sanitizer in the restroom to clean the bed pan. On 4/7/2026 at 2:20 PM in an interview with the Social Services Director (SSD) D stated they used to be a CNA here for 11 years up until five weeks ago. They stated that bed pans are kept in the rooms in garbage bags. The bed pan would be removed from the garbage bag and placed under the resident. After the resident was finished using the bed pan, the bed pan was rinsed out into the sink in the resident bathroom using a cup and if available some foam soap. The pan was rinsed with water and placed in a garbage bag and stored again for the next use. On 4/7/2026 at 2:34 in an interview with CNA's F and G, CNA F stated bedpans are stored in the closets in the room of the resident and after use by the resident, the bed pans are emptied in that resident's toilet. CNA G stated that some CNA's dry the bed pan after rinsing and place baby powder in the bedpan, before placing the pan in a garbage bag for storage. On 4/7/2026 at 3:00 PM the DON provided the policy/procedure for bedpan and urinal use and stated the facility currently had 5 residents that required bed pan usage. The Bedpan and urinal use policy Revised: December 15, 2025 states that after the contents of the bedpan or urinal are emptied into a toilet or designated waste area, the bedpan or urinal is to be rinsed with water and cleaned thoroughly using a facility-approved disinfectant solution to prevent the spread of infection.

Based on observation, interviews, and record review, the facility failed to protect the residents' right to be free from willful neglect in answering a call light for one Resident (8) of 4 residents reviewed, resulting in Resident #8 waiting for over 20 minutes to be addressed while moaning, crying out and thrashing. Based on the reasonable person concept Resident #8 exhibited signs and symptoms of extreme pain and overwhelming anxiety caused by this extended time of unmet needs.Findings include: Review of a facility Abuse Prohibition Policy dated 10/14/2022 read in part: Policy-Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents. Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies.The subject of abuse should be routinely and openly discussed.Staff members, volunteers, family members, and others shall immediately report incidents of abuse and suspected abuse, and should be assured that they will be protected against repercussions. Abuse can be guest/resident-to-guest/resident, staff-to-guest/resident, family-to-guest/resident, visitor-to-guest/resident etc.Neglect is the failure of the facility, its employees or service providers to provide goods and services to a guest/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware, or should have been aware of, goods or services that a guest/ resident(s) requires but the facility fails to provide them to the guest(s)/resident(s), resulting in physical harm, pain, mental anguish or emotional distress. Alleged violations of neglect include cases where the facility demonstrates indifference or disregard for guest/resident care, comfort or safety, resulting in physical harm, pain, mental anguish or emotional distress.Resident #8 (R8)Review of an admission Record revealed R8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral palsy, anxiety and difficulty swallowing.Review of a Minimum Data Set (MDS) assessment for R8, with a reference date of 1/14/2026 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated R8 was severely impaired.Review of R8's Care Plan read in part: FOCUS: R8 was at risk for pain r/t Chronic Physical Disability = cerebral palsy, scoliosis and contractures Date Initiated: 01/28/2025.INTERVENTIONS: Observe and report any (signs/symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Report abnormal findings to the physician. Date Initiated: 01/28/2025.Review of R8's Kardex (CNA care guide) read in part: MONITORS: Observe and report any s/sx (signs/symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Report abnormal findings to the physician.During initial pool observations on 4/6/2026 at 2:42 PM., a crying/moaning sound was coming from a resident's room and could be heard from the middle of the unit, from approximately 25 feet or more away. This surveyor proceeded down the unit to find the resident who could be heard crying. This surveyor reached the end of the unit to the last room on the right-hand side and the resident in the first bed was noted to be R8. This surveyor knocked but there was no answer and crying was still heard. This surveyor announced self and entered the room. In the first bed, R8 was observed lying on her right side with a pillow underneath her left side. R8 was hooked up to a feeding tube which was running. R8 continued crying, moaning and thrashing her head back and forth. This surveyor approached the right side of the bed and observed R8's hair matted to the back of her head and it appeared greasy and unkempt. R8 was noted to have tears coming from her eyes. There were dried crusted tears in which the white substance (aqueous layer-watery part from lacrimal glands, containing salts, proteins, and enzymes) from the tears was noticed to be dry on her right temple and upper cheek, there was also a collection of wet tears on her left inner eye canthus (the corner of the eye nearest the nose where the upper and lower eyelids meet, playing a key role in tear drainage). R8 appeared sweaty and her bed linens were strewn about the bed. R8 appeared to be restless, tense and it seemed as though she was trying to swallow. R8 had a copious (abundant) amount of secretions in her mouth, her tongue was moving back and forth and sticking in and out. R8 was still crying and there was a noticeable rattle-gurgling sound from her throat. This surveyor made their presence known, although R8 was unable to answer questions, or make any verbal contact she appeared to be calming down, she began pushing her head back into her pillow with less thrashing. R8's front upper and bottom teeth had a thick dry, stuck on plaque, tarter and sputum in layers approximately three quarters of an inch thick. R8's teeth could not be seen. R8's mouth, lips and chin also had areas of wet and dry crusted sputum-secretions. R8's call light was noted to be clipped to the pillow behind her out of reach. R8 was noted to have limited range of motion with her upper extremities, and her arms were contracted inward up near her chest. R8 continued to cry and moan, as well as continued distress and thrashing of her head. At approximately 2:47 PM, this surveyor pressed R8's call light to note call light wait times. This surveyor noted R8's roommate was in her bed asleep, her call light was a round pad type, R8s call light was a button press style. This surveyor noted approximately 2-3 Certified Nurse Aides (CNA) staff members enter the room directly across from R8. The sign on the door read Employee Breakroom This surveyor looked outside R8's bedroom doorway above the door to ensure the call light had triggered properly for staff to respond timely. The call light was on and was lit up. At this time, which was 3:04 PM., no staff were noted on the unit. R8 appeared to have noticed this surveyor when reapproaching the right side of her bed, taking note of the bedside table which held a basin full of mouth swabs, suction pieces individually wrapped and various other oral-mouth care items. This surveyor took note of R8's garbage next to her bed, noted it was a clear garbage bag with nothing in it and the bathroom garbage was also empty.On 4/6/2026 at 3:10 PM., CNA J was observed entering R8's room and walked in front of this surveyor (standing 1-foot away from the foot of R8's bed). CNA J walked around R8's bed on the right side, and shut the call light off. CNA J did not make eye contact, look at or say anything to R8. CNA J then walked over to R8's roommate who was asleep. CNA J asked the roommate if she needed anything, no answer or sound was made by R8's roommate and her eyes remained closed. CNA J walked past this surveyor, not looking at R8 and exited the room.This surveyor then approached CNA J, and in an interview/observation on 4/6/26 at 3:12 PM., was asked what he completed in R8's room. CNA J stated I saw the call light on and know that R8 cannot use her call light, so I went over to bed 2 and asked her what she needed. She (R8's roommate) said she hit the call light by accident. when further prompted, CNA J responded by stating I am assigned to both residents in R8's room, I did not look closely at R8, and I have not done cares on her since this morning CNA J was asked what R8's baseline for breathing, oral-mouth appearance, hair, toileting and her typical behaviors were. CNA J stated R8 cries out when something was wrong or she is uncomfortable and/or in pain. CNA J stated I didn't look at her or check on her when I turned the call light off, I did not notice the 2 call lights were not the call lights for the residents. CNA J stated I lied, R8's roommate did not say anything to me when I asked her if she needed anything, she was asleep. I did not do anything to assist R8 when it was clear she was uncomfortable, and I lied to you when you (this surveyor) asked me, because I don't know the answers to the questions you were asking about R8. CNA J reported he should have looked at R8's Kardex, and/or gotten assistance from the nurse on duty to ensure R8 was okay. CNA J reported he has never completed oral care on R8 and did not provide any type of oral care for R8 today, because he thought only the nurses were to do it. CNA J and this surveyor observed R8's mouth, CNA J stated it should not look like that, it seems like she has a lot of secretions built up and stuck in her throat, and she needs to be cleaned up. In an interview and observation on 4/6/2026 at approximately 3:20 PM., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) H accompanied this surveyor to R8's room. Both DON and ADON H reported they were concerned about the overall appearance of R8. ADON H and DON were both informed of this surveyor's earlier observation of R8, and the interview with CNA J, as well as the multiple staff who entered the Staff Breakroom while R8's call light was on. ADON H appeared visibly upset and reported they would take care of R8 cares and oral cares. The DON responded with concern and stated, the staff failed R8 by ignoring her call light and did not provide proper care and services, which is unacceptable care for any resident. This surveyor informed DON and ADON H that CNA J openly admitted to lying in an interview with this surveyor about completing earlier care for R8 and turning off a resident call light without meeting the needs of residents, because he did not know what to do. DON and ADON H both began to gown up and proceeded to start care on R8. ADON H stated she would be speaking to CNA J and the staff once R8's care was complete.

This citation pertains to Complaint # 2972928.Based on interview, and record review, the facility failed to timely readmit one Resident (#1) of three residents reviewed for admission, transfer, and discharge rights, resulting in Resident #1 feeling of unnecessary separation from family and friends and uncertainty related to continued medical care and financial stress, as well as psychological stress and anxiety.Findings include:Resident (R1)Review of an admission Record revealed R1 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: respiratory failure.Review of the Minimum Data Set (MDS) assessment for R1 dated 2/12/2026 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating R1 was cognitively intact.Review of R1's EMR read in part: Date of Service 3/19/2026 14:16 Behavioral Health Visit Type Psychiatry Follow up - His Brief Interview for Mental Status (BIMS) score is 14.Review of a State Agency Complaint dated 4/2/2026 at 1:51 PM., read in part: Allegation Details-It was alleged that the facility failed to allow the resident (R1) to return to the facility after a discharge to a hospital .Please provide the location where the incident occurred. (out of state hospital name omitted). Hospital dumping refusal to re-admit resident . Resident Relation: Patient Advocate . Please provide the name or description of the witness/witnesses: Case Manager (CM) M at (out of state hospital name omitted) . Please describe the specific incident that is prompting this complaint including any injuries that resulted: Resident (R1) wishes to return to the nursing home. Resident has made a health decision not to be placed on a AVAPs (Average Volume-Assured Pressure-Oxygen (O2) Machine) but to return on the BiPAP (Bilevel Positive Airway Pressure-O2 Machine) as the nursing home does not manage AVAP. Resident was on BiPAP at this home; therefore, they are able to manage it. (Nursing Home Administrator-NHA) states that the resident is bipolar and making bad decisions and it is not a safe discharge back to the nursing home. The resident states he was bipolar, on BiPAP and made the same decisions before he left the nursing home. He knows the risks and wants to return on BiPAP. Resident states the hospital case manager has educated resident what this means. Hospital physician also has explained the risks to the resident, and he (R1) wishes to make this decision. Resident states he has a right to make his own decisions good or bad. Resident asks to be readmitted to this nursing home. This appears to be a case of hospital dumping.Review of R1's Electronic Medical Record (EMR) read in part: 3/26/2026 19:19 Alert Note Text: (R1) No BM (bowel movement) For 3 Days Sent to (Local emergency department (ED) name omitted) .In an interview/record review on 4/8/26 at 10:15 AM., R1's Assistant Director of Nursing (ADON) H. ADON H reported it appears R1 was discharged from the facility and admitted to the hospital on [DATE]. ADON H reported there should be more information in R1's EMR. ADON H and this surveyor reviewed R1's EMR which read in part: 3/26/2026 (R1) No BM For 3 Days sent to (ED). ADON H reported R1's EMR does not show R1's discharge was properly documented, and the information was not clear. ADON H stated I am honestly unsure exactly why R1 was sent out.ADON H reported there should be pertinent information in his EMR because the facility practice was not to send residents out because of not having a BM for 3 days, unless they are showing other signs/symptoms. ADON H reported R1 had alternative medications/measures that should have been used to alleviate constipation. ADON H reported R1's discharge out of the facility was not properly documented, and it is unclear by review exactly why he would have been sent out that day. ADON H reported R1's baseline O2 sats are usually mid to upper 80% range. In an interview on 4/8/2026 at 1:29 PM., the NHA reported R1 initially transferred to the local ED because he had an hypoxic episode (a low oxygen level in the blood) R1 was then transferred out to a hospital (in another state-name omitted). NHA reported the local Ombudsman (OMB L) was recently in a to discuss R1 and his return to the facility. The NHA reported she received R1's discharge (return to this facility) referral last week from the Registered Nurse/Case Manager (RN/CM) M (from the out of state hospital). The NHA reported she did not think R1 was stable enough to come back to the facility. When the NHA was asked what stable meant, they stated I will not readmit R1 until he's stable, it's my understanding that he needs a AVAP machine, which we do not know how to use, and he also needs to have arterial blood gases (ABG's) drawn daily from the lab. The NHA reported R1 would like to come back to the facility, and she (NHA) has no problems re-admitting him when he was medically cleared. The NHA stated In my conversation with Omb L, I told her that I don't think that neither of us have the clinical knowledge to know for sure that R1 was clear to come back. She (Omb L) filed an appeal on behalf of R1 with the State Agency saying we are involuntary discharging him; the State Agency wanted me to forward the Involuntary Discharge form; I haven't gotten anything back on that. The NHA was asked to provide this surveyor with any and all information regarding R1's discharge from the facility to the emergency department (ED), then to the out of state hospital and all communications to and from the hospital. This surveyor informed the NHA that the last documented note in R1s EMR was that he had not had a bowel movement in 3 days. The NHA reported being unaware of the documentation in R1s EMR. The NHA reported that whatever was in R1's EMR was what the facility had for R1 and his discharge out on 3/26/26. The NHA stated R1 was sent out to the ED for a hypoxic episode, whenever a resident's O2 levels are blow 90% and in the 80% range they are sent out to the ED Review of R1's EMR oxygen saturations (O2's) from 1/23/26-3/25/36 revealed R1's O2 sats baseline results were documented in the mid 80's and lowest O2 sats documented were 69% and 71% .Review of R1's hospital (out of state) paperwork dated 1/5/26 read in part: nursing home resident. chronic hypoxic respiratory failure on 2 L of oxygen at baseline . Presented to the emergency room after long-term care facility noted his oxygen was 65% at baseline 2 L. He also had sepsis secondary to bilateral pneumonia-UTI-bacteremia- he also had respiratory coronavirus He also had an E. coli UTI, pneumonia.In an interview on 4/9/26 at 7:25 AM., Omb L reported R1's she has spoken with R1, CM M at the out of state hospital where R1 was currently, and with NHA. Omb L reported R1 wants to come back to the facility and has been educated for weeks on any risks if not on a AVAP machine when taking naps and going to bed. Omb L reported the NHA has been repeatedly delaying R1s readmission to the facility by telling R1 and CM M the facility cannot or does not have the ability to care for someone on an AVAP machine. Omb L stated that is just not true, I also advocate for residents in the sister facility, they have residents with AVAP machines, the staff there and the DON N are all one team (This information was corroborated by an interview on 4/9/26 aprx. 10:00 am with the Director of Nursing (DON) N from the sister facility, DON N reported she did have experience and a resident with an AVAP machine). Omb L reported after conversations with CM M and R1's status R1 has reported it was easier and smaller than the BiPAP machine he had previously been self-administering at the facility. Omb L reported the hospital respiratory department, CM M and doctors have been explaining to R1 all risks if he was unable to get a AVAP machine and only use the BiPAP. Omb L reported R1 has demonstrated to them that he indeed can use it properly. Omb L stated it is R1's right to leave the current hospital AMA (Against Medical Advice) and it is also his right to be able to go back to the facility. Omb L reported as for today, there are no concerns about his going back to the facility the hospital staff are confident he is capable to make his own medical decisions. Omb L reported R1 has had lengthy conversations with all medical personnel and knows that he could potentially die. Omb L reported the hospital sent him out a few weeks ago and the facility was ready to re-admit him based on the same issues today, so the hospital discharged him. They put him in the ambulance style van, drove him to the facility which was a nearly 5-hour one way trip. Omb L stated NHA and the facility staff let R1 sit in that van for hours after a 5-hour drive, get to the facility door and lock it. The driver was trying to contact everyone and anyone but it was after hours, so the hospital staff (CM M) luckily receive one of the calls from the driver and she had him sent back another 5 hour drive to another state.that just breaks my heart to think of R1, or any resident being put under that much stress, and pain R1 called me the next day and said he felt like he was put in a meat wagon.Review of R1's EMR and hospital admission (out of state) dated 3/26/26 read in part: History obtained from: Chart review/Discussion with referring. chronic respiratory failure requiring nocturnal (night) BiPAP on 2L. presents from a nursing facility with acute worsening dyspnea and hypoxia.Oxygen saturation was 83% on 3 L nasal cannula and dropped to 55% while on BiPAP at the facility, prompting transfer to the emergency department Reviewed of R1's EMR progress notes, vital signs, documents scanned in and all pertinent records from 3/1/26-3/26/26 revealed no documentation of R1s O2 sats dropping to 55% as indicated in R1s hospital admission on [DATE] which read in part: History obtained discussion from referring.Review of R1s EMR progress notes read in part: Change In Condition (CIC) 3/26/202613:52 Summary for Providers Situation: The CIC reported are-evaluation are/were: Shortness of breath at the time of evaluation (R1's) vital signs, weight and blood sugar were: - Weight: W 548.8 lb. - 3/25/2026 08:00 Scale: Mechanical Lift- Pulse Oximetry: O2 84.0 % - 3/26/2026 12:38 Method: Oxygen via Nasal Cannula. Recommendations: Sent to ER for evaluation.In an interview on 4/9/26 at 9:54 AM., R1 reported he was sent out to the ED on 3/26/26 and did not know why. R1 reported he felt fine that day, he had not been experiencing any medical concerns that he was expressing to the staff. R1 reported one moment everything was fine the next thing I knew the nurse managers were worried about my oxygen status. R1 reported he initially went to the ED and then was sent to an out of state hospital. R1 reported he was obese and currently over 500 pounds, he has had respiratory problems for a long time and uses oxygen at 4 liters during the day, and a BiPAP machine for naps at night when he goes to bed. R1 reported he wants to go back to the facility to finish out his rehabilitation and hopefully return home. R1 reported he has a great family support system; his mother goes to the facility to see him daily and brings him lunch. R1 reported he was not always compliant with his diet and eating habits, but that is his right to eat what he wants and likes. R1 reported that the hospital wants him to have an AVAP machine at night and for naps, but the facility is refusing to accept him back, stating reasons that make no sense to him. R1 reported he knows he can leave the hospital AMA and does not want to do that. R1 reported he now knows how to use the AVAP machine, which is better for him, and easier to use than the BiPAP which is at the facility. R1 stated I told them I don't care about the AVAP machine I can use my regular BiPAP, I understand the risks, and that I could die. I would much rather die near my hometown, my mother and family than being stuck in another state. R1 reported he was in the hospital at the beginning of the year because he had the flu, pneumonia and covid-19. R1 stated [NAME] me this, how can I get that sick when I stay in my room, that's the staffs fault for bringing those infections to me, not the other way around which is why I stay in my room, there is always something going on with infections that staff and other residents being sick or a bug going around. When I was sick, the facility took me back then, this time I am not even sick. That's because the (NHA) does not like me and doesn't want to have a 500-pound man to take care of because it takes 2 staff and a long time to do my cares so they have to staff more on my unit. R1 reported the first time I went to the hospital (January) I felt like I was going to die. R1 reported they had a meeting and I was supposed to go back to the facility; everything was set up. R1 reported he was fully aware of his weight and how facility staff and other people treat him, which makes it worse for him to want to leave his room, R1 reported he hears what they say. When asked who they were, R1 stated I don't want to get into it, it's not worth it R1 reported he wants to return to the facility, his home for now and hopes to continue rehab, lose weight and properly discharged to the community so he can spend time with his family. R1 stated I was driven from the hospital I am in now, in another state about 5 hours or more. When we go to the facility the doors were locked and the facility staff was told by NHA not to open the doors, answer the calls from the driver or me and not to let me in.the driver had to turn around and take me back to the hospital out of state.the ride made me feel like I was a piece of garbage to be thrown out of a meat wagon.In an interview on 4/9/26 at 11:01 AM., CM M (RN-Case Manager- out of state hospital) reported R1 has been repeatedly denied re-admission back to the facility. CM M reported R1 has been medically stable since on 3/31/26. CM M reported initially the physician wanted R1 to have daily labs and be on a AVAP machine. CM M reported by the end of March it was evident that R1 understood the risk of leaving the hospital without those in place. R1 was educated over. CM M reported ultimately it is R1's choice to make his own medical choices. CM M reported the driver was told by staff when he was at the facility door he had to leave with R1, they would not open the door. CM M reported after that incident we decided as a team it was time to get the State Agency involved for R1. CM M reported R1 had to suffer over a 10 hour round trip car ride, which had to be painful, embarrassing and stressful for R1. CM M stated I have been sending the progress notes to NHA only to have her say she wasn't getting them. CM M reported I called again I spoke with the receptionist to ask to speak with the admissions coordinator, or NHA. CM M reported the receptionist said it has been really busy here, I will let them know. state is here CM M stated I said well if state I there, they may want to speak with me . CM M reported it wasn't until early this morning that I had a request from the NHA that she wanted R1s discharge paperwork, and a good contact number because a state surveyor would like to speak to me. CM M reported he does not need the ABG's (daily labs). CM M reported she was hoping for a resolve with this situation for R1 and what he has gone through the last few months. CM M reported all R1s medical records, discharge summary and referral have now been sent to the facility and NHA confirmed that she had received them at 8:20 AM today (4/9/26).Interview/Record review on 4/9/26 at 8:30 AM., this surveyor made requests to NHA for R1's hospital records, pertinent documents not noted in R1s EMR. On 4/9/26 at 9:02 AM., this surveyor received 9 pages of a 54 pages (R1's discharge summary) NHA reported at first the medical records from CM M were sent on 4/8/26 and faxed to the sister facility on 4/8/26, when this surveyor asked why there were only 9 pages, NHA stated our admissions coordinators printer ran out of paper This surveyor had requested documents throughout the survey 4/6/26-4/9/26 from NHA with multiple delays. (speaking with CM M, she reported none of R1's medical records were faxed to the sister facility, she has/had only been faxing to R1's current facility on both of his hospital stays)Review of a facility Transfer and Discharge policy dated 4/22/25 read in part: Purpose The transfer and discharge process must provide sufficient preparation and orientation of residents to ensure a safe and orderly transfer or discharge from the facility.Definitions Transfer and discharge: Includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Specifically, transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected.Criteria for Transfer/Discharge1. The facility will transfer or discharge a resident under the following documented conditions in the medical record:A. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;B. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;C. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;D. The health of individuals in the facility would otherwise be endangered;The facility may not transfer or discharge the resident while the appeal is pending, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.Criteria for Transfer/Discharge DocumentationFor circumstances under the criteria for transfer/discharge (1) A and B above the resident's physician or a non-physician practitioner (in accordance with State law) must document information on the basis of the transfer or discharge: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. For (A) above, the inability to meet the resident's needs, the documentation made by the resident's physician must include: The specific resident needs the facility could not meet. The facility efforts to meet those needs; and The specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the facility.If a resident's clinical or behavioral status (or condition) endangers the health or safety of individuals in the facility, documentation regarding the reason for the transfer or discharge must be provided by a physician, not necessarily the attending physician.Timing of notice1. The notice of transfer or discharge required under this section must be made by the facility in writing at least 30 days before the resident is transferred or discharged and in a manner they understand.Contents of the notice1. The reason for transfer or discharge;2. The effective date of transfer or discharge;3. The specific location to which the resident is transferred or discharged (if a change in destination indicates that the original basis for discharge has changed, a new notice is required);4. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;5. The name, address (mailing and email) and telephone number of the Office of the State Long- Term Care Ombudsman;6. For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000; and7. For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally III Individuals Act; or8. Per State law.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include:On 4/6/2026 at 1:17 PM observed the large stand mixer covered with a plastic bag. DM A was asked why the bag was covering the mixer and they stated that the bag meant that the mixer had been cleaned and covered to show that it was ready to use again. The covering was removed and food debris was noted on the protective wire bowl guard and on the underneath splash zone area where the beater is attached to the unit.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. On 4/7/2026 at 10:04 AM observed upon opening the door to the exterior walk-in freezer that the stainless-steel covering on the interior of the door is completely missing and the foam insulation underneath is completely exposed. According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.

Based on observation and interview, the facility failed to maintain general repair of patient equipment and the premises resulting in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents of the facility. Findings Include:On 4/7/2026 at 8:25 AM in room [ROOM NUMBER] Bed A, observed that the headboard was broken away from the bed and sitting askew with the left corner of the headboard sitting on the floor. During this observation, resident 1 stated that they had requested this be repaired three to four months ago and nothing had been done yet. On 4/7/2026 at 09:29 AM observed duct tape on the handle of the hopper water hose that is used to rinse out soiled linens. During this observation, Maintenance Director (MD) E stated that the duct tape was to give the handle some traction so it would hang in the bracket above the bowl without falling out. On 4/7/2026 at 10:04 observed peeling sealant on exterior soffits on the two hundred wing and just to the left of the emergency exit door on the three hundred wing. Paint was noted missing from the area below the exterior window frames below four sets of windows.

Based on interview and record review, the facility failed to ensure Medication Regimen Reviews (MRRs) were addressed by the physician in a timely manner and maintained in the clinical record for three Residents (#5, #45, and #52) of five residents reviewed for MRRs.Findings include:Resident #45 (R45) Review of R45's admission Minimum Data Set (MDS) assessment, dated 6/25/25, revealed R45 was admitted on [DATE] with active diagnoses that included the following, in part: Non-Alzheimer's dementia, anxiety disorder, and restlessness and agitation, Resident R45 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition, with no documented behaviors. Medications administered upon admission included an antipsychotic and antidepressant. Review of R45's MRR Recommendations (to Physician), provided by the facility, revealed the following, in part: Review of R45's Electronic Medical Record (EMR) revealed MRR documentation was not present or not addressed by the physician for the following months: July 2025 August 2025 September 2025: Resident has received buspirone 20 mg (milligrams) BID (twice daily) for anxiety since at least 3/2025. Resident also receives trazodone. Please consider a gradual dose reduction (GDR) to buspirone 15 mg BID. If GDR is clinically contraindicated at this time this contraindication may be documented by including medical rational for the contraindication below in lieu of performing a GDR. The Physician Response, Signature, and Date were absent any documentation and unaddressed by the physician. October 2025 MRR Date: 10/15/26 Resident (R45) receives risperidone for 'anxiety'. Anxiety is generally not considered an acceptable antipsychotic use per CMS F330/F758. Please clarify the diagnosis for the use of the antipsychotic agent in the directions of the order and reissue as a new order. OR please taper and discontinue if no valid diagnosis exists for this order. Physician/Prescriber Response, Signature and Date were blank: absent any physician documentation. November 2025: MRR Date: 11/19/25 This notated MRR Recommendation, with the same recommendation as issued 10/15/25, was provided to this Surveyor on 4/8/26 at 7:33 a.m., by Unit Manager/RN K. The 11/19/25 MRR Recommendation was signed by the physician on 2/10/26, nearly 3 months following the pharmacy recommendation, and noted by nursing staff on 3/7/26 and 3/9/26. December 2025 January, February and March 2026: MRR Dates: 1/20/26, 2/17/26 and 3/17/26 Pharmacy Recommendations to the Physician revealed the following, repeated information: Anxiety is generally not considered an acceptable antipsychotic use per CMS F330/F758. Please clarify the diagnosis for the use of the antipsychotic agent in the directions of the order and reissue as a new order. OR please taper and discontinue if no valid diagnosis exists for this order. Physician/Prescriber Response, Signature and Date were blank: absent any physician documentation. Resident #52 (R52) Review of R52's MDS assessment dated [DATE], revealed R52's admission to the facility with diagnoses that included anxiety disorder and depression, in part. R52 scored 15 of 15 on the BIMS, reflective of intact cognition. Review of R52's Electronic Medical Record (EMR) revealed the MRR documentation was not present or not addressed by the physician for the following months: August 2025 September 2025: Resident has received buspirone 20 mg (milligrams) BID (twice daily) for anxiety since at least 3/2025. Resident also receives trazodone. Please consider a gradual dose reduction (GDR) to buspirone 15 mg BID. If GDR is clinically contraindicated at this time this contraindication may be documented by including medical rational for the contraindication below in lieu of performing a GDR. The Physician Response, Signature, and Date were absent any documentation and unaddressed by the physician. October 2025 November 2025 December 2025 January 2026 March 2026 During an interview on 4/8/26 at 7:18 a.m., the DON stated, There was a break in the (MMR) process. When there was an interim DON there was a break in the process of getting these (MMRs) taken care of. The DON acknowledged that not all MMR documentation was present for R45 or R52 in the medical record. Review of the Timeliness of Medication Regimen Review Reports, policy, last revised 9/7/23, revealed the following, in part: Policy: The pharmacist will review and report any medication irregularities at least once a month. 1. With new admissions the consultant pharmacist will complete a MRR and provide a report via secure email within 72 hours to the Director of Nursing/designee. 2. Clinically significant medication issues . must be communicated to the prescriber or designee and resolved by 11:59 p.m. the following day. 3. The consultant will provide monthly MRR reports addressed to the Medical Director, Director of Nursing, and Attending Physician within 3-5 days of completion via secure e-mail or hard copy. 4. The attending physician is expected to review the resident's individual MRR and document and sign that he/she has reviewed the pharmacist' identified recommendations within 14 days of receipt. 5. The attending Physician does not respond to the resident's MRR report within 14 days, the Director of Nursing will notify the physician of pending MRR reports. 6. If by the 21st day, the attending physician has not yet responded to the resident's individual MRR report, the Director of Nursing will notify the Medical Director to review and respond to the pending MRR reports. 7. If the medical Director is also the attending physician, the Director of Nursing will escalate the issue to the facility Administrator. 8. When the consultant pharmacist identifies a recommendation that requires immediate or urgent action, the pharmacist will notify the director of Nursing and the assigned nurse at the time the recommendation is identified. Resident #5 (R5) Review of R5's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 8/6/21, with diagnoses that included Non-Alzheimer's dementia and schizophrenia. R5 scored 0 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of R5's Electronic Medical Record (EMR) did not contain MRR for the following months: August 2025 October 2025 November 2025 December 2025 February 2026 March 2026 During an interview on 4/8/26 at 7:34 a.m., the Director of Nursing (DON) reported, I cannot find MRR's for the months of August, October, November, and December of 2025.and I cannot find the MRR's for February or March of 2026 for R5. During an interview on 4/8/26 at 2:42 p.m., the DON and Nursing Home Administrator (NHA) acknowledged the facility did not have the MRR's for R5.

Based on interview and record review, the facility failed to ensure accurate advanced directive information was in place for one Resident (7) of two residents reviewed for accuracy of advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time).Findings include:According to Legal and Ethical Issues in Nursing, 4th Edition, ([NAME], G, 2006), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete.Resident #7 (R7)Review of an admission Record revealed R7 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: right femur fracture.Review of a Minimum Data Set (MDS) assessment for R7, with a reference date of 2/9/2026 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated R7 was mild cognitive impairment.Review of R7's Electronic Medical Record (EMR) on 4/07/2026 at 11:05 AM., read in part on the face page of the EMR R7 was listed as (Advance Directives) Full Code by Default .Review of R7's EMR in the Documents (various original paper form documents uploaded to view) Advance Directives original signed document had R7 listed as a No Code or Do Not Resuscitate In an interview/record review on 4/07/2026 at 3:40 PM., Assistant Director of Nursing (ADON) H reported R7 should be a Do Not Resuscitate his EMR in both areas of his medical chart. ADON H reported it was not clear at this time and would have to look into it.

Based on interview and record review, the facility failed to ensure unnecessary psychotropic medications were not administered for an extended duration and without appropriate indications for use for 2 Residents (R45 & R59) of 5 residents reviewed for unnecessary medications/chemical restraints. This deficient practice resulted in administration of antipsychotic medications for an extended duration, administration of antipsychotic medication without appropriate diagnoses for use, and lack of timely gradual dose reductions (GDRs). Findings include:Resident R45Review of R45's admission Minimum Data Set (MDS) assessment, dated 6/25/25, revealed R45 was admitted on [DATE] with active diagnoses that included the following, in part: Non-Alzheimer's dementia, anxiety disorder, restlessness and agitation, Resident R45 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition, with no documented behaviors. Medications administered upon admission included an antipsychotic and antidepressant. Review of R45's quarterly MDS assessment, dated 10/9/25, revealed diagnoses that included anxiety disorder and non-Alzheimer's dementia. Psychotic Disorders was documented no. BIMS remained cognitively intact with a 15 of 15 score. Medications continued to include an antipsychotic and an antidepressant. Antipsychotics were routinely administered with no GDR and no documented contraindication for a GDR. Review of R45's quarterly MDS assessment, dated 12/23/25, revealed diagnoses that included non-Alzheimer's dementia and anxiety disorder. Psychotic Disorders was documented no. BIMS score was 13 out of 15, reflective of intact cognition. Medications included antipsychotic and antidepressants. Antipsychotics were administered routinely with no GDR and no documented contraindication for a GDR in the medical record. Review of R45's quarterly MDS assessment, dated 4/1/26, revealed diagnoses that included non-Alzheimer's dementia and anxiety disorder. BIMS score was not completed for this assessment. Behaviors were also not assessed. Medications included antipsychotic, anti-anxiety and antidepressant. The Antipsychotic Medication Review revealed antipsychotics were administered on a routine basis, and a GDR was attempted on 3/15/26. No documentation by the physician was documented as clinically contraindicated. Review of R45's 9/18/25 Nursing Notes revealed Resident (R45) noted to have increased anxiety at times, worried about her breathing, worrying about her husband and things such as lunch etc. I spoke with PA (physician assistant) regarding this, new order to increase Risperdal (antipsychotic medication). Resident aware. Review of R45's MRR Recommendations (to Physician), provided by the facility 4/8/26 at approximately 1:10 p.m., revealed the following, in part:MRR Date: 10/15/26 Resident (R45) receives risperidone for 'anxiety'. Anxiety is generally not considered an acceptable antipsychotic use per CMS F330/F758. Please clarify the diagnosis for the use of the antipsychotic agent in the directions of the order and reissue as a new order. OR please taper and discontinue if no valid diagnosis exists for this order. Physician/Prescriber Response, Signature and Date were blank: absent any physician documentation.MRR Date: 11/19/25 This notated MRR Recommendation, with the same recommendation as issued 10/15/25, was provided to this Surveyor on 4/8/26 at 7:33 a.m., by Unit Manager/RN K. The 11/19/25 MRR Recommendation was signed by the physician on 2/10/26, nearly 3 months following the pharmacy recommendation, and noted by nursing staff on 3/7/26 and 3/9/26.MRR Dates: 1/20/26, 2/17/26 and 3/17/26 Pharmacy Recommendations to the Physician revealed the following, repeated information: Anxiety is generally not considered an acceptable antipsychotic use per CMS F330/F758. Please clarify the diagnosis for the use of the antipsychotic agent in the directions of the order and reissue as a new order. OR please taper and discontinue if no valid diagnosis exists for this order. Physician/Prescriber Response, Signature and Date were blank: absent any physician documentation.Review of a 9/18/25 Physician Visit with a Chief Complaint of Anxiety, revealed the following, in part: [R45] is having anxiety that is not controlled with her current dose of Risperdal. I will increase her Risperdal to 1 mg BID (milligram twice a day). May consider Buspar (anti-anxiety medication) in the future .Behavior/Psychiatric: Positive: Normal mood and affect, Cooperative . Completed by Physician Assistant O.Review of Psychiatric Follow up Visit for R45 on 2/19/26 revealed the following, in part: [R45] .history of dementia and anxiety . BIMS score is 15 (intact cognition). [R45] . is overdue for Gradual Dose Reduction (GDR) for Risperdal, and the indication for starting Risperdal is unclear. Facility staff report no problematic behaviors. The patient denies hallucination, paranoia, or nightmares. She is described as pleasant but experiences episodes of anxiety. Risperdal is not used for managing her anxiety, and adjustments to her anxiety medications could be considered if necessary . During an interview on 4/8/26 at 1:15 p.m., the Director of Nursing (DON) and DON/Registered Nurse (RN) N provided a copy of R45's Risperdal (antipsychotic) medication orders and changes which were listed on 22 separate lines within R45's Risperdal Order Review listing within the Electronic Medical Record (EMR). The DON and DON N provided and confirmed the following Risperdal medication information in writing:6/19/25 admission order (for behaviors exhibited in the acute care hospital prior to admission) 1 mg (milligram) at HS (hour of sleep). 0.5 mg in AM.6/24/25 No dose change. Changed indication for use (to anxiety).9/18/25 1 mg BID (daily dose increased). During an interview at this same time, DON N and the DON said Risperdal continued prescribed for the diagnosis of anxiety.1/19/26 No dose change (1 mg BID). 2/21/26 1 mg at HS. 0.5 mg at AM. (Same order as that ordered 6/19/25).3/7/26 Diagnosis changed from anxiety to restlessness and agitation.3/8/26 0.5 mg BID (Diagnosis of restlessness and agitation.)3/10/26 1 mg at HS 0.5 mg at AM.3/16/26 No dose change.3/24/26 0.5 mg BID 3/28/26 No dose change (0.5 mg BID). During an interview at this same time, when asked if anxiety was an appropriate indication for use for R45's Risperdal, DON N stated, I agree anxiety is not an appropriate diagnosis . When asked how pharmacy recommendations to the physician will be monitored for appropriate antipsychotic documentation and usage, the DON stated, (We will have) a different process to review (the MRRs) timely, contact the physician and get that process in place (including ensuring consents for psychotropics were obtained prior to administration.)During a telephone interview on 4/8/26 at 4:07 p.m., Consultant Pharmacist P was asked about R45's Pharmacy Recommendations to the Physician related to R45's antipsychotic medication - Risperdal. Consultant Pharmacist P stated, I have not always gotten back the physician recommendations. That has been a struggle for the physician. I don't know if it is the physician not answering, or if the facility is breaking down in communication. Antipsychotic (medication) is an automatic resubmit and I bring it up every month and say here is an antipsychotic diagnosis that did not get answered each month . I told them month in and month out that these reports (needed to be addressed) . Review of the Psychoactive Medication Management policy, last revised 1/28/26, revealed the following, in part: The facility does not use chemical restraints which are defined by federal regulations as drugs used for discipline or convenience and not required to treat medical symptoms .When pharmacological interventions are indicated, the licensed staff will verify that the physician order includes the appropriate clinically supported diagnosis and/or behavior symptoms .Residents receiving psychoactive medications upon admission, those with new psychoactive medications orders or an increase in the dose of the medication, will have a psychotropic medication informed consent completed. Before initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase .Review of the Risperdal Black Box Warning and Indications for Use, revised 1/2025, revealed the following, in part: WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS . Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. RISPERDAL is not approved for use in patients with dementia-related psychosis. (5.1) ---RECENT MAJOR CHANGES---- Warnings and Precautions (5.6) 1/2025 ----INDICATIONS AND USAGE---- RISPERDAL is an atypical antipsychotic indicated for: Treatment of schizophrenia (1.1) As monotherapy or adjunctive therapy with lithium or valproate, for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder (1.2) Treatment of irritability associated with autistic disorder (1.3) .

Based on observation, interviews, and record review, the facility failed to implement its Abuse Program Policy and Procedure and immediately protect other this and other residents from neglect, for 1 Resident (#8) from 4 residents reviewed for abuse/neglect. This deficient practice resulted in the potential for continued resident abuse/neglect. Findings include:Review of a facility Abuse Prohibition Policy dated 10/14/2022 read in part: Policy-Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment. Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies.Neglect is the failure of the facility, its employees or service providers to provide goods and services to a guest/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware, or should have been aware of, goods or services that a guest/ resident(s) requires but the facility fails to provide them to the guest(s)/resident(s), resulting in physical harm, pain, mental anguish or emotional distress. Alleged violations of neglect include cases where the facility demonstrates indifference or disregard for guest/resident care, comfort or safety, resulting in physical harm, pain, mental anguish or emotional distress. Further review of the facility policy revealed:G. Reporting abuse and facility Response to the allegation1. The staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown source to the Administrator immediately.2. The Administrator or designee will notify the guest's/resident's representative. Also, any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury; all others not later than 24 hours). At the conclusion of the investigation, and no later than 5 working days of the incident, the facility must report the results of the investigation and if the alleged violation is verified, take corrective action.3. Substantiated complaints against nurse aides for acts of guest/resident abuse, mistreatment, neglect or misappropriation of a guest's/resident's property shall be reported to the state Nurse Aide Registry when the facility has knowledge. Nurses will be reported to the State Board of Nursing for violations that are substantiated. The facility has the obligation to report to state nurse aide registry or licensing authorities any knowledge it has of court actions against an employee that would make them unfit for service.4. In cases of abuse, neglect, misappropriation of guest/resident property, and exploitation, the Quality Assurance Performance Improvement Committee will review the circumstances to determine if changes in policies and procedures are necessary to provide further preventative measures. All cases will be reviewed at the QAPI meetings.Resident #8 (R8)Review of an admission Record revealed R8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral palsy, anxiety and difficulty swallowingReview of a Minimum Data Set (MDS) assessment for R8, with a reference date of 1/14/2026 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated R8 was severely cognitively impaired.Review of R8's Care Plan read in part: FOCUS: R8 was unable to tolerate nutritionally adequate food and/or fluids by mouth requiring the use of a feeding tube R/T (related to) dysphagia, quadriplegic cerebral palsy, seizures, epilepsy and Nothing BY Mouth Diet order. Date Initiated: 01/27/2025 .INTERVENTIONS: ORAL HYGIENE: Resident is dependent on staff for oral hygiene and requires one person assistance. Date Initiated: 01/29/2025 .Review of R8's Care Plan read in part: FOCUS: R8 was at risk for pain r/t Chronic Physical Disability = cerebral palsy, scoliosis and contractures Date Initiated: 01/28/2025.INTERVENTIONS: Observe and report any (signs/symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Report abnormal findings to the physician. Date Initiated: 01/28/2025.During initial pool observations on 4/6/2026 at 2:42 PM., a crying/moaning sound was coming from a resident's room and could be heard from the middle of the unit, from approximately 25 feet or more away. This surveyor proceeded down the unit to find the resident who could be heard crying. This surveyor reached the end of the unit to the last room on the right-hand side and the resident in the first bed was noted to be R8. This surveyor knocked but there was no answer and crying was still heard. This surveyor announced self and entered the room. In the first bed, R8 was observed lying on her right side with a pillow underneath her left side. R8 was hooked up to a feeding tube which was running. R8 continued crying, moaning and thrashing her head back and forth. This surveyor approached the right side of the bed and observed R8's hair matted to the back of her head and it appeared greasy and unkempt. R8 was noted to have tears coming from her eyes. There were dried crusted tears in which the white substance (aqueous layer-watery part from lacrimal glands, containing salts, proteins, and enzymes) from the tears was noticed to be dry on her right temple and upper cheek, there was also a collection of wet tears on her left inner eye canthus (the corner of the eye nearest the nose where the upper and lower eyelids meet, playing a key role in tear drainage). R8 appeared sweaty and her bed linens were strewn about the bed. R8 appeared to be restless, tense and it seemed as though she was trying to swallow. R8 had a copious (abundant) amount of secretions in her mouth, her tongue was moving back and forth and sticking in and out. R8 was still crying and there was a noticeable rattle-gurgling sound from her throat. This surveyor made their presence known, although R8 was unable to answer questions, or make any verbal contact she appeared to be calming down, she began pushing her head back into her pillow with less thrashing. R8's front upper and bottom teeth had a thick dry, stuck on plaque, tarter and sputum in layers approximately three quarters of an inch thick. R8's teeth could not be seen. R8's mouth, lips and chin also had areas of wet and dry crusted sputum-secretions. R8's call light was noted to be clipped to the pillow behind her out of reach. R8 was noted to have limited range of motion with her upper extremities, and her arms were contracted inward up near her chest. R8 continued to cry and moan, as well as continued distress and thrashing of her head. At approximately 2:47 PM, this surveyor pressed R8's call light to note call light wait times. This surveyor noted R8's roommate was in her bed asleep, her call light was a round pad type, R8s call light was a button press style. This surveyor noted approximately 2-3 Certified Nurse Aides (CNA) staff members enter the room directly across from R8. The sign on the door read Employee Breakroom This surveyor looked outside R8's bedroom doorway above the door to ensure the call light had triggered properly for staff to respond timely. The call light was on and was lit up. At this time, which was 3:04 PM., no staff were noted on the unit. R8 appeared to have noticed this surveyor when reapproaching the right side of her bed, taking note of the bedside table which held a basin full of mouth swabs, suction pieces individually wrapped and various other oral-mouth care items. This surveyor took note of R8's garbage next to her bed, noted it was a clear garbage bag with nothing in it and the bathroom garbage was also empty.On 4/6/2026 at 3:10 PM., CNA J was observed entering R8's room and walked in front of this surveyor (standing 1-foot away from the foot of R8's bed). CNA J walked around R8's bed on the right side, and shut the call light off. CNA J did not make eye contact, look at or say anything to R8. CNA J then walked over to R8's roommate who was asleep. CNA J asked the roommate if she needed anything, no answer or sound was made by R8's roommate and her eyes remained closed. CNA J walked past this surveyor, not looking at R8 and exited the room.This surveyor then approached CNA J, and in an interview/observation on 4/6/26 at 3:12 PM., was asked what he completed in R8's room. CNA J stated I saw the call light on and know that R8 cannot use her call light, so I went over to bed 2 and asked her what she needed. She (R8's roommate) said she hit the call light by accident. when further prompted, CNA J responded by stating I am assigned to both residents in R8's room, I did not look closely at R8, and I have not done cares on her since this morning CNA J was asked what R8's baseline for breathing, oral-mouth appearance, hair, toileting and her typical behaviors were. CNA J stated R8 cries out when something was wrong or she is uncomfortable and/or in pain. CNA J stated I didn't look at her or check on her when I turned the call light off, I did not notice the 2 call lights were not the call lights for the residents. CNA J stated I lied, R8's roommate did not say anything to me when I asked her if she needed anything, she was asleep. I did not do anything to assist R8 when it was clear she was uncomfortable, and I lied to you when you (this surveyor) asked me, because I don't know the answers to the questions you were asking about R8. CNA J reported he should have looked at R8's Kardex, and/or gotten assistance from the nurse on duty to ensure R8 was okay. CNA J reported he has never completed oral care on R8 and did not provide any type of oral care for R8 today, because he thought only the nurses were to do it. CNA J and this surveyor observed R8's mouth, CNA J stated it should not look like that, it seems like she has a lot of secretions built up and stuck in her throat, and she needs to be cleaned up.In an interview and observation on 4/6/2026 at approximately 3:20 PM., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) H accompanied this surveyor to R8's room. Both DON and ADON H reported they were concerned about the overall appearance of R8. ADON H and DON were both informed of this surveyor's earlier observation of R8, and the interview with CNA J, as well as the multiple staff who entered the Staff Breakroom while R8's call light was on. ADON H appeared visibly upset and reported they would take care of R8 cares and oral cares. The DON responded with concern and stated, the staff failed R8 by ignoring her call light and did not provide proper care and services, which is unacceptable care for any resident. This surveyor informed DON and ADON H that CNA J openly admitted to lying in an interview with this surveyor about completing earlier care for R8 and turning off a resident call light without meeting the needs of residents, because he did not know what to do. DON and ADON H both began to gown up and proceeded to start care on R8. ADON H stated she would be speaking to CNA J and the staff once R8's care was complete. In an observation and interview on 4/8/26 at 9:00 AM., CNA J was noted on the 500 unit. CNA J approached this surveyor and apologized for lying in his interview yesterday. CNA J stated after I left from work, I reflected on what I had done, and I was wrong for lying. I should have checked on (R8) more often and asked for help or just said I didn't know the answers to your questions. CNA J reported he had not been removed from the unit, or from providing care to residents.

Based on observation, interviews and record review the facility failed to investigate a report of neglect for 1 Resident (#8) of 4 residents reviewed for abuse/neglect, resulting in the potential for continued abuse and/or neglect of residents residing in the facility to go unrecognized.Findings include:Review of a facility Abuse Prohibition Policy dated 10/14/2022 read in part: Policy-Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment. Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies.Neglect is the failure of the facility, its employees or service providers to provide goods and services to a guest/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Alleged violations of neglect include cases where the facility demonstrates indifference or disregard for guest/resident care, comfort or safety, resulting in physical harm, pain, mental anguish or emotional distress. Further review of the facility policy revealed:Investigation.1. Allegations by anyone who becomes aware of verbal, physical, mental, sexual or emotional abuse and mistreatment, neglect, exploitation, involuntary seclusion or misappropriation of property must immediately report it to his/her Administrator.2. The Director of Nursing or designee will complete an assessment of guest(s)/resident(s) and document findings in the medical record.3. An Incident Report (and/or grievance forms per state specific requirements) will be completed.4. The licensed nurse will:a. Notify the physician if requiredb. Notify the family member/responsible party/emergency contact/legal guardian (not necessarily all individuals)1. A preliminary, on-site investigation will be initiated within twenty-four (24) hours of any report.F. Protection of Guests/Residents during the Investigation1. If the accused is an employee of the facility, he/she will be suspended until the investigation has been completed.Resident #8 (R8)Review of an admission Record revealed R8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral palsy, anxiety and difficulty swallowing.Review of a Minimum Data Set (MDS) assessment for R8, with a reference date of 1/14/2026 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated R8 was severely impaired.Review of R8's Care Plan read in part: FOCUS: R8 was at risk for pain r/t Chronic Physical Disability = cerebral palsy, scoliosis and contractures Date Initiated: 01/28/2025.INTERVENTIONS: Observe and report any (signs/symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Report abnormal findings to the physician. Date Initiated: 01/28/2025.Review of R8's Kardex (CNA care guide) read in part: MONITORS: Observe and report any s/sx (signs/symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Report abnormal findings to the physician.During initial pool observations on 4/06/2026 at 2:42 PM., a crying/moaning sound coming from a resident's room could be heard from the middle of the unit. At the very end of the unit last room on the right in the first bed, it was noted R8. R8 was crying, moaning and thrashing her head back and forth. R8's hair was matted to the back of her head, her hair was greasy and she appeared unkempt. R8 was noted to have tears coming from her eyes. R8 was sweaty and her bed linens were strewn about the bed. R8 appeared to be restless, tense and it seemed as though she was trying to swallow. R8 had a copious (abundant) amount of secretions in her mouth. R8 continued crying and there was a noticeable rattle-gurgling sound from her throat. R8's front upper and bottom teeth had a thick dry, stuck on plaque, tarter and sputum in layers approximately three quarters of an inch thick. R8's mouth, lips and chin also had areas of wet and dry crusted sputum-secretions. R8's call light was noted to be clipped to the pillow behind her out of reach. At approximately 2:47 PM, this surveyor pressed R8's call light to note call light wait times. This surveyor noted R8's roommate was asleep in her bed. In an interview/observation on 4/6/26 at 3:12 PM., CNA J stated I saw the call light on and know that R8 cannot use her call light, so I went over to bed 2 and asked her what she needed. She (R8's roommate) said she hit the call light by accident. CNA J reported he did not look closely at R8 and had not done cares on her since this morning. CNA J stated I lied, R8's roommate did not say anything to me when I asked her if she needed anything, she was asleep. CNA J reported he did provide care to R8 when she was uncomfortable, he should have looked at R8's Kardex, and/or gotten assistance from the nurse on duty to ensure R8 was okay. CNA J reported he has never completed oral care on R8 and did not provide any type of oral care for R8 today. CNA J stated her mouth should not look like that, it seems like she has a lot of secretions built up and stuck in her throat, and she needs to be cleaned up. In an interview and observation on 04/06/2026 at approximately 3:20 PM., Director of Nursing (DON) and Assistant Director of Nursing (ADON) H accompanied this surveyor to R8's room. Both DON and ADON H reported they were concerned with the overall appearance of R8. This surveyor explained the earlier observation/interview with CNA J. ADON H appeared visibly upset and reported she would take care of R8 cares and oral cares. DON responded with concern and stating failure on CNA J part to ensure goods and services were provided was not acceptable care for any resident.In an observation and interview on 4/8/26 at 9:00 AM., CNA J was noted on the 500 unit where R8 resides. CNA J approached this surveyor and apologized for lying in his interview yesterday. CNA J stated after I left work, I reflected on what I had done, and I was wrong for lying. I should have checked on (R8) more often and asked for help or just said I didn't know the answers to your questions. CNA J reported he had not been removed from the unit, or from providing care to residents.In an interview on 4/8/2026 at 3:22 PM., ADON H reported after the incident of alleged neglect for R8 on 4/6/26 regarding CNA J failing to provide care for R8, she and DON informed the Nursing Home Administrator (NHA) of the concerns this surveyor had. ADON H reported she was unsure if NHA reported anything to the State Agency. ADON H reported she did not complete an Incident Report or provide education on Abuse to all staff.In an interview on 4/8/26 at 4:10 PM., NHA and DON were seated in NHA office. NHA was asked if an incident report or a Facility Incident Report (FRI) was completed and/or R8s alleged neglect was reported to the state agency. NHA stated I was unaware that the incident happened like it did, and the word neglect was never said. DON reported she informed the NHA of what occurred in R8's room on 4/6/26 after she and ADON H had provided care to R8. DON reported she did not fill out an Incident Report. NHA stated I was only told that the CNA had lied to the surveyor. NHA reported the incident was not reported or investigated as an allegation of abuse/neglect. Review of the State Operations Manual read in part: 483.12(c)(3) Prevent further potential abuse, neglect. While the investigation is in progress. Prevention .the facility must immediately put effective measures in place to ensure that further potential abuse, neglect. Does not occur while the investigation is in process. Examples of instances where the facility failed to provide protection include, but are not limited to: The alleged perpetrator continues to have access to the alleged victim and/or other vulnerable residents.

This citation pertains to Intake Complaint # 2972928.Based on interview and record review, the facility failed to fully implement their policy and procedure and provide applicable bed hold policy information, written transfer notifications, and required hospital documents for 1 (Resident #1) of four residents reviewed for hospitalizations resulting in worry, fear and frustration for R1 and the delay in his re-admission from a lengthy out of state hospitalization.Findings include:Resident (R1)Review of an admission Record revealed R1 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: respiratory failure.Review of a Minimum Data Set (MDS) assessment for R1 with a reference date of 2/12/2026 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated R1 was cognitively intact.Review of R1's Electronic Medical Record (EMR) read in part: 3/26/2026 19:19 . (R1) No BM (bowel movement) For 3 Days Sent to (Local emergency department-name omitted) .During an interview/record review on 4/7/26 at 9:51 a.m., ADONH reviewed the EMR and reported there was no written notification of transfer from the facility to the hospital and indicated it should have been in the EMR.Review of R1's EMR Hospital Discharge Summary dated 1/23/26 read in part: 1/5/26-Presentation and hospital course R1 is [AGE] year-old year old male with a history of diabetes, class III obesity, chronic hypoxic respiratory failure on 2 L oxygen at baseline, hypothyroid,-hypertension (high blood pressure) was transferred to our (out of state hospital) from outside emergency room. (R1) Presented to the emergency room after long-term care facility noted his oxygen saturation was 65% at baseline 2 L. Patient was admitted for acute on chronic hypoxic respiratory failure and acute hypercapnic respiratory failure. He also had sepsis secondary to bilateral pneumonia-UTI-bacteremia-cellulitis that was present on admission.In an interview/record review on 4/8/26 at 10:15 AM., R1's EMR progress notes, under the miscellaneous tab (contains original paper copies/documents scanned into the facilities EMR belonging to individual residents) were reviewed with Assistant Director of Nursing (ADON) H. ADON H reported it appears R1 was discharged from the facility and admitted to the hospital on both 1/5/26 and 3/26/26. Further review with ADON H revealed R1's EMR had no evidence of a written notification of transfer and no bed hold policy being provided to R1.At the time of exit on 4/9/26 at approximately 3:30 PM., there was no required documentation in R1's EMR requested during this investigation. Including bed hold, transfer notice, and hospital transfer paperwork. Review of a facility policy and procedure with a revision dated 4/22/25 read in part: Transfer and Discharge Purpose.The transfer and discharge process must provide sufficient preparation and orientation of residents to ensure a safe and orderly transfer or discharge from the facility. Definitions Transfer and discharge: Includes movement of a resident to a bed outside of the certified facility. Procedure: Emergency Transfer to Acute Care1. When a resident is transferred on an emergency basis to an acute care facility, notice of the transfer is provided to the resident and the resident representative as soon as practicable.2. A physician's order is obtained including the date of the transfer and the reason for the transfer.3. A facility designee will provide notice, in writing, of the facility's bed-hold and readmission policies to the resident.at the time of transfer, or in the case of emergency transfer within 24-hours and documented in the medical record.4. A transfer form is completed; a list of medications and a copy of the care plan goals is sent to the receiving hospital 5. Nursing documents the hospital transfer in the medical record.

Based on interview and record review the facility failed to obtain a PASARR (Preadmission Screening/Annual Resident Review) prior to admission for one Resident (#3) of two residents reviewed for PASARR screening.Findings include:Resident #3 (R3)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE] with diagnoses that included: anxiety disorder, depression, bipolar disorder, and schizophrenia. R3 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition.Review of R3's Electron Medical Record (EMR) revealed a PASARR was not completed until 2/21/26.During an interview on 4/7/26 at 2:22 p.m., the Director of Nursing (DON) reported, PASARR's are completed when the residents are admitted to the facility. The DON acknowledged the PASARR had not been completed upon admission.During an interview on 4/8/26 at 2:42 p.m., the DON and Nursing Home Administrator (NHA) acknowledged the concern regarding PASARR's not being completed and the NHA offered Past Non-Compliance (PNC).During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included.On 1/24/26 the facility identified PASARR's were not completed upon admission and annually since October of 2025. The facility audited all residents regarding PASARR completion. Education was provided to the admissions coordinator and the Social Services Designee. A spreadsheet was created to indicate when the PASARR was completed and when the annual PASARR was due. Audits were completed to ensure completion. The facility date of compliance was 2/24/26.

Based on observation, interview, and record review, the facility failed to provide oxygen services per standards of practice for two Residents (#65 & #83) of four residents reviewed for respiratory care.Findings include: Resident #83 (R83) Review of R83's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 5/19/25, with diagnoses that included respiratory failure and Chronic Obstructive Pulmonary Disease (chronic inflammatory lung disease that causes obstructive airflow from the lungs, making breathing difficult). R 83 scored a 00/15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of physician orders revealed R83 to be administered oxygen at 4L/min (liters per minute) via nasal cannula for SOB [shortness of breath]. Review of R83's care plan last revised 3/30/26, read in part . R83 to have supplemental O2 [oxygen] 4L as ordered. During an observation on 4/7/26 at 8:49 a.m., R83 sat in a wheelchair in the dining room and received oxygen from an oxygen tank with a flow rate set at 3L. During an observation on 4/7/26 at 4:18 p.m., R83 sat in a wheelchair in the dining room and received oxygen from an oxygen tank with a flow rate set at 2L. During an interview on 4/7/26 at 4:20 p.m., Registered Nurse (RN) I reported, The orders have not been changed but I am monitoring his oxygen sats (saturation) .the NP [nurse practitioner (NP) talked about possibly lowering the flow rate so I lowered the flow rate of oxygen, but there is no order from the NP yet. During an interview on 4/7/26 at 4:32 p.m., the Director of Nursing (DON) reported, The oxygen flow rate should not be changed unless there is an order from the NP or physician. During an interview on 4/8/26 at 2:42 p.m., The DON and Nursing Home Administrator (NHA) acknowledged the RN should not have changed the flow rate without having an order from the NP or physician. Resident #65 (R65) Review of an admission Record revealed R65, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic obstructive pulmonary disease. Review of a Minimum Data Set (MDS) assessment for R65, with a reference date of 1/9/26 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated R65 was cognitively impaired. In an observation on 4/7/2026 at 10:31 AM., Resident #65 was awake in his bedroom sitting in his wheelchair. R65's Oxygen (O2) tubing dated 3/27/26. In an interview on 4/7/26 at 11:10 AM., Assistant Director of Nursing (ADON) H reported oxygen tubing should have a physician's order to change the tubing weekly and as needed. Review of Resident #65's Physicians Order read in part: Order Summary: 2/10/26 O2 2L/min via nasal cannula for SOB (Short of breath) every day and night shift Review of R65's Physicians Orders revealed R65 has no order to change oxygen tubing and or clean oxygen concentrator weekly. Review of R65's Care Plan read in part: R65 has a potential for difficulty breathing and risk for respiratory complications R/T (related to) Emphysema/COPD., SOB: on exertion, Date Initiated: 11/17/2025 .

Based on observation, interview, and record review the facility failed to ensure resident medications were securely stored in locked compartments for all Residents residing on the 200 Hall. This deficient practice resulted in the potential for tampering and/or diversion of resident medication. Findings include:During an observation on 4/7/26 at 5:05 p.m., the 200 Hall medication cart, staffed by Licensed Practical Nurse (LPN) R, was observed unlocked, facing outward into the hall, as LPN R entered room [ROOM NUMBER]. Dietary Manager (DM) A was present near the nurse's station and was motioned to the 200 Hall medication cart by this Surveyor. The 200 Hall medication cart verified as unlocked, when it was opened in front of DM A. DM A stated, That is not good. The 200 Hall medication cart was then closed awaiting the return of LPN R. Following exit from room [ROOM NUMBER], when asked if it was acceptable to have the medication cart unlocked and unsupervised, LPN R stated, Absolutely not. During an observation on 4/8/26 at 8:50 a.m., two inhalers, one green and white, the other red, were left on top of the 300 Hall medication cart while LPN S entered R70's room to administer morning medications. Upon return from R70's room, when asked if it was acceptable to leave Resident medications out on top of the medication cart, LPN S stated, No, absolutely not. When queried regarding whose inhalers had been left on top of the medication cart, LPN S reported they belonged to Resident #7 (R7). One was a Symbicort inhaler, the other Spiriva.During an interview on 4/8/2026 at 7:28 a.m., when asked about the security of medications in the medication carts, the Director of Nursing (DON) said the medication carts need to be locked and not left open unsupervised. Review of the Medication/Treatment Cart Use policy, last revised 8/15/23, revealed the following, in part: .The medication/treatment cart and its storage bins are kept locked until the specified time of medication/treatment administration. If an emergency occurs during the medication/treatment pass, the nurse securely locks the medication/treatment cart before attending to the emergency situation. During routine administration of medications, the cart may be kept in the doorway of the resident's room with: Drawers unlocked and facing inward, and within sight of the nurse. No medications are kept on top of the cart. The cart must be clearly visible to the person administering medications, and all outward sides must be inaccessible to persons passing by .

This citation pertains to intake: 2674136Based on interview and record review, the facility failed to implement preventative measures, promptly assess and treat constipation for 1 resident (Resident #1) of 3 residents reviewed for quality of care and prevent further medical complications from constipation. This failure resulted in actual harm when R1was hospitalized for a small bowel obstruction, leading to acute kidney injury and sepsis.Findings include:According to Legal and Ethical Issues in Nursing, 4th Edition, ([NAME], G, 2006), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time-period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete.Resident #1Review of the Face Sheet revealed R1 was originally admitted to the facility on [DATE] with a diagnosis of dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed R1 had a brief interview for mental status (BIMS) score of 8 out of 15 which indicated she was cognitively impaired. Section H Bowl and Bladder on the MDS assessment revealed: R1 was always continent of bowel movements. Review of R1's facility Progress Notes read in part: 10/24/2025 10:52 Nurses Notes Text: No BM (Bowel Movement) x 3 days. Senna 8.6-50 mg) given.Review of a facility Communication Document from a facility nurse to a facility Physician dated 4/2/25 read in part: Concern: R1 is constantly on the BM (Bowel Movement) list for not having a BM every 3 days, she (R1) is currently getting Senna (stool softener/laxative medication) 1 time daily . can we increase to 2 tabs . Review of R1's current Medication Administration Record (MAR) read in part: Senna Plus Oral Tablet 8.6-50 MG [Sennosides-Docusate Sodium) Give 2 tablet by mouth one time a day for Constipation Start Date-4/05/2025 .Review of R1's current (October 2025) MAR for PRN (As needed medications) had the following orders for relief of constipation: Senna Oral Tablet 8.6 MG (Sennosides) Give 8.6 mg by mouth every 72 hours as needed for Constipation-Start Date-09/16/2024 Bisacodyl Rectal Suppository (Bisacodyl) Insert 1 unit rectally every 72 hours as needed for Constipation-Start Date- 09/16/2024 Fleet Saline Enema Rectal Enema 7-1 9GM/197ML (Sodium Phosphates) Insert 1 unit rectally every 72 hours as needed for Constipation-Start Date-09/16/2024Review of R1's Certified Nurse Aide (CNA) toilet continence documentation for the month of October 2025 revealed. R1 had no bowel movements documented from 10/4/25 at 7:21 PM until 10/11/25 at 5:00 PM. (R1 went 6 days without a bowel movement). Review of R1's current MAR revealed R1 had 3 alternative PRN (as needed medications) Fleet Saline Enema Rectal Enema, Senna Oral Tablet 8.6 MG and Bisacodyl Rectal Suppository for relief of constipation, none of which were documented as administered to R1 from 10/4/25 through 10/22/25.Review of R1's CNA toilet continence documentation for the month of October 2025 revealed. R1 had 1 medium sized bowel movement (10/18/25) documented from 10/14/25 at 6:40 PM until 10/25/25 at 7:30 AM. (R1 went 10 days with 1 medium bowel movement).Review of R1's facility Progress Notes read in part: R1-10/29/2025 16:12 Nurses Notes Text: Resident had complaints of abdominal pain. Abdominal assessment: Bowels sounds active in all four quadrants, rectal suppository given. Resident had medium bowel movement but says she still has some abdominal pain .Review of R1's facility Progress Notes read in part: 10/29/2025 18:55 Nurses Notes Text: Resident still having abdominal pain. Resident put to bed shortly after dinner arrived and she did not eat much. Residents still have active bowel sounds and abdomen is soft and tender to touch.Review of R1's facility Progress Notes read in part: 10/29/2025 20:05 Nurses Notes Text: Resident had a large dark brown emesis (vomit) with food (content). No fecal smell or blood noted. Writer assessed resident abdomen, bowel sound present in all quadrants. Vital signs: BP (blood pressure) 171/98, T- 99.0 (Temperature) .Writer called PA (Physician's Assistant) . Order an abdominal Xray, a one-time Zofran 4mg (antinausea medication) .Liquid diet until we have abdomen Xray result. (PA) said to continue monitoring and call if anything changes. Review of R1's facility Physicians Assistants (PA) Progress Notes read in part: Date of Service: 10/29/2025-09:00 Visit Type: Telehealth - Details: NOTES Resident had an episode of emesis which was dark brown with regurgitated meal fragments. No evidence of hematemesis, fecal residue or blood. complain of slight discomfort to the lower (abdominal) fields. Medical course of action/plan: I have placed her on liquid diet until abdominal.X-ray is done tomorrow (10/30/25). Concerns for ileus or partial blockage.Review of R1's facility Progress Notes read in part: 10/30/2025 17:44 Situation: The Change In Condition/s (CIC) reported on this CIC Evaluation are/were: Abdominal pain Abnormal .Altered mental status. Fever .Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) Nausea/Vomiting Seems different than usual Talks/Communicates Less Tired, Weak, Confused, or Drowsy Review of R1's facility Progress Notes read in part: 10/30/2025 19:01 Nurses Notes Position: Registered Nurse (RN) A Note Text: (R1) sent to (hospital emergency department-name omitted) for evaluation of Fever and hypotension.Review of R1's Hospital Discharge Paperwork dated 11/4/25 read in part: (R1) Patient presented to the emergency room due to fever of 101.3 along with lethargy that began on day of admission [DATE]) . Interval History: Patient (R1) has had increasing pain and increasing nausea. Flat plate Abd (X-Ray) today shows evidence of higher-grade obstruction with transition point. Patient having more emesis today as well. Care plan discussed with daughter to describe her clinical findings and concern for possible death in days.Further review of R1's Hospital Discharge Paperwork dated 11/4/25 read in part: (R1) Hospital Course: She (R1) was found to have a small bowel obstruction resulting in acute kidney injury and sepsis (Sepsis: a life-threatening condition that arises when the body's response to an infection becomes dysregulated, leading to widespread inflammation and potential organ failure. It often develops from bacteremia or other infections and can cause symptoms such as fever, rapid heart rate, confusion, and difficulty breathing) . The diagnosis of small bowel obstruction was confirmed by CT imaging, which demonstrated dilated loops of small bowel with air-fluid levels and a transition point in the right lower quadrant, without evidence of free air or bowel ischemia. Laboratory studies on admission revealed leukocytosis (White Blood Cells-WBC 14.04-indicating infection), neutrophilia, elevated BUN (35), creatinine (2.48), and decreased GFR (18), consistent with acute kidney injury and systemic inflammatory response. Urinalysis was concerning for possible cystitis, and blood cultures were positive for gram-negative bacilli, supporting the diagnosis of sepsis and bacteremia (Bacteremia: A condition when bacteria enter the bloodstream) . General surgery was consulted and recommended non-operative management due to her advanced age and comorbidities, with broad-spectrum antibiotics (Zosyn), fluid resuscitation, and NPO status. She was not considered a surgical candidate, and after discussion with her family, the plan shifted toward comfort-focused care as her obstruction progressed, and symptoms worsened. Symptom management included IV antiemetics and analgesics, and scopolamine was added for emesis control as upper GI symptoms increased. During the admission, she experienced intermittent abdominal pain, nausea, and episodes of bilious emesis, with progressive decline in functional status. By hospital day 3, her decision maker requested further discussion regarding aggressive management of the obstruction, but after review, comfort care remained the recommended approach due to high risk of complications and lack of surgical options. (R1) was discharged to (Facility Name Omitted) with hospice services for ongoing comfort-focused care.In an interview on 12/16/25 at 2:15 PM., Assistant Director of Nursing (ADON) B reported R1 was no longer in the facility and had passed away with hospice care a few weeks ago. ADON B reported R1 had been sent out of the facility on 10/30/25 because she had been experiencing increased lethargy, abdominal pain and fever. ADON B reported R1 did have a history of constipation and had PRN medications if needed. ADON B reported the family elected not to have surgery to remove the small bowel impaction/obstruction because there was a high possibility R1 would not tolerate the surgery and may pass away. In an interview on 12/16/25 at 3:45 PM., Registered Nurse (RN) A reported that she was the nurse working on 10/29/25 when R1 had vomited, had a low-grade fever and was complaining of abdominal pain. RN A reported she recalls on 10/29/25 R1 had reported to her, she didn't feel well and had abdominal pain abruptly after lunch. RN A reported she looked back in R1's medical record and MAR and noticed she had not seen any significant bowel movements charted. RN A reported she immediately gave R1 a PRN rectal suppository, completed a change of condition and called the on-call physician's assistant. RN A reported Zofran (antinausea medication) was given to R1. RN A reported she had asked R1 when the last time was, she had a BM and R1 could not recall. RN A reported R1 had a history of constipation and had many medications that can cause constipation, which is why R1 had multiple different stool softeners, laxatives and PRN medications to relieve constipation. RN A reported the following day she worked the 7:00 am -7:00 pm shift which was 10/30/25 and noticed R1 was lethargic, and she wouldn't open her eyes, and appeared very sick. RN A reported she again called the on-call PA, and they ordered an abdominal X-ray. RN A reported while waiting for the X-Ray technician to arrive R1's medical status appeared to be declining, she recalls R1 was hot, sweating and was no responding to stimuli. RN A reported once the X-ray arrived, R1 was placed on the flat plate underneath her and did not moan, groan or wince in pain, R1 did not respond which was abnormal because R1 was typically in a lot of pain when moved. RN A reported the decision was made to send her out to the hospital. RN A reported R1's baseline was normally she was continent of bowel movements and could tell staff when she had to go. RN A reported R1 could not remember when she last had a BM because of her dementia but was typically able to make her needs known. RN A reported after R1 left for the hospital she further reviewed the CNA and nurse documentation and noticed that R1 had not been frequently having regular bowel movements and PRN medications were only given a few times in the last couple days. In an interview on 12/16/25 at 4:35 PM., Director of Nursing (DON) reported she recently started working at the facility and noticed there were issues with documentation on bowel movements for residents. The DON reported she has put into place in the Electronic Medical Record (EMR) alert charting area that will trigger any resident that has not had a bowel movement charted for 3 days. The DON reported R1 should not have gone as long as she did during the month of October 2025 without regular bowel movements. The DON reported it appears lack of communication between staff, and failure to follow the measures that were in place for R1 were not implemented. Nursing assessment is the deliberate and systematic collection of data of the residents' health and functional status and is the first step in Nursing Process. The data obtained in the assessment is communicated to other care givers and health professionals and is used to diagnose the problem and plan and implement care . Nursing judgment is critical when medications that are ordered PRN (as needed) are given. The nurse documents the assessment made and the time of medication administration. The nurse should make frequent evaluation of the effectiveness of the medication and record findings in the appropriate record. The record is a means by which health care team members communicate (resident) needs, and progress, individual therapies .The record should be the most current and accurate source of information about a (resident)'s health care status. ([NAME], P. A. & [NAME], A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby) . Review of a facility Policy and Procedure titled Bowel & Bladder Continence Program with a revision date of 4/26/22 read in part: Purpose: Assisting a resident to maintain or restore bowel and bladder continence may promote the following: Dignity Independence Participation in activities and social functions Confidence Improved skin integrity Reduction in falls and associated injuries Reduction in sleep disturbances Reduced potential for urinary tract infections (UTI)A resident is screened upon admission for participation in the Bowel and/or Bladder Continence Program. Potential factors or underlying causes that may be contributing to bowel and/or bladder incontinence are identified and addressed by the IDT (Interdisciplinary Team) .5. Behavior modification programming may be initiated for residents who meet the following requirements:a. Bladder or Bowel Retraining Program:i. Able to communicate with a need to eliminateii. Experience an urge to eliminateiii. Physical ability to delay elimination until reaching toiletiv. Willing and able to participate, independently or with promptsa. Prompted/Structured Toileting:i. Able to establish patterns and/or cues indicating time and need for toiletingii. Willing and able to participate, independently or with prompts5. Discuss the findings with the resident, family and/or legal representative and determine interventions to be included in the plan of care. Determine the resident's willingness and ability to participate in interventions.10. Documentation:a. Document resident daily participation, including actual number of minutes participating in Point of Careb. Evaluate effectiveness of interventions and document progress towards goals in Point Click Care on the Restorative Toileting Evaluationc. Modify goals and interventions as needed. Update care plan and Kardex.Communicate any modifications to the direct care providers.

This citation pertains to intake #2674136Based on interviews and record review the facility failed to implement, review and revise care plans and interventions for 1 of 3 residents (Residents #1) reviewed for quality of care resulting in delay in treatment for constipation, development of a small bowel obstruction, and hospitalization.Findings include:Resident #1 (R1)Review of the Face Sheet revealed R1 was originally admitted to the facility on [DATE] with a diagnosis of dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed R1 had a brief interview for mental status (BIMS) score of 8 out of 15 which indicated she was cognitively impaired. Section H Bowl and Bladder on the MDS assessment revealed: R1 was always continent of bowel movements.Review of a facility Communication Document from a facility nurse to a facility Physician dated 4/2/25 read in part: Concern: (R1) is constantly on the BM (Bowel Movement) list for not having a BM every 3 days .Review of R1's Care Plan read in part: FOCUS (R1) is at risk for constipation R/T (related to): decreased mobility, medications side effects, opioid use. Date Initiated: 1/13/2023. GOAL: Will have a normal bowel movement at least every 3 days through the review date. Date Initiated: 01/13/2023.INTERVENTIONS: Observe for s/sx (signs and symptoms) of constipation, consistency of bowel movements.distention/tenderness/guarding/rigidity, vomiting .Date Initiated:1/13/2023 .Administer medications as ordered and observe for ineffectiveness/side effects. Report abnormal findings to the physician. Date Initiated: 01/13/2023.Review of R1's Certified Nurse Aide (CNA) documentation for the month of October 2025 revealed. R1 had no bowel movements documented from 10/4/25 at 7:21 PM until 10/11/25 at 5:00 PM. (R1 went 6 days without a bowel movement).Review of R1's Certified Nurse Aide (CNA) documentation for the month of October 2025 revealed. R1 had 1 medium sized bowel movement documented from 10/14/25 at 6:40 PM until 10/25/25 at 7:30 AM. (R1 went 10 days with 1 medium bowel movement).Review of R1's Medication Administration Record (MAR) for the month of October 2025 revealed R1 had 3 alternative PRN (as needed medications) for constipation relief including stool softeners/laxatives, suppositories and enemas. None of which were documented as administered to R1 from 10/4/25 through 10/22/25.Review of R1's facility Progress Notes read in part: 10/29/2025 20:05 Nurses Notes Text: Resident had a large dark brown emesis (vomit) with food (content). No fecal smell or blood noted.Review of R1's facility Physicians Assistants (PA) Progress Notes read in part: Date of Service: 10/29/2025-Visit Type: Telehealth - Details: NOTES Received a call from facility regarding female resident: Resident had an episode of emesis which was dark brown with regurgitated meal fragments.Review of R1's facility Progress Notes read in part: 10/30/2025 19:01 Nurses Notes Position: Registered Nurse (RN) A Note Text: (R1) sent to (hospital emergency department-name omitted) for evaluation of Fever and hypotension.Review of R1's Hospital Discharge Paperwork dated 11/4/25 read in part: (R1) Patient presented to the emergency room due to fever of 101.3 along with lethargy. Interval History: Patient (R1) has had increasing pain and increasing nausea. Flat plate Abd (X-Ray) today shows evidence of higher-grade obstruction with transition point. (R1) Hospital Course: She (R1) was found to have a small bowel obstruction resulting in acute kidney injury and sepsis. Care plan discussed with daughter to describe her clinical findings and concern for possible death in days.In an interview on 12/16/25 at 5:06 PM., the DON reported R1's Care Plans should be person centered, and the interventions should be implemented to ensure R1, and all residents have the appropriate interventions to meet her/their goals. DON reported that R1's care plan was not followed to ensure accurate assessment and treatment for constipation was followed. Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, If the patient's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, modify the nursing care plan. 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 revise related factors and the patient's goals, outcomes, and priories. Date any revisions. Revise specific interventions that correspond to the new nursing diagnoses and goals. Revisions need to reflect the patient's present status. [NAME], P. A., [NAME], A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 257-258 the requisite knowledge to complete an accurate assessment .Review of the MDS 3.0 RAI Manual v1.16, Chapter 3 Section N: Medications, revealed .The intent of the items in this section is to Revisions need to reflect the patient's present status. [NAME], P. A., [NAME], A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 257-258. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 2: Assessments for the Resident Assessment Instrument (RAI), revealed .the resident's care plan must be reviewed after each assessment .and revised based on changing goals, preferences and needs of the resident and in response to current interventions .Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan .

This citation pertains to intake #MI00150692 Based on observation, interview, and record review, the facility failed to treat a resident with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life and individuality for 1 Resident (#1) of 4 residents reviewed for dignity and resident rights, resulting in R1 having increased anxiety, and feelings of frustration. Findings include: Resident #1 (R1) Review of an Admission Record for R1 revealed an original admission to the facility on [DATE] with diagnoses including paraplegia. Review of a Minimum Data Set (MDS) assessment for R1, with an assessment reference date (ARD) of 2/6/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating R1 was cognitively intact. Section D Mood of the assessment revealed R1 was Feeling down, depressed, or hopeless. for 2-6 days during the seven day look back period. Section E Behavior revealed no significant behaviors. Review of R1's Kardex (CNA care guide) revealed (R1) was unable to use his power wheelchair in the facility due to safety concerns and disregard for others as he will not listen to staff r/t (related to) w/c (wheelchair) speed. He (R1) transfers into the power wheelchair in the front lobby prior to leaving the facility. On 5/6/25 at 1:45 PM., an interview was conducted with Certified Nurse Aide (CNA) B who reported R1 has been upset lately, and has expressed his feelings about how certain management staff have treated him. R1 has been feeling disrespected because management has not honored his choices and rights. CNA B reported he recently had a care conference meeting where he told the former Nursing Home Administrator (NHA) he did not want the Director of Nursing (DON) present in the meeting. CNA B reported R1 told them, the DON was in the meeting and the former NHA said to him this is my building, my name is on the wall, I make the rules, and she (DON) will attend because I make the rules CNA B reported R1 has been very bothered by this, and feared anything he does will be considered grounds to have him discharged from the facility. CNA B reported R1 was a pleasant resident, who was younger than most residents, and had paraplegia (paralyzed from the waist down). CNA B indicated R1 was of sound mind. On 5/6/25 at 2:00 PM., an interview was conducted with R1 who reported he suffers from anxiety and indicated the way the former NHA and DON treated him, made it feel even worse. R1 reported he made a mistake and bumped into a resident in the past with his electric wheelchair over a year ago, and has since not been able to have it back. R1 reported other residents have theirs. R1 reported he feels targeted and bullied, the former NHA would not listen to him when he told her and the current DON he did not want the DON to attend his recent Care Conference meeting. R1 reported the DON did attend, and the former NHA said to him 'I run this building, I make the rules and you will follow them, and I said I want her (DON) there, so she will be at the meeting'. R1 reported he felt threatened, scared and targeted. R1 reported he is not perfect, but other residents hit one another, yell all the time, go into other resident rooms and other things and they are not treated the way he is treated. R1 reported he feels unworthy, and does want to move out of the facility because he has friends and family close that he can visit, and get to with his electric wheelchair. R1 reported he was sorry about the accident, but feels he shouldn't have pay for it forever, and have it held over his head as if he ran into the resident on purpose. R1 reported he fears speaking with this surveyor, but also has a sense of relief and has hope that the new NHA and DON can work towards a better relationship, and build trust up. R1 reported he doesn't feel like they (former NHA/DON) treated him fairly. R1 reported he has not spoken with the new NHA because he didn't want to have (former NHA/DON) speak about him. R1 reported, I just don't want her to be biased. R1 reported he has a great relationship with the staff in the facility and many try to advocate for him. Review of R1's Care Plans Revealed: Focus-(R1) is unable to use his power wheelchair in the facility due to safety concerns and disregard for others as he will not listen to staff r/t w/c speed. He transfers into the power wheelchair in the front lobby prior to leaving the facility. Date initiated 9/22/22 with a revision date of 8/28/23 . Interventions noted on the care plan revealed the most recent updated intervention: Remind resident (R1) of the facility's policy on leaving the property and risks of not following it. Date Initiated: 08/28/2023 . Review of R1's Care Plans Revealed: Focus-(R1) is at risk for safety concerns r/t he frequently leaves off site and smokes while he is off site. (R1) is non-compliant with the facility's policy on signing out when leaving the property. Per (R1) I will sign out in the a.m. and when I decide to go to bed. He will come and go throughout the day and not notify staff. Date Initiated: 09/22/2022 Created by: DON Revision on: 08/28/2023 . Interventions noted on the care plan revealed the most recent updated interventions: If the resident wishes to smoke the facility will assist them to find other placement to meet their needs. Date Initiated: 05/31/2024 . Review of R1's Care Plans Revealed: Focus-(R1) has experienced trauma related to his disease process. Current diagnosis include Hereditary Spastic Paraplegia and Major Depressive Disorder. In the far past, resident had thoughts of harming himself and thinking he would be better off dead. He has not verbalized these thoughts since he has lived at (the facility). Trauma may be expressed by: -irritability, -fear, -anxiety, -loss of interest, -loneliness, -insomnia, Date Initiated: 04/20/2023 . Interventions noted on the care plan revealed the most recent updated interventions: Establish and maintain a trusting relationship date initiated 4/20/23, Maintain a calm non-threatening relationship by listening to (R1) .date initiated 4/20/23. On 5/6/25 at 3:10 PM., an interview was conducted with Registered Nurse (RN) F, who reported R1 has been through a lot. RN F reported currently R1 was unable to use his electric wheelchair in the facility because one time, well over a year ago he bumped another resident in the heel. RN F reported there was no injury to the resident, and R1 felt very bad about it. RN F reported, at the time the former NHA took his right to have his electric wheelchair near him, or in use throughout the facility. RN F reported no education to her knowledge was provided to him, or staff about it after the incident. RN F reported R1 has not receive a second chance and he has expressed that management keeps telling him No, he cannot be trusted with it. RN F reported R1 has expressed frustrations and feelings of being targeted because of that incident, his TV was recently off-line and he mentioned it to everyone, staff mentioned it to management and the Local Ombudsman was involved. RN F reported the former NHA did not do anything to remedy that situation, and it wasn't until R1 refused to pay money that the TV situation was fixed. RN F stated R1 really likes his certain TV programs, especially at night. RN F reported R1 goes out in the community on his own and visits family members he has in the community. RN F reported she thinks at certain times the previous NHA's approach towards R1 has been less than professional. RN F reported the former NHA and R1 did not get along at all, and R1 has had bad experiences with previous NHA's that the facility has had. RN F reported R1 has told her how he feels. When asked if RN F had documented this information, RN F reported she had not documented this in his progress notes, or filled out concern/grievance forms when R1 has expressed how he was feeling. RN F reported she also has not communicated this to the social worker or management. RN F reported she just thought it was common knowledge for everyone, because R1 speaks up and advocates for himself RN F reported R1 was a very sweet guy who doesn't really have any behaviors, and he has not been problematic. On 5/6/25 at 4:00 PM., an interview was conducted with CNA C who reported R1 often expresses his feelings about fear of being discharged and feels he is being targeted. CNA C reported R1 was upset that other residents can have their electric wheelchairs in the facility and because he had one accident his was taken away. CNA C reported R1 feels ignored, and it's painful for him to go back and forth from his regular wheelchair to the electric one when he goes outside to smoke. CNA C reported R1 was a paraplegic, but doesn't let that limit him. CNA C reported R1 goes out in the community almost daily, he goes shopping, uses the city bus, and visits friends and family. CNA C reported the former NHA made him put a huge orange flag on the back of his electric wheelchair for safety reasons, despite him not wanting it on there. CNA C reported R1 told her that he didn't want the flag but felt pressured into having it placed, because of the way the former NHA spoke to him, and how he felt if he said no, he would be in trouble. CNA C reported recently R1 had a care conference meeting and he expressed to the former NHA, the DON and staff numerous times, he did not want the DON present in the meeting. CNA C reported the DON attended the meeting regardless of his rights and choices. CNA C reported R1 has been extremely upset, and felt his rights were violated. On 5/6/25 at 4:30 PM., an interview was conducted with the facility Ombudsman (Omb) H who reported she has met with facility management including the former NHA and current DON. Omb H reported R1 often expresses frustration and feelings of fear/anxiety of being thrown out because one time he accidentally bumped into another resident with his electric wheelchair, and the fact the facility is a non-smoking campus but allow staff to smoke out front in their cars despite their own policy upsets him because he has to transfer in and out of his electric wheelchair just to go smoke and it can be painful. Omb H reported at R1's recent Care Conference meeting R1 requested to the NHA at the time the he did not want DON to attend the meeting. Omb H reported the former NHA did not care, nor did she follow the regulations on resident rights, dignity and/or their own policy. Omb H reported DON attended the meeting despite R1 expressing his feelings and his rights. Omb H reported there have been ongoing issues between management and R1, and it is unfortunate because R1 is always pleasant, does not exhibit behaviors that staff or management have expressed to her, besides at times he forgets to sign in and out when he leaves the facility. Omb H acknowledged there are safety concerns with R1's electric wheelchair and the fact that he did bump into another resident. Omb H reported that happened once, he has not been given another chance, and his rights have been violated. Omb H reported the former NHA bullied him into agreeing to have a large orange flag placed on his wheelchair for safety, despite the fact he said he didn't want it on there. Omb H reported the former NHA said she almost ran into him in the facility parking lot, Omb H responded to the former NHA with well how fast are you going in the parking lot, you know residents are outside in their wheelchairs, it is your facility . Omb H reported R1 is a younger resident, he has different needs than other residents. Omb H reported the facilities have Facility Reported Incidents (FRI's) for falls, accidents, allegations of abuse, as well as resident to resident abuse situations, and those residents are not treated any differently when these unsafe situations arise, why would it be any different for R1 who accidentally bumped into another resident, this does not mean his rights should be taken away, his electric wheelchair should be restricted, and flagged. On 5/6/25 at 5:30 PM., an interview was conducted with Director of Nursing (DON) who reported R1 was upset that his electric wheelchair had been taken away from him about a year ago. The DON reported he had run into another residents heel, no major injury was noted, but the resident had some pain following the incident. The DON reported at that time it was unwitnessed,and other residents reported it the following day or so, and when asked R1 openly admitted to bumping into the resident. The DON reported R1 did not deny the incident happened. The DON reported the electric wheelchair was taken away from him at that point. The DON reported he has not been given the chance to have it back, but he does get transferred into the electric wheelchair in the lobby when he wants to go outside to smoke or go out for the day. The DON reported recently he had a care conference and requested to the former NHA that he did not want me (The DON) present. The DON reported she did attend the care conference despite the fact R1 requested she not attend because the former NHA instructed her to attend the meeting. When asked if the DON advocated for R1's rights, The DON reported no, she did not, and attended the care conference regardless of R1 wishes, and rights. Review of a facility Policy with a revision date of 3/12/25 revealed: Resident Dignity & Personal Privacy Policy: The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. Information Each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth. Procedure 1. Care for residents in a manner that maintains dignity and individuality: a. Call individuals by their preferred name b. Use adult terms o Avoid terms commonly used with children - diaper rash, bibs, etc. c. Knock on doors before entering; ask for permission to enter and announce your presence d. Roll wheelchairs/geri-chairs in a forward direction e. Include the resident in conversation f. Dress in appropriate and desired clothing g. Groom appropriately and to resident's desire h. Maintain radio and television on desired setting. Do not change settings without resident's permission . Review of a facility Policy with a revision date of 5/14/24 revealed: Resident Rights Policy: The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility staff will safeguard the privacy of resident's protected health information from improper use and disclosure and will inform the resident both orally and in writing of his or her rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during his or her stay in the facility. Facility staff will assist residents in exercising their rights. Facility staff will not hamper, compel by force, treat differently, or retaliate against a resident for exercising his or her rights. Information: Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting resident conduct and those regulations governing the protection of resident health and safety All residents in long term care facilities have rights guaranteed to them under Federal and State law. Requirements concerning resident rights are specified in SS483.10, 483.12, and 483.15. Section 483.10 is intended to lay the foundation for the remaining residents' rights requirements which cover more specific areas. These rights include the resident's right to: o Exercise his or her rights; o Be informed about what rights and responsibilities he or she has); o If he or she wishes, have the facility manage his personal funds. o Choose a physician and treatment and participate in decisions and care planning; o Privacy and confidentiality; o Voice grievances and have the facility respond to those grievances; o Examine survey results; o Work or not work; o Privacy in sending and receiving mail; o Visit and be visited by others from outside the facility; o Use a telephone in privacy; o Retain and use personal possessions to the maximum extent that space and safety permit; o Share a room with a spouse, if that is mutually agreeable; o Self-administer medication, if the interdisciplinary care planning team determines it is safe; and o Refuse a transfer from a distinct part, within the institution. o Choose a physician and treatment and participate in decisions and care planning; o Privacy and confidentiality; o Voice grievances and have the facility respond to those grievances; o Examine survey results; o Work or not work; o Privacy in sending and receiving mail; o Visit and be visited by others from outside the facility; o Use a telephone in privacy; o Retain and use personal possessions to the maximum extent that space and safety permit; o Share a room with a spouse, if that is mutually agreeable. o Self-administer medication, if the interdisciplinary care planning team determines it is safe; and o Refuse a transfer from a distinct part, within the institution. A facility must promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. 5. Nothing in this rule is intended to expand the scope of authority of any resident representative beyond that authority specifically authorized by the resident, State or Federal law, or a court of competent jurisdiction .

This citation pertains to Intakes: MI00147097 and MI00147132. Based on observation, interview, and record review, the facility failed to assure residents received food as prescribed by a physician and in accordance with preferences for three residents (R12, R13, and R15) of four residents reviewed for therapeutic diets. This deficient practice resulted in a potential for choking and the potential for health complications. Findings include: On 10/15/24 at 12:33 PM, the meal tray for R13 was observed. The lunch tray contained a tray card indicating no bread unless its a sandwich. The meal included manicotti, green beans and a dinner roll. After the meal was completed, the tray was returned to the food cart with the roll still contained in the protective baggie and was unopened and untouched. During an interview on 10/16/24 at 8:25 AM, the Certified Dietary Manager (CDM) D stated Sometimes bread is on his tray so he can have a sandwich - but with manicotti - no bread should have been on the tray per his request. On 10/15/24 at 5:17 PM, R12 was observed in her room trying to cut a turkey slice with the side of her fork. The tray card for R12 read: Regular/Ground Meats, Fluid Rest 1500 mL (milliliters). R12 was asked if she would rather have her turkey ground asindicated on her therapeutic diet, and she shook her head yes. Certified Nurse Aide (CNA) B was asked about R12's meal which included a slice of turkey. CNA B said, That's not right, one of the CNAs should have noticed that. CNA B went to the dietary department to get ground turkey for R12. On 10/16/24 at 8:19 AM, R15 was observed in her room with a breakfast tray including a salt packet. R15's tray card indicated a therapeutic diet of Regular, No Added Salt. Registered Nurse (RN) C also observed the salt and said, Oh, she has hypertension and should not have salt.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services to promote healing and prevent wound infection for two Residents (R57 & R71), out of four residents reviewed for pressure injuries. This deficient practice resulted in harm with delay and/or removal of recommended pressure relieving mattresses, delayed healing, and worsening of condition with the development of osteomyelitis for R71. Findings include: This deficiency pertains to Intake MI00140165. Resident R71 During a telephone interview on 2/22/24 at 4:19 p.m., Confidential Complainant C (a licensed, medical professional) expressed concern regarding the facilities failure to timely implement pressure injury interventions to promote healing. Complainant C stated, What the (specialty) wound clinic had ordered the facility has not implemented (timely) . [R71] went septic (extreme response to an infection) and was diagnosed with osteomyelitis (a serious bone infection) . I don't think [R71] would be in the condition [they] are in if [the facility] was putting dressings on [the] wounds, turning [R71] every two hours . The pressure ulcer went down to the bone and became infected. [R71] has an implanted PICC (peripherally inserted central catheter used for many types of intravenous (IV) antibiotics) and is starting a six-week course of antibiotics . [R71] went into the facility with this (sacral) wound but it has gotten progressively worse. Review of R71's Minimum Data Set (MDS) assessment, dated 12/19/2023, revealed R71 was admitted to the facility on [DATE], with active diagnoses that included the following, in part: Urinary tract infection (UTI) (Last 30 days), malnutrition, pressure ulcer of sacral region, Stage 4, need for assistance with personal care, muscle weakness, and morbid obesity. R71 scored 8 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. Section M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage revealed one (1) Number (Stage) 4 pressure ulcer, present upon admission, defined on the MDS assessment as Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. During a telephone interview on 2/27/24 at 3:13 p.m., when asked about the specialty Wound clinics repeated recommendation for a pressure relieving mattress, Complainant C stated, [R71's] wounds were getting worse and worse not having the pressure relieving mattress that was ordered, lack of repositioning, lack of following wound care orders . I was concerned that R71 was going to get osteomyelitis. When asked if the facility appeared to begin to comply with wound clinic orders and recommendations near the time of R71's diagnosis of osteomyelitis, Complainant C stated, exactly! During an observation of wound care for R71 on 2/28/24 at 12:07 p.m., Registered Nurse (RN)/Wound Care Nurse F removed the dirty [Name Brand] sterile gauze from the interior of R71's sacral pressure injury. RN F sprayed wound cleanser unto two separate sterile 4 x 4's for cleansing of the interior of R71's pressure ulcer. RN F used a clean, gloved hand (not sterile) as she inserted her hand into the interior of R71's large Stage 4 pressure injury and attempted to wipe the entire inside surface of the wound with the two separate 4 x 4's. No wound cleanser was sprayed, irrigated, or rinsed inside of the wound. The surface of the wound was mechanically wiped in an attempt to cleanse the entirety of the Stage 4 wound. Undermining was noted to be present in the wound. RN F measured the wound on 2/28/24 at approximately 12:12 p.m., as: 8.4 cm (centimeters) length x 12.6 cm wide, depth of 5.1 cm, and 6.4 cm maximum undermining. During the continued observation of wound care, RN F packed sterile [Name Brand] rolled gauze into R71's Stage 4 pressure injury, by placing her hand, repeatedly inside of the wound as additional sterile gauze was placed inside the pressure ulcer. RN F applied an absorbent pad over the wound with only one piece of tape securing the pad on the top side of the wound. The absorbent pad edges were open on the side and the bottom, with a tail of the wound open to potential exposure by feces, as well as the packing of the sacral pressure injury. There was no barrier to prevent feces from contaminating the Stage 4 pressure injury or the open tail area of the wound. During an interview at this same time, RN F was asked when the APP (Alternating Pressure Mattress) was placed on R71's bed, RN F said she would have to check R71's medical record. During an interview on 2/28/24 at 12:36 p.m., RN F confirmed the Specialty Wound Clinic had recommended a low air low mattress to aid in healing R71's Stage 4 pressure ulcer. RN F reviewed R71's Care Plan and confirmed the care plan was revised to show the new mattress on 1/19/23. RN F acknowledged that was most likely the day that R71 received the pressure relieving mattress. RN F stated, Originally, we (facility) did not have a (pressure relieving mattress) at the time (of the Wound Clinic Order). As people (residents) come and go, and we had talked about ordering (a pressure relieving mattress), but I don't know where that happened. Review of the Specialty Wound Clinic Progress Note Details for R71, provided by the facility revealed the following visit details: 10/5/23: This information was obtained from the Patient (R71) .[admitted ] 9/13/23 to [Facility Name] on PO (oral) Vanco (vancomycin), which has been completed. The wound VAC (vacuum) had been used up until October 3, when the nursing home decided to discontinue it and switch to wet-to-dry dressings with Dakin's (wound solution). Per [Family Member (FM)] who is a nurse and is present at the bedside and patient, there were not enough staff trained in how to use the wound VAC and once she got to the nursing home, they had repeated problems keeping it on and to suction. Since being admitted to the nursing home, she has unfortunately developed multiple satellite areas of breakdown has non-blanchable redness to purpuric changes to the skin on bilateral buttocks/perineal area. Patient reports she has to call the staff requesting to be turned. She has a regular mattress . Wound VAC to be reapplied by nursing home. Contact [Name] if education is needed. App (alternating pressure mattress)/Dolphin mattress needed. Reposition every 2 hours . Recheck in 3-4 weeks. Wound Assessment (10/5/23) of the Coccyx, Stage 4 Pressure Injury Pressure Ulcer measurements are 7.8 cm length x 7 cm width x 8 cm depth, with an area of 54.6 sq (square) cm and a volume of 436.8 cubic cm. No tunneling, sinus tract, or undermining was noted. Wound Orders from the wound clinic on 10/5/23 included the following for the Stage 4 pressure injury: .Off-Loading (of pressure): Specialty Bed/Mattress for Pressure Reduction: Alternating pressure relief mattress. Turn every 2 hours. Avoid direct pressure over wound site while limiting side lying position to 30-degree tilt and/or HOB (head of bed) elevations to 30 degrees in bed . Negative Pressure wound Therapy: Wound VAC negative 125 mmHg Continuous - Black foam to wound bed, assuring that no foam is touching good skin. Cover with drape. Track to patients left flank area if tolerated. Change 3x/week. 10/27/23 Wound Clinic Progress Note: .Wound VAC supplies were not sent (by the facility) with the patient (R71) and our supplies are not compatible with the NPWT (Negative Pressure Wound Therapy) device the patient has .Patient still has not received an APP pressure relieving mattress, stating this was not ordered, but review of orders sent 10/5/23 show this was included with the orders. Today, orders faxed and printed, highlighted, and sent with patient. Staff should call with questions . Recheck in 1 month. 12/7/23 Wound Clinic Progress Note: The sacral wound is measuring larger with new breakdown along the right lateral margin. The wound VAC is not in place. A week after the prior visit a staff member called to let us know the VAC was leaking and having other issues, so they decided to discontinue it. The patient still does not have an APP or comparable pressure-relieving mattress. FM reports .told by staff at [Facility Name] that it was 'too expensive' . A wound VAC remains the best option for the wound and order will be sent to reapply this. Patient still needs APP mattress . 1/15/24 Wound Clinic Progress Note: Pt (patient) returns for recheck of sacral pressure ulcer . [R71] has developed new breakdown around the sacral wound and has a slough and eschar-covered wound to the left buttock. The sacral wound is with significant slough, new undermining from 6:00 - 11:00, sacrum can be felt at the base of the wound, and there is new tunneling within the wound bed around 8 o'clock and 11o'clock. There is tissue necrosis along the wound edges where the undermining is greatest .The nursing home is not able to continue with the wound VAC and their local provider gave orders to hold it due to worsening wound. A culture of the wound was taken, and patient was placed on Vanco and Rocephin (strong antibiotics). Will request culture results. [FM] is present and reports MRSA and e. coli were both present . She is still on a regular mattress and family is still being told a new one will not be purchased as she is on a wait list for transfer to a different facility once a bed becomes available. [R71] reports not being repositioned side to side to keep her off the sacral area more than a few times in a 24-hour period, and repositioning is limited to placing a pillow under her back. Encouraged to set an alarm on her phone for every 2 hours and to call out for assistance with repositioning if this is not occurring .I am concerned about new bone exposure, tissue necrosis, and tunneling toward new wound. Imaging for further evaluation and evaluation of osteomyelitis is recommended. I do still think the wound VAC is the best option for wound care and encouraging some granulation . Review of a 2/7/24 MRI (Magnetic Resonance Imaging) of R71's sacrum without contrast Patient Communication revealed the following, in part: FINDINGS: There is a large soft tissue ulceration overlying the distal sacrum measuring 7.4 cm (centimeters) craniocaudal by 7.6 cm transverse by 2.5 cm in depth. There is surrounding inflammatory thickening of the adjacent fat and soft tissues. Inflammatory changes extend into the sacral spinal canal . In addition to spinal canal involvement, there is abnormal marrow signal involving the first and second coccygeal segments, consistent with osteomyelitis .IMPRESSION: 1. Large soft tissue ulceration overlying the sacrum . osteomyelitis of the upper coccygeal segments, and presacral soft tissue edema . The report was noted on 2/9/24, with IV Vancomycin for six weeks and IV Rocephin prescribed in the physician handwriting on the document. Section M1200. Skin and Ulcer/Injury Treatments (check all that apply), included the following: pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressings and applications of ointments/medications . Of note, C. Turning/repositioning program was not checked to show R71 was participating in a structured turning and repositioning program for pressure ulcer treatment for the Stage IV sacral pressure injury. Review of R71's POC (Plan of Care) Response History for ADL (activities of daily living) from 2/14/24 through 2/27/24, documented the provision of routine standard care which includes evaluating skin daily and reporting changes . turning and repositioning . Certified Nurse Aide (CNA) staff were to document once per shift confirming they had provided that routine standard care for R71. Review of the 14-day period revealed 6 days out of the 14-day period had undocumented shifts for turning and repositioning as specified in the routine standard care. During an interview on 2/27/24 at 8:27 a.m., R71 was observed sitting in bed at an approximate 30-degree angle. When asked about wound care interventions provided by the facility, R71 said the facility did not always turn and reposition her every two hours and commented that she did not routinely refuse turning and repositioning. An IV pole for administration of antibiotics was observed on the right, exit side of R71's bed, and a PICC line was visible on R71's right arm. When asked about a mattress to distribute pressure on the Stage IV (four) sacral wound, R71 stated, It is an air mattress, but it is not plugged in (to an electric outlet) or anything. When asked how long she had the new pressure distribution mattress, R71 stated, I have had it for about a month, maybe a little more. When asked about the facility follow through with the specialty wound clinic recommendations, R71 stated, The Wound clinic would comment about my bad care (at the facility), and they would write a recommendation about the care they wanted me to receive . Review of R71's Care Plan History Report (showing all care plan intervention changes), revealed the following pressure ulcer interventions, in part: 9/13/23 (admitted ): Pressure reduction mattress to bed. Date Initiated: 9/13/23. Revision on 1/19/24 to [Name Brand] mattress in place for pressure redistribution. Resolved on 2/26/24 (at time of recertification survey): Frequently turn/reposition [R71] in shorter periods at a 30-degree angle to relieve pressure and PRN (as needed.) [R71] often allows a pillow to be placed at her side, however, [R71] does not allow the pillow to be placed to offload pressure adequately and likes it to be placed more for comfort. Date Initiated: 10/19/2023, Resolved Date: 2/26/24. Initiated 2/26/24 (during survey): Turn q (every) 2 hr., avoid direct pressure over the wound site while limiting the side-lying position to 30-degree tilt &/or HOB elevation to 30 degrees in bed. Use pillows for positioning. During an interview on 2/28/24 at 5:30 p.m., the Director of Nursing did acknowledge the Wound clinic did recommend a new pressure relieving mattress for the resident (R71) as early as 10/5/23, and a mattress was not placed on R71's bed until 1/19/24. The mattress was taken off of a bed in a hall being renovated and placed on R71's bed. No action was taken by the facility for three months, although a pressure relieving mattress was ordered (recommended) every visit at the wound clinic. When asked how the DON would have packed sterile gauze into R71's Stage 4 sacral pressure injury, the DON stated, I would have used a sterile, cotton-tipped applicator. When asked about using two sterile 4 x 4's sprayed with wound cleanser, to insert your hand into the wound and mechanically rub the areas of the wound you could access as a method of wound cleaning, the DON said she would spray the wound cleanser into the wound and did not think that the mechanical rubbing of the wound would cleanse all aspects of the deeply undermined pressure ulcer. The DON acknowledged the concerns regarding the potential for continued fecal contamination of both the main Stage 4 sacral wound and the tail on the sacral wound. Review of the Skin Management policy, dated 12/15/2022, listed the National Pressure Ulcer Advisory Panel (NPUAP) Guidelines in the 'Cross-References' section of the policy. The NPUAP changed its name to the National Pressure Injury Advisory Panel (NPIAP) in 2019. The NPIAP Clinical Practice Guidelines (npiap.com) provide standards for cleansing wounds. The guidelines included in part . Apply cleansing solution with enough pressure to cleanse the wound bed without damaging tissue or driving bacteria into the wound, generally between 4 and 15 pounds per square inch (Expert opinion) . irrigation pressure between 4 and 15 psi should be adequate to clean the surface of the pressure injury without causing trauma to the wound bed. 49310 Resident #57: A review of the Electronic Medical Record (EMR) for Resident #57 (R57) revealed admission to the facility on [DATE] with a sacral stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone). A review of the Minimum Data Set (MDS) assessment dated [DATE] identified R57 as requiring maximal staff assistance with turning while in bed. R57 attended a wound clinic monthly for evaluation and treatment of the pressure injury. The MDS documented the use of a pressure-reducing device for R57's bed. A review of the care plan for R57 revealed a plan of care for impaired skin integrity. The care plan contained an intervention for a specialty air mattress to R57's bed. The care plans indicated R57 required extensive assistance with two staff assistance to reposition and turn in bed. On 2/27/24 at 8:15 a.m. and 3:23 p.m., R57 was observed in a back-lying position on a standard mattress. R57 was asked if the mattress on the bed was the same mattress used since admission. R57 responded, No - I don't have the good one anymore. A review of wound clinic notes revealed R57 was last assessed on 2/1/24. The wound clinic notes included an order for the use of a specialty bed/mattress for pressure-reduction. The order provided the name of a fluid immersion-simulation mattress or an air mattress to be used on R57's bed. On 2/28/24 at 10:42 a.m., the facility wound nurse, Licensed Practical Nurse F (LPN F), was observed completing a dressing change to R57's wound. The sacral wound was a stage 4 pressure injury measuring 7.1 cm x 5.4 cm x 6.8 cm with 4.0 cm of undermining (the destruction of tissue or ulceration extending under the skin edges). LPN F was asked why R57 did not have the mattress ordered by the wound clinic. LPN F said R57 used to be on a [name of a specialized mattress with air cell technology used for advanced wounds]. When asked the reason R57 was not currently on the air mattress, LPN F said R57 moved rooms from one unit to another unit and the mattress wasn't moved with R57. LPN F did not provide a response when asked why the air mattress wasn't moved when R57 was moved to a different unit. On 2/28/24 at 3:43 p.m., the wound clinic orders for a specialty mattress were reviewed by the DON. The DON agreed R57 should be on an air mattress and said the air mattress should have been moved when R57 was moved to another unit. The DON said the facility had air mattresses, but the mattresses were misplaced. The DON said they were attempting to locate the missing air mattresses. R57 was moved from the previous unit to the current unit on 12/23/23. Wound clinic orders on 12/4/23, prior to R57 moving to the current unit, included the order for R57 to be on a specialty bed/mattress for pressure reduction, either an air mattress or a fluid immersion-simulation mattress. The 'Skin Management' policy read in part . Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Appropriate preventative measures will be implemented on guests/residents identified at risk and interventions are documented on the care plan. R57 was identified as being at high risk for pressure injury development. R57 scored 12 on a Braden scale (a tool used in health care to assess and document risk for developing pressure injuries). According to the 'Skin Management' policy section Appendix A Intervention Guidelines, residents with a Braden score of 12 require a pressure redistribution support surface placed on the bed. The 'Skin Management' policy section 'Attachments' included a mattress grid. The grid read [name of a specialized mattress with air cell technology] is good for residents with stage 3 & 4 [pressure injuries]. The NPIAP clinical practice guidelines (npiap.com) include in part: . Support surfaces are an important element in pressure injury prevention and treatment because they can prevent damaging tissue deformation and provide an environment that enhances perfusion of at-risk or injured tissue. support surfaces play a significant role in an individualized comprehensive management plan for pressure injury prevention and treatment. For individuals with existing full thickness pressure injuries (i.e., Category/Stage III or IV pressure injuries, unstageable pressure injuries and deep tissue pressure injuries), perfusion to injured tissue benefit from support surfaces with additional features (e.g., alternating pressure or air fluidized) . Specialty support surfaces to consider for individuals with a pressure injury include alternating pressure air mattresses, mattresses with a low-air-loss feature and air fluidized beds (Expert opinion) .

This citation is linked to intake #MI00139805 Based on observation, interview, and record review the facility failed to care for multiple pressure wounds according to physician orders for three Residents (R4, R5, & R6) out of three residents reviewed for pressure ulcer care. This deficient practice resulted in R6 developing infection, deterioration of pressure wound, hospitalization , wound debridement, and sepsis. Findings include: Resident #6 (R6) Review of R6's progress note, dated 7/12/23 at 10:46 AM, read in part, Nursing noticed during morning medication pass that patient was difficult to arouse. Resident will fall asleep suddenly during conversation . (Providers name) notified of patient's current condition. Advised to continue to monitor. Review of R6's progress note, dated 7/12/23 at 12:01 PM, read in part, .Writer in to assess, will only arouse with deep sternal rub, very weak and lethargic .New orders obtained for x-ray of coccyx to rule out osteomyelitis . Review of R6's progress note, dated 7/12/23 at 6:28 PM, read in part, .Patient has noted spitting up some clear thick mucus from her mouth. Review of R6's progress note, dated 7/12/23 at 9:05 PM, read in part, .O2 (oxygen saturation) was taken and found to be at 75-80%. Oxygen was increased to 4 liters and O2 was 100%. Pupils were dilated and unresponsive. On call was notified, and the resident was sent to the ER (emergency room ). Review of R6's skin and wound evaluation, dated 4/12/23, revealed, Wound type, open lesion, coccyx fistula, measured 1.5 cm (centimeter) x 0.5 cm x 1.5 cm, present on admission. According to the MDS (Minimum Data Set) assessment dated , 4/19/23, R6 was cognitively intact, non-ambulatory and required extensive assistance with mobility, with diagnoses including weakness, chronic pain, pressure ulcer stage 4, urinary incontinence, and obesity. Review of R6's skin and wound evaluation, dated 4/20/23, revealed, Wound type, open lesion, coccyx fistula, measured 0.4 cm x 0.2 cm x 1.9 cm, and was noted to be deteriorating. Review of R6's skin and wound evaluation, dated 5/4/23, revealed, Wound type, MASD (moisture associated skin damage), sacrum, measured 7.7 cm x 5.2 cm, and noted to be deteriorating. Further skin and wound evaluations were as follows: a. On 5/11/23 measured 9.3 cm x 7.0 cm, b. On 5/18/23 measured 8.6 cm x 8.2 cm, c. On 5/25/23 measured 7.3 cm x 5.5 cm with eschar. The Physician order, dated 5/4/23, revealed, Sacral unstageable: cleanse with wound cleaner, pat dry, apply Medi honey to gauze and then apply to wound bed, cover with (brand name foam dressing), every shift for MASD. Review of R6's TAR (treatment administration record), dated 5/4/23 through 5/25/23, revealed, wound care was not performed on the 10th during day shift and on the 13th, 14th, 15th, 16th, 21st, 22nd, and on the 25th during evening shift. Review of R6's provider progress note, dated 5/19/23 at 12:00 AM, read in part, .Wound has improved slightly overall but unfortunately the (sic) are is consistently soaked with urine which is impeding healing .Addendum Details: Wound .Dressing intact, however saturated with urine. Staff provided education on urinary incontinence, frequent changes, and turning and repositioning every two hours side to side while in bed .Wound nurse to initiate unavoidable pressure injury tool .Addendum created date: 5/29/2023 at 1:16 PM. *Note: This addendum was placed after the resident was admitted to the hospital on 5/25/23 and ten days after the originally dated 5/19/23 progress note. Review of R6's progress note/resident at risk (Managerial Review Meeting), dated 5/23/23 at 1:52 PM, read in part, .A number of educational attempts have been made with resident for education on turning and repositioning side to side, getting up in wheelchair, and allowing more frequent changes . *Note: No nursing notes or other documents were provided as requested to show documentation regarding R6 refusal of cares. Review of R6's progress note, dated 5/25/23 at 7:17 PM, read in part, Writer entered resident's room at 6:00 PM with dinner medications, resident was lethargic, difficult to arouse. Writer was able to arouse her, resident was only oriented to person .not able to answer questions .PCP (primary care physician) was notified .order to her resident sent to (local) ER for evaluation . Review of R6's local hospital ER provider note, dated 5/25/23, read in part, Patient has noted redness bilateral buttocks .bilateral redness to buttocks and coccyx are high suspicion for acute infection . Review of R6's progress note, dated 5/25/23 at 11:59 PM, read in part, Call received from (local) ER regarding resident status .resident will be transferred to (out of state hospital) for sepsis. Review of R6's hospital records, dated 5/26/23 through 6/2/23, revealed, an elevated white blood cell count, initiation of two different antibiotics, wound debridement, and a wound vac (a wound vacuum device that uses negative pressure to assist with wound healing). Review of R6's census, revealed she was readmitted to the facility on [DATE]. Review of R6's skin and wound evaluation, dated 6/16/23, revealed, Wound type, stage 4 pressure ulcer, sacrum, measured 11.8 cm x 9.6 cm x 5.5 cm, and undermining 4.2 cm, and noted to be deteriorating. Further skin and wound evaluations were as follows: a. On 6/29/23 measured 10.7 cm x 8.2 cm (lacked documentation of depth and undermining). Review of R6's care plan, dated 6/13/23, read in part, .is at risk for impaired skin integrity/pressure injury related to .pressure injuries, pain, decreased mobility .follow facility policies/protocols for the prevention/treatment of impaired skin integrity, observe dressing frequently to ensure it is intact and adhering, report loose dressing to nurse .provide incontinence care with each incontinent episode and as needed . The Physician order, dated 6/14/23, revealed, Change wound vac Monday, Wednesday, and Friday. Clean with wound cleanser, one time a day every Mon, Wed, Fri for wound. Review of R6's TAR, dated 6/14/23 through 6/28/23, revealed, wound care was not performed on the 19th and the 28th and marked 5 which indicated hold and see nurses note. *Note: No notes could be found to describe why the dressing was held on these dates. Review of R6's skin and wound evaluation, dated 7/6/23, revealed, Wound type, stage 4 pressure ulcer, sacrum, measured 9.5 cm x 8.4 cm x 6.8 cm, and undermining 3.3 cm. Review of R6's hospital records, dated 7/13/23 through 7/27/23, read in part, .admitted on [DATE] with fevers, bradycardia and hypotension, and lethargy, requiring intubation .If wound vac is off for more than 2 hours, the dressing should be removed and packed with dakins (wound bleach solution used to clean out the wound bed) 0.25% moistened gauze, and covered with ABD (abdominal pad dressing). This should be changed daily until vac can be reapplied .Acute medical issues: septic shock - secondary to either UTI (urinary tract infection) versus stage 4 sacral decubitus ulcer POA (present on arrival) . finished 5 day course of levofloxacin (antibiotic) . Review of R6's census, revealed she was readmitted to the facility on [DATE]. The Physician order, dated 8/9/23, revealed, Change wound vac Monday, Wednesday, and Friday. Clean with normal saline, pat dry, and apply new wound vac dressing .one time a day every Mon, Wed, Fri for coccyx wound. Review of R6's skin and wound evaluation, dated 8/17/23, revealed, Wound type, stage 4 pressure ulcer, sacrum, measured 9.8 cm x 7.9 cm x 4.1 cm, and undermining 4.3 cm, and noted to be deteriorating. Further skin and wound evaluations were as follows: a. On 8/24/23 measured 7.7 cm x 6.3 cm x 4.0 cm, and with undermining of 3.2 cm. Review of R6's TAR, dated 8/8/23 through 8/19/23, revealed, wound care was not performed on the 11th during day shift. The Physician order, dated 8/22/23, revealed, Change wound vac Tuesday, Thursday, and Saturday. Clean with normal saline, pat dry, and apply new wound vac dressing .one time a day every Tue, Thu, Sat for coccyx wound. Review of R6's TAR, dated 8/22/23 through 8/31/23, revealed, wound care was not performed on the 22nd and the 31st during the day shift and marked 5 which indicated hold and see nurses note. The Physician order, dated 9/1/23, revealed, Sacral ulcer: cleanse with Dakin's solution, packed with dampened Dakin's gauze. Cover with ABD pad with tape to affix. Place dry gauze between anus and wound dressing to serve as a barrier for fecal matter, every shift for pressure ulcer (once every 12 hours). Review of R6's TAR, dated 9/1/23 through 9/30/23, revealed, wound care was not performed on the 10th, 13th, 20th, 24th, and the 27th during the day shift and marked at 7 which indicated sleeping on the evening shift the 2nd, 3rd, and the 17th. Review of R6's skin and wound evaluation, dated 9/8/23, revealed, Wound type, stage 4 pressure ulcer, sacrum, measured 10.6 cm x 9.1 cm x 6.5 cm, and undermining 5.2 cm. Review of R6's TAR dated 10/1/23 through 10/10/23, revealed wound care was not performed on the 5th during day shift and marked 5 which indicated hold and see nurses note. Review of R6's progress notes, in the EMR (electronic medical record), dated 4/12/23 through 10/10/23, revealed no nursing notes as to why the wound dressing was incomplete. Review of R6's MDS's, dated 4/19/23, 5/25/23, 6/19/23, 7/12/23, 8/14/23, and 8/23/23, all revealed, section E behaviors, E800 Rejection of care: None exhibited. On 10/10/23 at 9:50 AM, an interview was conducted with R6. R6 was asked if staff reposition her every two hours and replied, Sometimes staff reposition her, but not always they are busy. On 10/10/23 at 3:50 PM, an observation was made of R6's wound care completed by LPN (Licensed Practical Nurse) C and the DON (Director of Nursing) assisted. R6's sacral area had some granulated tissue and some slough. R6's incontinence pad had a ring around the top half that was yellowish brown in color and appear to be either old, dried urine or serosanguinous drainage from her sacral wound. The DON was asked if she could see the ring on the incontinence pad and replied, Yes. The DON was asked if she felt that the ring should be on the pad and replied, No. We will change it after we are done doing her dressing change. On 10/11/23 at 8:30 AM, an interview was conducted with R6. R6 was asked how her night went and replied, I went to bed around one this morning. R6 was asked when she was awakened or last seen staff after she had fallen asleep and replied, It was around four this morning. My catheter was leaking last night, and they were in to change me around four. R6 was lying in her bed on her right side. On 10/11/23 at 11:30 AM, an observation was made of R6 in her room lying in her bed and remained on her right side in the same position for three hours. On 10/11/23 at 11:45 AM, an interview was conducted with the DON. The DON was asked about the wound dressing changes on the TARs and if there should be any blank spots on them and replied, No. The TARs should not have any blank spots on them and if they do then the nurse should write a progress note explaining why the wound dressing change was incomplete. The DON was asked if any wound dressing changes should be missed with an additional order scheduled as needed and replied, No. The 'as needed' gives nurses extra dressing changes for times when the first dressing change was missed, the dressing becomes loose, or is soiled. Resident #4 (R4) According to the MDS assessment dated , 4/28/23, R4 was non ambulatory and required extensive assistance with mobility, with diagnoses including end stage renal disease, diabetes mellitus, chronic pain, and arthritis. Review of R4's skin and wound evaluation, dated 10/5/23, revealed, A stage 3 pressure ulcer, right heel, measured 4.0 cm x 2.4 cm x 0.3 cm, with an initial start date of 7/6/23. *Note initially wound started on 7/6/23 and was a reddened area measuring 2 cm x 2 cm and later declined. Review of R4's care plan, dated 7/6/23, read in part, .has an actual impaired skin integrity related pressure ulcer right heel .treatment as ordered. The Physician order, dated 7/24/23, revealed, Right heel: clean with wound cleanser, dry, apply skin prep, each shift (twice daily), and leave open to air. Float heel. Review of R4's TAR, dated 7/24/23 through 7/31/23, revealed, wound care was not performed on the 25th or the 27th during day shift. The physician order, dated 8/3/23, revealed, Right heel: clean with wound cleanser, dry, apply gauze and wrap with kerlix and tape, every shift (twice daily). Review of R4's TAR, dated 8/1/23 through 8/31/23, revealed, wound care was not performed on 8th, 10th, or on the 13th during day shift, and on the 16th during evening shift. The physician order, dated 8/19/23, revealed, Right heel: clean with wound cleanser, dry, apply Medi honey to gauze, apply gauze to wound bed, and wrap gently with kerlix and tape, every shift (twice daily). Review of R4's TAR, dated 8/1/23 through 8/31/23, revealed, wound care was not performed on 21st, 23rd, 26th, 27th, or on the 28th during day shift. The physician order, dated 8/29/23, revealed, Right heel: clean with wound cleanser, dry, apply Medi honey to gauze, apply gauze to wound bed, and wrap gently with kerlix and tape, every day-on-day shift. Review of R4's TAR, dated 9/1/23 through 9/30/23, revealed, wound care was not performed on 1st, 5th, or the 6th, and on the 7th signed out as 5 (which indicated hold see nurses note), or on the 25th marked as 3 (which indicated absent). *Note R4 also had another physician order for the same wound care as needed which was not documented as completed for the same days the routine wound care was not signed out as completed daily. Review of R4's TAR, dated 10/1/23 through 10/10/23, revealed, wound care was not performed on the 5th. Review of R4's progress notes, in the EMR, dated 7/24/23 through 10/10/23, revealed no nursing notes to explain why the wound dressing changes were not electronically signed as completed. On 10/10/23 at 3:30 PM, an observation was made of R4's wound care completed by LPN C and assisted by the DON. R4's right heel was open with some slough and eschar. LPN C cleaned R4's right heel and applied the treatment per physician orders. Resident #5 (R5) According to the MDS assessment dated , 3/31/23, R5 was non-ambulatory and required extensive assistance with mobility, with diagnoses including chronic pain, contractures of the hand and ankle, and quadriplegia (paralysis of all four extremities). Review of R5's skin and wound evaluation, dated 9/28/23, revealed, Pressure stage 4, right trochanter, in house acquired, 1.0 cm x 1.8 cm x 0.9 cm, with undermining 1.3 cm, with an initial start date on 10/20/21. Review of R5's care plan, dated 3/17/23, read in part, .has an actual impaired skin integrity related to pressure injury to right trochanter and left medial plantar foot .conduct skin assessment weekly and measure area(s) and document .treatment as ordered. The Physician order, dated 2/17/23, revealed, Right trochanter: cleanse with wound cleaner, pat dry. Place collagen crystals to undermining and to wound bed, cover crystals with one layer of calcium alginate. Cover with optifoam (dressing), every, day shift for pressure injury. Review of R5's TAR, dated 7/1/23 through 7/31/23, revealed, wound care was not performed on the 1st, 3rd, 5th, 7th, 11th, 15th, 16th, 21st, 25th, 27th, and on the 29th during day shift. Review of R5's TAR, dated 8/1/23 through 8/31/23, revealed, wound care was not performed on the 8th, 9th, 10th, 12th, 17th, and on the 26th during day shift. Review of R5's TAR, dated 9/1/23 through 9/30/23, revealed, wound care was not performed on the 6th, 15th, and on the 22nd during day shift. Review of R5's TAR, dated 10/1/23 through 10/10/23, revealed, wound care was not performed on the 5th during day shift. The Physician order, dated 7/6/23, revealed, Left plantar aspect of left great toe and right lateral aspect of foot: cleanse with wound cleanser, pat dry, apply ski prep and attempt to keep pressure off. Review of R5's TAR, dated 8/1/23 through 8/31/23, revealed, wound care was not performed on the 8th, 9th, 10th, 12th, 17th, and on the 26th during day shift. Review of R5's TAR, dated 9/1/23 through 9/30/23, revealed, wound care was not performed on the 6th during day shift. Review of R5's progress notes, in the EMR, dated 7/1/23 through 10/10/23, revealed no nursing notes to explain why the wound dressing changes were not electronically signed as completed. On 10/10/23 at 4:15 PM, an observation was made of R5's wound care completed by LPN C and assisted by the DON. R5's right trochanter was open and undermined with granulated tissue. R5's left great medial wound was dry with eschar and dressing removed was dated 10/8/23. R5 wore an adult brief and his brief was noted to be soiled in the back and in the front the wetness indicator was indicating wetness. *Note foot dressing was overdue to be changed and noted to be signed out as completed on 10/9/23 and the nurses who performed the dressing change did not change his brief, they just reapplied the brief as it was. Review of facility policy titled, Clean Dressing Change, dated 9/18/23, read in part, 1. Check physician order for current, correct treatment .16. Document treatment given and wound/site appearance and changes in nurses' notes and elsewhere as needed. Review of facility policy titled, Skin Management, dated 7/14/21, read in part, Policy: It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries .4. Guest/residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing. A physician's order for treatment .5. The licensed nurse will initiate documentation in the electronic health record (EHR), which includes a description of the skin impairment as follows: In the EHR facilities, the licensed nurse will document on the skin and wound evaluation for pressure injury and vascular ulcers. Document weekly until the area is resolved .9. The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with injury for one Resident (#1) of three residents reviewed for falls. This deficient practice resulted harm to Resident #1 from a fall from a transport van to the ground, emergency medical care, multiple CT scans to assess for injury, and an L1 (first lumbar verterbra/lower back) spinal compression deformity. Findings include: Review of Resident #1's Minimum Data Set (MDS) assessment, dated 1/28/21, revealed Resident #1 had the following active diagnoses: [CONDITION(S)] (ESRD), arthritis, Alzheimer's disease, anxiety, depression, acute [CONDITION(S)], muscle weakness, and other reduced mobility. Resident #1 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. Resident #1 used a wheelchair for mobility and was totally dependent upon staff for transfers and locomotion. Review of the Incident and Accident Investigation Form, dated 2/22/21 at 0450 (4:50 a.m.) revealed the following: Conclusion . Lift was not fully up (to the level of the van floor) when [Transporter C] assisted [Resident #1's] wheelchair onto the lift causing wheelchair to tip backwards and fall to the ground with [Resident #1] in the wheelchair where she then rolled out of the wheelchair . Location of Injury: Skin tear to L (left) forearm - Mild Compression Deformity L1 . Review of the undated Investigation Summary of Resident #1's 2/22/21 fall from the facility transport van revealed the following: [Transporter C] forgot that the (wheelchair lift) was not in the raised position. The lift was elevated approximately one foot off of the ground. [Transporter C] pushed [Resident #1] out onto the lift, her wheelchair fell backwards with [Resident #1] in the wheelchair . After the wheelchair hit the ground, [Resident #1] rolled out of the chair and onto the ground . 911 was then called . and transported her to the ER (emergency room ) . [Resident #1] was assessed at the ER and had multiple CT scans done . Review of the CT Chest, Abdomen, Pelvis Without Contrast, dated 2/22/21 revealed the following: History . female with pain. Injury. fell , Trauma . IMPRESSION: . 2. New mild compression, deformity superior endplate L1 vertebra . During an interview on 3/2/21 at 9:47 a.m., Transporter C was asked to described Resident #1's fall from the facility transport van on 2/22/21. Transporter C said he had gone to the back of the van, opened the doors and lowered the wheelchair lift platform about two-thirds down toward the ground. Transporter C opened the side door, entered the van and unbuckled the straps and seat belt that secured Resident #1's wheelchair in the van. Resident #1 was facing forward - looking out the front window on the van. Transporter C stated, [Resident #1's] feet stick way out (from the wheelchair) - so she is really long (as seated in the wheelchair in the van) . I had both hands on the (wheelchair) foot plates and was pushing her backwards out of the van, unto what I thought was the platform . I tried to grab her, and the back wheels hit the ramp (approximately 2 feet below the level of the van floor). The ramp was about a foot off the ground . The wheelchair ended on its side (on the ground) .I don't know if she rolled out the side (of the wheelchair) or what (unto the ground). When asked if Resident #1 expressed any pain, Transporter C stated, I think so . Review of the Operator's Manual for [Name Brand] Public Use Wheelchair Lifts, March 2010, revealed the following, in part: .Position and secure (buckle, engage, fasten, etc.) the wheelchair-equipped occupant seat belt (torso restraint) before loading onto the wheelchair lift platform . The lift attendant should not ride on the platform with the passenger . Vehicle (Floor Level) Loading and Unloading: The platform must be fully raised (at floor level) and the inner roll stop (bridge plate) must be properly positioned when loading or unloading passengers in or out of the vehicle. It is the responsibility of the lift attendant to ensure the platform and the inner roll stop are properly positioned at floor level when loading and unloading passengers . The transportation van with an installed wheelchair lift was observed on 3/2/21 at 10:20 a.m. with Transporter C and Maintenance Director D. Transporter C was asked to place the wheelchair lift in the same approximate position as at the time of Resident #1's fall. Maintenance Director D measured the distance between the wheelchair lift platform and the ground at 9.75 inches, and the distance from the van floor (where Resident #1 was positioned prior to being pushed out of the van) and the wheelchair lift platform at 21 inches. Review of the Transportation/Van Driver Job Description, signed by Transporter C 7/30/2013, revealed the following: The Transportation/Van Driver is responsible for the safe and secure transport of the Residents to various outings such as doctor's appointments . ESSENTIAL FUNCTIONS AND RESPONSIBILITIES .Perform job in a safe, secure and professional manner at all times . During an interview on 3/2/21 at 10:40 a.m., Resident #1 recalled the fall from the facility transport van in her wheelchair. Resident #1 stated, Yes, I was hurt . it still hurts . During an interview on 3/2/21 at 11:07 a.m., when asked about training involving the van wheelchair lift for Transporter C prior to Resident #1's fall, the Nursing Home Administrator (NHA) stated, I don't have it - showing any (documentation of) training. When asked if pushing a resident out of the van by pressing on the wheelchair foot plates was acceptable, the NHA stated, That is not how I would teach him to do it . The NHA agreed if Transporter C had been closer to Resident #1's wheelchair (by use of the arm handles) he may have been able to control the wheelchair and pull it back from the edge (back of the van). Review of Employee Performance Appraisals for Transporter C found yearly appraisals completed in 2013, 2014, 2015, 2016, and 2017. No Employee Performance Appraisals were found within Transporter C's personnel file, nor were they provided for 2018, 2019, or 2020 when requested from the facility. During an interview on 3/2/21 at 12:15 p.m. the NHA was asked about the lack of performance appraisals for Transporter C. The NHA stated, [Transporter C] would have been due for a yearly evaluation in January of 2021 . he is now 2 months late. The NHA agreed, after review of Transporter C's personnel file, that no yearly performance reviews were available in the file for 2018, 2019, or 2020. Review of a Disciplinary Action Record Work Rules for Transporter C, dated and signed 3/1/2021, revealed the following: Final Warning . Employee forgot to engage the lift properly on the van when transporting a resident . During an interview on 3/2/21 at 11:30 a.m., when asked for the cause of Resident #1's fall from the van on 2/22/21, the NHA stated, For sure it was lack of adequate supervision by [Transporter C] for [Resident #1], when she was being removed from the van.

This Citation pertains to Intake MI# 081, MI# 086, MI# 927 and MI# 173: Based on observation, interview, and record review, the facility failed to protect three Residents (#20, #25, #84) from staff and resident to resident abuse and neglect. This deficient practice resulted in Resident #84 being transferred to the hospital and diagnosed with [REDACTED].#20, staff abuse of Resident #25, and the potential for ongoing feelings of fear. Findings include: Resident #84 A review of a progress note dated 9/9/19 revealed, Resident (#84) was observed on the floor 0445 (4:45 AM). Sent out for evaluation related to knee and hip pain . A review of the documented titled, Hosptial admission notes with a 'fax received date' of 9/10/19 revealed, .HPI (history prior illness): with left [MEDICAL CONDITION] being admitted for Procedure(s): left hip short tfn (Trochanteric Fixation Nail). The elderly female (Resident #84) is in SNF (skilled nursing facility) resident who is independently ambulatory with a walker resides in nursing home due to dementia. Apparently there was an unwitnessed fall this morning at the nursing home and [MEDICAL CONDITION] identified at the (emergency room ). She is transferred for definitive orthopedic care . A review of the facility document titled, SNF(skilled nursing facility)/NF (nursing facility) to Hospital Transfer Form for Resident #84 dated 9/9/19 revealed, . Usual funtional status before the Acute Change in Condition. Mobility: Ambulates only with human assistance . Risk Alerts: High Fall Risk . This document revealed that Resident #84 required the assistance of staff for ambulation. A review of Resident #84's medical record revealed she admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 7/11/19 Minimum Data Set (MDS) assessment revealed she was severely cognitively impaired and required limited assistance of one staff for walking and locomotion. A review of Resident #84's care plan revealed the following for the Activities of Daily Living (ADL) care plan intiated 3/16/17, . Ambulation: (Resident #84) may ambulate independently in hallway with FWW (front wheeled walker)and proper footwear. Assist (Resident #84) as needed . This intervention was revised on 3/4/19. No update was made to the care plan after the most recent 7/11/19 MDS coding her as needing the assistance of one for ambulation. A review of a Incident and Accident Report completed by Registered Nurse (RN) K, dated 9/9/19, revealed, time of day 0445 (4:45 AM) .observed on floor . type of injury: fracture . location of injury: [MEDICAL CONDITION] . activity before: ambulation . Resident external rotation to right leg, and right leg was slightly shorter than left leg . Responsible Party of Contact: (Family AA) date notified: 9/9/19. Time Notified 0800 (8:00 AM) . A Review of the POS [REDACTED]. Resident was lying at the foot of (room) 502A bed on her back . Observed on the floor unwitnessed. Another Residents room [ROOM NUMBER]A . What type of assistance was Resident receiving at the time of fall: none . Gait Assist Devices at time of fall: none . Were there any changes in the residnent's normal routine? Yes. If yes, explain: (nothing documented) . Resident was walking by the lobby, Resident walked down the hallway and into room [ROOM NUMBER][NAME] Resident fell at the foot of the bed . A review of the Quality Assurance Interview Summary dated 9/9/19 revealed, (RN K) Interview: Resident (#84) was in the hallway near lobby around 0430 (4:30 a.m.) She stated there was a 'witchy woman' that she was trying to get away from. At 0445 (4:45 a.m.) Resident (#84) was observed on the floor in another rst's (residents') room. There were no other residents in the room besides the two Residents who were in bed . (Interview with Resident who was in bed) States he was sleeping at the time of the incident, but woke up with all the commotion. When he woke 'a little woman' was lying on the floor near end of his bed! . (Interview of second Resident in room) States that he doesnt know what happened as he was sleeping at the time . (Interview with Certified Nurse Aide (CNA) J) (Resident #84) was walking with her walker hear nurses station around 0430 . After talking with her I went down 200 hall to take care of another resident. When I came out I was told by (RN K) that (Resident #84) fell . Review of these interviews revealed that RN K and CNA J both observed Resident #84 up walking with her walker but did not provide her assistance with her ambulation prior to her being found in room [ROOM NUMBER] on the floor. On 2/14/20 at 8:46 a.m., an interview was conducted with the DON regarding Resident #84's injury. When asked about Resident #84 being documented as requiring staff assistance for ambulation despite witness statements stating they had observed the Resident up ambulating independently, and whether it was a lack of staff to assist her or the staff just simply did not assist, the DON stated, It was probably the latter. We have enough staff. When asked whether a [MEDICAL CONDITION] would be considered significant injury, the DON stated, I would say yes, but it's not suspicious. When asked how she would be able to rule out neglect since the facility acknowledged that they had not updated the care plan and the Resident (#84) had sustained a significant injury, the DON stated, I don't think its reportable. On 2/14/20 at 10:17 a.m., the DON provided an addendum to the abuse policy which revealed, all alleged violations including abuse neglect, exploitation, or mistreatment including injuries of unknown source . When asked about information regarding the facility's definitions of 'injury of unknown source' and 'significant injury', the DON stated, We go by the (State Agency) definitions. The facility's policy and procedures for abuse did not clearly define or describe what injuries of unknown source are or what should be done to investigate them to rule out abuse and neglect. Resident #25 A facility reported incident was filed with the State Agency (SA) on 2/5/2020. The report alleged that on 2/5/2020 at 4:00 a.m., CNA [NAME] threw a brief at Resident #25, refused to assist with toileting and told the Resident to change herself. The report also alleged CNA [NAME] hit the Resident three times on the arm. The facility investigation document, Alleged Incident Summary, not dated or signed, revealed CNA [NAME] admitted to refusing to help Resident #25, and was terminated for failing to follow the facility code of conduct policy. The document also revealed Resident #25's roommate was present during the incident. The document had no conclusive statement as to whether the facility substantiated abuse, or the findings of the investigation. According to the MDS assessment, dated 12/2/19, Resident #25 was mildly cognitively impaired, with [DIAGNOSES REDACTED]. On 2/12/20 at 9:56 a.m., Resident #25 was interviewed in her room. The Resident was well dressed and groomed, and was pleasant and cooperative. When asked about the incident on 2/5/2020, the Resident immediately recalled the incident and became upset. Resident #25 said CNA [NAME] hit her twice when CNA [NAME] was helping her back from the bathroom. The Resident said CNA [NAME] took her call light away, and it got tangled around her neck, when the Resident did not want to give it away, and struggled. Resident #25 stated, I was very upset. She (CNA E) let me have it twice. (The Resident mimicked a punch with her arm.) Resident #25 was visibly upset, speaking with urgency and grimacing. Resident #25 stated, You should not hit anyone. Why would you hit someone? The Resident said she screamed and hollered for someone to come help her get CNA [NAME] away, but nobody came. The Resident said her roommate, Resident #29, was present and opened the curtain between them and yelled at CNA [NAME] to leave. Resident #25 granted permission to speak with Resident #29 about the incident. Resident #29 agreed to be interviewed and was brought into the conversation at that time. Resident #29 confirmed Resident #25's account of the incident and provided additional details, which Resident #25 confirmed. Resident #29 said she could hear the entire event as the only barrier was the hanging dividing curtain. Resident #29 said CNA [NAME] came to answer Resident #25's call light, who requested to be toileted. CNA [NAME] assisted Resident #25 to the bathroom then threw a brief at the Resident and told her to put it on herself. CNA [NAME] refused to assist Resident #25, stating her back hurt and she could not bend over. Resident #25 was forced to care for herself as CNA [NAME] stood by and said, I have all night. Resident #29 said she heard the slap of skin at least twice and knew CNA [NAME] was hitting Resident #25, when the Resident yelled, Stop hitting me. You hit me. Resident #29 confirmed Resident #25 was yelling for help, when she had enough and opened the curtain and told CNA [NAME] to leave the room and stop hurting Resident #25. Resident #29 confirmed CNA [NAME] told Resident #25 if she had to get a sleeping pill for Resident #25, she was going to shove it down her throat. When Resident #25 was screaming for help, CNA [NAME] told the Resident, You're going to have to deal with me. Resident #29 said the call light cord was around Resident #25's neck and CNA [NAME] told her to settle down Resident #25, because CNA [NAME] couldn't deal with her. Resident #29 said CNA [NAME] told her Resident #25 was acting crazy, but Resident #29 knew that was not true. Resident #29 said she told CNA [NAME] to leave or she was going to the desk to tell someone. Both Residents confirmed CNA J came to the room after CNA [NAME] left, and they both reported the incident. According to the facility Alleged Incident Summary, Resident #29 was cognitively intact. Both Residents #25 and #29 were lucid, and clear in their account of the incident. Both accounts were congruent with the facility investigation. During a phone interview on 2/14/20 at 8:53 a.m., RN D said on 2/5/20 CNA [NAME] was assigned to another hall but was covering for CNA J assigned to Resident #25 and #29's hall, who was on break. RN D confirmed CNA J came to her and reported the incident. RN D said she went to Resident #25 who reported the account per the above interview. RN D said Resident #25 was crying and upset. RN D said after she reported the incident to the DON and Nursing Home Administrator (NHA), she told CNA [NAME] to leave the building. During an interview on 2/14/20 at 9:35 a.m., the NHA and DON were present. The NHA confirmed she authored the document Alleged Incident Summary, not dated or signed. When asked what the conclusion of the facility investigation was, neither the DON or NHA would provide a conclusion. The NHA said CNA [NAME] was terminated for failure to follow the facility code of conduct policy. When asked how the facility monitors staff burn out and abuse prevention for staff, both the NHA and DON said they talk with staff daily. When asked how afternoon and night shift staff were monitored, the DON said she sometimes went into the facility on off shifts. When asked for any evidence of off shift staff monitoring of burnout or abuse prevention, none was provided. Attempts were made to contact CNA [NAME] by phone on 2/14/20 at 10:01 a.m. and on 2/18/20 at 3:59 p.m., without success. The facility Abuse Prohibition Policy, dated 7/2018, revealed, .Each resident shall be free from abuse, neglect .Abuse shall include .verbal, mental, .physical .To assure residents are free from abuse, neglect .the facility shall monitor resident care and treatments on an on-going basis .Abuse means the willful infliction of .intimidation or punishment with resulting .pain or mental anguish. This also includes the deprivation by and individual .of goods and services . Resident #20 A review of the facility handwritten Incident and Accident Investigation Form dated 2/10/20, as presented by the NHA on 2/12/20, included a Brief Description of the Incident as: at 0630 (6:30AM) Res (Resident #2) was noted sitting on the edge of (Resident #20's) bed on the left side. (Resident #20) was noted to be lying in bed. (Resident #2) had BM (bowel movement) on his left hand. (Resident #20) was noted to be lying in bed and had BM on her right hand and left side. (Resident #2) had no pants on. (Resident #2) was immediately removed. This investigation form included the names of six staff members who were listed as Interviewees. None of the six interviewees had signed this form. The form was undated and unsigned. On 02/19/20 at 2:48PM, CNA Q stated in a phone interview that she had given a statement of her account of the event she witnessed involving Resident #2 and Resident #20, but she was not sure the statement was all recorded. CNA Q stated, I didn't read anything or sign anything, so she did not know what had been written. CNA Q was glad to give this information as she had not heard anything more. I almost quit my job as it was not taken seriously. CNA Q stated that on 02/10/20, Resident #2 was having a night where he was sexually inappropriate. Resident #2 was described as sexually inappropriate often by CNA Q. When asked to explain this, CNA Q said, He was masturbating when I went into his room to check on him. He was startled and CNA Q apologized. (Resident #2) continued to masturbate and said to me, 'Do you want some of this?' and 'Why don't you crawl in here' with me . Usually he stops when you ask him to stop, but that night he did not . He kept it up and was thrusting his hips and kept saying those things . I had to put his brief and his pajama pants on and left the room to help another resident. CNA Q then saw Resident #2 in his doorway to the hall and CNA Q had to put his brief and pants back on again. CNA Q said she told the nurse LPN O that Resident #2 was being more inappropriate than usual. CNA Q was back down the hall coming out of a room slightly diagonal to Resident #20's room and saw that Resident #20's door was closed and the call light over the door was on. CNA Q stated, This door is never closed, and (Resident #20) never uses her call light. CNA Q said the roommate only uses the call light if someone wanders in. CNA Q went in and the room was dark. She saw a wheelchair next to the bed. CNA Q said it was not Resident #20's wheelchair as that was in the hallway. CNA Q stated she flipped on the light and saw Resident #2 sitting with his left hip on the bed, facing the head of the bed where Resident #20 was in bed lying flat with her head slightly elevated on the pillow. Resident #2 had BM on his left hand, and he was wiping his left hand off on Resident #20's positioning pillow which had BM handprints on it. Resident #20's right hand was holding on to his wheelchair which was at the side of the bed. CNA Q stated that Resident #20 had 4 brown fingerprints on her left arm (which she does not move) and streaks of BM on her belly. CNA Q went on to say that Resident #20 had nothing on her hands. CNA Q was sure that Resident #2 was the only one with BM on his left hand. CNA Q stated, I later was the one that cleaned her (Resident #20) up, and I did not have to wash anything off her hands . I cleaned up (Resident #2) and he had BM all over his left hand even underneath his fingernails . CNA Q said that Resident #20's brief had been ripped off her on the left side. It was not like the left tab had just come undone, but it was torn away. All the BM was on her left side, not on the side of the brief of the arm (of Resident #20) that works. When asked about Resident #20's demeanor, CNA Q said that Resident #20 does not show emotion, but she had a furrowed brow. CNA Q reported telling Resident #2 three times to get back into his wheelchair and then she assisted him back to his room. CNA Q stated, I got him back to his room . and (went) to find my nurse. LPN O told CNA Q to go tell the charge nurse. CNA Q stated, I was crying and really shaken up. I did not want to tell another person, I wanted to get back to (Resident #20) to take care of her. CNA Q said, It was messed up to walk into something like that. It was sexual assault that I walked in on. After CNA Q reported the incident to the nurse, CNA Q went back to take care of Resident #20 and she appeared to cry. Later, the DON came into the facility and interviewed CNA Q around 7:00AM or 8:00AM. CNA Q said, she had told the DON about the entire event. A review of the local police report indicated that the incident was reported to the police department on 02/10/20 at 8:16PM, The police report designated the nature of the call was suspicious. The report states only contact was made with the NHA and a report was filed with the State Agency (SA). A review of Resident #20's medical record, revealed she admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 12/12/19 MDS assessment revealed a score of 4/15 indicating severe cognitive impairment, and the functional status was coded as requiring extensive assistance with the help of two or more staff for bed mobility, transferring, toileting, and personal hygiene. A review of Resident #2's medical record, revealed he admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. A review of the 01/23/20 MDS assessment revealed a score of 7/15 indicating severe cognitive impairment, and his functional status was coded as requiring extensive assistance with the help of one staff for bed mobility, transferring, locomotion, dressing, and personal hygiene. On 02/19/20 at 11:19 AM, Resident #20's Durable Power of Attorney (DPOA) V was interviewed in person. DPOA V stated that Resident #20 had been through so much in her life. DPOA V said the facility did tell her there was an incident, but they did not tell me he (Resident #2) had feces on his hands . I overheard that he did. DPOA V stated that she wanted a meeting with the facility and that was when she was told that Resident #2 had Resident #20's feces on his hands. DPOA V was adamant and stated, She (Resident #20) probably was pushing his (Resident #2's) hands away. He touched her. DPOA V said the facility personnel said Resident #2 was not in the room that long. DPOA V said, I told them, 'what the hell are you talking about' He touched her. He had poop on his hands. When asked if DPOA V would like to change Resident #2's room, as Resident #2's room was on the same unit across the hall, DPOA V said, They (facility staff) never asked me to change the room. She (Resident #20) just had a room change. When asked if the facility ever got back to her with the investigation conclusions, DPOA V stated they had not given her a conclusion or gotten back in touch. DPOA V said the facility said Resident #20 was not hurt, but She (Resident #20) does not understand questions like: Were you touched in any way or are you afraid. DPOA V stated, With the man having dementia so bad and they knew how this man was, shouldn't they have something in place to protect the other residents? A review of Resident #2's nursing progress and behavior notes revealed the following: documented on (MONTH) 4, 6, 7, 11, 12, 16, 22, 2019, (MONTH) 22, 23, 24, 28, 29, 2019, (MONTH) 7, 8, 17, 28, 2019, (MONTH) 12, 24, 2020, and (MONTH) 3, 10, 2020, Resident #2 was up and wandered the hallways at night. Resident #2 had documented instances of going into other residents' rooms in the night on 11/23/19, 12/17/19, and 2/10/20. The care plan for Resident #2 with a focus of fluctuations in mood initiated on 10/26/18, noted: He will wander throughout the facility and often needs to be redirected to his room . The Abuse Prohibition Policy received upon entry to the facility on [DATE] and dated as revised on 07/2018, read on page one, Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator (NHA), and reported to the appropriate state agencies . On 02/18/20 at 02:36 PM, the NHA was asked about details of the incident on 02/10/20. The NHA stated the investigation had not been completed and The conclusion is that we do not know what happened. The NHA stated that Resident #20 is now in the room that Resident #2's wife was in when she was here, which may have been the reason that Resident #2 went across the hall to that room. The NHA said that room changes were discussed with the guardian for Resident #20, but the guardian had wondered how that would prevent a recurrence for any other resident and did not advocate for a room change. The NHA was asked how the facility was working to prevent another similar episode. The NHA stated that Resident #2 now had a motion sensor alarm which alarmed when anyone enters or exits the room. If Resident #2 exited his room, the alarm would sound and per the NHA, stays alarming until someone comes to investigate. On 02/18/20 at 02:02PM, observations of the motion sensor alarm on Resident #2's door revealed the alarm sounded for 2 beeps and stopped. No employees checked to see if Resident #2 was in his room. On 02/18/20 at 2:13PM, the door motion sensor was tripped again and only 2 beeps sounded again and stopped. No employees came to investigate. On 02/18/20 at 02:50 PM, this Surveyor, the NHA, and RN P tested the motion alarm on Resident #2's door. We walked into the room and the alarm went off sounding 3 beeps and stopped. RN P stated the alarm had fallen off the wall the day before and she had put it back together. After it fell off the wall, the alarm was malfunctioning and would not stop alarming. The NHA said, We are probably going to stop using the alarm as it is not working. No other preventative measure was discussed. On 02/18/20 at approximately 04:30 PM, the DON presented the completed incident investigation for the 2/10/20 incident. The investigation concluded both residents had BM on their hands and the left side of Resident #20's brief was unfastened. Certified Nurse Aide (CNA) Q had not seen Resident #2 touch Resident #20. The investigation summary states, (CNA Q) immediately asked (Resident #2) to get off of the bed and in his wheelchair which he did with no issue. She (CNA Q) ensured that (Resident #20) was safe. (Resident #20) had no signs of distress. (CNA Q) called for assistance from nurse (LPN O) who assessed (Resident #20) and did not note any physical injuries and did not observe any negative behaviors or signs of distress . The investigation actions taken for Resident #2 included a motion alarm to alert staff when he exits his room . A pysch (psychiatric) consult was set up to evaluate behaviors and medication regime. Medication changes were made per pysch consult and motion alarm was discontinued. The final investigation report of the incident of 2/10/20 included a page of nursing progress notes from Resident #20's medical record. The progress note dated the day of the incident 2/10/20 and written by LPN O read: At approx. 0630 (6:30AM) CNA noted another resident (Resident #2) sitting on her (Resident 20's) bed on the left side. Noticed her brief to be torn off at the left side, blankets around her knees. BM noted to be smear on her (Resident 20's) left side and stomach, as well as left arm. Other resident (Resident #2) was immediately removed from the room. Assessment of (Resident 20) show no new skin concerns, Her mood is at baseline. She does not appear to be in physical or mental distress. Resident had [NAME]M. cares provided and resident brought up to the nurses station. There was no mention of BM on Resident #20's hands. On 2/14/20 at 9:59, Licensed Practical Nurse (LPN) O was called to discuss her witness statement as typed by the DON and her nursing progress note of 2/10/20. LPN O did not answer and a voice mail was left. On 02/19/20 at 07:53AM, a second attempt was made to call LPN O, and another voice mail was left. No return call was received back from LPN O by the end of the survey.

Based on observation, Interview and record review, the facility failed to prevent an avoidable fall of one Resident (#701) of five residents reviewed for falls. This deficient practice resulted in injury, hospitalization , decreased quality of life, and decreased functional abilities for Resident #701. Findings include: A review of the face sheet dated 7/10/19 revealed Resident #701 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #701 was subsequently readmitted to the facility on [DATE] with an additional [DIAGNOSES REDACTED]. A review of an incident report for Resident #701 dated 6/25/19 revealed the following: A fall was caused by Certified Nurse Aide (CNA) I pushing a Rollator (type of four wheeled walker) along the sidewalk while Resident #701 was sitting on the seat cushion of the Rollator. The wheels of the walker got caught on a raised section of the sidewalk which caused the walker to tip and Resident #701 fell backwards onto the sidewalk. The incident occurred on 6/25/19 at 12:25 PM. An assessment of Resident #701 by Physician B revealed bleeding of the posterior scalp, contusions (bruises)/abrasions (scrapes) of both elbows, and a laceration across the nasal bridge. Per the incident report: When (CNA I) attempted to push the (Rollator), the wheels got caught on the crack/lip of the sidewalk causing the walker to tip backwards and (Resident #701) fell . On 7/09/19 at 2:00 PM an interview was conducted with the Director Of Nursing (DON) who stated This (accident on 6/25/19) was an unusual occurrence. It was a beautiful day, (Resident #701) wanted to walk to the doctor's office using his front wheeled walker. (CNA I) walked with(Resident #701) to go to the doctor's office a block and a half away. (Resident #701) got tired part of the way there, and sat down on the seat cushion part of the four wheeled walker. Apparently (Resident #701) asked (CNA I) if she could push him the rest of the way. The back wheels got caught on the sidewalk. Well I guess that would be the front wheels. (Resident #701) went backwards and struck the back of his head on the sidewalk, and he got his elbows, and he got a cut from his sunglasses across the bridge of his nose. When asked if CNA I should have been transporting Resident #701 in a manner not consistent with the manufacturer's recommendations, the DON stated, No, she should not have. However, he was fully independently ambulatory. A review of the investigation file revealed a summary of interview on 6/25/19 with CNA I: (Resident #701) decided to take his walker because it was such a nice day and the Dr. (doctor) office is so close (Approximately one block away from the facility). He got tired and wanted to sit for a minute. I thought it would be ok to just push him because it was so close. I was trying to help him out. I guess I didn't realize I couldn't do that . On 7/10/19 at 7:40 AM, an observation of the Rollator walker for Resident #701 revealed warning labels along both sides of the walker along the support bars stating Warning: Do Not Move Rollator While Seated. These warning labels would have been in direct view when CNA I attempted to push Resident #701 while sitting on the Rollator seat. The labels also would have had to be within view of CNA I for the direction Resident #701 had to sit on the Rollator seat, and the manner in which Resident #701 fell backwards. There was also damage noted along the left side of the Rollator. The DON stated the left bottom cross bar bent as a result of the accident, and the marks along the front shaft support is where an oxygen tank holder was attached to the left side. The DON stated Resident #701 did have an E-tank size oxygen tank attached to the left side of the Rollator at the time of the fall. The DON stated she did not feel the oxygen tank contributed to the fall. A review of the manufacturer's recommendations provided by the facility regarding the Rollator revealed an Important Safety Notice: Do not have anyone push you while you are seated on the Rollator. This is a walking aid only and is not to be used as a transportation device. A review of the Review of (Emergency Medical Services) EMS run report dated 6/25/19 revealed the following: Resident #701 was treated and transported via EMS . and was admitted to (Hospital) following transport to the ER. Provider impression: Vomiting, Monitoring Required, Nausea, Trauma Injury. Resident had sustained a laceration to the head, as well as head pain, and lacerations were sustained to both elbows . a C-Collar (neck stabilizing device) was placed and ECG was attached to resident for transport. An IV (intravenous line) was placed and [MEDICATION NAME] (anti-nausea medication) was administered to (Resident #701). Wounds were dressed. According to the EMS report Staff stated a worker of (the facility) was bringing the patient back to (the facility) from an appointment. Patient was sitting in his walker, which is a style that has a seat on it. While pushing the patient down the sidewalk towards (the facility) the wheels of the walker hit a crack in the sidewalk . (Resident #701) assessment, (Resident #701) appeared to be confused . Due to the mechanism of injury being susceptible to a head bleed,[MEDICAL CONDITION] assessment was conducted which was negative. (Resident #701) had an abrasion on the back of his head and a laceration on the bridge of his nose. Staff stated (Resident #701) fell forward, however was unable to inform EMS why he had an abrasion on the back of his head. (Resident #701) had glasses on when the fall occurred. C-spine while patient sat up. While in the sitting position, patient stated he had a headache in the front and back of his head. Large swelling was noted on the left upper part of patient's back. Examination did not present with any firmness in the affected area. Some pain in the area upon palpation. Staff stated that was not normally present with patient. C-collar was placed as precaution. Patient had abrasions on both elbows with minimal bleeding . (Resident #701) stated he was feeling nauseous. After a few minutes of sitting, (Resident #701) vomited into an emesis bag. (Resident #701) was then brought to the ambulance and loaded . (Resident #701) stated he still felt nauseated. Enroute to the hospital, IV lock was established. [MEDICATION NAME] 4 mg (milligrams) IV was administered for nausea. Bandaging was performed on both elbows for the lacerations. As EMS was pulling in the ambulance garage while re-evaluating mentation, (Resident #701) stated he didn't remember falling nor the entire incident . A review of the History & Physical 6/25/19 from the hospital Resident #701 was treated revealed the following: Patient's [AGE] year-old male who sustained a fall out of a seated walker on the cement earlier today striking his head. He was evaluated within the emergency department at which time a CT scan was performed. The CT (Cat Scan) scan did demonstrate an acute right frontal and left temporal subdural hematoma, though relatively small in nature. (Resident #701) is noted to be on both aspirin and [MEDICATION NAME] (clot prevention) daily . Neurosurgery was consulted and the patient was subsequently transferred . for neurosurgical services and and a higher level of care. Upon arrival to the emergency department . the patient was complaining of a headache and was also experiencing nausea and vomiting. A repeat head CT was performed at that time which does demonstrate propagation (spreading) of the subdural hematoma. Platelets have been ordered. His aspirin and [MEDICATION NAME] will be on hold. He will be admitted to the intensive care unit for close neurosurgical evaluation, and vital sign monitoring . Risks of Admission: Further propagation of the subdural hematoma, temporary or permanent disability, loss of lifestyle, death. A review of the CT for Resident #701 dated 6/25/19 revealed the following: There are subdural (under first protective layer of the brain) hematoma (blood) collections along the falx (crescent shaped fold of a brain layer), left tentorium (structure covering and supporting the back of the brain and cerebellum), left frontal (front) and left temporal (temple area) lobes. There is also minimal subdural hemorrhage along the anterior right front lobe . There is subarachnoid (under the second protective layer of the brain) hemorrhage which is most pronounced around the anterior front lobes. There is a non-displaced right occipital (back of head) bone fracture . A review of the hospital discharge summary for Resident #701 dated 7/04/19 from the hospital and return to the facility revealed . Patient remained encephalopathic for multiple days and also experienced some [MEDICAL CONDITION]ly related to hospitalization . He made a slow improvement though continued to experience persistent headache and nausea which gradually improved as he approached discharge . Patient did continue to receive [MEDICATION NAME] intermittently which controlled his headache, and his headache seemed to have improved by the time of discharge. He also continued to experience nausea that was alleviated by [MEDICATION NAME], which also gradually improved leading to discharge. A review of the hospital patient discharge instructions for Resident #701 revealed the following: . Start taking these medications: [REDACTED] [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg (milligram) tablet . 1 tablet by mouth every 6 to 8 hours as needed (moderate pain) . [MEDICATION NAME] ([MEDICATION NAME] (nausea)) 4 milligram by mouth 4 times per day as needed (nausea and vomiting) . [MEDICATION NAME] 325 milligram by mouth every 4 hours as needed . A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. There was no use of any other types of pain medication or any anti-nausea medication for the month of June. A review of the (MONTH) 2019 MAR for Resident #701 revealed 4 administrations of [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg over 7/08/19 through 7/09/19. Resident #701 continued to receive [MEDICATION NAME] 4 mg as needed for nausea, and received 3 doses since readmission to the facility on [DATE] through 7/10/19 at 09:42 AM when the MAR indicated [REDACTED] On 7/09/19 at 2:57 PM, an interview with CNA J who stated he is one of the regular CNAs for Resident #701 revealed the following: He fell out here on (street sidewalk unnamed) in front of the apartment complexes next to this building . I saw a commotion at the front door, and one of the nurses came flying in the door and told one of the other nurses to call EMS, and since (Resident #701) was one of my residents, I went out to see if I could help. (Resident #701) was laying on the ground, and his legs were over his walker. The walker was folded up and his legs were still over the walker with his feet pointed towards the wheels . Where (Resident #701) fell , the concrete panels has a big crack, one of them is raised a good inch . When asked if CNA J was trained in appropriate on propelling of residents, CNA J stated, . The walker itself says right on it to not push a resident on them. Immediately after that incident happened, we had an all staff meeting on four wheeled walker safety. We talked about that we are never to push a resident sitting on a four wheeled walker. Everybody who was there had to sign the sign-in sheet . When asked if anything changed for Resident #701 since the incident, CNA J stated, (Resident #701) is now a extensive one assist with transfers, which is new. (Resident #701) tells me he has a headache all the time. Every time I wake (Resident #701) up, he tells me he has a headache, and they get him some more medicine for it, and he says it helps. (Resident #701) used to walk up to the front and visit with other residents, but (Resident #701) hasn't done that since he has been back. I think it's because of (Resident #701's) headaches . One of the daughters came in to get some of his personal things, and she said (Resident #701) was having problems with his memory in general, and he didn't remember even falling, and they were worried about him not remembering them . He did a couple of days ago remember his son came to visit him . On 7/09/19 at 3:34 PM an interview with Registered Nurse (RN) K revealed the following: (Administrator), and (DON), and (ADON) were already out there and had assessed (Resident #701). (Resident #701) was laying on the sidewalk on his back. I walked with (CNA I) who was with (Resident #701) away, just so I could pull (CNA I) away from the scene. (CNA I) was crying, and I asked her what happened. (CNA I) said (Resident #701) was walking and he needed to rest, and he sat down on the walker. Then (CNA I) had pushed it (Rollator), and they hit a bump, and he fell . When asked if it was acceptable practice to push a resident sitting on a Rollator, RN K stated, I don't believe you should. When asked if there was training provided to the staff after the incident, RN K stated, Yes. When asked what the content of the training was, RN K stated, About not pushing residents sitting on a (Rollator). On 7/09/19 at 3:48 PM an interview with RN L revealed the following: I went out to help and I assisted in holding up a towel because the sun was hurting (Resident #701's) eyes . (Resident #701) was complaining of a headache. When asked if (Resident #701) had headaches prior to this incident, RN L stated, Maybe occasionally, but not to my knowledge. When asked what (Resident #701) was like prior to the incident, RN L stated (Resident #701) was pretty independent, and he would ask occasionally for toileting needs, and he was independent with his walker. When asked what (Resident #701) was like now, RN L stated I just saw (Resident #701) coming back from therapy. (Resident #701) is working on strength after coming back from the hospital. (Resident #701) is working with therapy now. (Resident #701) is needing more assistance, but therapy would know more about that. When asked if (Resident #701) was in therapy before the incident, RN L stated, Not recently, no. On 7/09/19 at 3:59 PM an interview with RN M revealed Resident #701 . had some headaches off and on since he's been back from the hospital, but the day nurse didn't say he complained about anything (received in report per RN M). (Resident #701) is in therapy right now and (Resident #701) is asking for something for his back. (Resident #701) is hurting. On 7/9/19 at 5:00 PM during multiple observations throughout the afternoon since 1:00 PM: Resident #701 has spent most of the day resting in bed outside of going to therapy for treatment. This Surveyor made several attempts to visit, and each time # 701 was resting with covers over his head. On 7/09/19 at 5:49 PM an interview with CNA I revealed the following: (Resident #701 and CNA I) were walking over to the doctor's and it was hot out. (Resident #701) had his push walker, and I thought I would push him out of the sun. There was a ledge, and I tried to hold onto the walker and (Resident #701) went over and I couldn't stop it. I ran as hard as I could back to the facility, and I said please call an ambulance. (Resident #701) went back hard, and he really got hurt . I wasn't thinking. If I had it to do all over again, I would have gone and gotten a wheelchair to get (Resident #701) over instead of pushing him with the walker. I really blew it. (Resident #701) was doing great with the walker, and we got outside the parking lot, and he said he needed to rest. On 7/09/19 at 6:11 PM, an interview with Family Member (FM) H revealed the following: It says in there (incident report) my dad said he wanted to walk, but he can't walk 20 feet without getting short of breath. (Resident #701) had a fracture to the skull, and three brain bleeds, and that's why he went to the ICU at the hospital. (Resident #701) did finally start remembering who we were about (MONTH) 1st . (Resident #701) pretty much has a headache all the time right now, and nausea. (Resident #701) told us that. I just don't know how he could have had so much damage as a result of this. Another thing is I noticed it took away more hearing. I know that you're not supposed to push those walkers over, it's just for seating. There at the hospital they were doing MRI's (Magnetic Resonance Imaging) every day at the hospital, and they had to give (Resident #701) platelets because of the blood thinners. Then the brain bleeds finally stopped. (Resident #701) needs more help right now, and he used to play bingo and visit with others, he was a social bug. (Resident #701) is not able to do those things right now. I think (Resident #701) is just starting to be able to feed himself, but he couldn't for a while. When (Resident #701) sits up he still feels sick. On 7/09/19 at 6:35 PM, an interview with FM G revealed the following: Before this all happened my dad could have a conversation with you like nobody's business, he could walk all over the place, and he went around visiting with everyone. Now he talks a little bit, but it's usually just one word. (Resident #701) can't walk by himself. (Resident #701) can't go and play games . (Resident #701) used to come over to my house and visit, and have dinner, and now he can't even do that anymore. My dad should have never gone over there without a wheelchair, and he shouldn't have had an oxygen tank attached to his walker and I think it contributed to him falling. Now all of a sudden (Resident #701) is getting a new walker, and a smaller oxygen tank to go in his walker cubby under the seat, and no one is allowed to leave the building without a wheelchair now . We were told by the people at the hospital that Dad wouldn't be coming home. I'm glad (Resident #701) is ok, but he shouldn't have had to deal with this. On 7/10/19 at 07:45 AM, an observation of the scene with the DON and RN F revealed Resident #701 was approximately 150 feet from the building; they indicated where Resident #701 had stopped and had to rest, and where the incident took place. The cement sidewalk pane was raised completely across the pane where the Rollator had gotten caught on the sidewalk. On 7/10/19 at 08:14 AM, an interview with Occupational Therapist (OT) D and Therapy Director revealed the following: When asked what Resident #701's last known functional status was prior to the incident, OT D stated, (Resident #701) was independent with a (Rollator) throughout the building, supervision for bathing, independent for dressing, toileting, and bed mobility, and transfers. When asked how Resident #701 was following the fall on 6/25/19, OT D stated, (Resident #701) is contact guard assist for ambulating with the (Rollator). I think (Resident #701) was able to ambulate 5 feet and 10 feet on 7/8/19. Bed mobility would be standby assist, transfers are contact guard assist, extensive assist for dressing, toileting is extensive (assist), and bathing is extensive (assist). When asked if Resident #701 was back to his baseline, OT D stated, No, he came in on the 4th and has had 4 treatments each of PT and OT, and is making good progress. When asked if Resident #701 had any complaints, OT D stated, The biggest thing is the dizziness and nausea, and he is also more hard of hearing compared to prior. So noticeably more hard of hearing, (Resident #701) was mild (hard of hearing) prior to, and I would say moderately hard of hearing now. The concern was brought to me yesterday by (Resident #701) and (FM H) yesterday, and I have to bring it to the team for evaluation. A review of the Physical Therapy PT Evaluation & Plan of Treatment with a start of care date of 7/04/19 revealed the following: . Reason for Referral: (Resident #701) referred to PT (Physical Therapy) due to new onset of decrease in strength, decrease in transfers, reduced ability to safely ambulate, reduced functional activity tolerance, reduced static and dynamic balance and increased need for assistance from others indicating the need for PT to minimize falls, improve dynamic balance, increase functional activity tolerance, enhance rehab potential, facilitate (I) (independence) with all functional mobility, promote safety awareness and increase independence with gait (walking) . Assessment Summary (Resident #701) presents requiring increased assistance for daily fxnl (functional) tasks. Pt requires SBA (Stand By Assist) for bed mobility tasks and CGA (Contact Guard Assist (Hands On)) for fxnl transfers w/4ww. (Resident #701) is non-ambulatory at time of evaluation 2/2 (secondary to) c/o (complaint of dizziness and need for frequent rest breaks. (Resident #701) states R (Right) hip pain increases in standing. (Resident #701) has generalized weakness from hospitalization , as well as reduced activity tolerance. A review of the Occupational Therapy OT Evaluation & Plan of Treatment with a start of care date of 7/04/19 revealed the following: . Reason for Referral : Readmission following fall from 4ww, causing head injury, requiring OT intervention to return to prior functional level or maximal functional potential for ADL's (Activities of Daily Living) . A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #701 revealed a Brief Interview of Mental Status (BIMS) assessment of 15, indicating Resident #701 was cognitively intact. Review of the functional status section of the MDS for Resident #701 revealed the following: Bed mobility: Limited assist of one person Transfers: Limited assist of one person Dressing: Limited assist of one person Hygiene: Limited assist of one person Eating independent with set-up help only Ambulation: Independent Locomotion: Independent Toileting: Extensive assist of one staff Bathing: Extensive assist of one staff Moving from seated to standing, walking, turning around, moving on and off toilet, and surface to surface transfers were all rated as not steady, but able to stabilize without staff assistance. The pain section of the MDS indicated Resident #701 denied any pain over a five day period prior to the assessment. Resident #701 was also not shown to have received any therapy for this assessment period. A review of the MDS 5-day admission assessment in progress dated 7/11/19 had functional status data from caregiver charting as follows: Bed Mobility: Extensive assist with one person Transfers: Extensive assist with one person Locomotion on Unit: Extensive assist with one person Eating: Supervision with one person assist Toilet Use: Extensive assist of one person Personal Hygiene: Extensive assist of one person On 7/10/19 at 9:30 am an interview with Resident #701 revealed the following: When I'm laying down here I'm doing pretty good, but when I sit or stand I get dizzy. Any time I get up I get a headache and nausea, and I get wobbly. When asked how often was pain medication being taken, Resident# 701 stated, Every day. When asked how often nausea medication was taken, Resident # 701 stated, Almost every time I get up. When asked if these symptoms of headaches and nausea had made Resident #701 want to stay in bed more than before, Resident #701 stated, Oh, Yeah. When asked if no showers had been received since being back to the facility, Resident #701 stated, That's right. I can't take it (showers) because I'm too dizzy. When asked if Resident # 701 had lost a lot of weight, Resident #701 stated, Oh Yeah. When asked if there was anything else there were issues with, Resident #701 stated, My hearing. I think it got worse. When asked what type of activities Resident #701 enjoyed, Resident #701 stated, I used to go up and play bingo, and visit people in the lobby. When asked if Resident #701 was able to enjoy those things since coming back from the hospital, Resident #701 stated, No. When asked if there was anything else that is worse since the accident, Resident #701 stated, My back. It all depends on how I lay. When asked if the pain was worse since the accident, Resident #701 stated, Oh yeah. When asked to rate pain prior to the incident on a scale of 0-10, Resident #701 stated, Oh, about a 2-3. When asked what is the worst the pain gets now, Resident #701 stated, In my back about a 5-6. When asked how about pain ratings for the headaches, Resident #701 stated, Oh it gets bad. When asked what the worst the pain gets for headaches, Resident #701 stated, oh about an 8-9. When asked if this happens every time Resident #701 sits up, Resident #701 stated, Almost every time, yes. Up to the point of this interview, #701 was sleeping in bed with covers over his head since arrival to the facility at 7:15 AM. A review of the Weights and Vitals Summary for Resident #701 provided by the facility revealed weights between 214.2 and 203.6 pounds. Resident #701's weight one day prior to the incident was 207.6 pounds. Resident #701 returned to the facility on [DATE], and was weighed on 7/05/19 at 162.7 pounds. Estimated weight loss was calculated using the most recent weight prior to the accident, and the weight after return to the facility. The weight loss was calculated at 21.63%. On 7/10/19 at 10:09 AM, an interview with Assistant Director Of Nursing (ADON) A revealed the following: So we showed them (staff) the signage and stated not to push anyone on the walker. There is signage indicating you can't push someone while sitting on the walker. There is a picture on it and a line through the picture indicating not to push someone sitting on the walker. Call for assistance from another staff member if the resident gets tired to go and get a wheelchair. On 7/10/19 at 10:25 AM, an interview with RN C (Primary RN for Resident # 701)revealed (Resident #701's) hearing and level of assistance have gotten worse since he's been back. I noticed the hearing and so did the family. On 7/10/19 at 10:57 AM during Exit Interview with the DON, ADON, and the Administrator, when asked what the expectation was for staff to have the proper use and safety knowledge of a Rollator, the Administrator stated, You know it's like giving people shoes and instructing them that they don't go on your head. When asked if she was referring to the instructions that state do not push the four wheeled walker with someone sitting on the seat, the Administrator stated, Yes . this whole thing was unfortunate.

Based on observation, interview, and record review, the facility failed to perform wound care according to treatment order and professional standards for one Resident (#58) of 12 residents reviewed for skin concerns including pressure ulcers, out of a total sample of 31 residents. This deficient practice resulted in harm to Resident #58 with the removal of intact skin on bilateral calves, and the potential for delayed wound healing and infection. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 11/20/2017, revealed Resident #58 is [AGE] years old, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #58 scored 15/15 on the Brief Interview for Mental Status (BIMS), reflective of being cognitively intact and able to make his needs known. The MDS assessment documented Resident #58 as not having any skin concerns. On 1/9/2018 at approximately 3:20 p.m., Registered Nurse (RN) F was observed to remove, cleanse and reapply gauze compression dressings (for [MEDICAL CONDITION]) to Resident #58's bilateral calves. RN F was observed to place the bottom edge of the bandage scissors on the skin of Resident #58's bilateral calves as she removed the gauze compression dressing. Resident #58 winced in pain multiple times. RN F asked Resident #58 if the procedure hurt him, and he stated, Yeah. RN F used the same gloves to wet clean washcloths and attempted to remove the dried skin protectant paste on Resident #58's bilateral calves. The dried skin protectant paste appeared difficult to remove and RN F used physical pressure on the wet washcloths to remove the old skin protectant paste. RN F scrubbed the inner, middle left calf leaving a pink, shiny area where intact skin had been removed from the pressure applied to the wet washcloth. This Surveyor asked Resident #58 if the skin protectant removal hurt, and he said yes. The skin on Resident #58's left and right legs appeared to slough off with the paste, in small oblong pieces, as RN F scrubbed the skin leaving distinct areas of shiny, pink, wound-like skin clearly visible on both legs. Review of Resident #58's January 2018 Treatment Administration Record (TAR) revealed the following order with a 12/12/2017 start date, and a 1/9/2018 1736 (5:36 p.m.) D/C (discontinue) date: BLE (bilateral lower extremities) every day shift every Tue (Tuesday), Fri (Friday) for BLE [MEDICAL CONDITION] Gently rub in ([MEDICATION NAME]/[MEDICATION NAME] ointment) prn (as needed) prior to cleanse with warm soap and water, pat dry, Apply (skin protectant paste gauze compression bandages) and wrap . Nursing staff initials were not present on Resident #58's TAR order to document a change of his bilateral gauze compression bandages on Friday, 1/5/2018. During an interview on 1/9/17 at 3:45 p.m. Licensed Practical Nurse (LPN)/Wound Care Nurse/Unit Manager Q was asked to describe the procedure for removing the dried skin protectant paste from Resident #58's skin. LPN Q stated, You can rub it, I wouldn't scrub it. LPN Q measured and documented the date of onset as 1/9/18 for the following wounds described as vascular on Resident #58's bilateral calves: left inner calf: 5 cm x 4 cm (documented as 6 cm x 5 cm), left lateral calf: 6 cm x 5 cm, right inner, upper ankle: 6 cm x 5.5 cm, right front shin 17.4 cm x 13 cm, and right top foot: 5 cm x 5.5cm. When asked if Resident #58's skin was fragile, LPN Q stated, His skin is very fragile, yes. Review of Resident #58's 1/5/18 Nursing Weekly (Head-To-Toe) Skin Assessment completed by LPN Q documented Resident #58's skin to be intact with no problems. Skin Alteration included BLE (Bilateral lower extremities) - reddened and [MEDICAL CONDITION] - per residents usual state - (gauze compression bandages) in place and were changed today. Review of a 1:1 Educational Inservice for RN F, completed by LPN Q after Resident #58's dressing change, documented the following, in part: .Spoke with (RN F) regarding wound cleansing (for Resident #58) and removing of cream from wound sights (sic). It was explained that you should gently cleanse areas. If there is difficulty with cream removal, use of ([MEDICATION NAME]/[MEDICATION NAME] ointment) then washing with warm soap and water usually works well ., completed and signed on 1/9/18 by RN F and LPN Q. On 1/17/18 at 2:30 p.m. the Director of Nursing (DON) was asked about Resident #58's gauze compression bandage change completed on 1/9/18 by RN F. The DON stated, It did not follow standards of practice and she (RN F) was educated immediately. During an interview on 1/17/18 at 4:58 p.m. RN F said she had worked at the facility for three months, changing Resident #58's gauze compression bandages one time previously. RN F stated, When I was cutting (off the old bandages) it really hurt his legs . When asked what she would do differently the next time the gauze compression bandages and dried skin protectant paste were removed, RN F stated, I would use ([MEDICATION NAME]/[MEDICATION NAME] ointment) with soap and water to help it (dried skin protectant paste) come off easier so I wouldn't have to scrub so hard . I definitely understand now what the concern is (regarding removal of the cream from his legs).

BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE LIFE RESUSCITATING MEASURES IN ACCORDANCE WITH THE RESIDENT'S ADVANCE DIRECTIVES IN ONE (RESIDENT #1) OF SIX RESIDENTS REVIEWED FOR ADHERENCE WITH ADVANCE DIRECTIVES/DEATHS OCCURRING WITHIN THE FACILITY IN A TOTAL FACILITY POPULATION OF 97 RESIDENTS. THIS FAILURE RESULTED IN CARDIOPULMONARY RESUSCITATION AND EMERGENCY MEDICAL SERVICES NOT BEING PROVIDED WHICH PLACED RESIDENT #1 IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON [DATE] AT 1:50 P.M. THE IMMEDIATE JEOPARDY BEGAN ON [DATE] AT 5:10 A.M. WHEN LICENSED PRACTICAL NURSE (LPN) "E" WAS ALERTED BY CERTIFIED NURSE AIDE (CNA) "F" THAT RESIDENT #1 WAS "NOT BREATHING." LPN "E" FOUND RESIDENT #1 TO BE "COLD", WITHOUT RESPIRATIONS AND THEN SOUGHT THE ASSISTANCE OF REGISTERED NURSE (RN) "B" WHO DETERMINED THAT RESIDENT #1 HAD NO VITAL SIGNS. DESPITE RESIDENT #1'S NEED FOR EMERGENCY MEDICAL SERVICES AND RESIDENT #1'S DOCUMENTED MEDICAL DETERMINATION DIRECTING FACILITY STAFF TO PROVIDE FULL RESUSCITATION EFFORTS, LPN "E" AND RN "B" DID NOT ALLOW RESIDENT #1 TO EXERCISE HER RIGHTS AND FAILED TO INITIATE CARDIOPULMONARY RESUSCITATION (CPR) AND ACTIVATE EMERGENCY MEDICAL SERVICES (EMS). A REVIEW OF A COMPLAINANT INTAKE DATED [DATE] READ, "ON [DATE], RESIDENT (#1) WAS admitted TO THE FACILITY. FOR 8 HOURS, THE MIDNIGHT SHIFT NURSE (LPN "E") admitted THAT SHE NEVER CHECKED ON THE RESIDENT. SHE NEVER EVEN SAW HER. AT 5:00 A.M., RESIDENT WAS FOUND ICE COLD. RESIDENT WAS FULL CODE AND NO ONE DID ANYTHING, NO CPR WAS PERFORMED...." A REVIEW OF THE "2010 AMERICAN HEART ASSOCIATION GUIDELINES FOR CARDIOPULMONARY RESUSCITATION AND EMERGENCY CARDIOVASCULAR CARE SCIENCE" FOUND AT WEBSITE HTTP://CIRC. AHAJOURNALS.ORG, REVEALED THAT CARDIOPULMONARY RESUSCITATION (CPR) IS AN EMERGENCY PROCEDURE WHICH IS PERFORMED IN AN EFFORT TO MANUALLY PRESERVE INTACT BRAIN FUNCTION UNTIL FURTHER MEASURES ARE TAKEN TO RESTORE SPONTANEOUS BLOOD CIRCULATION AND BREATHING IN A [MEDICAL CONDITION]. IT IS INDICATED IN THOSE WHO ARE UNRESPONSIVE WITH NO BREATHING OR ABNORMAL BREATHING. CPR ALONE IS UNLIKELY TO RESTART THE HEART; ITS' MAIN PURPOSE IS TO RESTORE PARTIAL FLOW OF [MEDICATION NAME] BLOOD TO THE BRAIN AND HEART. THE OBJECTIVE IS TO DELAY TISSUE DEATH AND TO EXTEND THE WINDOW OF OPPORTUNITY FOR A SUCCESSFUL RESUSCITATION. CPR MAY SUCCEED IN INDUCING A HEART RHYTHM WHICH MAY BE SHOCKABLE. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON [DATE] AT 1:55 P.M. AND A WRITTEN PLAN FOR REMOVAL WAS REQUESTED. ON [DATE], THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE SURVEYOR VERIFIED THE FOLLOWING: - ALL RESIDENTS' MEDICAL RECORDS HAD BEEN REVIEWED BY THE FACILITY TO ENSURE THAT A FULL CODE STATUS WAS DOCUMENTED FOR 39 OF 96 RESIDENTS IN THE FACILITY AS OF [DATE]. - IDENTIFICATION OF FOUR LICENSED NURSES WHO DID NOT HAVE CURRENT CPR CERTIFICATION ON FILE WERE SCHEDULED FOR CPR CLASSES ON [DATE]. THE WORK ASSIGNMENTS OF THESE FOUR NON-CPR CERTIFIED NURSES WERE ADJUSTED SO THAT THEY DO NOT PROVIDE NURSING CARE TO RESIDENTS WITH FULL CODE STATUS UNTIL THE NURSES WERE CERTIFIED IN CPR ON [DATE]. - ON [DATE], THE FACILITY DEVELOPED A WRITTEN POLICY TITLED, "INITIATING CPR" TO ENSURE COMPLIANCE WITH A RESIDENT'S ADVANCE DIRECTIVE. BY [DATE], 19 OF 29 LICENSED NURSES, WHOSE JOB DESCRIPTION INCLUDES PROVIDING DIRECT CARE OF RESIDENTS, WERE EDUCATED ON THE NEW POLICY. - THE DIRECTOR OF NURSING HAD BEGUN AUDITING NURSES ON ALL SHIFTS TO ENSURE THAT THEY COULD DEMONSTRATE AN UNDERSTANDING ON WHEN TO INITIATE CPR. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AT A PATTERN LEVEL FOR MORE THAN MINIMAL HARM, UNTIL: - ALL LICENSED NURSING STAFF HAVE BEEN EDUCATED REGARDING THE NEW POLICY ON WHEN AND HOW TO INITIATE LIFE RESUSCITATION MEASURES. - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH ACKNOWLEDGING AND IMPLEMENTING LIFE RESUSCITATING MEASURES IN ACCORDANCE WITH EACH RESIDENT'S ADVANCE DIRECTIVE. FINDINGS INCLUDE: A REVIEW OF RESIDENT #1'S MEDICAL FILE REVEALED, ON HER RESIDENT INFORMATION SHEET (DATED [DATE]), THAT SHE WAS AN [AGE] year-old WOMAN admitted FROM A HOSPITAL to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A FACILITY FORM, TITLED "MEDICAL DETERMINATION," SIGNED BY A PHYSICIAN ON [DATE], CERTIFIED THAT RESIDENT #1 WAS CAPABLE OF PARTICIPATING IN HER MEDICAL TREATMENT DECISIONS. RESIDENT #1 HAD SIGNED A FACILITY FORM TITLED, "RESIDENT CODE STATUS" ON [DATE], CHECKING THE BOX FOR "FULL CODE," WHICH READ, "FULL RESUSCITATION AND LIFE SUSTAINING TREATMENT (INCLUDES ALL TREATMENT ITEMS OUTLINED BELOW UNDER "SELECTIVE CODE" SELECTIVE RESUSCITATION) AS DESIGNATED BY RESIDENT OR HEALTHCARE LEGAL DECISION MAKER." THE TREATMENT ITEMS REFERRED TO UNDER SELECTIVE CODE INCLUDED, BUT WERE NOT LIMITED TO, CPR AND hospitalization . A DECLARATION OF DEATH POLICY DATED 2003 DEVELOPED BY THE AMERICAN MEDICAL DIRECTORS ASSOCIATION (AMDA) FOUND AT WEBSITE WWW.AMDA.COM, READS IN PART, "...WE EMPHASIZE THE IMPORTANCE OF IDENTIFYING PATIENTS' ADVANCE DIRECTIVES AND TREATMENT PREFERENCES AND THE MORAL OBLIGATION OF PHYSICIANS, NURSES, AND OTHER HEALTH CARE PROVIDERS TO HONOR THOSE DIRECTIVES... WE RECOMMEND THAT THE INDIVIDUAL (NURSE OR PHYSICIAN) WHO PRONOUNCES A RESIDENT'S DEATH UNDERTAKE AND DOCUMENT A SYSTEMIC EVALUATION OF THE PATIENT AS A PREREQUISITE FOR DETERMINATION OF DEATH. THIS EVALUATION SHOULD INCLUDE THE MEASUREMENT OF VITAL SIGNS AND IDENTIFICATION OF OTHER SIGNIFICANT CLINICAL FACTORS SUCH AS PUPILLARY DILATATION, DEPENDENT POOLING OF BLOOD, COOLING OF THE BODY, MUSCULAR RIGIDITY, ETC..." A REVIEW OF RESIDENT #1'S MEDICAL RECORD REVEALS A NURSE NOTE DATED [DATE] REFLECTING RESIDENT #1 WAS admitted TO THE FACILITY AT 5:55 P.M., AT WHICH TIME A "NURSING COMPREHENSIVE EVALUATION" WAS COMPLETED. A SECOND NURSE NOTE ON THIS DATE, SHOWED RESIDENT #1 RECEIVED TYLENOL ARTHRITIS FOR COMPLAINT OF RIGHT SIDE PAIN AT 8:30 P.M. AND WAS SLEEPING AT 10:00 P.M. AT 12:00 MIDNIGHT, A NURSE NOTE DATED [DATE], REVEALED RESIDENT #1'S BLOOD PRESSURE, TEMPERATURE, RESPIRATIONS, AND PULSE (VITAL SIGNS) HAD BEEN OBTAINED. LICENSED PRACTICAL NURSE (LPN) "E" WROTE (NO TIME), "AFEBRILE. NO COMPLAINTS OF PAIN THROUGH NIGHT." AT 5:10 A.M. ON [DATE], LPN "E" WROTE IN RESIDENT #1'S MEDICAL RECORD, "CNA IN TO ANSWER CALL LIGHT OF RESIDENT'S ROOMMATE. NOTICED RESIDENT (#1) COLOR THEN CALLED FOR ASSISTANCE OF THIS WRITER. VITALS (VITAL SIGNS) ABSENT PER RN ("B")"; AT 5:15 A.M., "FAMILY/SON NOTIFIED"; AT 5:20 A.M., "DR... ON CALL FOR DR... OK'D RELEASE OF REMAINS TO FUNERAL HOME"; AT 5:25 A.M., "...FUNERAL HOME NOTIFIED"; AND, AT 6:00 A.M., "...FUNERAL HOME HERE FOR REMAINS." A REVIEW OF THE NURSES NOTES REVEALED NO DOCUMENTATION OF RN "B"'S ASSESSMENT OF RESIDENT #1'S SIGNIFICANT CLINICAL CONDITION PRIOR TO THE FAMILY'S NOTIFICATION OF HER DEATH. A COPY OF RESIDENT #1'S CERTIFICATE OF DEATH, SIGNED BY THE PHYSICIAN ON [DATE], REVEALED CAUSE OF DEATH AS "[MEDICAL CONDITION], ISCHEMIC [DIAGNOSES REDACTED], [MEDICAL CONDITION], AND [MEDICAL CONDITION] FIBRILLATION". THE RECORDED ACTUAL OR PRESUMED TIME OF DEATH AND THE TIME PRONOUNCED DEAD WERE BOTH 5:10 A.M. ON [DATE]. CERTIFIED NURSE AIDE (CNA) "C" WAS INTERVIEWED ON [DATE] AT 10:45 A.M. CNA "C" STATED, "I WAS ASSIGNED TO (RESIDENT #1) THAT NIGHT (11 PM-7 AM SHIFT ON [DATE]). I SAW HER TWICE. SHE WAS A NEW ADMIT SO I WENT IN AT THE BEGINNING OF MY SHIFT... THEN I CHECKED HER AGAIN AT MIDNIGHT. I GOT HER VITAL SIGNS... SHE HAD NO COMPLAINTS BUT SHE WAS TIRED... AT 2:00 A.M., I POKED MY HEAD IN HER ROOM TO MAKE SURE SHE WAS IN BED; I DIDN'T GO IN AND PHYSICALLY ASSESS HER... AROUND 5:00 A.M., A FLOAT CNA ("F") HAD GONE INTO (RESIDENT #1'S) ROOM TO GET A COMMODE FROM NEXT TO HER BED. (CNA "F") SAID (RESIDENT #1'S) 'COLOR WAS ODD'. NO, NOBODY WAS DOING CPR WHEN I GOT DOWN THERE." NUMEROUS ATTEMPTS TO INTERVIEW CNA "F" BY TELEPHONE ON [DATE] WERE UNSUCCESSFUL AS THERE WAS NO ANSWER. LICENSED PRACTICAL NURSE (LPN) "E" WAS INTERVIEWED BY TELEPHONE ON [DATE] AT 11:30 A.M. LPN "E" STATED, "I SAW (RESIDENT #1) AROUND MIDNIGHT; SHE HAD NO COMPLAINTS. SHE DENIED PAIN. HER CALL LIGHT WAS WITHIN HER REACH. THE CNA TOOK HER VITAL SIGNS. SHE WAS AFEBRILE. I WENT ABOUT MY BUSINESS. AT AROUND 5:00 A.M., I STARTED MY MED PASS. AN AIDE CAME AND GOT ME. (RESIDENT #1'S) BODY WAS 'COLD'. NO, I DID NOT START CPR. I GOT THE RN (REGISTERED NURSE); SHE SAID THERE WERE NO VITAL SIGNS AND THAT WE DIDN'T NEED TO START CPR. I WASN'T SURE WHAT TO DO BECAUSE HER BODY WAS COLD; THAT'S WHY I GOT THE RN. IT TOOK A COUPLE OF MINUTES AT THE MOST TO GET THE RN." ON [DATE] AT 12:05 P.M., THE DIRECTOR OF NURSING (DON) WAS ASKED FOR THE FACILITY'S POLICY ON WHEN TO INITIATE CPR. SHE STATED, "WE DON'T HAVE A POLICY ON WHEN TO START CPR...." HOWEVER, AT 1:30 P.M., THE DON PRESENTED A DOCUMENT TITLED, "CPR," WITH A REVISED DATE OF [DATE]. THE DON STATED, "THIS IS OUR POLICY. I KNOW IT'S NOT WHAT YOU WANT, BUT..." THIS DOCUMENT INCLUDED THE PURPOSE, FUNDAMENTAL INFORMATION, EQUIPMENT AND DOCUMENTATION FOR PERFORMING CPR BUT IT DID NOT INCLUDE ANY INFORMATION REGARDING CODE STATUS OR ANY CIRCUMSTANCES IN WHICH CPR MIGHT NOT BE INITIATED. THE DON FURTHER STATED AT 2:00 P.M., "CORPORATE SAID WE HAVE NO POLICY. THEY SAID TO JUST GO BY MICHIGAN LAW (THAT AN RN CAN PRONOUNCE DEATH)." REGISTERED NURSE (RN) "B" WAS INTERVIEWED ON [DATE] AT 9:13 A.M. RN "B" STATED, "I WAS THE NURSE IN CHARGE THAT NIGHT. I HAD BEEN IN THE BATHROOM. WHEN I CAME OUT, (LPN "E") CAME UP TO ME IN THE HALL AND SAID, 'MY RESIDENT died .' I SAID, 'WHERE? WHAT'S HER CODE STATUS?' SHE SAID, 'FULL CODE.' I ASKED, 'DID YOU START CPR?' SHE SAID, 'NO, SHE'S DEAD; SHE'S GONE.' I WENT INTO (RESIDENT #1'S) ROOM; SHE WASN'T BLUE ANYMORE--SHE WAS A GRAYISH/YELLOW. SHE WAS COLD. MY ASSESSMENT WOULD HAVE BEEN THAT SHE'D BEEN GONE FOR AWHILE. I DID NOT CALL A CODE; WE DID NOT START CPR. I FOUND OUT SINCE THEN THAT I SHOULD HAVE STARTED CPR. (LPN "E") SHOULD HAVE STARTED CPR RIGHT AWAY." WHEN ASKED IF THE FACILITY HAD EVER TOLD HER WHEN/WHEN NOT TO START CPR, RN "B" STATED, "NOBODY EVER HAS. IF I'D KNOWN I WAS SUPPOSED TO DO CPR, I WOULD HAVE DONE IT." A REVIEW OF THE NURSES NOTES REVEALED NO DOCUMENTATION OF RN "B"'S ALLEGED ASSESSMENT OF RESIDENT #1'S CLINICAL CONDITION PRIOR TO THE FAMILY'S NOTIFICATION OF HER DEATH. DURING A DISCUSSION WITH THE ADMINISTRATOR ON [DATE] AT 11:00 A.M., IT WAS CONFIRMED THAT THE FACILITY FAILED TO HAVE A WRITTEN POLICY THAT DIRECTED FACILITY STAFF TO HONOR AND IMPLEMENT RESIDENTS' ADVANCED DIRECTIVES REGARDING RESUSCITATION MEASURES. A CERTIFIED INSTRUCTOR FOR THE AMERICAN HEART ASSOCIATION (AHA), WHO IS THE FACILITY'S CPR INSTRUCTOR SCHEDULED TO PROVIDE CERTIFICATION CLASSES AT THE FACILITY ON [DATE], WAS INTERVIEWED ON [DATE] AT 8:45 A.M. SHE WAS ASKED, ACCORDING TO THE AHA GUIDELINES FOR CPR, AND REGARDING A PERSON WHO IS A FULL CODE STATUS, ARE THERE ANY CIRCUMSTANCES WHERE YOU WOULD NOT INITIATE CPR? SHE STATED, "ACCORDING TO THE AHA, NO. IF YOU COME ACROSS A PERSON WITHOUT VITAL SIGNS, YOU START CPR REGARDLESS OF THE CIRCUMSTANCES." SHE WAS ASKED IF CPR SHOULD BE INITIATED EVEN IF THE BODY IS COLD; SHE REPLIED, "YES." THE FACILITY'S MEDICAL DIRECTOR WAS INTERVIEWED ON [DATE] AT 9:40 A.M. THE MEDICAL DIRECTOR WAS ASKED, REGARDING HER RESIDENTS IN THIS FACILITY WHO ARE FULL CODE STATUS, WOULD SHE EXPECT STAFF TO INITIATE CPR EVEN IF THE RESIDENT'S BODY WAS FOUND COLD. SHE STATED, "YES. EVEN IF CPR WAS FUTILE; THOSE ARE THE RESIDENT'S WISHES." ( ) --