Every finding on record at Courtney Manor

This Citation Pertains to Intake 3133516. Based on interview and record review, the facility failed to implement surveillance as part of the facility's Infection Control (IC) program encompassing process surveillance including lack of tracking of potential infections, including rashes, and lack of investigation and identification of trends for scabies (contagious skin infestation caused by microscopic mites) within the facility, resulting in the potential spread of microorganisms and contagious infestations for all 74 facility residents. Findings include:Review of intake documentation dated as received 8/4/26 revealed a concern the facility has a scabies outbreak involving multiple residents and staff. The intake further indicated the facility did not address resident rashes until a resident tested positive for scabies at an external Health Care Provider (HCP).An interview as conducted with Witness U on 8/26/26 at 11:30 AM. When queried if they were aware of any residents in the facility having scabies, Witness U stated, We have a resident who has confirmed scabies. When asked who was diagnosed with scabies Witness U stated Resident #703. When queried if they were aware of any other residents who had scabies, Witness U revealed multiple residents have had/have rashes, but the facility will not say the rashes are scabies without a scrapings (microscopic confirmation of mites, eggs, or excrement) being completed to confirm diagnosis. Witness U further stated the facility wound not send them to an external HCP to be tested. Witness U was asked if they were aware of any staff who had rashes and/or scabies and verbalized they were. Witness U revealed they knew a staff member who recently quit and was treated for scabies.Record review revealed Resident #703 was admitted to the facility on [DATE] with diagnoses which included Dementia with Lewy bodies and agitation, depression, and traumatic brain injury. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #703 was severely cognitively impaired, required supervision for ambulation, and displayed wandering behaviors daily.Review of Resident #703's Electronic Medical Record (EMR) revealed the following:- 7/8/26 at 8:00 AM: Physician Progress Note. seen for 60-day follow-up. has baseline confusion but is pleasant . A peppered rash on bilateral feet has been noted; appears consistent with heat rash (miliaria rubra) . independent with ambulation. Will continue to monitor.- 8/6/26- Dermatology Office Visit Note: Diagnosis: Scabies. Irritated, erythematous minute crusted papules hands, feet, and distal lower legs with some definitive burrows on wrists and ankles. Treatment Plan: [NAME] (potassium hydroxide- skin scaping) taken from right ankle and is positive for scabies. Discussed contagious nature, will treat (spouse) and notify (Resident #703's) facility. Recommend facility do decontamination protocol and bring in any symptomatic residents for treatment.There was no nursing documentation of a rash present in Resident #703's EMRA review of facility IC data was completed on 8/26/26 at 12:10 PM with IC Registered Nurse (RN) A and the Assistant Director of Nursing (ADON). Review of the line list for August 2026 revealed 26 residents were treated for scabies. Twenty-three of the 26 residents treated resided on the 200 hall and the other three residents resided on the 500 hall. Resident 703 was the only resident identified as being positive for scabies, all other residents were identified as receiving prophylactic treatment. The line list specified the onset date was 8/6/26 for all residents treated for scabies on the 200 hall, including Resident #703, and one resident on the 500 hall. The other two residents on the 500 hall were listed as having an onset date of 8/12/26. During a concurrent interview, when asked regarding the scabies identified on the line list, IC RN A stated, We had one confirmed case and indicated other residents were treated prophylactically. When asked when Resident #703's symptoms of scabies first started and when the rash appeared, the ADON stated, I don't know that. When queried how they were able to complete comprehensive and effective surveillance to prevent the spread of infection/potential infection if they did not know the date in which symptoms began, IC RN A acknowledged the concern and verbalized understanding. When asked if the Physician was the first person to identify Resident #703's rash, the ADON stated the nursing staff would have notified the Physician and asked them to look at Resident #703's skin. When asked why there was no documentation indicating Resident #703 had a rash in nursing documentation including assessment documentation, the ADON responded they would review the Resident's EMR. When asked if Resident #703's rash was included on the July 2026 line list, IC RN A stated it was not. When asked how they track potential infections to prevent spread, IC RN A and the ADON responded potential infections are not tracked. When asked if rashes have the potential to be contagious, IC RN A responded they do. When queried regarding staff statements indicating multiple residents, especially on the 200 hall, had rashes, none of which were listed on the line listing, the ADON stated they do not track rashes. The ADON then stated, It (rashes) comes and goes every year. When queried regarding the inability to identify trends due to the lack of tracking rashes which may or may not receive treatment, IC RN A confirmed they could not identify trends to identify and mitigate potential spread.An interview was completed with LPN R on 8/26/26 at 1:37 PM. When queried if they were aware of any residents and/or staff having scabies, LPN R stated, I've heard about it and I know that people got treatment. LPN R was asked if they were referring to residents or staff and replied, Both. When asked if they were aware of any residents being in isolation due to scabies, LPN R stated, Not that I am aware of.On 8/26/26 at 3:00 PM, Resident #703 was not in their room and was observed wandering throughout the facility.An interview was completed with CNA Y on 8/26/26 at 3:05 PM. CNA Y confirmed they were familiar with Resident #703, and they were asked regarding the rash testing positive for scabies. CNA Y stated, I did not know (Resident #703) was positive. When queried if Resident #703 had been in contact precautions beginning on 8/6/26, CNA Y stated, (Resident #703) was not on contact. CNA Y was then asked if they were aware of anyone else having a rash and stated, Yes, me on my arms but I didn't think anything of it.A follow up interview with the ADON and IC RN A was conducted on 8/26/26 at 3:15 PM. When asked if they were able to locate nursing documentation pertaining to Resident #703's rash and when it was first identified, the ADON stated, All I saw was that Doctor note (dated 7/8/26). When asked, the ADON confirmed there was no nursing documentation of a rash. When asked how they would know the actual date the rash began, both IC RN A and the ADON agreed a specific date of symptom onset was unable to be determined. The ADON stated, I guess there is nothing supported in the documentation. When queried why staff said they were unaware of Resident #703 having scabies, the ADON replied, I don't know. When asked if staff received education regarding scabies including what to look for and what to do, the ADON replied, I would say yes. We have been talking about it for months. The ADON was asked why they had been talking about it for months when the first time Resident #703's rash was documented was at the beginning of July, The ADON did not provide a response. IC RN A and the ADON were then asked if they would be able to provide a list of all residents in the building who have a rash, the ADON stated, No, you have our line list. We have never tracked prophylactically. When queried why the two residents on the 500 hall who were treated for scabies were not started on treatment until 8/12/26, IC RN A responded the residents were treated prophylactically for potential exposure. When asked how they were potentially exposed, after the Residents on the 200 hall had completed their treatment and why they were treated almost a week later, an explanation was not provided. IC RN A and the ADON were asked if Resident #703 wanders throughout the building and confirmed they do. When asked if staff are shared and/or moved between units and halls, both the ADON and IC RN A verbalized they do. The ADON and IC RN A were then asked why all facility residents and staff were not treated prophylactically to ensure eradication of the scabies in the facility, IC RN A responded, staff were encouraged to see their own Health Care Provider (HCP) if they began to have symptoms. A review of the employee illness tracking log for August 2026 was completed at this time. The log contained two staff members who had been treated for scabies. None of the staff members listed on the employee infection log were staff members interviewed. When queried regarding interviews with staff who verbalized rashes and/or receiving treatment for scabies not being on the IC tracking list, IC RN A responded that they are not always informed by staff of infections.An interview was conducted with the Director of Nursing (DON) on 8/18/26 at 4:00 PM. When queried regarding the facility not tracking potential infections, including rashes and early identification of potential infections to prevent spread, the DON revealed they were unsure about tracking rashes and potential infections. During an interview on 8/27/26 at 11:05 AM, Licensed Practical Nurse (LPN) W was asked if they were aware of any residents in the facility being diagnosed with scabies, LPN W stated, I was the nurse the day that a resident attended a dermatology appointment and had a scraping that was positive. When asked, LPN W revealed the Resident who tested positive for scabies was Resident #703. LPN W revealed it is normally their job to review documentation when residents return from external HCP appointments. LPN W continued, I never got to read or reviewed it, but because of the nature of the results, my DON (Director of Nursing) intercepted it. When asked what happened after the test results were received by the facility, LPN W stated, There was an implementation of the policy to follow whatever the dermatology order was. LPN W was asked what they meant when they said implement the policy and replied, I can't speak to what the DON, Administrator, and charge nurse did. When queried regarding treatment, LPN W revealed the dermatologist ordered Ivermectin (prescription medication used to treat parasitic infections), shower, and cream. When asked if the medication treatment was immediately initiated, LPN W indicated they were not and stated, I wasn't there the following day when the treatments were to be performed. When queried if any treatment was completed on the day the results were received, LPN W stated, We took out everyone's stuff to be deep cleaned. When queried if Resident #703 was placed in isolation upon their return to facility, LPN W stated, No, but I think they stayed on the unit. LPN W revealed Resident #703 typically wanders throughout the facility and is very ambulatory. When queried what education staff received related to scabies, including exposure and transmission, LPN W stated, I don't recall getting an education, but I think there was a sign put up at the nurses' station to sign. When asked what they meant by a sign to sign, LPN W revealed they could not remember but everyone had to sign it. When asked if they were aware of anyone else having a rash suspicious for scabies, LPN W hesitated and then stated, Yes, me. With further inquiry, LPN W revealed they went to their HCP on 5/6/26 because of a rash and stated, My (HCP) thought that was what it was (scabies). LPN W revealed they disagreed with their HCP and got an order for Clobetasol (topical steroid cream). LPN W then stated, It never went away and then I got permethrin cream (prescription medication used to treat scabies). That cleared it (rash) up. LPN W was asked when they went back to their HCP and got the permethrin cream for scabies and stated, 8/11/26. When asked if any residents had a rash in May, LPN W stated, I did observe (Physician E) and the DON look at a resident and come back with a diagnoses of heat rash around that time. With further inquiry, LPN W stated, I was informed it was contact dermatitis that occurs every season. When asked what they meant, LPN W revealed the residents on the 200 hall (where Resident #703 resides) continuously have rashes which come and go. When asked if they informed facility administration/IC staff about their rash and their HCPs initial diagnosis of scabies, LPN W responded, I did. When queried if they received any education regarding scabies, LPN W stated, There was a clinical/all staff meeting with an education about rashes. We were asked to stop telling people in the community that there was scabies in the building because there were no positive diagnosed residents. When queried if they were aware of any of residents and/or staff having scabies, LPN W stated, There were other positive staff and revealed other residents were treated prophylactically. LPN W revealed the facility did not consider any rashes as scabies without a positive scraping.An interview was completed with Travel RN N on 8/27/26 at 1:05 PM. When queried if they were aware of a resident having scabies in the building, RN N replied, Yes, when I got (to facility), I felt like it was very hush/hush. It was really weird. With further inquiry, RN N stated, They didn't treat everyone at once. When asked what they meant, RN N indicated not all residents received treatments at the same time and were still wandering throughout the facility. With further inquiry, RN N stated, They didn't treat everyone on 500 hall after a couple residents were treated and staff were not treated prophylactically. When queried if they knew of any staff who contracted scabies, RN N responded they were aware of multiple staff, primarily CNAs. An interview was completed with Physician E on 8/27/26 at 8:58 AM. When asked regarding Resident #703's rash and final diagnosis of scabies, Physician E stated, The nurses noticed it and let me know. Physician E was asked when the nursing staff informed them of the rash and revealed they were unsure of the date. When queried why they initially diagnosed it as heat rash and not scabies, Physician E responded that it was not a typical presentation of scabies as Resident #703 did not complain of itching to them. Physician E added that it was very hot in the facility at that time and there were other residents who had similar rashes. With further inquiry regarding other residents having similar rashes, Physician E responded, I saw three people that day. Physician E then revealed that the facility does not have supplies to perform scraping for scabies testing, so they have to send residents out to a dermatologist to have a scraping completed and to diagnose scabies definitively. When queried regarding the facility IC staff not being about to identify the onset dates of the scabies rash to effectively track the origin of the infestation, Physician E verbalized understanding but did not provide further explanation. When queried why all residents and staff were not treated, due to the highly contagious nature of scabies, Physician E responded, they advised staff to see their Health Care Provider if they became symptomatic.Review of facility policy/procedure entitled, Care of Resident with Scabies (Dated 3/5/25) revealed, Policy: To adequately treat cases of scabies and prevent transmission to others. Any resident with positive evidence of Scabies (Sarcoptes scabiei) must be treated upon physician's order. ALL suspected or diagnosed cases should be reported to the Infection Preventionist. Scabies is an infectious disease of the skin caused by the Sarcoptes scabiei or itch mite. Transmission occurs most often by close personal contact; prolonged casual contact also can result in transmission. Bedding and clothing (freshly contaminated) can sometimes be a source of transmission. In persons without previous exposure, a period of 2-6 weeks usually elapses before the onset of symptoms. Persons who previously have been infected develop symptoms 1-4 days after exposure. To Avoid Reinfestation: A. Clean ALL clothing, bedclothes, etc. that have been in recent contact with the resident. Transport these items in sealed plastic bags. Wash clothes and bedding in HOT soapy water and dry on HOT cycle of dryer. B. Wipe down beds, pillows, mattresses, furniture, etc. with a germicidal solution. D. Confining the resident to his/her room for 12-24 hours after treatment is desirable. E. Contact precautions for associates consist of wearing gloves and a gown if in close contact with an infested person or things (i.e. applying gloves, bedding, etc.). This is necessary before treatment and for 12-24 hours after treatment.The major activities of the program are: A. Surveillance of infections with implementation of control measures and prevention of infection. There is on-going monitoring to identify possible communicable disease or infections among resident and staff. B. Outbreak Investigation: systems are in place to facilitate recognition of increases in infection as well as clusters or outbreaks.

This Citation pertains to Intake Numbers 3133404 and 3133393. Based on observation, interview and record review, the facility failed to promote dignity and ensure availability of resident incontinence products for one (#702) of three residents reviewed.Findings include:Resident #702Review of intake documentation dated as received 8/3/26 revealed a concern pertaining to Resident #702 as follows:Resident #702 utilizes briefs due to incontinence and limited mobility. The intake detailed the facility ran out of incontinence briefs over the weekend and facility staff instructed the Resident to urinate and defecate directly in their bed and that the facility staff would put some pad underneath them to attempt and absorb the urine which necessitated a complete bed change every time, as the pad rarely contained the excrement. The intake specified, It's really ridiculous to think that a facility would either lock up or use budget as an excuse for someone to suffer this sort of indignity and revealed Resident #702 had a friend go to the store and purchase incontinence briefs using their own money.A second intake dated as received 8/4/26 revealed a concern from an anonymous resident affecting multiple residents. The intake revealed an allegation that the facility does not provide adequate incontinence products for the residents in the facility. Per the intake, the facility limits the number of diapers/briefs residents are given for a set number of days and have gone without specific sizes of briefs/diapers for 2-3 days necessitating residents to either wear briefs that are the incorrect size or go without any sort of incontinence protection. The intake further specified the facility did not currently have all brief sizes, and the Resident had to lay in bed with pads around them so they did not flood the bed every time they eliminated. The intake revealed facility staff leave (residents) in bed naked to use the bathroom on yourself and come to clean them up every couple hours.Record review revealed Resident #702 was admitted to the facility on [DATE] with diagnoses including heart failure, depression, anxiety, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and dependent upon staff for toileting, bathing, personal hygiene, and transfers. The Resident was also rated as frequently incontinent of urine and always incontinent of bowel.An interview was completed with Resident #702 on 8/26/26 at 11:33 AM. When queried, Resident #702 revealed they are dependent upon staff for transferring and utilize briefs due to incontinence. When queried regarding availability of briefs at the facility, Resident #702 indicated they knew the reason for the survey and stated, It was the weekend to beat all weekends. Resident #702 was asked when the weekend was and replied, The tail end of July. When queried why it was the weekend to beat all weekends, Resident #702 stated, They had no briefs. With further inquiry, Resident #702 stated, They (facility) keep them all locked up. When asked what they did if there were no briefs, Resident #702 responded, They wanted us to just do our business on ourselves, those of us who can't get out of bed. When queried how it made them feel when staff told them to urinate and defecate on themselves, Resident #702 stated, Really, really bad. Resident #702 then stated, It was horrible and revealed their friend drove two hours to bring them briefs. Resident #702 stated, That should never happen and verbalized that it costs a lot of money to be in the facility, the facility is open 24 hours a day/seven days a week, and they should not have to worry about not having briefs. When queried if this was the first time this had happened, Resident #702 revealed they are frequently worried about running out because they are only allowed so many briefs per week. When asked what they meant when they said they are only allowed so many briefs per week, Resident #702 revealed a staff member comes to their room three times a week and puts a specific number of briefs in their closet which is all the briefs they are allowed to have. An observation of Resident #702's closet was completed at this time. Nine briefs (not contained in a package) were observed sitting on top of the Resident's personal items in the closet. When queried regarding the number of briefs in their closet, Resident #702 stated, She just came and brought briefs into me. I don't know how long that is supposed to get me through. Resident #702 continued, They (staff) come in here and take briefs out of my cupboard because they don't have access to get to any for other residents. When asked to clarify, Resident #702 explained when other residents run out of their allotted number of briefs or new residents are admitted , facility staff take briefs for other people who run out or for the new residents who have not received their allotted number yet. When asked, Resident #702 revealed it upset and made them anxious when that happened do to concerns of running out.An interview was completed with Certified Nursing Assistant (CNA) C on 8/26/26 at 11:40 AM. When queried where incontinence briefs are stored in the facility, CNA C stated, The briefs are in the resident's closets. CNA C was asked if extra briefs are stored on the unit and did not respond. When queried if there were briefs in the clean utility room in case a resident ran out in their closet, CNA C responded there were not and stated, Have to contact (Staff D) if need more. With further inquiry regarding where extra briefs are stored, CNA C stated, In a room somewhere locked. When asked, CNA C revealed floor staff, including nurses, did not have access to the locked room.An interview was completed with Staff D on 8/26/26 at 11:48 AM. When queried, Staff D revealed they distributed briefs and incontinence products to residents as part of their job responsibilities. When queried regarding the facility process/procedure related to incontinence products and briefs, Staff D revealed the facility places an order every week on Monday and is delivered on Friday. With further inquiry, Staff D revealed they distribute incontinence products and place in individual resident closets three times a week on Mondays, Wednesdays, and Fridays. Staff D stated, On Mondays and Wednesdays, I can only pass 10 incontinence products per resident and on Friday I can pass 20. Staff D further revealed they are required to count what is in the closet and enough briefs to equal the total number allowed. When asked to clarify, Staff D verbalized that if there were two briefs left in the closet on Wednesday, they were only allowed to add eight so the total number in the resident's closet was 10. Staff D stated, They (residents) are only allowed 40 briefs (incontinence products) per week. When asked if incontinent residents were only able to be changed every 5.7 times a day (40 divided by 7), Staff D responded, They (residents) are not supposed to wear briefs at night to let it all air out. Staff D was asked where additional incontinence products are kept in the facility and responded, They are locked up. When asked if staff had access to the locked room where the extra briefs were stored, Staff D responded that the only people who had keys were the maintenance director, themselves, the Director of Nursing (DON), and probably the Administrator. Staff D then stated, We have no back up (briefs). It is week by week. When asked what they meant, Staff D stated, I have no medium or large (briefs) right now and reiterated the facility places an order each week. Staff D was asked what happens if there is a delay in the order when they do not have any back up stock and did not provide a response. When queried they recalled any instances where the facility did not have enough briefs, Staff D stated, We have run out. When asked what had happened, Staff D responded, There was a Friday that there was no shipment and then they ran out. Staff D was asked if they recalled the date and stated, I think it was the shipment for July 31st (2026). Staff D was asked if they recalled any other times when there were concerns related to incontinence product availability and indicated there was. Staff D verbalized the facility used to have a scheduler who would send the amount of incontinence products needed for the week to the Director of Nursing (DON) who would then place the order. When asked, Staff D revealed the facility no longer had a scheduler and now they sent the amount needed to the DON to be ordered. Staff D revealed there had been instances where the number of incontinence products ordered and received was a lot less than the number needed that was sent to the DON.An interview was conducted with the DON on 8/26/26 at 4:00 PM. When queried if they were aware of the facility running out of incontinence products and staff telling a resident to urinate and defecate in their bed, the DON responded they were not. The DON was then informed of the interview completed with Resident #702 and correlation with staff related to lack of briefs and responded that there was no reason for staff to do that and they are always able to contact them if supplies are needed.An interview was completed with the facility Administrator on 8/26/26 at 5:00 PM. When queried regarding the facility running out of incontinence products, Resident #702 being told to urinate and defecate in their bed, the Administrator verbalized that was unacceptable. The Administrator verbalized they were unaware and indicated staff are able to contact them anytime and could also have gone to the store to purchase products if needed.An interview was completed with Resident #702's friend Witness D on 8/27/26 at 4:45 PM. When queried regarding Resident #702's care at the facility, Witness D revealed there had been an incident when the Resident called them because the facility ran out of briefs. Witness D stated, It was a tough situation and revealed Resident #702 was upset because the facility staff had told them to just go.

This Citation Pertains to Intake 3171112.Based on interview and record review, the facility failed to ensure the facility provided updated communication to the physician provider related to a change in condition following failed interventions for one Resident (#701) of three residents reviewed. Findings include:Review of intake documentation revealed a concern that, on [DATE], Resident #701 fell out of their bed and was found unresponsive and required Cardiopulmonary Resuscitation (CPR). Resident #701 was subsequently transferred to the hospital and passed away. The intake specified concerns related to lack of assessment, care, and monitoring at the facility prior to Resident #701 being found unconscious on the floor as well as communication pertaining to the Resident's change in condition.An interview was conducted with Family Member Witness S on [DATE] at 10:24 AM. When queried regarding Resident #701's care in the facility and death on [DATE], Witness S stated, One of the biggest concerns is that they (facility) would not respond to our questions. When asked to explain, Witness S responded that the facility staff called Resident #701's Spouse (Witness T) the night of [DATE] and told them that the Resident had fallen and to go to the hospital because the ambulance was taking them to the hospital. Witness S disclosed the facility staff then called Witness T back and told them to come to the facility. Witness S revealed Witness T called them to tell them what was going on and they called the facility. Witness S indicated the staff member who answered was unable to and/or did not answer their questions and Witness S requested to speak to Resident #701's nurse, charge nurse, patient advocate, or supervisor. Witness S admitted to calling several times and becoming upset during the phone call. Witness S stated the facility staff informed them they were not doing this and could call back tomorrow. When queried regarding the time the incident occurred, Witness S was heard asking Witness T who responded Resident #701 was not feeling well in the morning and the facility was going to complete labs. When asked again when the facility called them and told them they were going to send the Resident to the hospital, Witness S responded, Everything started happening around 10:15 PM.Record review revealed Resident #701 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute and chronic respiratory failure with hypercapnia (elevated levels of carbon dioxide in the blood), Chronic Obstructive Respiratory Failure (COPD), gastrointestinal hemorrhage (bleeding in the digestive tract), Congestive Heart Failure (CHF), mitral and tricuspid (heart) value insufficiency, atrial fibrillation (A-fib- irregular heart rhythm where the top and bottom chambers of the heart do not beat in sync), sepsis (infection which causes a life threatening extreme toxic response in the body), infection caused by Extended-Spectrum Beta-Lactamase (ESBL- antibiotic resistant bacterium), Vancomycin Resistant Enterococcus (VRE- antibiotic resistant bacterium), and Methicillin Resistant Staphylococcus Aureus (MRSA- antibiotic resistant bacterium), diaphragmatic hernia (condition where an opening or weakness in the diaphragm allows abdominal organs to move up into the chest cavity), diabetes mellitus, lung nodule, and anemia (lack of adequate hemoglobin to carry oxygen to the body).Review of the Minimum Data Set (MDS) assessment for Resident #701 dated [DATE] revealed intact cognition, and they were rates as dependent upon staff for all Activities of Daily Living (ADLs) with the exception of requiring maximum assistance for upper body assistance and set-up assistance for eating.Resident #701 was transferred to the local hospital via ambulance on [DATE] at 10:35 PM.Review of Resident #701's Electronic Medical Record (EMR) revealed the following documentation:- [DATE]: SBAR Communication Form. This started on: [DATE] Since this started it has gotten. Stayed the same. Medication Alerts: Changes in the last week (describe): levofloxacin (antibiotic). 1. Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) . Respiratory Evaluation. Other respiratory changes (describe). crackles bilat. lower lobes. 10. Neurological Evaluation. Altered level of consciousness (hyperalert, drowsy but easily arousable, difficult to arouse, unarousable) . Describe symptoms or signs: while receiving care this afternoon CNA noted resident to be lethargic. Review and Notify: Primary Care Clinician Notified: Yes, Date: [DATE] 12:30 PM. Recommendations of Primary Clinicians (if any): labs, UA (Urinalysis).- [DATE] at 2:21 PM: Nurses Notes. (Physician E) contacted about C02 (carbon dioxide) levels (normal range 21.6-31.8) at 42.8, no new orders.- [DATE] at 5:03 PM: Nurses Notes. (After Hour Nurse Practitioner F) contacted to review lab results. Possible dehydration encourage water. Still waiting for. chest x-ray.- [DATE] at 9:40 PM: Nurses Notes. 2140 (9:40 PM): CNA was rounding on resident; resident was observed on the floor face down. CPAP was on as well as O2 and immediately called for the nurse to come and assist. 2145 (9:45 PM): Nurse entered room and observed resident on floor and unresponsive when calling name. Resident was wearing CPAP lying on right side. Vitals were attempted but no pulse was detected. Nurse called code blue over intercom for another nurse to get crash cart and get AED machine . (Licensed Practical Nurse [LPN] G) contacted family to notify of the change in condition. Stuporous rub to sternum but still no response. Nurse noted cyanotic fingers, lips, and toes with abrasion to leg, chin and great toe. Nurse and (CNA) rolled resident over to place back board under resident and called 911 while starting chest compressions and Ambu bag at 2145 (9:45 PM). Staff placed AED (Automated External Defibrillator) machine on resident on third round of chest compressions and was told to continue compression due to no activity; chest compressions continued. Pupils were non-reactive to light and fixed. 2150 (9:50 PM): EMS arrived and assisted with code and chest compressions. Resident was transferred on to EMS gurney and continued with Ambu bag until on EMS truck.- [DATE]: SNF/NF to Hospital Transfer Form. Vital Signs: BP (blood pressure) 95/68 (low) [DATE] at 12:20 PM. Treatments: Respiratory: O2 (supplement oxygen) at 93 (sic) L (liters)/min (minute) by Nasal Cannula/Mask. Chronic. CPAP. BiPAP (Bilevel Positive Airway Pressure - non-invasive respiratory device that delivers pressurized air at two alternating levels- higher pressure during inhalation to help push air into lungs and lower pressure during exhalation) .No other documentation of Physician and/or Provider notification was present in Resident #701's EMR for [DATE].An interview was completed with Staff U on [DATE] at 12:10 PM. When queried, Staff U responded they recalled Resident #701. With further inquiry, Staff U revealed they provided care to the Resident the day they coded at the facility. When queried regarding how the Resident was during the day, Staff U stated, (Resident #701) looked very pale. (Licensed Practical Nurse [LPN] R) said (Resident #701) doesn't look good but their vitals were fine. When asked how the Resident didn't look good, Staff U stated, (Resident #701) couldn't sit and kept leaning to the side. With further inquiry, Staff U stated, (Resident #701) was not very responsive. When asked if that was different, Staff U verbalized it was and revealed Resident #701 was normally a yeller.On [DATE] at 1:23 PM, an interview was completed with LPN G. When asked if they were working the night that Resident #701 had a change in condition and passed away, LPN G replied, Yes. LPN G then stated, I was not (Resident #701's) nurse and verbalized they did the paperwork for the transfer. When asked if they saw Resident #701 during their shift, LPN G stated, I only went into the room and saw the nurse doing CPR. LPN G revealed they contacted the Resident's family to notify them of the change in condition and got the transfer to hospital documentation ready. LPN G did not notify the Resident's physician.An interview was completed with LPN R on [DATE] at 1:37 PM. When queried if they were working on [DATE] and recalled Resident #701, LPN R stated, Yes, I was working as a CNA that day. With further inquiry, LPN R stated, I left at 7:00 PM the day (Resident #701) coded. LPN R was asked how Resident #701 was when they were caring for them and stated, (Resident #701) just seemed off and wasn't themselves. They were normally more talkative. When asked, LPN R stated, I notified the nurse.On [DATE] at 2:00 PM, during an interview, Travel Nurse Q was asked if they were working the night Resident #701 coded. Travel Nurse Q confirmed they were working and stated, I was in the middle of med pass. When queried what happened, Travel Nurse Q revealed the CNA came to get them and asked them to come help because (Resident #701) was on the floor. When asked what was observed when they entered the room, Travel Nurse Q stated, I was calling (Resident #701's) name and they weren't answering. (Resident #701) was on their side and their fingers and toes were purple. Travel Nurse Q stated they told the CNAs to get me some help and then another nurse came around and brought the crash cart. Travel Nurse Q revealed Resident #701 was not breathing and did not have a heartbeat, so they initiated compressions and did 4 or 5 rounds of CPR while LPN H applied AED pads prior to EMS arrival. Travel Nurse Q revealed EMS arrived and took over resuscitation efforts. Travel Nurse Q confirmed Resident #701 had a CPAP in place for respiratory support. Travel Nurse Q was asked how Resident #701 was fine if they couldn't breathe but did not provide a response. Travel Nurse Q was asked if they were familiar with Resident #701 and they indicated they were not as it was their first shift as a travel nurse at the facility. Travel Nurse Q was asked if the CNA had indicated what concern they had regarding Resident #701's condition and Travel Nurse Q indicated the CNA stated Resident #701 wasn't feeling good. Travel Nurse Q stated, I went in there (Resident #701's) room and (Resident#701) said they weren't feeling good but couldn't say what. When asked if the CNA had reported anything else to them, Travel Nurse Q replied, The CNA said (Resident #701) keep leaning to the right and that they weren't feeling right. Travel Nurse Q was asked if they notified the Physician of Resident #701's condition not improving following interventions. Travel Nurse Q stated they had not notified the physician.An interview was conducted with Infection Control (IC) RN A and the Assistant Director of Nursing (ADON) on [DATE] at 3:35 PM. When queried why the laboratory tests and chest x-ray were ordered the day they coded on [DATE], IC RN A stated, (Resident #701) was confused and lethargic. The ADON then stated, Put the BiPAP on (Resident #701) and they made some improvement. When asked if Resident #701 had a CPAP or BiPAP due to documentation specifying the Resident had a CPAP, both IC RN A and the ADON both verbalized the Resident definitely had a BiPAP. When queried when Resident #701 was supposed to wear the BiPAP, the ADON revealed the Resident wore the BiPAP at night when they were sleeping. The ADON were asked why Resident #701 was placed on the BiPAP during the day if they were only supposed to wear it at night and responded that Resident #701's spouse informed them that was how the Resident acted when their CO2 became elevated and they were hoping that using the BiPAP would help the Resident blow off the excessive CO2.On [DATE] at 4:10 PM, an interview was completed with the DON. When queried regarding Resident #701's change in condition on [DATE], the DON stated, We did all the labs and a chest x-ray. When asked why the facility did not send Resident #701 to the hospital sooner in the day due to their change in condition and known co-morbidities, the DON stated, We called the doctor and went from there. The DON was asked if the staff working on [DATE] were familiar with Resident #701 and revealed RN Q was a travel nurse, and it was their first night working at the facility.An interview was completed with CNA P on [DATE] at 7:46 AM. When queried if they were working the night Resident #701 coded, CNA P responded, Yes. CNA P revealed they were not Resident #701's assigned CNA but were helping. When queried, CNA P revealed Resident #701 was not feeling well and not acting normally throughout their shift.An interview was completed with Physician E on [DATE] at 8:58 AM. Physician E was asked if they recalled Resident #701 and responded they did. When queried if facility staff contacted them on [DATE] regarding the Resident's laboratory testing results, Physician E stated, They did, said (Resident #701) was having change in behavior and was drowsy. When queried what their plan was regarding the change, Physician E stated, Do admission labs and x-ray now. Physician E was asked when admission labs are supposed to be completed and responded they are typically completed within the first week of admission unless they were completed at the hospital right before admit to the facility and then they will have them done the week following admission. Physician E was asked when Resident #701 had labs completed in the hospital prior to admission to the facility and indicated they would have to look. After reviewing Resident #701's EMR, Physician E revealed the most recent laboratory tests they were able to locate in the EMR were from [DATE]. When asked if they were notified of the laboratory testing results, Physician E stated, They called me for the CO2 (elevated level) and I told them (Resident #701) needed to be on the BiPAP. When queried if they recalled which staff member they told (Resident #701) needed their BiPAP on, Physician E responded they did not recall. When asked why there was no documentation in the EMR from them, Physician E stated, I didn't even have a chance to see (Resident #701) yet since (the Resident) came back on a Thursday and passed on a Tuesday. Physician E stated, When I came in to see (Resident #701) the other day they told me (Resident #701 passed). I didn't even know. When queried why they did not send (Resident #701) to the hospital when they were notified of the critical CO2 lab result, Physician E stated, (Resident #701's) baseline CO2 (level) was greater than 45. Physician E continued, (Resident #701) shouldn't be on 5 L of O2. I tried to educate (Resident #701) and both (the Resident) and their family were like no. Physician E further indicated they wanted to see if use of the BiPAP machine would improve the Resident's respiratory status. When queried if Resident #701's condition improved after using the BiPAP, Physician E stated, I don't know, they (facility staff) didn't contact me. When queried why the Resident was not sent to the hospital when their condition did not improve after using the BiPAP, Physician E reiterated they were not contacted by staff and stated, It makes sense to me. If (Resident #701) was not getting better, why not send them out.A review of Resident #701's hospital ED Note Physician/Provider note documentation dated [DATE] revealed unsuccessful resuscitation efforts continued at the hospital and the hospital physician declared Resident #701's time of death at 10:33 PM.On [DATE] an interview was completed with CNA O at 12:09 PM. When queried if they were Resident #701's CNA when they coded in the facility, CNA O confirmed they were. CNA O was queried regarding the Resident's condition during the shift and responded, I kept trying to assist (Resident #701). I was in there a lot. CNA O reported the Resident was restless and kept wiggling in bed and trying to take their mask off. When asked why they were in Resident #701's room a lot, CNA O stated, We were always checking their O2. I treated (Resident #701) as a one on one as much as I could. When queried if they provided care to Resident #701 often, CNA O replied, No. I was not normally on that hall. CNA O verbalized they were concerned about the Resident's condition and had reported their concerns to the nurse. When asked if they reported their concerns to anyone, as they were not familiar with Resident #701, CNA O stated, I kept telling the nurse that I was concerned about the leaning and taking the mask off.An interview was completed with Travel RN N on [DATE] at 1:05 PM. When queried if they were Resident #701's assigned nurse on [DATE] during the day shift, RN N confirmed they were. RN N was asked if there were any concerns with the Resident during their shift and responded the off going night shift nurse told them that Resident #701 had been up most of the night yelling and seemed more tired than usual but they attributed the tiredness to being up during the night. RN O stated I had two halls to pass meds, so I was pretty busy. RN N revealed they went to break between 11:00 AM and 1:00 PM and when they got back (LPN R) who was working as a CNA that day said, our girl isn't going so hot. RN N verbalized they assessed Resident #701 and they had crackles in bilat (lung) bases (abnormal finding indicative of poor air exchange). RN N then stated, The ADON, IC RN A and Unit Manager LPN K came down to assist and took over care. I went to go pass meds. RN N then stated, When I got back to my computer, I had a call from lab and (Resident #701) had a critical CO2 level. I called (Physician E) and let them know. When asked if they received any new orders from Physician E, RN N stated, No, (Physician E) said they expected that because they are a COPD-er. When queried if Physician E told them to keep the BiPAP on to blow off CO2, RN N stated, No, they did not tell me that. RN N disclosed they had to go to the dining room at that time because a nurse was required to be in the dining room and stated, I told (LPN R) to keep an eye on (Resident #701). RN N then stated, I went to go check on (Resident #701) and they had their BiPAP machine on. RN N revealed Resident #701 only wore their BiPAP at night and they were unsure why it was in place. With further inquiry, RN N stated, Nobody told me what the plan was (for Resident #701's care). When asked what they meant, RN N revealed, The ADON, IC RN A, and LPN K went home without reporting care and/or treatment provided to Resident #701. When asked, RN N stated, I was confused on what we were doing. That is one of the things, they put the BiPAP on, but I don't know what the plan was with it. RN N stated, There is really poor communication at the facility. RN N revealed they spoke to Unit Manager RN M and were instructed to contact the on-call provider, Nurse Practitioner (NP) F and not Physician E to discuss the rest of Resident #701's lab results. When asked, RN N verbalized NP F told them Resident #701 was possibly dehydrated and to encourage fluids. When queried regarding the information regarding Resident #701 provided to the next shift during report, RN N stated, I told (RN Q) that I would check on (Resident #701) like every 15 minutes because I was worried. When asked why they said they would check on the Resident so frequently, RN N verbalized they were concerned because Resident #701's vital signs were stable but seemed lethargic. An interview was conducted with the DON on [DATE] at 1:40 PM. When queried if Resident #701's HCP was notified of Resident #701's change in condition and code in the building, the DON reviewed the Resident's EMR and revealed they did not see documentation of HCP notification. The DON revealed they would review the Resident's EMR further and contact the on-call provider to see if they have records of staff notification. When queried why Resident #701 was not transferred to the hospital sooner after they did not improve with use of the BiPAP, the DON stated they were unaware the Resident did not improve. The DON was informed of staff statements related to continued concerns and did not provide further explanation. An interview was conducted with Unit Manager LPN K on [DATE] at 2:28 PM. When queried if they provided care to the Resident #701 on [DATE], LPN K stated, We got report that (Resident #701) was acting funny and (the DON) asked me to help out. LPN K revealed they went to the Resident's room and got orders for UA (urinalysis), labs, and chest x-ray. When asked if they spoke to Physician E, LPN K stated, I talked to (Physician E). They gave me the lab orders. When queried regarding Resident #701's BiPAP, LPN K stated, We did place their BiPAP on them. LPN K was asked if Resident #701 was experiencing respiratory distress and/or changes and indicated the Resident always had respiratory difficulty. LPN K then retracted and stated they did not place the BiPAP on the Resident and did not know who did.A second interview was completed with IC RN A on [DATE] at 2:00 PM. When queried if they provided care to Resident #701 on [DATE] due to a change in condition, IC RN A responded they did. When queried regarding the Resident's BiPAP and who put the BiPAP on the Resident, IC RN A stated, (Resident #701's spouse) did make a statement that (the Resident) has a history of CO2 retention and said that is how (the Resident) acts when they retains (CO2) but as far as who (placed the BiPAP on the Resident), I do not know.At 2:10 PM on [DATE], an interview was completed with the ADON. When queried what care they provided to Resident #701 on [DATE], the ADON stated, Discussed with (Resident #701's spouse) that that is what (the Resident) does when they retain CO2. The ADON revealed they placed the Resident's BiPAP on them in an attempt to correct the Resident's potential elevated CO2. When queried if they spoke to Physician E regarding utilization of the BiPAP, the ADON replied, No. The ADON was asked when Resident #701 used their BiPAP and responded that they primarily use their BiPAP at night and oxygen during the day. The ADON revealed the Resident required supplemental oxygen at all times. When queried what the plan of care was after the BiPAP was placed, the ADON stated, (Resident #701) had the order. The ADON then stated, I told someone that I did that because we were probably going to correct the CO2 (level) even though the labs would not reflect that. The ADON was asked who they told that to and responded, I don't know. It was at the nurses' station.The DON and Administrator were unable to provide documentation of Physician notification of code/change in condition and transfer to the hospital by the conclusion of the survey.Review of facility policy/procedure entitled, Notification of Change (Revised: [DATE]) revealed, The facility must inform the resident; consult with the resident's practitioner. when there is a change in condition. A change in status would include the following. A significant change in the resident's physical. status. A decision to transfer or discharge. Procedures: 1. Changes in the resident's status. nurse will notify the resident attending practitioner.

This Citation Pertains to Intake Number 2724891. Based on observation, interview and record review, the facility failed to ensure that interventions were implemented to ensure a safe environment for one resident (Resident #2) of three residents reviewed for falls, resulting in Resident #2 being transferred without an electronic lift which was required by the plan of care, resulting in Resident #2 sustaining several lacerations and a transfer to the hospital. Findings Include: Resident #2:A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #2 was admitted to the facility on [DATE] with diagnoses: Heart failure, history of falls, chronic kidney disease, history of a stroke, hypertension, hypothyroidism, atrial fibrillation, left leg pain, arthritis and asthma. The MDS assessment, dated 11/26/2025, indicated the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed assistance with all care and was dependent with transfers.A record review of an incident report completed by Nurse C, dated 11/11/2025 at 1:00 PM, identified the following: Resident was being transferred from beauty salon chair to w/c (wheelchair) by OT B (Occupation Therapist) and CNA A (Certified Nursing Assistant). This RN thought resident was care planned as a 2-assist lift prn (as needed) but res (resident) is a lift at all times. Resident hit left foot pedal and made 3 big skin tears on left leg. Leg kept bleeding. Pressure applied to stop the bleeding and res (resident) transferred over to (the Hospital Emergency Room) for treatment. Injury Type: Laceration; Injury location: Left thigh- front; Notes 11/12/2025: Area assessed immediately after the incident occurred. A review of the Care Plan for Resident #2 revealed the following: (Resident #2) has a functional ability deficit and requires assistance with self-care/mobility r/t (related to): weakness, impaired mobility, pain. And poor endurance, date initiated and created 8/29/2024 and revised 1/11/2024 with Interventions including: Transfer: Resident is a two assist Invacare lift (electronic lift) with large size Invacare sling, date initiated 9/3/2024 and revised 6/23/2025. (Resident #2) has actual impairment to skin integrity r/t MASD (moisture associated dermatitis) to bilateral buttocks, lacerations/skin tears to RLE and LLE (right lower extremity and left lower extremity), date created 8/29/2024 and revised 1/10/2026, with Interventions including, Treatment to skin impairment to bilateral buttocks/left and right lower legs per order, date initiated 9/3/2024 and revised 1/10/2026; and Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces, date initiated 6/6/2025.A record review of the progress notes for Resident #2 identified the following: 11/11/2025 at 1:35 PM, a Skin/Wound Progress Note, Noted to have skin tear to left lateral upper leg with skin flap not approximated. Area approx. 8 cm (to visual eye r/t (related to) amount of bleeding). Skin flap slowly maneuvered to cover wound bed and approximated well with steri strips. Distal to this area is approx. 10 cm open injury which was unable to slow bleeding enough to assess. Pressure applied to area and pressure dressing applied to area. Resident is on Eliquis (a blood thinner) and ASA (aspirin). Resident was transferred with two-assist into w/c (wheelchair) from beauty shop chair. Leg hit w/c where pedal attaches to w/c. CN (Charge Nurse) notified to have resident sent to ER for evaluation. Resident c/o (complains of) burning pain to area.A review of the Hospital Emergency Department discharge report, dated 11/11/2025 at 2:08 PM, identified the following: . Reason for Visit: Leg laceration. Final Diagnosis: 1. ISTAP (International Skin Tear Advisory Panel) type 3 skin tear (a skin tear with a total flap loss, where the entire wound bed is exposed due to the loss of the skin flap) of left lower leg; 2: Skin tear of left lower leg without complication; 3: Hematoma of left lower leg; 4: current use of long term anticoagulation. Keep your area clean and dry and keep compression over the area so the hematoma does not get larger elevate when non-ambulatory. Follow-up with wound care nurse to ensure proper healing of the wound keep area clean and dry.A review of a Medication Administration note dated 12/7/2025 for Resident #2 identified, Cleanse left leg laceration with NS (normal saline) and pat dry. Apply Vaseline gauze to wound, cover with nonadherent dressing and apply kerlix., every shift for laceration to left leg.A review of the Treatment Administration Record (TAR, dated November 2025 for Resident #2, identified a wound treatment to her left leg dated 11/11/2025 to 2/12/2026.A review of the November 2025 Medication Administration Record (MAR) for Resident #2 indicated that the resident had an order for narcotic pain medication Hydrocodone-Acetaminophen Oral tablet 5-325 mg, Give 1 tablet every 8 hours as needed for pain, start date 5/11/2025. The resident had not received any doses of the pain medication from November 1, 2025, to November 10, 2025. After she sustained the leg injury on November 11, 2025, she received 11 doses of the pain medication for the month. On 3/10/2026 at 11:20 AM, the Director of Nursing/DON was interviewed about the incident with Resident #2 and said there was an incident involving the resident during a transfer in the Beauty shop. She said two staff members were transferring the resident to her wheelchair from the Beauty shop chair, and the resident obtained an injury on the foot pedal of the wheelchair during the transfer. She said the two staff were also supposed to use an electronic lift during the transfer, per the resident's plan of care.During an interview with Resident #2 on 3/10/2026 at 3:20 PM, she showed her lower legs with long scars on each. She said she had started to fall during a transfer in the Beauty shop and injured her legs. She said it was healed now but took a long time to heal and had been very painful.During an interview with the Director of Nursing and Administrator on 3/10/2026 at 4:00 PM, the transfer and injury to Resident #2's left leg was reviewed. The Administrator said Nurse C assigned to the resident had told CNA A that the resident could be transferred with a 2-person assist and not use the Invacare lift, so the CNA had someone else help him with the transfer (OT B) and the resident was injured. The DON and Administrator both said CNA A and Nurse C no longer worked at the facility.A review of the Facility Policy titled, Fall Management, dated origination 5/1/2020 and revised 7/8/2025 provided, Policy: The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk of falls. A plan of care is developed and implemented based on this evaluation.

This Citation pertains to Intake Number 2739781.Based on interview and record review, the facility failed to ensure that grievances or concerns were addressed per the facility policy for concerns/grievances for one resident (Resident #6), who had concerns voiced during meetings with the State Ombudsman, of three residents reviewed for complaints. Findings include:Resident #6 (R6):A review of R6's medical record revealed an admission into the facility on 1/6/26 and readmission on [DATE] with diagnoses that included encounter for orthopedic aftercare following surgical amputation, depression, anxiety disorder, paranoid personality disorder, and post-traumatic stress disorder. A review of the Resident's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 15/15 that indicated intact cognition and that the Resident needed partial/moderate assistance with dressing, substantial/maximal assistance with bathing and was dependent on a helper with toileting hygiene and chair/bed to chair transfer. On 3/10/26 at 11:22 AM, an interview was conducted with State Ombudsman (SO) F regarding R6's concerns. The Resident had given consent to discuss multiple concerns that the Resident had voiced to the State Ombudsman. The Ombudsman reported that Elder Advocate K had been witness to staff being rude and inappropriate to the resident when answering the Resident's call light, shutting off the call light and saying they were too busy, which took place on February 2, 2026, approximately 1:00 PM. The Ombudsman reported staff rolling eyes, raising their voice, leaving and not returning to assist the resident. It was relayed to the Administrator (NHA) through correspondence by email. The NHA had responded to the email to the SO. The SO reviewed other concerns the Resident had voiced. When asked if all the concerns were addressed and the Resident was content with resolution, the SO reported the Resident felt concerns continued with call light answered but staff shutting it off, saying they were too busy, needs not met and rude and inappropriate staff. The SO reported it as costumer service/dignity issues. On 3/10/26 at 11:40 AM, an interview was conducted with R6 who answered questions and engaged in conversation. An observation was made of R6, well dressed and groomed, sitting in their wheelchair in their room. The Resident had multiple concerns and reported she had talked to the Ombudsman regarding the concerns, and the Ombudsman had been back to talk with her. When asked about resolution to concerns, the Resident indicated nothing had been resolved. The Resident was asked about staff being rude and reported continued issues with multiple staff, staff answering her call light and they tell her, 'We are taking care of other people.' The Resident reported waiting extended time for staff to answer call lights or staff turn it off and say they will be back then don't show back up, told by staff to go in her brief and they will be back, therapy staff not working enough on transfers to the toilet/bedside commode that is over the toilet. The Resident reported she had her own glucometer, and they made her send it back home, telling her she was not allowed to keep it at the facility. When asked if she had discussed concerns with the Administrator, Director of Nursing or Unit Manager, the Resident reported she did not want to talk to them and would prefer to talk to the Ombudsman. When asked if staff had offered to help her write up a concern form, the Resident reported they had not offered to write any concern forms. When asked if she had been given any concern or grievance forms, the Resident reported she had not received any. When asked if they gave her any concern forms with resolutions to issues brought up to the Ombudsman, the Resident reported she had not gotten any papers regarding her concerns but indicated she knew the Ombudsman had discussed concerns with the Administrator. On 3/10/26 at 3:24 PM, an interview was conducted with Nurse E who reported she had a good rapport with R6. The Nurse reported going to talk to R6, but the Resident had not given her any concerns, and she had not filled out a grievance form. The Nurse reported that her dressing was not done but they were done, I checked the date and the dressing was changed. The Resident had voiced some concerns about not getting therapy, but she had refused, now she is getting up and doing therapy every day. The Nurse also reported concerns with an eye doctor appointment and did not have her dressing change completed. When asked about facility policy for grievances, the Nurse reported that if there was a concern, you write it up if there was an issue. When asked about staff being rude, the Nurse reported the Resident did not voice those concerns. On 3/10/26 at 3:35 PM, Nurse J was interviewed regarding R6 not getting a dressing change to her right stump on the day of her eye appointment. The Nurse reported the dressing had not been completed prior to leaving for the appointment and when she came back, the Resident had some behaviors and was upset and did not want the dressing changed. When asked about complaints from the Resident regarding staff rudeness, the Nurse reported the Resident often had complaints of the staff from one shift the another and stated, She complains of the past shift to the next shift, that is why she is a two person assist all the time. When asked if she had filled out any concern forms, the Nurse stated, It's normal behavior and her personality. CNA I reported she had not had any complaints from the resident of other staff and reported always having two people when going into the room. A review of the email from the Ombudsman to the Administrator that included, .I have some concerns that came through for your facility regarding Resident 6. That need to be looked into and addressed. The concerns were listed and included the Elder Advocate who had visited with the resident and witness to concerns of staff response to the call light and to R6. The NHA had followed up with an email of the listed concerns. On 3/11/26 at 9:50 AM, an interview was conducted with the Administrator (NHA) regarding multiple concerns from the Ombudsman in an email to the administrator. The NHA reported addressing the staffing concerns and the staff had been educated but had not returned to the facility to work. When asked about a grievance or concern policy on handling concerns, the NHA reported they had a Care Program. When asked if any concern forms or grievances had been written up for R6's concerns, the NHA explained the concerns had been taken care of and that they were not ongoing issues. The NHA reported not filling out concern forms for R6 and that the concerns were being taken care of in real time and addressed. On 3/11/26 at 10:32 AM, an interview was conducted with Ombudsman F. The Ombudsman was asked if the facility had offered to write out a complaint form or a Visitor Assistance Form. The Ombudsman reported they had not offered to have her write it out and was not aware they had written any out or gave it as an option to write them out. The Ombudsman reported that the Resident did not feel comfortable going to the NHA directly but felt comfortable going to the Ombudsman. The Resident has the right to go through an advocate with her concerns, and the concerns should be addressed to the Residents' satisfaction. When asked if they felt the concerns were addressed to the resident's satisfaction, the Ombudsman reported the resident continues to call with concerns and stated, (Resident's name) is frustrated that things have not changed. A review of the facility policy titled, Care Program, last revised 7/8/25, revealed, Purpose: To ensure that the facility actively resolves any concerns/grievances submitted orally or in writing to the Administrator, Director of Nursing, or any other member of the facility's staff. Information: Any resident, his or her representative, family member, employee, or appointed advocate may file a concern/grievance without fear of threat or reprisal. All concerns/grievances are investigated, resolved, and documented.C=Concern: 1. If a resident, a resident's representative, or another interested person has a concern (including missing items), a staff member should encourage and assist the resident, or person acting on the resident's behalf to file a written concern/grievance with the facility. The concern/grievance can be documented using the Resident, Family, Employee, and Visitor Assistance Form. 2. If the Facility receives a concern/grievance orally, staff should document the concern using the Resident, Family, Employee and Visitor Assistance Form.A=Action: 1. Staff receiving the concern/grievance should acknowledge receipt of concern and immediately address the concern if possible and document the resolution. 2. All concerns shall be discussed with the Department Managers during the morning Interdisciplinary Team (IDT) meeting. the team will determine who will investigate the concern. The investigation and report should be completed using a Resident, Family, Employee and Visitor Assistance Form and forwarded to Administrator. 4. If a resident, family member or visitor feels that their concern/grievance has not been addressed to their satisfaction with the Administrator or the individual wants to directly convey their concerns to the Corporate Compliance Officer .R=Response: . The Administrator will send all concerns to ERMA so they may be logged on the facility Concern QA&A log. The report will be used internally for tracking and trending as part of the Facility's Quality Assessment Performance Improvement Program.E=Evaluation: . The Administrator/designee will follow-up with the individual filing the concern again within 7 days after the initial follow-up to assure that the concern is addressed to their satisfaction. The resident's concerns, when the policy was not followed, lead to a lack of: documentation of the concerns on the facility forms that may not lead to facilitate action of investigation and IDT discussion, response with tracking and trending for quality assurance, and evaluation to address satisfaction.

Based on observation, interview, and record review the facility failed to ensure that there was adequate staff available to meets the needs of the residents, resulting in resident verbalizations of waiting long periods of time to answer call lights and receive assistance with activities of daily living (ADL), including toileting and incontinence care, for a Confidential Group of Residents from a census of 78 residents Findings Include: FACILITY Sufficient and Competent Nurse Staffing: During a review of the facility Offsite survey preparation dated 1/1/2026, the document indicated the facility had Low weekend staffing for the 4th Fiscal Year quarter in 2025; this was July 2025- September 2025. A further review of the CMS (Centers for Medicare and Medicaid Services) PBJ Staffing Data Report for Fiscal Year Quarter 4 2025 (July1 - September 30) identified Excessively Low Weekend Staffing. The document also provided, Triggered = Submitted Weekend Staffing data is excessively low. On 1/6/2026 at 11:46 AM, the Director of Nursing and Administrator were interviewed and asked about the PBJ Staffing Data Report indicating the facility had Fiscal Year 4th quarter Excessively low weekend staffing. The Administrator said that was true; the weekend staffing had been low. On 1/6/2026 at 1:12 PM, during an interview with a Confidential Group of Residents, they identified several recent instances when the facility had low staffing. One resident stated, Last night there were only 2 staff on, and it took 3 hours to get help to go to bed. It was 11:30 PM before they got there and I had been asking since about 8:30 PM. Some people (residents) take 2 people (staff) to help them. A lot of people have quit, so there aren't enough. The residents said they would like to have 2 staff on each hall (with 4 halls), but sometimes there were 2 staff (nurse aides) for the whole building. One Confidential Resident said sometimes it was over 2 hours before she would receive help. The residents said they did not always receive their evening snack, because there were not enough staff to pass them, If they are short-handed, we go without something. A review of the posted nurse staffing forms titled, Report of Nursing Staff Directly Responsible for Patient Care and the facility Skilled Nursing and Rehab Nursing Staff Daily Assignment sheets identified several days when the facilities staffing was low, as identified in the following: 12/15/2025 on the day shift there were 2 nurses and 3 aides with another partial shift aide for a census of 84 residents. 12/31/2025 on the midnight shift, 2 nurse aides and 3 nurses worked for a census of 80 residents. 1/1/2026 on the day shift 3 nurse aides were listed and 3 nurses for a census of 80 residents. 1/5/2026 on the Afternoon shift, 4 of 6 nurse aides called in and did not work that shift; One was replaced leaving 3 nurse aides and 3 nurses to assist residents with the evening meal, toileting and activities of daily living/adl's for a census of approximately 80 residents. On the Midnight shift, 4 of 6 nurse aides called in, with 2 replaced for a total of 4 nurse aides to assist approximately 80 residents to bed. On 1/6/2026 on 3:15 PM, the Director of Nursing and Administrator were asked to view the time cards for nursing staff, including nurses and nurse aides for the dates 11/1/2025, 11/21/2025, 11/25/2025, 12/2/2025, 12/7/2025, 21/9/2025, 12/16/2025, 12/17/2025, 12/24/2025, 12/25/2025, 1/1/2026, 1/3/2025, as during a review of the posted nurse staffing sheets titled, Report to Nursing Staff Directly Responsible for Patient Care identified inconsistencies with the Skilled Nursing and Rehab Nursing Staff Daily Assignment documents. In addition, there were many staff crossed off the assignment sheets and call ins, and some were identified as Quit, it was difficult to determine which staff and how many were working. On 1/7/2025 at 1:25 PM, Nurse H was interviewed about staffing. She said nurses and nurse aides were working mandatory overtime and it was difficult. On January 7th, 2026, at 1:29 PM, the clinical nursing staff assigned to daily patient care timecards were received for review for the days requested for the nurse aides, but not for the nurses. Timecards for one nurse/an RN were received for 3 days: 11/1/2025, 11/9/2025 and 12/17/2025. There were no additional nurses' timecards received for review. On further review of the timecards, it was identified that many of the nurses and nurse aides were working repeated 16-hour shifts. This was identified also, by the Confidential Group of Residents who said the staff began quitting because of this. On 1/7/2026 at 2:35 PM the Director of Nursing/DON was asked about the timecards and schedules. She identified four nurse aides who had recently quit. Reviewed with the DON that the residents were upset about the care they were receiving when there was not enough staff to care for them. She confirmed the nurse aides and nurses were working 16-hour shifts at times, and the facility was trying to hire additional staff. Reviewed the facility had flagged for Excessively low staffing on the 4th quarter 2025 (July-September 2025) PBJ staffing report and the low staffing continued currently, in addition, the daily staff assignment sheets and Report to Nursing Staff Directly Responsible for Patient Care posted staffing, did not match on many days. A review of the facility policy titled, Nursing Staffing dated origination 9/1/2013, last revised 9/14/2023 and effective 11/1/2024 provided, The nursing services department provides 24-hour nursing services. The facility ensures sufficient nursing staff. to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Nursing service is provided by number and type of personnel to ensure that each resident: Receives treatments, medications and diets as prescribed; Receives rehabilitative nursing care as needed; Receives proper care to maintain their highest level of functioning (prevent decline in function or poor clinical outcomes); Is kept clean, comfortable, and well-groomed; Is protected from accidents, injury and infection. The facility will staff to meet the needs of the residents at the facility. Documentation: Maintain time schedules that indicate the number and classification of nursing personnel, including relief personnel, who work on each unit for each tour of duty (shift). A review of the Facility Assessment provided, . II Staffing, Training, Services & Personnel . A. 1. Function - Sufficiency Analysis Summary A. 1. (The facility) considers the specific needs of each resident unit in the facility to adjust as necessary (ie. Number of staff, skill sets) on a daily basis. This includes the staffing needs for each shift, such as day, evening, night and weekends.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food-borne illnesses to all residents who consume food from the kitchen. Findings include: On 01/05/2026 at 9:30am-10:05am, during the initial kitchen tour with Certified Dietary Manager (CDM) A and Dietician B, this surveyor observed a bag of pepperoni with a discard date of 12/24/25 inside the walk-in refrigerator. When interviewed, CDM A stated that the pepperoni should have been thrown out and proceeded to throw out the pepperoni. On 01/05/2026 at 9:30am-10:05am this surveyor observed a bag of shredded lettuce with a best by date of 1/2/26 inside the walk-in refrigerator and CDM A proceeded to throw away the bag of shredded lettuce. On 01/05/2026 at 9:30am-10:05am the sanitizer bucket sitting on the counter in the main dining area was tested with Hydrion QT-40 test strips and the result was zero. When interviewed on what range the sanitizer should be in, CDM A stated they keep the solution between 150-400ppm and they change out the bucket when it's visibly soiled or when starting a new task. On 01/05/2026 at 9:30am-10:05am this surveyor observed the microwave visibly soiled on the interior's ceiling and walls, located in the main dining area. When interviewed on how often the microwave is cleaned, CDM A stated it's cleaned after each meal. On 01/05/2026 at 9:30am-10:05am observed crumbs on plates stacked by the steam table located in the main dining area. When interviewed on whether the plates were supposed to be clean, CDM A stated yes, and she removed the dirty plates from the stack. On 01/05/2026 at 9:30am-10:05am observed a takeout pizza box dated 1/4/26 in the fridge, located in the 400-hallway kitchenette. When interviewed on whether this was the received or discard date, CDM A wasn't sure, and the pizza box was removed from the fridge. On 01/05/2026 at 9:30am-10:05am observed a red stain from an unknown liquid on the inside wall of the fridge, located in the 200-hallway kitchenette. When interviewed on how often the fridge is cleaned, CDM A stated it's cleaned when the fridge is restocked. On 01/05/2026 at 9:30am-10:05am observed the drain line to the ice machine sitting directly inside the drain, located in the 900-hallway kitchenette. On 01/05/2026 at 9:30am-10:05am observed a turkey sandwich with a discard date of 1/4/26 in the fridge, located in the 900-hallway kitchenette. On 01/05/2026 at 11:07am-12:15pm during lunch observation, observed plates with crumbs on the surface stacked beside the steam stable, located in the main dining area. On 01/05/2026 at 11:07am-12:15pm observed [NAME] C scoop up the baked ziti with a utensil and batted away a string of extra cheese off the utensil with her bare hand, and the extra cheese fell back into the serving pan. According to the 2022 Food Code, 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.According to the 2022 Food Code, 3-304.14 Wiping Cloths, Use Limitation, Cloths in-use for wiping counters and other equipment surfaces shall be .Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114 and The sanitizing solution must be changed as needed to minimize the accumulation of organic material and sustain proper concentration. Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit.According to the U.S. Environmental Protection Agency for Multi Quat Sanitizer with the registration number 1677-198, the designated chemical solution range for food contact sanitizer is 150-400ppm. According to the facility's policy on Food from Outside Sources, All food brought in is to be checked by the Nurse, Dietary Manager, or Dietician. It must be placed in a sealed container and labeled for the content, the guest's/resident's name and date the food was received, and an expiration date of 3 days after food was brought in.According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.According to the 2022 Food Code, 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).According to the facility's Food Safety policy, Food items will be served onto clean dishes using clean utensils. Bare hand contact will not be permissible with food. According to the 2022 Food Code, 3-301.11 Preventing Contamination from Hands, Except when washing fruits and vegetables . food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.

Based on observation, interview and record review, the facility failed to ensure that residents' needs were met timely and failed to ensure that call lights were not discontinued without residents' needs being met for three residents (R2, R7, R70) of four residents sampled and a confidential group of residents, resulting in feelings of unimportance and incontinence. Findings include:Resident #7: R7 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy, altered mental status, muscle wasting and major depressive disorder. On 01/05/2026 at 1:02PM, an interview was conducted with a family member present in the room. The family member of R7 stated that the call light wait time is an average of 20 minutes and sometimes it can be even longer. The family member also stated, I understand they are low on staff, but when you need to use the bathroom, it can be a long time for someone to sit and wait. The family member was asked if R7 was ever incontinent due to not getting the call light answered timely. The family member stated, yes, there have been a few times she has not made it to the bathroom due to the long wait. Resident #2: On 1/05/2026, at 9:43 AM, Resident #2 was sitting in their wheelchair in their room. Resident #2 complained there wasn't enough help. Resident #2 complained that they have wet their pants waiting on help to the bathroom. Resident #2 continued to offer that the cna's are overworked and when you get a good one, they either leave or get fired. Resident #2 further shared that we save our life for this and we should get what we need. On 1/05/2026, at 3:30 PM, a record review of Resident #2's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes, Stroke and high cholesterol. Resident #2 had intact cognition and required assistance with Activities of Daily Living. During survey, a confidential resident complained when they use their call light for help staff often cancel it before meeting their needs. Confidential resident further complained staff often say it will be an hour before I get back to you. Confidential resident complained that made them feel unimportant, but they understood as they are often short staffed. Resident #70: On 1/7/2026, at 9:40 AM, Resident #70 was in bed. Their call light was activated with the lighted visual on in the hallway. Resident #70 explained they needed to get up as their daughter was coming at 11 for a visit. On 1/7/2026, at 9:41 AM, Resident #70 remained in bed. Their call light remained on/activated. Certified Nursing Assistant (CNA) D entered the room and asked can I help you. Resident #70 was overhead explaining they needed to get up and ready as their daughter was coming at 11 to visit. CNA D was overheard telling the resident they would go get help as they cancelled the call light. On 1/7/2026, at 9:48 AM, Resident #70 remained in bed. Resident #70 offered they needed to get up and ready. On 1/7/2026, at 9:49 AM, CNA D was observed pulling the clean linen cart towards the end of the 500 hall and stopped three rooms passed Resident #70's room. CNA D offered they were going to start checking people. On 1/7/2026, at 9:52 AM, CNA D was observed assisting another resident into the bathroom and making beds. On 1/7/2026, at 10:00 AM, CNA Dwas overheard telling their hall partner they needed to go into room [ROOM NUMBER]. Both CNA's were observed entering room [ROOM NUMBER]. On 1/7/2026, at 10:07 AM, Resident #70 remained in bed and now had placed their call light back on which was quickly answered. On 1/7/2026, at 10:08, Scheduler Answered Resident #70's call light and stopped CNA D in the hallway alerting them (Resident #70) needs to get up their daughter is coming. CNA D stated were going there next. On 1/7/2026, at 10:22 AM, Resident #70 was observed in their wheelchair in their bathroom brushing their teeth with CNA D assistance. On 1/7/2026, at 11:30 AM, a record review of Resident #70's electronic medical record revealed an admission on [DATE] with diagnoses that included debility, heart failure and anemia. Resident #70 had moderately impaired cognition and required assistance with all Activities of Daily Living.

Based on observation, interview and record review the facility failed to ensure clinical staff posting was accurately completed for several days in December 2025 and January 2026, resulting in the inability for residents and visitors to know which clinical staff were working on those days.Findings Include: On 1/6/2026 at 11:40 AM, a daily posted nurse staffing sheet (a document listing all nurse staff by discipline (RN, LPN or Nurse aide working in the building on each shift- posted per federal guidelines), titled Report of Nursing Staff Directly Responsible for Patient Care, for 1/6/2026 with a Census of 78 residents was observed posted on the wall in the hallway near the front entryway desk. There were no hours for an RN/Registered Nurse working that day. On 1/6/2026 at 11:45 AM, the Director of Nursing was asked about the posted nurse staffing form for that day, as it was incomplete with no RN hours and she said there was a new scheduler and she would have it fixed. On 1/6/2026 at 1:30 PM Staff Scheduler E was interviewed about the postings, when she provided the schedule book containing the daily staff postings and assignment sheets. She said sometimes the assignment sheets were updated when staff called in for their shift and the daily posted staffing sheets were supposed to be updated also. A review of the Daily posted staffing sheets from December 2025-January 7th, 2026, identified several incomplete forms for the following days: 1/5/2026, 1/6/2026, 12/29/2025, 12/17/2025, 12/16/2025, 12/13/2025, 12/12/2025. Some of the forms did not indicate if an RN had worked that day or how many hours the RN worked in a 24-hour day. Some of the forms did not have RN or LPNs listed or their hours. On 1/5/26 at 12:26 PM, an observation was made of required daily posting of nursing staff hours. The posting was on the wall near the front entrance of the facility by the entrance towards the 200-hall unit. The document for the staffing hours was dated 1/5/26. The information on the document revealed the number of Certified Nursing Assistants (CNA) as 5.5 for day shift with total CNA hours worked 44; afternoon shift was documented as 5 CNAs with total CNA hours worked as 40; and night shift as 5 CNAs with total CNA hours worked as 40. There was no documentation for RN (Registered Nurse) coverage or LPN (Licensed Practical Nurse) coverage for any shift for the number of RN and LPN staff and no documentation of hours worked for RN or LPN staff.

Based on observation, interview, and record review, the facility failed to ensure that one resident (Resident #25), with a significant weight loss, was weighed as ordered by the practitioner and the weights were documented in the medical record of two residents reviewed for nutritional status. Findings include:Resident #25:On 1/6/26 AM, an observation was made of Resident #25 sitting up in the room and staff were providing care. After care was completed, an interview was conducted with the Resident who could express simple answers to questions but did not converse in conversation. Resident #25 denied issues with the food he received at the facility. The Resident had been sick with Covid and indicated he was feeling better. The Resident was observed to not have any cough or congestion and denied any pain in his throat. The Resident continued under isolation precautions. A review of Resident #25 (R25) medical record revealed an admission into the facility on 1/22/25 with diagnoses that included cerebral ischemia, dementia, depressive disorder, and Covid-19. A review of the Minimum Data Assessment revealed a Brief Interview of Mental Status score of 5/15 that indicated severely impaired cognition and the resident needed set-up or clean-up assistance with eating. A review of R25's medical record of weights revealed the following:8/1/25, 166.5 lbs (pounds).9/1/25, 165 lbs.10/1/25, 163.5 lbs.11/1/25, 172.5 lbs.11/1/25, 172.5 lbs.12/1/25, 161.5 lbs.12/2/25, 160.0 lbs.An order was for weight monitoring for R25 revealed an order dated 12/8/25 for Weekly Weight, Order Summary: Weekly Weight every day shift every Mon (Monday) for 8 weeks. and signed by the Practitioner on 12/8/25. A review of the Medication Administration Record revealed Weekly Weights every day shift every Mon for 8 weeks with a start date 12/15/25, documented with a check as completed on 12/15/25 and 12/22/25 with no documentation of the weight obtained. Documented as a 5 on 12/29/25 with corresponding progress note that indicated weight held at this time r/t (related to) being on isolation precautions. Further review of the medical record of progress notes revealed a lack of documented weights obtained on 12/15/25 and 12/22/25. Progress notes dated 12/28/25 revealed the Resident had tested positive for Covid. Dated 12/29/25 at 1:28 AM, Afebrile. Denies discomfort. Covid precautions in place. Dated 12/29/25 at 9:10 AM, Dietary Note, Resident noted w (with)/Covid-19 infection w/increased est nutritional needs due to the same. He is at risk for appetite and weight changed r/t Covid-19, as well as social disruption r/t isolation per protocol. Supplements already prescribed for increased est needs and will continue to monitor intake, weights, and labs as available. Progress notes for Resident #25 revealed:-Dated12/20/25 at 10:51 AM, Resident afebrile, EBP (enhanced barrier precautions) in place, VS (vital signs) WNL (within normal limits). Resident productive cough noted. Denies pain or discomfort. -Dated 1/1/26 at 1:09 AM, Isolation precautions continues for covid positive. VS WNL. Denies symptoms. Fluids encouraged.-Dated 1/2/26 at 12:56 AM, .No complaints voiced by resident at this time. VS WNL. Afebrile.-Dated 1/2/26 at 1:30 PM, .Resident remains non-symptomatic of Covis S&S (signs and symptoms), BIL (bilateral) lung sounds clear, VS and WNL. Resident pleasantly confused, calm demeanor.-Dated 1/3/26 at 11:07 AM, Continues on isolation, resident feeling much better he states, LS (lung sounds) are CTA (clear), no coughing noted, no Covid symptoms are present. On 1/7/26 at 9:11 AM, an interview was conducted with Dietitian (RD) B regarding Resident #25's weight loss. A review of the December weights of 11 and 11.5 lbs weight loss with approximately 7% weight loss in a month. The RD indicated that 5% or more would be a significant weight loss. The RD reported that it was expected wt loss and that the Resident was expected to return to his baseline. The RD reported their assessment was conducted on 12/5/25 and supplements were increased and the physician was notified. The RD was asked about the order for the weights for 8 weeks. The RD was not aware of the Resident's current weekly weights obtained. Review of the medical record revealed a lack of documentation of the weights obtained for the weekly weights for 12/15 and 12/22. For the weight that was to be obtained on 12/29, the RD indicated we would try not to contribute to more discomfort during illness of Covid until after out of isolation. The RD reported that they could do weights on someone in isolation if it was medically necessary. The RD reported that the weights, if they had been obtained, should be documented in the medical record. The RD left to try to find if the weights had been obtained. The RD returned with the document titled Vital Signs and Intake/Output Record for the date of 12/22/25 and 12/15/25 for the 200 hall. Resident #25's first name only was on the bottom of the page under the area reweights with the wt of 161 for 12/15/25 and 162 for 12/22/25. The RD agreed that the weights should be in the medical record for analysis of the Resident's weight loss and to determine if the Resident continued to lose weight and if further interventions were needed. The last weight obtained that was documented in the medical record was on 12/2/25 at 160 lbs. which was a weight loss of 11.5 lbs from the prior months weight of 172.5 on 11/1/25. The order for weekly weights was not followed while the Resident was under isolation and the RD reported that everyone was assessed on an individual basis and stated, If needed to, if medically necessary, we could weigh them. The RD reported that the shower room was where the scale was located and when asked if he could use PPE (personal protection equipment) to obtain a weight, the RD responded yes. A review of facility policy titled, Weight Management, effective 7/30/25, revealed, .Practice Guidelines. 2. Residents will be weighed upon admission/readmission; weekly x 4, then monthly or as indicated by the physician and/or the medical status of the resident and document the results in the medical record. 5. Residents determined to be at risk or have significant weight changes will be weighed on a weekly basis. Residents at risk are: .f. Residents with insidious weight loss and 5% in one month. H. Residents deemed necessary by the practitioner, Director of Nursing, Registered Dietitian, or interdisciplinary team. Exceptions to weekly weights include residents with a diagnosis or condition that contraindicates weekly weights, e.g., hospice/terminal residents with a physician's order or planned weight changes under a physician's order or treatment plan.

Based on observation, interview and record review, the facility failed to ensure nail care was provided to one resident (Resident #6), of one resident reviewed for Activities of Daily Living (ADL) care. Findings Include:Resident #6:On 1/5/26 at 11:21 AM, an observation was made of Resident #6 (R6) lying on her back in bed, dressed in a gown, lights on and R6 was awake. The call light was hanging on a piece of plastic on the wall, in line with the Resident's feet and not in reach for the Resident with the push mechanism hanging below bed frame. The Resident was asked questions, answered them, but did not engage in conversation. The Resident pulled the covers up around her shoulders. An observation was made of long fingernails. The Resident reported she didn't want to answer questions and turned herself facing the wall. The Resident was left alone. On 1/6/26 at 3:45 PM, an observation was made of R6 lying in bed, awake and dressed in a gown. An observation was made of the Resident's fingernails that were long except for one that was irregular and down to the skin on the 5th right digit. The other nails were long with one curling under, and a couple were jagged and uneven. When questioned about the length of her nails, the Resident reported she liked short nails and that they were sharp and she scratched herself. On 1/6/26 at 4:00 PM, Certified Nursing Assistant (CNA) F and CNA G were interviewed regarding R6's nail care. CNA F was asked about bathing and the CNA explained that sometimes she takes a shower and sometimes it's a bed bath depending on her mood. When asked about nail care the CNAs indicated it should be offered during bathing or as needed. They were unsure when the Resident last had nail care done. CNA F reported she had done morning care with the Resident but did not do the nails and reported, they usually look at the nails on shower days to see if it needs to be done. When asked about refusals for care, the CNAs reported they would let the Nurse know and they would go in after that. CNA G reported they would type in what she didn't want us to do and the nurse will come out and try. When asked if she would allow nail care, the CNAs indicated it would depend on her mood. A review of Resident #6's medical record revealed an admission into the facility on 5/8/25 with diagnoses that included dementia, anxiety disorder, diabetes, depressive disorder and excoriation (skin-picking) disorder. A review of Resident #6's Minimum Data Set assessment revealed a Brief Interview of Mental Status of 10/15 that indicated moderately impaired cognition and the Resident needed substantial/maximal assistance with personal hygiene and dependent on helper with shower/bathing. A review of R6's medical record of a progress note dated 1/5/26, .Observed upon skin assessment during Treatments that residents BIL (bilateral) lower legs are almost healed from where resident scratches her legs with her nails. Previously open areas on residents legs are healed over with dry scabs. Residents groin and buttocks also showing improvement, somewhat mildlyred areas where resident is scratching her skin on her buttocks & groin with her nails. Education provided to resident on infection control of spread of redness if she would quit scratching the areas with her nails. Resident became irrational and agitated stating, It's not me, I don't scratch my skin. Resident then provided with assistance cleaning out dried skin and red dry scabs from under her fingernails. Resident continues to deny scratching as this nurse observed her scratching her buttocks with her nails. Further review of the progress notes revealed a note dated 12/10/25, that revealed, Residents legs assessed. Noted to have several small scratch marks with scabs present. No s/s (signs and symptoms) of infection present to area. Tx (treatment) in place. Nails checks and are short and well trimmed. Resident reports I am doing better at not itching.A review of the progress notes revealed a lack of documentation of the resident refusing nail care and interventions attempted from 1/6/26 back to the note on 12/10/25. A review of R6's care plan revealed a focus for risk for impaired skin integrity/pressure injury with an intervention Observe finger and toe nails on shower days to see if they need to be trimmed, date initiated 9/20/25. Further review of R6's care plan revealed a focus for Actual impairment to skin integrity r/t (related to) scratch marks to bilateral lower legs and red/yeasty buttocks, revision on 12/11/25. Interventions included, Instruct resident to avoid scratching and keep hands and body parts from excessive moisture, Keep fingernails short, created on 12/11/25.On 1/7/26 at 12:30 PM, an interview was conducted with the Director of Nursing (DON) regarding R6's nail care. The DON reported that with R6 it was a hit or miss with things indicating personal care and bathing. The DON reported that nail care was with shower care or as needed. When asked about refusals and facility policy on documentation of refusals, the DON reported the Nurses should have a note in if she refused. An observation was made with the DON of Resident 6's nails and reported that the nails should be attended to and the Resident agreed to have nail care completed. The DON indicated that the Resident may not allow the nail care to be completed. When asked if refusals for nail care should be documented, the DON indicated the nurse should be documenting it.

Based on observation, interview and record review, the facility failed to assess, monitor, and provide pain management for two residents (Resident #138, Resident #139) of 6 residents reviewed for pain management, resulting in the residents' verbalizations of unrelieved pain, frustration and helplessness. Findings Include: Resident #138: Pain Management A record review of the Face sheet and electronic medical record (EMR) for Resident #138 indicated the resident was admitted to the facility on [DATE] with diagnoses: pancreatic cancer, right upper quadrant abdominal swelling, mass and lump, anemia, diabetes, anxiety, depression, malignant ascites (fluid build up in abdomen), heart disease, right buttock Stage 2 pressure ulcer, left buttock Stage 3 pressure ulcer and GERD (gastroesophageal reflux disease). The resident was receiving Hospice services and died on [DATE]. On [DATE] at 11:30 AM, Resident #138 was heard moaning loudly from his room. Upon entry into his room, the resident was observed lying in bed and moving around. The resident said he was uncomfortable and had pain. He said he had pancreatic cancer and a lot of abdominal pain and motioned to his abdomen. The resident was asked if he had pain medication and he said he did, but was not sure if it was working. On [DATE] at 11:45 AM, Nurse N was observed in the hall preparing medications for another resident. Resident #138 could be heard moaning loudly. The nurse was asked about Resident #138. She said the resident had cancer and was having pain. She said he had received something for pain. Nurse N said she was also assigned to another unit (400 Hall) in the middle of the building. It was not visible from the Resident's unit and hallway, and she could not hear the resident when he was calling out. On [DATE] at 3:30 PM, Resident #138 had multiple instances of yelling out and moaning in pain during the day. A record review of the Pain Level Summary documentation for Resident #138 from [DATE] to [DATE] revealed Pain assessments were being routinely completed for the resident in the evening and early morning (usually before 7:00 AM). There were 3 mid- morning pain assessments: 8:10 AM on [DATE], 8:29 AM on [DATE] and 11:22 AM on [DATE]. All but 2 of the pain assessments were completed by the night shift nurse. The resident was not being assessed for pain during the day/afternoon. The pain scores ranged from ,d+[DATE]. A record review of the physician's orders for Resident #138 on [DATE] revealed the following: Oxycodone HCl capsule 5 mg, give 1 capsule by mouth every 6 hours as needed for moderate to severe pain, start date [DATE]. Omeprazole DR 20 mg capsule, Give 1 capsule by mouth one time a day for GERD, start date [DATE]. Meclizine HCl oral tablet 25 mg, Give 1 tablet by mouth every 8 hours as needed for Nausea or vertigo, start date [DATE]. Morphine sulfate solution 20 mg/ml, Give 0.5 ml by mouth every 4 hours as needed for Pain or shortness of breath, start date [DATE]. Oxycontin oral tablet ER 12 HR (Abuse-Deterrent) 10 mg (Oxycodone HCl), Give 1 tablet by mouth every 12 hours for pain, start date [DATE]. A record review of the [DATE] Medication Administration Record/Treatment Administration Record (MAR/TAR) for Resident #138 indicated the resident had received the following: 6 doses of Oxycodone from admission on [DATE]-,d+[DATE]. He was provided the medication sporadically: No doses were provided on [DATE]; 2 doses (at 5:45 AM and 10:44 PM) on [DATE]; 1 dose (at 11:50 PM) on [DATE]; 1 dose (at 6:47 AM) on [DATE]; no doses on [DATE]; 2 doses on [DATE] (at 2:05 AM and 8:10 AM). Omeprazole was received daily at 6:00 AM from [DATE]- [DATE]. Meclizine for nausea was not administered. Morphine was not administered from [DATE]-[DATE]. Oxycontin: The resident did not receive the medication on [DATE] at 9:00 PM (Hold), [DATE] 9:00 AM (not available), [DATE] 9:00 AM (not available). On [DATE], Resident #138's pain was rated at a 6 from a ,d+[DATE] scale (with 10 being the highest amount of pain) at 8:10 AM, he received Oxycodone and Oxycontin as ordered at that time and continued to yell out in pain at 11:45 AM. Further review of the Pain assessments for Resident #138 from [DATE] revealed the resident's pain had increased and was repeatedly rated from ,d+[DATE]. There were multiple instances that the resident's pain was a 10. Further review of the physician's orders indicated the Morphine and Oxycodone orders were adjusted on [DATE] due to the increased pain. Oxycodone HCl ER tablet 12 hour Abuse-Deterrent 20 mg, Give 1 tablet by mouth every 12 hours for moderate to severe pain, start date [DATE]. Morphine Sulfate solution 20 mg/ml by mouth every 2 hours as needed for Pain or shortness of breath, start date [DATE]. On [DATE] the resident had routine and as needed orders for Oxycodone and as needed orders for Morphine. The Oxycontin was discontinued. A review of the Care Plans for Resident #138 identified the following: (Resident #138) is at risk for pain and/or has (specify: acute/chronic) pain rt: Ascites, secondary to pancreatic cancer, date created and initiated on [DATE] with Interventions that included: Anticipate resident's need for pain relief PRN (as needed) and respond immediately to any complaint of pain, date created and initiated [DATE]; Notify physician if interventions are unsuccessful . dated [DATE]. The Pain Care Plan did not specify what type of pain, acute or chronic the resident had. The interventions were not followed. (Resident #138) is at risk for decline in condition, pain . (related to) terminal prognosis . date created and initiated [DATE] with Interventions that included: Observe resident closely for signs of pain, administer pain medication as ordered, and notify physician immediately if there is breakthrough pain . date created and initiated [DATE]. On [DATE] at 2:45 PM, Unit Manager C was interviewed and she said the Resident #138 also had a paper Hospice chart in a binder at the nurses' desk. She said each resident had their own Hospice chart. A review of the paper Hospice chart for Resident #138 was made. There were 2 visits documented in the chart: [DATE] and [DATE] by a nurse. It was noted the resident had verbalized to the Hospice nurse that he was not getting relief from the pain medication. The Hospice Care Plans were reviewed and the Pain Care Plan included Provide Hospice booklet Managing Pain. It was unclear who the booklet was provided to. Resident #139: Pain Management On [DATE] at 2:38 PM, Resident #139 was heard yelling out Help Me and moaning. He was observed sitting in bed. The resident was asked if he was having pain and he said he didn't feel well all over. On [DATE] from 11:30 AM to 4:00 PM, Resident #139 repeatedly yelled out Help Me and was heard moaning. A record review of the Face sheet and medical record indicated Resident #139 was admitted to the facility on [DATE] with diagnoses: acute respiratory failure, COPD, metabolic encephalopathy, weakness, need for assistance with personal care, diabetes, end stage kidney disease, acute kidney failure, need for dialysis, Addison's disease, hypothyroidism, hypertension, mild cognitive impairment, and unstageable pressure ulcers left and right heels. The Minimum Data Set/MDS assessment was not yet completed. A review of the Pain Level Summary for Resident #139 from [DATE] the day of admission, to [DATE] revealed there were 9 pain assessments: [DATE] and [DATE] each had 1 assessment. The pain scores were either 0 for no pain or 7 moderate pain. 7 of the assessments were early in the morning prior to 7:00 AM or in the evening or night. 1 assessment was at 8:35 AM and 1 assessment at 4:25 PM. There were no assessments in the late morning or early afternoon. A review of the Physician's orders for Resident #139 on [DATE] at 2:00 PM, identified the following: Zofran oral tablet 4 mg, Give 1 tablet by mouth every 6 hours as needed for nausea/vomiting, start date [DATE]. The resident had no order for pain medication until [DATE] at approximately 2:00 PM: Tylenol Extra Strength oral tablet, Give 500 mg by mouth 3 times a day for pain, dated [DATE]. A review of the Nurses notes for Resident #139 revealed he had fallen 2 times at the facility: [DATE] at 11:25 PM and [DATE] at 1:45 AM. After the fall on [DATE] the resident complained that his right knee was hurting. The nurse applied ice and there was no additional mention of the resident's right knee. On [DATE] at 2:11 PM, Resident #139 was heard repeatedly yelling out for help and moaning. Resident #139 was transported to dialysis at 4:45 AM on [DATE]. He returned approximately 2:00 PM and was yelling out in discomfort, asking to lay down in bed. On [DATE] at 2:13 PM, the staff assisted the resident to lay down and he stopped yelling. Resident #139's sister Confidential Person O was visiting, and she said she went to dialysis with the resident and the dialysis staff had difficulty accessing his catheter. She said they couldn't start dialysis until they removed a clot. Confidential Person O said it took about 1.5 hours. She said it also took longer to have the resident picked up after dialysis and the resident was very uncomfortable. On [DATE] at approximately 11:50 AM, the resident had an episode of unresponsiveness. On [DATE] at 12:30 PM, Physician M was interviewed about Resident #139. He said he was transferring the resident to the hospital. He said the resident had several medical issues including Addison's disease (a chronic condition where the body does not make enough cortisol and aldosterone), kidney failure and an abnormal heart rhythm. Reviewed with the physician that the resident had been yelling out for several days, moaning and calling for help. Also reviewed the resident had 2 falls. The Physician said he had ordered Tylenol the day before. On [DATE] at 2:15 PM, Unit Manager C was interviewed about Resident #139 yelling out all day on [DATE] and after returning from dialysis on [DATE]. Review of the resident's pain assessments were usually completed by the night shift nurse and there was a lack of documentation related to the resident's discomfort and repeated moaning and Help me. The Unit Manager said the resident was confused and pain should always be considered when someone repeatedly yelled out. She reviewed the resident had Tylenol ordered on [DATE] and had not received any. A review of the Care Plans for Resident #139 identified the following: (Resident #139) is at risk for pain (related to) Addison's disease and impaired mobility, dated initiated on [DATE] and revised [DATE] with 2 Interventions created and initiated on [DATE]: Encourage/Provide non-pharmacological interventions to prevent/manage pain . and Notify physician if interventions are unsuccessful . There were no additional interventions and there were none prior to [DATE]. A review of the facility policy titled, Pain Management, origination date [DATE] and revised [DATE] provided, The facility will evaluate and identify residents for pain, determine the type, location and severity and develop a care plan for pain management . The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Persistent pain is defined as pain that continues for a prolonged period of time and that may or may not be associated with a well-defined disease process . In residents who have dementia and cannot verbalize that they are feeling pain, symptoms of pain can be manifested by particular behaviors such as: Calling out for help, pained facial expressions, refusing to eat, striking out when moved or touched, increased confusion .

Based on observation, interview and record review, the facility failed to ensure that professional standards of care were followed during medication administration of nebulizer treatment for one resident (Resident #82) and supervision of medication administration for one resident (Resident #50), of seven residents reviewed for medication administration, resulting in Resident #82 not observed during the administration of nebulizer medication, a lack of getting the prescribed amount of nebulizer medication, and the likelihood of medication not administered as prescribed/scheduled for Resident #50 and the exacerbation of medical conditions, Findings include: Resident #82: On 10/29/24 at 8:42 AM, the Medication Administration task of the survey was started. The following were observed: -At 9:42 AM, Nurse T was observed to prepare Resident #82's medications by removing the pills from the blister packets. Nurse S was observed to prepare the insulin. Nurse S uncapped the needle of the syringe, inserted the needle into the insulin vial, extracted the insulin and when completed with getting the amount needed from the vial, the Nurse recapped the insulin syringe with the cap that was between her 5th digit and palm of her hand. The Insulin syringe had a guard that could be extracted to cover the needle without having to recap the needle. -Nurse S gave the medications that were prepared by Nurse T to Resident #82. -Nurse S put the nebulizer medication, Ipratropium-Albuterol inhalation solution, for Resident #82 into the medication chamber of the nebulizer handheld apparatus, gave instructions to the Resident on how to turn on the machine, and pulled the curtain. The Resident was unable to turn on the machine and the Nurse opened the curtain, showed the Resident how to turn on the machine and pulled the curtain around the Resident. The Resident had been asking for help to get her shirt off. The Nurse left the room. The Resident could be heard from the hallway saying, Oh Please, and asking for help. Nurse S had not returned to ensure the Resident was doing the breathing treatment. An observation was made of the Resident sitting on the side of the bed and the nebulizer on the bed next to the Resident. Nurse T who was at the medication cart, was told the Resident was not using her nebulizer treatment. Nurse S returned to the medication cart and reported to Nurse T that the Resident wanted her shirt off but had to finish the breathing treatment. The Resident was told to continue the breathing treatment, neither Nurse S, nor Nurse T stayed with the Resident to observe if the Resident had completed the remainder of the nebulizer treatment. -Once the first nebulizer was completed for Resident #82, the Nurses did not listen to the Resident's lung sounds, monitor oxygen saturation, respirations or heart rate. The Resident was observed to be sitting on the side of the bed, appeared to be short of breath, asked for a breathing treatment and requested to have her shirt taken off due to it being tight. The Resident had a gown on, which she had a shirt on before that had been changed. Nurse S told her she had her gown on, and the shirt was changed. Nurse S was given the Resident's second medication for nebulizer treatment, Nurse S was not the Nurse who checked the medication record for the Resident or signed out the medication from the medication cart. Nurse S did not listen to lung sounds, monitor oxygen saturation or heart and respiratory rate. -At 10:00 AM, Resident #82 was given the second breathing treatment, Budesonide Inhalation Suspension, administered by Nurse S. The Nurse put the medication into the medication chamber of the nebulizer, instructed the Resident on how to turn on the machine. The Resident reported she could not turn it on, the Nurse showed her again how to turn it on, pulled the curtain and the Resident turned on the machine. The Nurse left the Resident to do the breathing treatment on her own without supervision. -After the second nebulizer was completed at 10:10 AM for Resident #82, Nurse S instructed the Resident to shut off the nebulizer. The Resident had not been observed during the administration of the medication. Nurse S listened to the Resident lungs at this time and got the oxygen saturation. On 10/29/24 at 2:20 PM, an interview was conducted with the Director of Nursing (DON) regarding concerns observed during the medication administration task of the survey. The nebulizer treatments for Resident #82 were reviewed of the Nurses not watching the Resident while administration of the medication. The DON was asked if the Resident had an evaluation to administer her own medication. The DON reviewed the Resident's medical record and reported the Resident did not. The DON indicated that the Nurse should observe the Resident getting the nebulizer treatment until completion. When asked about nebulizer treatment policy on assessment, the DON reported the Nurse was to check the lung sounds, pulse oxy (oxygen saturation), and pulse/respirations before and after the nebulizer treatment. A review of the facility policy received titled, Nebulizer therapy, small volume, revealed, .Obtain the patient's vital signs, assess the respiratory status, as ordered . As needed, assist the patient with applying the mouthpiece of mask, depending on the delivery system and patient-related factors, such as age and physical and cognitive ability .Remain with the patient and continue the treatment until the nebulizer begins to sputter. After treatment, obtain the patient's vital signs, assess the respiratory status, as instructed . 39059 Resident #50: On 10/27/24, at 12:03 PM, Resident #50 was sitting their wheelchair in their room. There was a plastic medication cup with numerous white pills in it sitting on their over bed table. Resident #50 moved about in their wheelchair toward the table, picked up the medication cup and took the medications. There was no nurse nor staff in the room. On 10/27/24, at 12:10 PM, Nurse F was standing at the medication cart down the hallway. Nurse F was asked if they were aware that Resident #50 had a cup of medications in their room that they consumed and Nurse F stated, Yeah. I just gave them to him. On 10/28/2024, at 11:30 AM, a record review of Resident #50's electronic medical record revealed an admission on 11/15/2022 with diagnoses that included Heart failure, chronic kidney disease and heart attack. A review of the care plans revealed no care planned intervention for self-administration of oral medications. On 10/29/24, at 9:15 AM, the Director of Nursing (DON) was alerted of the medication observation of Resident #50 on 10/27/24. The DON was asked to provide the medication administration policy. A review of the facility provided policy Medication Administration Last Revised 10/17/2023 revealed . Self-administration of medication will be reflected in the resident care plan along with any special considerations . 7. Observe that the resident swallows the oral medications. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication .

Based on observation, interview and record review, the facility 1) Failed to ensure that call lights were answered timely, with dignity, were within reach and needs were met timely, 2) Failed to provide assistance with feeding in a dignified manner, 3) Failed to ensure that food was a palatable temperature, offered substitution of meal items, and ensure the opportunity to eat in the dining room, and 4) Failed to ensure that residents could go outside for a confidential group of residents and Residents (#3, #15, #16, #29, #37, #44 and #64), resulting in complaints of frustration, unhappiness, delayed care with a likelihood of overall decreased quality of life. Findings include: On 10/28/24, at 2:00 PM, During the Resident Council task, the following complaints were voiced regarding not have healthy snacks and food choices: No fresh greens no fresh veggies no fresh fruit I dream about a beautiful red fresh tomato I would love a fresh ear of corn the meals are food of carbs if you want to gain wait, just eat the processed foods here you get the same thing for breakfast every day we want fresh cinnamon rolls the little butter packets are margarine we want real butter we don't want imitation cheese they run out of snacks they run out of honey buns you have to ask the CNA's for night time snacks and they say there isn't any The CNA's say they will go check for a snack but then they don't come back You have to go to the kitchen sometimes to get snacks you have to know who to go to, to get what you want we get a choice but you have to wheel your butt down there and make it you could tell your nurse or CNA but they're too busy to do it (referring to order slip for a different food choice They don't have time to little own do their job I can tell when my meds are late because I get tremors The following complaints were voiced regarding their care received and call light responses: I rang my buzzer. The girl that answered said, you listen, I'm doing the talking I want my meds on time, they're always late They don't have enough CNA's to take care of us adequately they pass the buck when they answer your call light they say well, I can't do that but let me get someone who can, and then they don't come back You end up having to put your call light back on after they cancel it because they don't come back sometimes, the CNA's work three sixteen hour shifts and we feel bad because they're tired They don't schedule enough CNA's They'll say just a minute or go on by the room You can hit the call light and wait 25 to 30 minutes, usually longer they come in and shut it off and say we'll be back in a minute and then they don't come back they rush in to turn it off the longest I've waited was 2 hours and I was sitting in soaked pants they say I don't have time right now they'll say I'm not qualified to do that but then still cancel the light If you can make it into the bathroom and pull the light down, that will get someone in there pretty quick there could be some improvements. You gotta wait a half hour to get to the bathroom A review of the facility provided . RESIDENT COUNCIL MEETING MINUTES FOR JULY 2024 revealed . As a group we discussed the call light times and all in attendance agreed that they have improved . A review of the . RESIDENT COUNCIL MEETING MINUTES FOR JUNE 2024 revealed no mention as to the complaints regarding call light wait times. A review of the . RESIDENT COUNCIL MEETING MINUTES FOR AUGUST 2024 revealed . Call light times. The majority agreed that they have improved and verbalized the understanding of times during meal times . A review of the . RESIDENT COUNCIL MEETING MINUTES FOR SEPTEMBER 2024 revealed . We discussed the call light times and staff answering them in a timely manner, all agreed that they have improved and the understanding of having to during meal times . On 10/29/2024, at 1:00 PM, Activity Director (AD) G was interviewed regarding the council minutes. AD G was asked why the minutes didn't mention the council members voiced concerns regarding call light wait times and AD G offered, the complaints were on different documents. The documents with the voiced concerns were not offered prior to exiting the survey. The following complaints were voiced regarding the ability to go outside and get fresh air: they lock the door when they don't want you to go out the front door is locked the door is screwed up and it's hard to get your wheelchair over the threshold The following complaints were made regarding the dining room being closed on the weekends: yes they do that often we're short staffed all the time on the weekends it's a problem because you have to eat in your room and when we get our room trays, they're cold yes. It's a problem when the dining room gets closed they could have told me the dining room was closed. I wheeled all the way down there to find out it was closed. I'm not real happy working on a skeleton crew On 10/27/24, at 11:35 AM, Anonymous facility staff H was interviewed regarding the dining room being closed for lunch. Anonymous Facility staff H was asked why the residents couldn't go to the dining room for lunch and Anonymous facility staff H offered, the dining room is closed because of low staffing. On 10/29/24, at 9:15 AM, the Director of Nursing (DON) was asked why the dining room was closed on day 1 (Sunday) of the survey for the lunch meal and the DON offered, that a nurse chose to close the dining room without calling management prior to making that decision. The DON was asked how often the dining room gets closed for meals and the DON offered, that the only time they will close the dining room would be if they had a music activity scheduled shortly after lunch time. On 10/29/24, at 12:57 PM, Activity Director (AD) G was interviewed regarding Resident Council complaints regarding not being able to go outside whenever they want to and that they complained the doors were often locked by maintenance. AD G offered the they thought door gets unlocked when the outside temperature was 70 or 72 degrees Fahrenheit. AD G planned to follow up with the residents to plan outside activities for cooler temperatures. On 10/29/24, at 2:48 PM, Certified Dietary Manager (CDM) I was interviewed regarding resident complaints of the facility provided food choices and items. CDM I was alerted of the complaints of no fresh fruit or veggies and CDM I offered the facility has celery and carrot snacks. CDM I was asked what fresh fruit the facility had in house for snacks and CDM I offered, bananas. CDM I denied having apples, oranges or grapes. CDM I was alerted of the complaints the facility didn't offer real butter and that the residents complained of the use of imitation cheese. CDM I offered I guess I haven't had anybody request real butter and that they do use Velveeta for the macaroni and cheese. 37771 Resident #15: A review of Resident #15's medical record revealed an admission into the facility on [DATE]. A review of the Minimum Data Set assessment revealed the Resident had moderately impaired cognition and needed setup or clean-up assistance with eating and oral hygiene and was dependent for other activities of daily living, mobility and transfers. On 10/27/24 at 12:23 PM, an observation was made of Resident #15 sitting up in bed with the head of the bed elevated. The Resident had a carrot in her left hand to help with contractures. When questioned the Resident said she can't use that hand. An observation was made of the call light positioned on the side of the left hand that had the carrot. When asked if she knew where her call light was, the Resident looked around and stated, I don't know where it is. When asked if the Resident used her left hand, the Resident reported she did not use that hand and did not raise the left hand when asked. The Resident was asked if she could reach over to get the call light that was positioned on the bed next to the lateral left hand. The Resident tried to reach for the call light but said she could not get it. The Resident was observed to have food on her clothing in the chest area and some food debris on her skin around her neck and there was food debris on her sheet that was across her abdomen. CNA P brought in the Resident's lunch tray, went to set the tray with the Resident and reported she would get a shirt protector, and change the Resident's sheet. When asked about the Resident's use of the left hand, the CNA reported the Resident did not use her left hand. When asked about the positioning of the call light by the outer aspect of the left hand, the CNA reported she had it clipped earlier to where the Resident could reach it and indicated the Resident must have moved it. The CNA went to get a shirt protector and reported she would change the Resident's sheet and clothing that was soiled from eating previously. Resident #16: A review of Resident #16's medical record revealed an admission into the facility on [DATE]. A review of the Minimum Data Set assessment revealed the Resident had intact cognition, needed setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene and was dependent with most other activities of daily living, mobility and transfers. On 10/27/24 at 1:00 PM, an observation was made of Resident #16 lying in bed and had her meal tray on the overbed table next to her. The looked like it had not been eaten except for what was on a small dessert plate. The Resident was asked about the meal. The Resident stated, That looks horrible, I can't eat it. Why don't they have better things?! The Resident expressed frustration at some of the foods that were served and explained, they had fish and French fries on Friday, reported the fish and the fries looked good, but they put a glob of stewed tomatoes, which she reported she would not eat those and stated the stewed tomatoes ran into everything, made everything soggy. The Resident expressed that she would like to see more fresh fruits and veggies and stated, We live in a farm country they have access to fresh stuff, why can't they get fresh cucumbers even. During the interview with the Resident, staff came in to pick up the tray. The Resident explained to the staff that she could not eat it and that she only ate the pie but just couldn't bring herself to eat what was on the plate. The staff did not ask the Resident if she wanted something else to eat. After the staff left with the tray, the Resident was asked if they offer alternatives. The Resident expressed that they just get what is served, don't have any choices to what comes, it just comes on a plate what ever they are cooking. If you don't like it then it's too much of a hassle, they have to go all the way down there and back, they are too short staffed for that. The Resident explained that she did not want the staff to have get other food items and stated, It's too hard for them to ask for something else. After the interview with the Resident, the staff that was picking up trays was approached. Dietary was asked why the Resident was not offered an alternative after she explained that she could not eat what was served. The Dietary staff reported that the Resident often declines but you are right, I should have asked her. The Dietary Staff returned to Resident #16's room and the Resident indicated she wanted a sandwich. Resident #29: A review of Resident #29's medical record revealed a reentry into the facility on [DATE]. A review of the Minimum Data Set assessment revealed the Resident had intact cognition, was independent with most activities of daily living, mobility and transfers, and needed partial/moderate assistance with ambulation and bathing. On 10/27/24 at 12:07 PM, an observation was made of Resident #29 eating lunch in his room. The Resident was dressed, in a wheelchair with their meal tray on the overbed table positioned in front of the Resident. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about any issues that they had with the care he received at the facility. The Resident reported they did not serve enough food, and he usually got more than this and indicated his meal tray. The Resident was asked if he was supposed to received larger portions. The Resident explained that he usually ate in the dining room, and he would ask for more of what he wanted. The Resident explained that the meal came up and he did not get larger portions. When asked why he did not go to the dining room to eat, the Resident stated, too short staffed, they said we had to eat in our room. The Resident reported that when he had to eat in his room that the food was not warm enough for his liking and stated, Food too cold that is an issue when we eat in our room. Resident #44: A review of Resident #44's medical record revealed an admission into the facility on [DATE]. The review of the Minimum Data Set assessment revealed the Resident had severely impaired cognition and needed setup or clean-up assistance with eating, substantial/maximal assistance with multiple areas of activities of daily living, was independent with roll left and right, and needed partial/moderate assistance with most other mobility and transfers. On 10/28/24 at 10:22 AM, an observation was made of Resident #44 lying in bed with the head of the bed elevated high up but not to 90 degrees. The Resident was sleeping and did not arouse with name voiced. The bed was in a low position. An observation was made of the call light on a bedside table. The call light was a push pad. The bedside table was up against the wall next to the resident's bed but was behind the raised head of the bed and not in reach for the Resident. The Resident was facing the wall with his face on a pillow that prevented him from having his face on the wall. The bed controller, that adjusted the height of the head of the bed, hung over the foot of the bed and not in reach for the Resident. Resident #64: A review of Resident #64's medical record revealed an admission into the facility on [DATE] and readmission on 6/10/24 with diagnoses that included need for assistance with personal care, muscle weakness, difficulty in walking, and anxiety disorder. A review of the Minimum Data Set assessment dated [DATE] revealed the Resident had intact cognition and needed substantial/maximal assistance with most activities of daily living, transfers and mobility. On 10/27/24 at 12:32 PM, an observation was made of Resident #64 sitting in their room. The Resident was interviewed, answered questions and engaged in conversation. When asked about any issues the Resident had with the care received while a Resident at the facility, the Resident reported that the food served in the room was not hot enough and discussed how the eggs often came cold, the soup was often lukewarm and by the time you got your food, the coffee was cold. The Resident complained of not getting enough fresh items like fruits and vegetables. When asked about other issues with their care, the Resident complained of the call light not answered for 45 minutes. The explained that sometimes pretty quick, but other times you wait a long time! A review of facility policy titled, Resident Rights, revised 5/14/24, revealed, 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 . 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 protection of resident health and safety . A review of facility policy titled, Call lights, revised 2/15/22, revealed, Policy: Call lights will be place within the guest's/resident's reach and answered in a timely manner. Procedure: .3. When a guest/resident is in bed or confided to a chair be sure the call light is within easy reach of the guest/resident . Responding to a Call Light: 1. Identify the location and answer the guest/resident promptly . 5. When finished, turn the call light off and replace the call light within guest's/resident's reach . 22348 During the dining room observation on 10/29/24 at 11:28 AM, residents R3 and R37 were observed eating in the dining room area. Observation 1: On 10/29/24 at 11:30 AM, during meal observation in the main dining room, R37 was observed eating independently on the table with no staff supervising or assisting close by her at the time. R37 was observed eating, trying to scoop the pudding with her fork, which was dripping as she tried to put the fork with the pudding into her mouth. R37 also used the same fork to eat her taco sandwich but was unsuccessful, and pudding was caught on her garment protector (bib). At 11:45 AM, a male certified nursing assistant (CNA) came with a chair, sat beside R37, and started assisting R37 with the Taco meat on a bun. Resident #37 (R37): R37 According to the facility's Electronic Medical Record (EMR), R37 was [AGE] years old and admitted to the facility on [DATE] with a diagnosis of Dysphagia in addition to other diagnoses. R37's Brief Interview for Mental Status BIMS Score dated 9/5/24 assessment was 02/15. A score of 0-7 indicates a patient's cognition is severely impaired. R37's Section GG of the MDS (Minimum Data Set), dated 9/5/24, indicated that R37 required set-up and clean-up assistance as the resident completed the activity. Section K for the MDS assessment on 9/5/24 was incomplete. R37 Care Plan for Eating and Nutrition indicated that R37 is a one-assist for meals. Assist to finish meals as needed. Provide diet as ordered. Observe and document food acceptance and offer substitutes as needed. Provide feeding/dining assistance as needed, including set-up, encouragement w/eating, and feeding PRN to optimize intake. R37 has a regular diet, mechanical soft texture, thin liquids: upright for all meals, alternate solids and liquids, check for pocketing, small bites, small sips, sippy cups, and scoop plate. It was updated on 10/29/24. Observation 2: On 10/29/24 at approximately 11:35 AM, R3 was sitting in his wheelchair and received feeding assistance with his lunch meal while the staff (MDS Nurse) was standing up, giving R3 a spoonful of food in his mouth. R3 was verified to receive the appropriate mechanical soft diet as ordered because of his diagnosis of Dysphagia. Resident #3 (R3): A review of R3's Electronic Medical Record revealed that R3 was [AGE] years old and admitted to the facility on [DATE], with the diagnosis of oropharyngeal Phase Dysphagia in addition to other diagnoses. R3's Brief Interview for Mental Status (BIMS) Score dated 10/2/2024 was 5/15. A score of 0-7 indicates a patient's cognition is severely impaired. Section GG of the MDS (Minimum Data Set) dated 7/3/24 indicated that R3 required supervision or touching assistance with eating (helper provides verbal cues or touching steadying assistance as the resident completes the activity. Section K for both MDS assessments for 7/3/24 and 10/2/24 were incomplete. On 11/29/24 at 2:00 PM, a review of R3's Care plan for Alteration in Nutritional Status r/t Dx of Oropharyngeal Dysphagia w/ needed for modified texture diet last revised on 7/8/24. It indicated for Staff will provide feeding and dining assistance, including a scoop plate, sippy cup, and soup spoon, to aid in self-feeding with setup. On 10/29/24 at 11:45 AM, it was verified by the Registered Dietician RD that RD observed the staff (MDS Nurse) was observed providing feeding assistance in an undignified manner, which is why she pulled a chair and placed it next to the staff to sit down when feeding R3. RD confirmed that the staff was standing up while feeding R3. The RD confirmed R3's name and the diet order status and identified the staff as the facility's MDS nurse.

Based on observation, interviews and record review, the facility failed to ensure sufficient nursing staff were available for a timely and adequate resident care for eight residents (R29, R38, R41, R61, R64, R80, R138, and Resident in room [ROOM NUMBER]B), of eight residents reviewed for adequate staffing resulting in long call light responses, unmet resident care needs, and late medication administration. Findings include: On [DATE] at 3:30 PM, a record review of Daily Staffing Assignment from [DATE] to [DATE] was reviewed with the staffing coordinator. Although there were daily call ins by staff, records and punch cards revealed that there was minimal staff assigned to each of the units because staff go through mandation or by volunteer for staffing coverages. For example, while accounting for staffing schedule per units, there was a daily trend of nurses filling some of the staffing shortages seen on days where there were call ins for license nurses. Some nurses work full their full shift (12.0 hours) plus another half a shift (6.0 hours) equivalent to 18.0 hours to cover or fill some call-ins for that day. Some Certified Nursing Assistants (CNA) work for 16 hours straight (2 shifts of 8.0 hours back-to-back) has been noted to cover some CNA shortages. Interview with the Staffing Coordinator on [DATE] at 11:05 AM revealed that the facility recently hired nurses. The shortage is due to the fact that five nurses quite at the same time. The staffing coordinator explained that the facility had to mandate nurses to stay extra more hours and have CNA stay another shift. Sometimes nurses stay for 18 hours and CNA's stay a double shift (16.0 hours). Daily shortage are covered by requiring them to stay over. Some nurses stay over and work as aides as needed. Resident #38 (R38): During the observation tour conducted at the 200 Hall on [DATE] at 1:00 PM, R38 got out of bed and was observed walking with an unsteady gait out in the hallway. The staff was busy and not in sight because they were in another room attending to another resident. The surveyor called for the nursing assistant's (CNA F) attention, and CNA F immediately took R38 back to her room. CNA F confirmed that R38 needed supervision when ambulating and will need her wheelchair for safety. CNA F explained that the other CNA in the unit is on lunch break, so she is by herself. It is just her, the nurse, and the housekeeper right now. A newly hired nurse who wished not to be identified was interviewed on [DATE] at 3:30 PM, stated that the ratio of 25 residents to one nurse is exhausting and heavy for 12 hours/shift providing medication, treatments, wound care, and other necessary special care need is jeopardized. We could not provide the quality of care especially the psychosocial aspect that the residents need as part of their daily care need. The residents deserve better care. 37666 Staffing Resident #80: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #80 was admitted to the facility on [DATE] with diagnoses: infected right knee after knee replacement, IV antibiotics, heart disease, anemia, GERD, and COPD. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities and needed assistance with care related to decreased mobility of the right leg. On [DATE] at 1:08 PM, Resident #80 was interviewed and she stated, The weekend staffing is bad; especially this weekend. They had 2 call ins. That is my only complaint; it takes a long time for them to answer your light. The resident said it was sometimes an hour before her light was answered. Resident #138: A record review of the Face sheet and electronic medical record/emr for Resident #138 indicated the resident was admitted to the facility on [DATE] with diagnoses: pancreatic cancer, right upper quadrant abdominal swelling, mass and lump, anemia, diabetes, anxiety, depression, malignant ascites (fluid buildup in abdomen), heart disease, right buttock Stage 2 pressure ulcer, left buttock Stage 3 pressure ulcer and GERD (gastroesophageal reflux disease). The resident was receiving Hospice services and died on [DATE]. On [DATE] at 11:30 AM, Resident #138 was heard moaning loudly from his room. Upon entry into his room, the resident was observed lying in bed and moving around. The resident said he was uncomfortable and had pain. He said he had pancreatic cancer and a lot of abdominal pain and motioned to his abdomen. Resident #138 was asked about the care he was receiving, and he stated, There's not enough staff. Sometimes it takes an hour for someone to come in; nights is worse. On [DATE] at 1:50 PM, Confidential Staff R said staff had called in over the weekend and it made it difficult to answer the call lights. Some of the staff working were trying to help on other halls in the building and were not available to care for their own assignments. 37771 An observation was made on [DATE] during the medication administration task of the survey of late medications administered and an interview regarding medications that had not been administered to Residents. The following interactions and observations included: -On [DATE] during medication administration observation, Nurse S and Nurse T were observed to be working together to administer morning medications to the Residents in the 500-hall unit. When asked, Nurse S indicated they were from the night shift and were asked to work over until staff came in. Nurse S was asked about how they accomplished the medication pass. Nurse S stated, one will pop (take out the medications from the bubble packaging) and one will deliver. The person signing for the meds does the popping, the other delivers the med. Helps to go faster. -On [DATE] at 10:05 AM, Nurse S reported she had stayed over on the 400-Hall until the Nurse came in for that hall and then came to help on the 500-Hall where Nurse T was staying over from the night shift until Nurse F came in for the day shift. When asked how often that happens that they are asked to stay over, Nurse S stated, They lost some Nurses and it left holes. -At 10:25 AM, Nurse F was observed during the medication administration task. Resident #78 had been given 11 medications with 8 of those medications given late that were scheduled at 8:00 AM. -At 10:33 AM, an observation was made of Resident #34 who approached the medication cart and informed Nurse F that she did not get her nasal spray and inhaler medication. Nurse F gave the Resident the Fluticasone nasal spray and the Wixela inhalation powder. On the computer, the Nurse had checked the Resident's list of medication, and the medication was documented as already given. When questioned, Nurse F reported that they were marked as given but knew the Resident and reported the Resident would know if she did or did not receive the medications. The medications were given late. -At 10:34 AM, an observation was made of Resident #75's medication administration by Nurse F. The Resident received 10 medications late that were scheduled at 9:00 AM and one medication, Miralax, that was not given to the Resident. -At 10:58 AM, Nurse F was questioned about the late medications. The Nurse indicated she had come in late, and the nightshift Nurse had stayed over. When asked how many Residents she had left to pass medication on that had late medications, the Nurse opened the computer screen and counted 12 Residents that were colored in red. The Nurse stated, 12 late meds right now. An interview with Confidential Staff was conducted regarding staffing issues. The Staff revealed that the facility does not have enough staff and nursing staff get mandated. When asked how often you get mandated, the staff replied, more then we should, and expressed concern of Nurses doing 12 hour shifts then asked to stay over to cover the next shift. When asked how long the Nurses were working, the Confidential Staff reported they would have to wait until someone else came in with variable times of up to 6 hours. The staff indicated there was holes in the schedule that were not filled and issues when someone calls in. The Confidential staff indicated issues with medications not passed timely and Nurses working too many hours and too many days in a row. Residents' concerns with long call light response times and insufficient staffing. Resident #29: On [DATE] at 12:07 PM, an observation was made of Resident #29 eating lunch in his room. The Resident was dressed, in a wheelchair with their meal tray on the overbed table positioned in front of the Resident. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about any issues that they had with the care he received at the facility. The Resident reported they did not serve enough food, and he usually got more than this and indicated his meal tray. The Resident was asked if he was supposed to received larger portions. The Resident explained that he usually ate in the dining room, and he would ask for more of what he wanted. The Resident explained that the meal came up and he did not get larger portions. When asked why he did not go to the dining room to eat, the Resident stated, too short staffed, they said we had to eat in our room. The Resident reported that when he had to eat in his room that the food was not warm enough for his liking and stated, Food too cold that is an issue when we eat in our room. Resident #41: On [DATE] at 12:43 PM, an observation was made of Resident #41 sitting in a chair with Family member U assisting with Resident eating. The Resident and Family Member were interviewed, answered questions and engaged in conversation. The Resident and Family Member were asked about any concerns related to care received by the facility. The Family Member indicated long call light wait times and stated, she has had to wait more than a half an hour, at times and reported insufficient staffing, short of help especially on the weekends. Resident #64: On [DATE] at 12:32 PM, an observation was made of Resident #64 sitting in their room. The Resident was interviewed, answered questions and engaged in conversation. When asked about other issues with their care, the Resident complained of the call light not answered for 45 minutes. The explained that sometimes pretty quick, but other times you wait a long time! Resident #61: On [DATE] at 11:55 AM, an interview was conducted with Resident #61. The Resident was asked about any concerns they had about the care received at the facility. The Resident reported a concern with insufficient staffing and stated, They are so short staffed, they quit and don't hire more. When asked about call light wait times, the Resident reported two hours was the longest, usually its about 20 minutes, sometimes more then 30 minutes. The indicated needing assistance with getting cleaned up and changed.

Based on observation, interview and record review the facility failed to ensure a medication error rate of less than 5% when 23 medication errors were observed for four residents (#35, #75, #78 and #82) from a total of 69 opportunities, of seven residents observed for medication administration, resulting in an error rate of 33.33% with the potential for adverse reactions related to the omission of medications and medications not administered timely with the potential of ineffective medication therapy and the exacerbation of medical conditions. Findings include: On 10/29/24 at 8:42 AM, the Medication Administration task of the survey was started. The following were observed: Resident #82: -At 9:42 AM, Nurse T was observed to prepare Resident #82's medications by removing the pills from the blister packets. Nurse S was observed to prepare the insulin. Nurse S uncapped the needle of the syringe, inserted the needle into the insulin vial, extracted the insulin and when completed with getting the amount needed from the vial, the Nurse recapped the insulin syringe with the cap that was between her 5th digit and palm of her hand. The Insulin syringe had a guard that could be extracted to cover the needle without having to recap the needle. -Nurse S gave the medications that were prepared by Nurse T to Resident #82. -Resident #82 did not receive Fenofibrate 67 mg (milligrams) as scheduled at 9:00 AM and did not receive Diclofenac external Gel 1% to affected area topically three times a day for pain, scheduled at 9:00 AM. When asked, Nurse S indicated the medication had not been sent by pharmacy and was not available in the back up medication supply. -Nurse S and Nurse T were observed to be working together to administer morning medications to the Residents in the 500-hall unit. When asked, Nurse S indicated they were from the night shift and were asked to work over until staff came in. Nurse S was asked about how they accomplished the medication pass. Nurse S stated, one will pop (take out the medications from the bubble packaging) and one will deliver. The person signing for the meds does the popping, the other delivers the med. Helps to go faster. Resident #78: -At 10:25 AM, Nurse F was observed during the medication administration task. Resident #78 had been given 11 medications with 8 of those medications given late that were scheduled at 8:00 AM. Resident #34: -At 10:33 AM, an observation was made of Resident #34 who approached the medication cart and informed Nurse F that she did not get her nasal spray and inhaler medication. Nurse F gave the Resident the Fluticasone nasal spray and the Wixela inhalation powder. On the computer, the Nurse had checked the Resident's list of medication, and the medication was documented as already given. When questioned, Nurse F reported that they were marked as given but knew the Resident and reported the Resident would know if she did or did not receive the medications. The medications were given late. Resident #75: -At 10:34 AM, an observation was made of Resident #75's medication administration by Nurse F. The Resident received 10 medications late that were scheduled at 9:00 AM and one medication, Miralax, that was not given to the Resident. -At 10:58 AM, Nurse F was questioned about the late medications. The Nurse indicated she had come in late, and the nightshift Nurse had stayed over. When asked how many Residents she had left to pass medication on that had late medications, the Nurse opened the computer screen and counted 12 Residents that were colored in red. The Nurse stated, 12 late meds right now. On 10/29/24 at 2:20 PM, an interview was conducted with the Director of Nursing (DON) regarding concerns observed during the medication administration task of the survey. When asked what time Resident #82 had come back to the facility on [DATE], a review of the medical record was conducted and the DON indicated late afternoon about 3:45 PM. The two medications had not been received from the pharmacy, but the other medications had been received, leaving the two medications, Fenofibrate and Diclofenac Gel not available for the Resident to have but were scheduled for administration. Resident #34 complained that she did not receive her inhaler and nasal spray, the Nurse administered the medication that had been signed out by another Nurse that the Resident received the medication was reviewed with the DON. The DON indicated the Nurse should have made sure by calling the Nurse that left to find out if they were given or not. It was reviewed with the Director of Nursing of a total of 23 errors that were observed during the medication administration task of medications that were not available and medications administered late.

Based on observation, interview and record review, the facility 1) Failed to ensure that ongoing surveillance for signs and symptoms of infectious illnesses in residents was collected, documented, analyzed and reported and 2) Failed to ensure that Transmission-Based Precautions were identified and Personal Protective Equipment/PPE was worn when indicated, hand hygiene was performed, when necessary, needles were not recapped, personal items were labeled with residents' names in shared bathrooms, and hair nets were readily accessible without risk of cross-contamination in the kitchen, resulting in a lack of compliance with infection prevention and control standards of practice which could result in exposure to infectious organisms and an outbreak of illnesses. Findings Include: FACILITY Infection Control On 10/29/24 10:10 AM, during an interview with Infection Prevention and Control/IPC Nurse A she said she began the IPC role in June 2024. Reviewed with the IPC Nurse on 10/27/2024 at 1:09 PM, a Contact Precaution sign was on the door of room [ROOM NUMBER]/Resident #80. Nurse N was observed walking into the room without performing hand hygiene or Donning/applying Personal Protective Equipment/PPE equipment. The IPC said there were two residents in Contact Precautions, and neither was in room [ROOM NUMBER]. The IPC said Resident #80 in room [ROOM NUMBER] was supposed to be in Enhanced Barrier Precautions and PPE would not be required to enter the resident's room. The IPC did not know Resident #80 had a Contact Precaution sign on the door. She stated, She had knee replacement, with some rejection and infected hardware; she's been on IV antibiotics. Reviewed with the IPC the resident's diagnosis list said MSSA (Methicillin Sensitive Staph. Aureus) and a nurse made a progress note that said MRSA (Methicillin Resistant Staph. Aureus). The IPC Nurse A reviewed the resident's medical record and said Nurse S had incorrect documentation in Resident #80's chart. She said Nurse S had documented MRSA which would require Contact Precautions and the use of PPE to enter the resident's room. The IPC showed a hospital document in the resident's medical record that listed MSSA; the IPC said that Contact Precautions were not needed for MSSA. She said she would make sure correct precautions were identified for Resident #80. During the interview with IPC Nurse A on 10/29/2024 at 10:20 AM, Infection Surveillance was reviewed. The IPC Nurse said if a resident was on antibiotics, then they were added to the Surveillance Report in the computer program. When asked for an Infection Line List, the IPC provided a monthly Infection Surveillance Report that was not a Line list. The document was separated by infection type and only contained Resident infections that were treated with an antibiotic. The Director of Nursing/DON entered the room and said she thought there was an Infection Line list in the computer program. The IPC showed a computer screen that had the residents with antibiotics listed. The screen had several residents to a screen, and it was multiple screens long. The DON said the form could not be printed out. There was no way to see all of the data at once. The data was then pulled out into reports. During the interview with the IPC Nurse and DON, on 10/29/2024 at 10:30 AM, they were asked if they were tracking resident's with signs and symptoms of infection to aid in preventing the spread of infection to other resident's, staff and visitors. They said they were monitoring the residents who were prescribed an antibiotic. The IPC was asked how she became aware of a resident with a potential infection and she said she looked at the antibiotic reports and residents started on antibiotics were reviewed in the morning meeting. The facility was not monitoring residents with signs and symptoms of infection on the Line Listings until they were prescribed an antibiotic, which could potentially lead to an outbreak. The report received from the facility titled, Infection Surveillance Monthly Report provided a monthly running total of infections, by category and listed the residents, infection and antibiotics. There was no identification of infectious organisms to track potential spread. In April 2024, there were 4 Urinary Tract Infections/UTI's identified in the report:1 resident was admitted with the UTI and infectious organisms were identified, although there was no room number for the resident. For the other 3 UTI's there was no identified organism. July 2024 identified 5 UTI's with one present on admission. There were no identified infectious organisms for the 5 UTI's. The facility was identifying there was an infection but was not analyzing the cause or potential results. On 10/29/2024 at 11:45 AM, the IPC provided an untitled printed document dated 7/24/2024-9/25/2024, that did not include resident last names and included those residents' receiving antibiotics. Some of the residents had identified infectious organisms listed and some did not. Some had room numbers listed and some did not. The untitled document identified 4 infections with Enterobacter cloacae: 2 wounds, 1 osteomyelitis and 1 UTI. It was not identified if the Enterobacter cloacae was a Multi-Drug-Resistant Organism/MDRO. The residents were not matched to the infection, and it was not reviewed on the Infection Surveillance Monthly Report. The untitled document also identified 6 infections with Escherichia coli/E. coli: 2 wounds and 4 UTI's. There were also 2 Klebsiella pneumoniae infections: 1 wound and 1 UTI. It was not identified if the organisms were MDRO's or to which resident they belonged and was not reviewed on the Infection Surveillance Monthly Report. A review of a U.S. Department of Health and Human Services: Centers for Disease Control and Prevention/CDC, Resource titled CRE: Carbapenem-resistant Enterobacterales/CRE, provided . Enterobacterales is an order of gram-negative bacteria that includes some organisms commonly identified in clinical microbiology laboratories, like Escherichia coli and Klebsiella pneumoniae . Common Enterobacterales Species: Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Citrobacter freundii, Serratia marcescens . Carbapenems are last-line antibiotics used to treat serious multidrug-resistant infections. In the United States, about 2-3% of Enterobacterales associated with healthcare-associated infections are resistant to carbapenems. CRE infections don't respond to common antibiotics and invasive infections are associated with high mortality rates . Who is at Risk: Hospital patients and long-term care facility residents . A review of the Centers for Disease Control and Prevention's CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in all Settings, dated April 12, 2024 provided the following: Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered . APIC (Association for Professional in Infection Control and Epidemiology) Text: Surveillance, revised publication January 17, 2024 provided, . Surveillance can be defined as a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the healthcare team to assist in improving those outcomes. Surveillance is an essential component of an effective IPC program. Infection surveillance is a process that includes review of both laboratory data and clinical data to allow for identification of specific infection types . A review of the facility policy titled, Infection Prevention Surveillance, origination date 8/1/2010 and last revised 9/29/2023 provided, The Infection Preventionist does surveillance of infections among residents and employees . Review of culture reports and other pertinent lab data, chart review, review of the 24-hour report, or morning stand-up meeting and walking rounds throughout the facility . Surveillance Symptoms Considerations: All symptoms must be new or acutely worse . a new symptom or change from baseline may be an indication that an infection is developing . 39059 On 10/27/24, at 11:25 AM, an observation of room [ROOM NUMBER] was conducted, there were numerous unlabeled personal items in the bathroom including toothpastes, soaps, lotions and mouthwashes. On 10/27/24, at 11:40 AM, An observation of room [ROOM NUMBER] was conducted, there were multiple unlabeled personal items in the bathroom including, toothpastes, brushes, and a denture cup. Resident in A bed offered, yes, we both use the bathroom. On 10/27/24, at 11:49 AM, Resident #26 was sitting in their room. There were multiple unlabeled personal items in the bathroom including a plastic cup with a toothbrush. Resident #26 offered, yes, we both use the bathroom. Resident #26 was asked if they brush their teeth in the bathroom and Resident #26 offered it was his toothbrush and quickly added, I hope he doesn't use my toothbrush. On 10/28/24, at 9:26 AM, Resident #53 was in their shared room. There were multiple unlabeled personal items in the bathroom including shaving creams, combs, lotions, mouth washes and toothbrushes. On 10/28/24, at 1:31 PM, an observation of a contact isolation room [ROOM NUMBER]. Nurse F was observed inside room [ROOM NUMBER] with no personal protection equipment (PPE) on. Nurse F provided the resident in bed A medications, left out of the room back to their medication cart without performing hand hygiene. Nurse F was asked which resident was in contact isolation and Nurse F stated, (the resident) and pointed to the resident in A bed. Nurse F was asked if they needed to wear PPE and Nurse F stated, No only if we're doing care. Nurse F was asked to clarify the isolation sign on the door was in fact a contact isolation sign and Nurse F reviewed the sign, did not respond and continued at their medication cart. On 10/29/24, at 10:52 AM, an observation of CNA E in room [ROOM NUMBER] was conducted. CNA E assisted the resident in B bed. CNA E was sitting on the bed without a gown on. 37771 On 10/29/24 at 8:42 AM, the Medication Administration task of the survey was started. The following were observed: -At 9:42 AM, Nurse T was observed to prepare Resident #82's medications by removing the pills from the blister packets. Nurse S was observed to prepare the insulin. Nurse S uncapped the needle of the syringe, inserted the needle into the insulin vial, extracted the insulin and when completed with getting the amount needed from the vial, the Nurse recapped the insulin syringe with the cap that was between her 5th digit and palm of her hand. The Insulin syringe had a guard that could be extracted to cover the needle without having to recap the needle. -At 11:05 AM, an observation was made of Nurse B giving insulin from a vial to a Resident. The Nurse was observed to draw up the correct amount of insulin and then pull the plastic sleeve over the needle. When asked if the needle should be recapped, the Nurse reported no, you should never recap a needle and explained how the sleeve went over the needle and if twisted then would lock into place which was to be done once the insulin was given to the Resident. On 2/29/24 at 2:20 PM, an interview was conducted with the Director of Nursing (DON) regarding concerns observed during the medication administration task of the survey. A review of the recapping of the insulin syringe was reviewed with the DON who indicated they should not be recapping the needle. 22348 Kitchen Observation During observation tour conducted on 10/27/24 11:29 AM ,the afternoon cook toured the surveyor and observed that the hairnets were not readily available at the entrance of the kitchen. There were 2 entrances that staff can enter the kitchen. Door 1 is where the dietary/kitchen employees enter and door 2 is where the kitchen staff go fin and out of the kitchen to the dining room area. Both doors did not have a box of hairnets or a hairnet dispenser. When the afternoon cook was queried, she stated that they keep all hairnet supplies in their chemical room. When the afternoon cook was ask to show the surveyor, the afternoon cook brought the surveyor into the soiled utility chemical storage room where the keep chemical supplies and dirty used janitorial supplies including dirty dustpans and brooms. The afternoon cook walked the surveyor through how one obtain a hairnet. from the employee door entrance Door 1, the kitchen staff would have to pass through the clean kitchen prep area with their street clothes and hair passing by the clean kitchen area. Then they enter the chemical room where all the dirty janitorial supply are kept and put the hairnet on. Then the surveyor asked where they go to wash hands after touching their hair and put on the hairnet. The afternoon cook walked the surveyor through where the employees wash their hands was to cross the clean food prep table again to get to the sink on the opposite side of the room from the chemical room where the store all the hairnets. When asked since when have they been without the dispenser of have the hairnet by the door before entering the kitchen? The afternoon cook said it has been over 6 years or so. When queried about sanitation and infection control and prevention, the afternoon cook stated, that's why I bring home my own hairnet and wear them before coming to work. The afternoon cook was asked if all staff wear their hairnets when working as part of the protocol, she said yes. Then she continued to describe that kitchen staff go through the employee Door 1, cross the clean food prep table area with no hairnet, take the hairnet out from the box in the chemical room, put them on their street contaminated hair, then cross the clean food prep table again to get to the sink to wash their hands and sanitize. The surveyor continued to ask, Do they have to cross the clean food prep area twice before their hair is covered and hands sanitized? The afternoon cook replied by saying yes. The dietary manager (on 10/27/24 at around 12:30 PM, confirmed that the hairnet was kept in the dirty chemical room. When discussed about crossing the clean area twice to get obtain the hairnet and wash/sanitize the hands, the CDM agreed of the cross contamination and that is where the employee wash their hands. The surveyor requested a copy of the hairnet and hand washing policy at 12:45 PM No policy was submitted upon request related to hairnet use and appropriate storage for hairnets. However, the Hand Hygiene Policy (Effective date 10/11/2023) was reviewed. Policy: To decrease the risk of transmission of infection by appropriate hand hygiene. Hand washing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects .

Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that residents' rooms, were clean, uncluttered, and in good repair, resulting in an unhomelike physical environment, with electric razors plugged in and resting over the back of toilets, chairs in disrepair and residents' rooms with drywall gouges and holes in the walls. Findings Include: FACILITY Environment On 10/27/2024 at 12:35 PM, Resident room [ROOM NUMBER] was observed to have large gouges and holes in the wall. When a Confidential Resident was asked about the damaged wall, the resident stated, They were going to fix it and didn't. I've been here since the beginning of the year. The gouged and open areas were near the head of the bed behind the chair and on the other side of the room on the opposite wall. 39059 On 10/27/24, at 11:22 AM, an observation of room [ROOM NUMBER] was conducted. There was an approximate 1-foot square of chipped drywall. On 10/27/24, at 11:40 AM, An observation of room [ROOM NUMBER] revealed an approximate 10 inch by 2-foot area with chipped drywall. On 10/27/24, at 11:25 AM, an observation of room [ROOM NUMBER] revealed, Resident #66 was sitting in their chair. The fan was pointed toward the resident and was on. The fan had a large amount of dusty buildup. The room smelled of urine. The bathroom floor was dirty and sticky with dried urine. There was an electric shaver plugged in and resting on the back of the toilet. The cord was long and appeared to be able to reach the toilet water. On 10/28/24, at 9:18 AM, an observation of room [ROOM NUMBER] revealed the shaver remained plugged in and resting on the back of the toilet. Resident #66's fan was off and remained with dusty build up. On 10/29/24, at 10:07 AM, an observation of room [ROOM NUMBER] revealed an electric shaver plugged in resting on the back of the toilet in reach of the toilet water. CNA E was asked if they normally store the electric shavers plugged in so close to the toilet water and CNA E offered, we normally put them away but it was running out of battery. A review of the facility provided Resident's Personal Property Last Revised 9/22/2023 policy revealed . Residents are permitted to keep reasonable amounts of personal clothing and possessions for their use while residing in the facility. Residents' property will be kept in a safe location that is convenient to the resident .

Based on observation, interview, and record review, the facility failed to follow up on advanced directives with the proper POA signature of DNR consent and ensure that the care planning matches the desired code status for 2 residents (Resident #47 and Resident #71) of 2 residents reviewed for code status resulting in lack of accurate assessment and documentation of code status and the potential for a resident to receive life-sustaining medical treatment against their wishes. Findings include: Resident #47(R47): Advance Directives According to the Electronic Medical Record (EMR) reviewed on [DATE] at 3:30 PM, R47 was admitted to the facility on [DATE] with the diagnosis of Unspecified Dementia, Psychotic Disorder with Delusions, General Muscle Weakness and the need for assistance with personal care in addition to other diagnoses. According to the face sheet, R47's daughter is the established Power of Attorney (POA). R47's Brief Interview for Mental Status (BIMS) Score is ,d+[DATE]. A ,d+[DATE] score indicates that the person has severe cognitive impairment. The Do-Not-Resuscitate Order Form was reviewed dated [DATE] for R47 was reviewed. A physician's signature was noted, dated [DATE]. However, the nurse wrote the co-advocate's name and noted phone date as [DATE]. There was no follow-up signature of the POA, and I was not given the right to sign the DNR papers. [DATE] 10:27 AM The DNR Order was not signed or validated by the guardian/POA. A Physician's order in R47's EMR dated [DATE], No CPR/DNR. (No Cardiopulmonary Resuscitation/Do-Not-Resuscitate) R47's care plan is a full code dated [DATE], which does not match the DNR Form. The care plan was never revised to match according to the DNR Order Form signed by the physician on [DATE]. The Care Plan's intervention was not followed: > Code status will be reviewed upon readmission, quarterly, significant change in condition, and at the resident's or responsible party's desire. (initiated and created on [DATE]) > The facility representative will attempt to contact the responsible party/emergency contact in emergencies. (initiated and created on [DATE]) > The facility will make attempts to sustain life in emergency situations. (initiated and created on [DATE]) Resident #71 (R71): Advance Directives A review of R71's EMR on [DATE] at 10:15 AM revealed R71 was [AGE] years old and admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease, Dysphagia, muscle weakness (generalized), and the need for assistance with personal care. BIMS score of ,d+[DATE] dated [DATE] Minimum Data Set Assessment. A ,d+[DATE] score indicates that the person has severe cognitive impairment. R71's Code Status Form was reviewed, and the DNR Order dated [DATE] (Do not resuscitate was selected. No signature was obtained from the healthcare legal decision maker, but the legal guardian's name was written and noted: phone consent dated [DATE], signed by witnesses (2 nurses) on [DATE]. The physician signed the order dated [DATE]. The Care Plan for R71 is a DNR initiated on [DATE] with the following interventions: c Advanced directives will be honored in emergency situations (Initiated and created on [DATE]) c Code status will be reviewed upon readmission, quarterly, significant change, and at the desire of the resident or responsible party. On [DATE] at 10:30 AM, the DON was queried on the DNR Process and obtaining an actual signature from the guardian. She stated she would check on how they obtain the actual signature by phone after the verbal. The DON was unsure how long the verbal authorization was valid per policy. She verified that both R71 and R47 had a discrepancy in the code or no code status and that verbal consent by phone was written on the form regarding Do Not Resuscitate. The DON validated that the DNR Order form did not have an actual signature by the Power of Attorney or Guardian. Advanced Directive Policy was reviewed on [DATE] at 3:30 PM. The Policy revealed: Title: Advance Directives- Michigan Effective Date: [DATE]. Policy:A. Recognition of Resident Self Determination. The Facility is committed to the promotion of the well-being of our Residents. We recognize each residents right to refuse treatment, to live a dignified life, and to self determination, which includes the right to refuse care and to formulate advance directive regarding future care . B. Non Descrimination. We will not descriminate against and Resident or potential Resident on the basis of race, sex, religion, age, handicap or because of a Resident's choice regarding cardiopulmonary resuscitation (CPR), or whether the Resident has signed an advanced directive . Procedures: Generally .B. Obtain Documents. Copies of Advanced Directives will be obtained from the Resident and or family and placed in the medical record. If applicable, A DNR Order will be signed and placed in the medical record. C. Cognitively Impaired Resident Unable to Make Medical Decisions with a Duly Executed Advanced Directive and DNR . The facility shall: >Determine the legal healthcare decision maker (i.e. DPOA-HC or guardian) . >Complete a DNR form if necessary. >Place copies of all paperwork in the Resident's chart. Review the Resident's advance directives quarterly and capacity at least annually and with any significant mental status changes. > If a DNR was requested it is re-signed annually, if still requested . Definition: . D. Do-Not Resuscitate Order (DNR). A DNR is a written document in which the Resident expresses his/her wish that if his/her breathing and heartbeat cease, the Resident does not want to be resuscitated. Unlike DPOA and living Wills, under certain conditions DNRs may also be requested by a patient advocate or a guardian, as well as the Resident themselves. A DNR becomes effective upon signature.

Based on observation, interview and record review, the facility failed to ensure comprehensive revised care plans for four residents (#26, #47, #53 and #68) out of five residents reviewed for care planning, resulting in unassisted unsafe ambulation, unassessed nutritional needs with the likelihood of unmet care needs and code status and the potential for a resident to receive life-sustaining medical treatment against their wishes. Findings include: Resident #26: On [DATE], at 9:24 AM, Resident #26 ambulated from the bathroom to their bed. Resident #26 was not assisted, was not wearing shoes and was not using any Assistive device. Resident #26 leaned forward and grabbed the foot of the bed. They used the bed for support to ambulate around to the right side of the bed where they sat down. On [DATE], at 11:04 AM, a record review of Resident #26's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes, History of falling, legally blind and Urostomy. Resident #26 required assistance with Activities of Daily Living. A review of Kardex as of [DATE] revealed no mention as to how much assistance Resident #26 required for ambulation and transfers. A review of the care plans revealed no intervention listed as to what assistance or any Assistive device the resident required for ambulation and transfers. Resident #53: On [DATE], at 12:57 PM, an observation of Resident #53 in their room. There was an electronic machine on their nightstand. There was a sticky note attached with certain cardiac information listed. On [DATE], at 11:00 AM, a record review of Resident #53's electronic medical record revealed an admission on [DATE] with diagnoses that included Paroxysmal Atrial Fibrillation, Diabetes and Left bundle branch block. A review of the care plan Focus (the resident) is at risk for cardiac complications r/t multiple cardiovascular diseases: Heart Failure, CAD, HTN, Pacemaker, Atrial Fibrillation, Lymphedema Date Initiated: [DATE] . Goal (the resident) will be free from s/sx of cardiac complications through the review date . There was no mention as to the pacemaker [NAME] machine at the bedside. On [DATE], at 2:20 PM, Resident #53 offered they weren't sure the name of their cardiologist and that the machine was for their pacemaker. Resident #53 offered that they had a cardiac ablation and that if they called their wife she would have all the information needed for the machine and the heart doctor. Resident #47(R47): Care Plan Advance Directives According to the Electronic Medical Record (EMR) reviewed on [DATE] at 3:30 PM, R47 was admitted to the facility on [DATE] with the diagnosis of Unspecified Dementia, Psychotic Disorder with Delusions, General Muscle Weakness and the need for assistance with personal care in addition to other diagnoses. According to the face sheet, R47's daughter is the established Power of Attorney (POA). R47's Brief Interview for Mental Status (BIMS) Score is ,d+[DATE]. A ,d+[DATE] score indicates that the person has severe cognitive impairment. The Do-Not-Resuscitate Order Form was reviewed dated [DATE] for R47 was reviewed. A physician's signature was noted, dated [DATE]. However, the nurse wrote the co-advocate's name and noted phone date as [DATE]. There was no follow-up signature of the POA, and I was not given the right to sign the DNR papers. [DATE] 10:27 AM The DNR Order was not signed or validated by the guardian/POA. A Physician's order in R47's EMR dated [DATE], No CPR/DNR. (No Cardiopulmonary Resuscitation/Do-Not-Resuscitate) R47's care plan is a full code dated [DATE], which does not match the DNR Form. The care plan was never revised to match according to the DNR Order Form signed by the physician on [DATE]. The Care Plan's intervention was not followed: > Code status will be reviewed upon readmission, quarterly, significant change in condition, and at the resident's or responsible party's desire. (initiated and created on [DATE]) > The facility representative will attempt to contact the responsible party/emergency contact in emergencies. (initiated and created on [DATE]) > The facility will make attempts to sustain life in emergency situations. (initiated and created on [DATE]) Resident# 68 (R68): Care Plan Wound Management A review of the Electronic Medical Record EMR on [DATE] at 3:30 PM revealed that R68 was [AGE] years old and admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease with Early Onset Type 2 Diabetes Mellitus and Major Depression. R68's Brief Interview for Mental Status BIMS score was ,d+[DATE] and assessed on [DATE]. His Care Plan for at-risk for impaired skin integrity was last revised on [DATE]. One of the interventions specified: > Observe skin with showers/care. Notify the nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, or discoloration noted during bath or daily care. > Conduct weekly head-to-toe skin assessments and document and report abnormal findings to the physician. During the tour observation on [DATE] at 02:11 PM, R68 complained about his bedside chair being in disrepair and needed to be replaced. R68 revealed he asked more than a week ago, and the reason why was he had cuts all over the left forearm due to the broken part on the chair (observed that a piece of the handle broke with an exposed metal sticking out) of the arm of the chair. He stated, It has a sharp edge and cuts my arm. On [DATE] at approximately 3:30 PM. R68 was found sitting in a wheelchair after a shower in front of the nurses' station with at least six other residents around him. It was noted that his left forearm was bleeding, dripping from a scabbed open area. The new nurse orientee was alone, passing pills. When alerted, she confirmed the area was bleeding and said she would take care of the bleeding arm immediately. During the interview with DON the following morning, [DATE], at 09:28 AM, the surveyor inquired with the Director of Nursing DON regarding R68's bleeding arm. The DON discovered after a review of records from yesterday, [DATE], that: 1. There was no record of assessment or nursing note documented related to the left forearm bleeding/cut of R68 found on [DATE] at 2:30 PM. 2. There is no incident report or investigation as to the cause of the cut and bleeding. 3. No treatment order was documented for R68 from yesterday's date [DATE]. 4. No care plan related to skin impairment was updated When the treatment started on [DATE], there was NO documentation of any wound assessment, and treatment in place No care plan update or revision was noted on [DATE] as conformed with the DON on [DATE] at 10:30 AM. The nurses' notes were reviewed on [DATE] at 4:01 PM, and the nurses' notes were entered on [DATE] at 10:55 AM. Note Text: Assessed area Left arm. Noted to have a scabbed area that is intact. No s/s of infection. Resident denies pain or discomfort at this time. A wound treatment order was entered on [DATE] at 1900. The new order was to Cleanse the scabbed area to the left posterior arm with normal saline. May cover with dry dressing if drainage is present. Monitor for s/s of infection. The facility's Skin Management Policy was requested on [DATE] at 10:30 AM and was reviewed at 4:00 PM. It indicated that 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. Ongoing monitoring and evaluation are provided to ensure optimal guest resident outcomes. 39059

This Citation pertains to Intake Number MI 728. Based on observation, interview and record review, the facility failed to provide adequate supervision and implement appropriate interventions to prevent falls for one resident (Resident #7) of three residents reviewed for falls, resulting in numerous documented self-transfers and four unwitnessed falls in a 45 day period, a pelvic fracture and the likelihood for more falls. Findings include: On 2/10/20, at 11:58 AM, Resident #7 was sitting in their wheelchair in the doorway into their room with their bedside table pushed up in front of them which had their lunch tray on top. CNA K was standing to the right side, leaning over Resident #7 and was assisting with a bite of their meal. CNA K was asked if they normally assist Resident #7 in the doorway and CNA K stated, yeah, so when we are going person to person, we can keep track of her. She likes to jump into bed. On 2/11/20, at 9:30 AM, a record review of Resident #7's electronic medical record revealed an admission on 5/31/2017 with [DIAGNOSES REDACTED]. Resident #7 had severely impaired cognition and required assistance with Activities of Daily Living (ADL's.) A review of the ADL Self Care Performance Deficit and requires assistance with ADL's and mobility r/T (related to) Dizziness and Giddiness . Staff reports that res is self transferring Date Initiated: 05/31/2017 . Revision on 06/08/2018 . Interventions . TOILET USE: Resident is a two assist. Assist to BR q (every) 2 hours and prn. (as needed) Date Initiated: 06/20/2017 . Revision on: 02/03/2021 . Encourage resident to use bell to call for assistance. Date Initiated: 06/20/2017 Created on: 06/20/2017 . A review of the at risk for falls r/t decreased mobility, antidepressant use, hx (history) of falls, decreased safety awareness. Date Initiated: 05/31/2017 Created on: 05/31/2017 . Revision on: 08/31/2020 . (the resident) will be free of injury related to falls through the review date . Interventions 15 min safety checks Date Initiated: 08/13/2018 Created on: 08/13/2018 . Revision on: 09/10/2018 . Anticipate and meet needs PRN. Date Initiated: 11/15/2020 . Encourage and educate resident to use call light and wait for assistance. Date Initiated: 01/02/2021 . Encourage resident to use call light for help. Date Initiated: 02/21/2019 . Sensor call light Date Initiated: 11/17/2020 . A review of Resident #7's Incident and Accident Report revealed the following falls: 12-19-20 . 8:45 am . Location Resident Room . Type of A/I (accident/incident) Observed on floor . No Injury . Res observed sitting on floor between w/c (wheelchair) + (and) bed sitting up right (with) back leaning against chair. Res had one hand/arm on w/c & one on bed . Interventions Implemented . place Res in door way during meal time . Fall Summary: Observed on the floor (unwitnessed) . What type of assistance was guest/resident receiving at time of fall? . Self Transfer and None were check marked. 12-29-2020 . 7:25 pm . Location Resident Room . Type of A/I Observed on floor . No Injury . observed on buttock with arms at sides, back resting on bed frame and both legs bent up at knees in front of her stated she was trying to go to the bathroom . Interventions Implemented . All Safety measures are in place and were followed. Request med review from pharmacy - therapy aware . Fall Summary: Observed on the floor (unwitnessed) . Attempting to self-transfer . What type of assistance was guest/resident receiving at time of fall? None was check marked. 1-2-21 . 9:30 pm . Location Resident BR (bathroom) . Type of A/I Observed on floor . No Injury . Resident observed sitting on her buttocks in her bathroom with her hands on safety rails attempting to pull self up with her left side on the side of the toilet with wheelchair on her right side. No injuries . Interventions Implemented . Encourage and educate resident to use call light and wait for assistance Is on therapies notified Post Void Residual . 7 day B 7 B (bowel and bladder) tracking form . Fall Summary Observed on the floor (unwitnessed) . Attempting to self-transfer . What type of assistance was guest/resident receiving at time of fall? Self Transfer . was check marked. 2-1-21 . 8:30 pm . Location Resident Room . Type of A/I Observed on floor . Type of injury . c/o pain R (right) hip . bump posterior R head . Observed resident lying on floor on her R side @ (at) the doorway between bed A & wall. Golf ball sized raised area posterior R head. Ice pack applied. AROM (active range of motion) c/o pain to R hip when bearing weight on it . Physician statement . obtain x-ray to R hip & pelvis. Send to (local hospital) for evaluation & tx (treatment) - Returned (with) pelvic Fx (fracture.) . Interventions Implemented . Medication Review . Investigation initiated. (the resident) has severe cognitive impairment (with) BIMS (brief interview of mental status) of 3 (and) is unable to recall incident. Denies any fear of any staff member . Staff observed 10 mins (minutes) prior in bed (with) call light . Fall Summary Observed on the floor (unwitnessed) . What was the guest/resident doing during or just prior to fall? Ambulating . What type of assistance was guest/resident receiving at time of fall? . Self Transfer was check marked. A review of progress notes revealed Resident #7 consistently attempted self-transfers prior to their fall causing their Pelvic Fracture. The progress notes revealed the following: 12/17/2020 02:57 resident was yelling for help. When staff went in there, resident was attempting to self transfer. Resident was told to wait for assistance and to use call light . 12/31/2020 11:42 . cont (continue) to self transfer . safety education complete several times, res states understanding of information . 1/3/2021 10:02 . res attempting to self transfer this morning, safety education repeated, res states understanding followed by I have never fallen. 1/15/2021 04:48 Resident self transferred several times to the bathroom, education provided behavior continued . 1/31/2021 02:36 Resident self transferred several times to the bathroom, education provided behavior continued . 2/1/2021 18:46 Resident very active today, self transferred several times, looking for her husband, believes that she just came from Texas, attempted to redirect, with some success, taken to activities for monitoring A review of EXTRA VISIT NOTE DATE OF SERVICE: 02/02/2021 . On night of 02/01/2021 the patient fell while trying to go to bathroom. I did talk to the nursing staff. The patient apparently already had gone to the bathroom and because of her underlying confusion and dementia she will try to go on her own without calling the nurse resulting in fall, mechanical . Assessment 1. status [REDACTED]. 2. Dementia Alzheimer's type getting progressively worse . Signed by Physician P. On 2/12/21, at 1:00 PM, a phone interview with Restorative Nurse A was conducted regarding Resident #7's numerous attempts of self-transfers and falls. Nurse A was asked what interventions the facility had implemented. Nurse A stated that they toilet her every two hours and perform fifteen-minute checks. Nurse A was asked how the fifteen-minute checks kept Resident #7 safe and Nurse A stated, She is fast. We have stopped falls during the fifteen-minute checks. A review of the facility provided Fall Management Policy, Revised 10/2019, revealed The facility will identify hazards and guests/resident risk factors and implement interventions to minimize falls and risk of injury related to falls . when a guest/resident is found on the floor, a fall is considered to have occurred . Guests/residents at risk for falls will have an initial plan of care developed to meet each guest/resident's needs. Interventions should relate to the risk factors as well as incorporating guest/resident's choice to help minimize the risk of a fall .

Based on observation, interview and record review, the facility failed to provide assessment, monitoring and appropriate wound care for 1 resident (#26) and ensure wound care was completed for 1 resident (#88) of 3 residents reviewed for wounds, resulting in Resident #1 developing a large right leg wound with no assessment or wound measurements for approximately 2 months, to ensure an appropriate treatment was provided, and Resident #88 did not have the ordered treatment applied to their wound, which could further lead to a lack of healing and worsening wounds. Findings Include: Resident #26 During the initial tour on 11/20/19 11:45 AM, Resident #26 was sitting in her wheelchair in her room and pointed to her right lower leg and stated, I have had a few sores on my lower leg for a few weeks. The resident said she was supposed to receive a dressing twice a day to the leg. She said she received a shower that morning stating, They put a wrap on it and will change it Friday to something else. The resident was observed to have 3+ [MEDICAL CONDITION] to both lower legs and feet; her legs were discolored purple. Resident #26's feet were on the floor. They were not elevated to aid in relieving the [MEDICAL CONDITION] and there were no footrests on the wheelchair. Resident #26 stated, I put them on the bed. I don't want them on the floor. I could use them; I have 2 bad knees. A review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #26 indicated the resident was admitted to the facility 12/4/14 with Diagnoses: [REDACTED]. The MDS dated [DATE] revealed Resident #26 had full cognitive abilities and needed assistance with bed mobility, transfers, ambulation, toileting, dressing and bathing. A review of the resident's Care Plan titled . at risk for skin breakdown due to decreased mobility/generalized weakness and incontinence . created 10/30/15 and revised 7/9/18 with Interventions: Apply [MEDICATION NAME] (lotion for dry skin) to bilateral legs (every night), initiated 7/9/18, Apply compression stockings on bilateral legs during the day take off at night, initiated 4/19/17, Check placement of the [MEDICATION NAME] wound dressing (every shift) to the medial right lower leg, initiated 9/26/19, (Normal Saline) cleanse the area to the medial right lower leg. Topically cover the area with a [MEDICATION NAME] wound dressing. Change (every night and as needed), initiated 9/12/19, Administer treatments as ordered and observe effectiveness, initiated 10/30/15. There was no mention of a wound on the left leg. A review of the progress notes revealed the following: Progress note dated 9/15/19 at 9:56 PM, Cleanse open areas x 2 to left anterior leg, cover with ABD (pad) and Kerlix (wrap) if any drainage, every shift for left leg [MEDICAL CONDITION] x 2. No open areas. Total Body Skin Assessment, dated 9/25/19 at 2:41 AM, Continues to have Stage 2 to outer area of right leg. Treatment in place in TAR (Treatment Administration Record) . Continues to have discoloration to (bilateral) lower legs. Skin Wound Progress Note, dated 9/26/19 at 3:18 PM, Assessed area to the medial aspect of the right lower leg. Upon assessment there is a open area that measures approx. 1.5 cm x 1.0 cm. The area is a skin tear. The base of the wound is pink. There is a small amount of drainage noted . EMAR Medication Administration Note, dated 11/8/19 at 10:42 AM, Profor Miscellaneous Apply to bilateral lower legs topically one time a day every Friday for [MEDICAL CONDITION] until 11/11/19 apply each Friday for 2 weeks, remove on Sundays contacted pharmacy, awaiting availability . EMAR Medication Administration Note, dated 11/15/19 Left lower leg wound cleansed with (normal saline) Profor wraps applied per order. EMAR Medication Administration Note, dated 11/15/19 at 7:26 PM, . bilateral leg pain . The last skin/Wound progress was dated 9/26/19 at 3:18 PM, by Nurse A, Assessed area to the medial aspect of the right lower leg. Upon assessment there is a open area that measures approx. 1.5 cm x 1.0 cm the area is a skin tear. The base of the wound is pink. There is a small amount of clear drainage noted. Treatment in place and care plan updated. Several of the progress notes mention a left leg wound, but the resident's wound was on the right leg. There was no mention in the medical record of how the resident obtained a skin tear to the right lower leg and some of the notes referred to the area as a stageable pressure ulcer. There was no consistency of care. During an interview with Wound Nurse A on 11/21/19 at 3:15 PM, she was asked about the resident's complaints of pain to her right lower leg and she confirmed the resident was having increased pain. Nurse A also confirmed 9/26/19 was the last documented wound measurements for Resident #26's right lower leg and stated, We don't usually measure for a skin tear. Asked if the wound was healing, I don't know. I haven't seen it. The physician orders were reviewed with the Wound Nurse as a new order was written on the night shift early am approximately 2:40 AM because the resident had increased drainage from the wound; Nurse A confirmed a new order was written but had not recently seen the wound. On 11/21/19 at 3:30 PM, Resident #26's wound was observed with Wound Nurse [NAME] She removed the kling wrap and [MEDICATION NAME] dressing on the right lower leg. There was +3 hard [MEDICAL CONDITION] from knee to foot, the leg was dark purple in color. The dressing had a moderate amount of serosanguinous (bloody yellow) drainage. No odor. The wound was large, round and red with defined margins. The Wound Nurse stated, It's much larger. It has worsened. I'm going to measure it and change the dressing to include collagen. The nurse measured the wound at 7.0 cm length x 5.0 cm width with 0.1 cm depth. The nurse applied a dressing of collagen powder on a [MEDICATION NAME] pad and Kerlix wrap and stated to the resident, It's much worse. It's a lot bigger. I'm glad I looked at it. I'm going to look at it next Monday and keep an eye on it. I will talk to the doctor about it. The Wound Nurse confirmed the resident was supposed to have a compression wrap to the lower legs, but there was still an order for [REDACTED]. Resident #88 A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #88 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss and needed assistance with all care. On 11/21/19 2:50 PM, Resident #88 was observed lying in bed. Nurses K and L were preparing to change the resident's wound dressing to her coccyx. When the nurses repositioned the resident to her side, there was no dressing in place on the wound. Neither nurse was aware the resident's dressing was not present. Nurse K stated, Maybe it came off when the aides were providing care. The nurses were asked if any staff had told them the dressing came off with care and both said, No. The nurses said they did not know how long the dressing had been off the wound. During the wound care observation, Resident #88 was observed to have 2 open areas on her coccyx; one area was larger than the other. They were approximately 0.5 length x 0.5 cm width and 1.0 length x 1.0 width. Both were observed to have depth, but without measurement. The wounds were dark red on the inside and both had small white areas on the edges of the wounds. The nurses did not know if it was slough or what it was. The nurses said the Wound Nurse (A) usually completed the wound measurements. On 11/21/19 at 3:20 PM, an Wound Nurse A was interviewed about the wound and stated, I see the wound weekly and measure it. A review of the progress notes and wound documentation revealed a Skin/Wound Progress Note dated 11/19/19 at 10:34 AM: The area to the sacrum (unstageable pressure injury) measures approx. 2.0 cm 0.2 cm. The base of the wound is pink with granulated tissue throughout. There no odor or drainage noted. The skin around the peri-wound appears as scar tissue . will continue with current treatment . A review of the physician orders provided: Normal Saline cleanse the area to the coccyx. Topically apply collagen powder to the base of the wound and cover with a mediplex ([MEDICATION NAME]) wound dressing. Change (every other day) and PRN (as needed). Every day shift every other day for Unstageable Pressure Injury, order date 10/29/19. 11/22/19 at 2:30 PM, during an interview with the Administrator, she was asked about the lack of assessment and monitoring of Resident #26's wound and said, The facility is in a period of transition and some staff are still getting used to their roles. When discussing Resident #88's lack of a dressing to the coccyx wound, she said, I don't know why that wasn't there. We will find out. A review of the facility policy titled, Skin Management, dated 5/2010 and revised 8/2016 provided, Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes .

This citation pertains to Intake Number MI 238. Based on observation, interview and record review the facility failed to prevent sexual abuse of two residents (Resident #4 and Resident #6) out of four residents reviewed for sexual abuse, resulting in psychosocial harm. Findings include: On 5/6/2019 at 4:40 PM it was reported by Resident #6 that Resident #5 touched Resident #4's breast. During an interview with the Nursing Home Administrator (NHA) on 9/25/2019 at 2:54 PM a facility reported incident pertaining to sexual abuse involving Resident #4, Resident #5 and Resident #6, the NHA stated, This incident was substantiated. To me (Resident #5) had intent. He had cognitive impairments. The police were contacted and there has already been one court date and the trial is coming up. He was one-to-one from the time of the incident until his discharge. According to Admission Record, printed on 09/26/2019, Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #4's Minimum Data Set (MDS) Resident Assessment completed on 8/13/2019, her Brief Interview for Mental Status (BIMS) score was 05/15, indicating her cognition was not intact. According to Admission Record, printed on 09/26/2019, Resident #6 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #6's MDS Resident Assessment completed on 2/13/2019, her BIMS score was 15/15, indicating her cognition was intact. According to the Admission Record, printed on 09/26/2019, Resident #5 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #5's MDS Resident Assessment, his BIMS score was 15/15, indicating his cognition was intact. Review of Resident #5's care plan revealed a focus area for actual behavior problem, initiated 5/7/2019. The focus area noted a resident-to-resident incident on 5/6/2019 and also noted episodes of yelling/screaming out, and verbally aggressive behaviors directed towards others including use of words [***] and [***] . Resident #5's care plan also noted that he is at risk for adverse reactions and side effects (related to) receiving multiple [MEDICAL CONDITION] medications (initiated 2/26/2019). Resident takes: Trazadone and [MEDICATION NAME]. According to Prescriber's Digital Reference (www.pdr.net) trazadone and [MEDICATION NAME] have the adverse effect of increased sex drive. Resident #5's care plan did not include interventions or goals related to sexual behaviors (masturbation, touching) until post-incident 5/6/2019. Review of Resident #5's Behavior Monitoring log for (MONTH) 2019, it was documented that Resident #5 exhibited Sexually Inappropriate behavior on 5/28/2019. It was documented on the log that the Kardex/individual service care plan interventions relating to the behavior were effective. Upon interview with Safety Nurse C on 9/25/2019 at 3:17 PM, Resident #5's behavior log was reviewed. When asked what the Sexually Inappropriate behavior was on 5/28/2019, Safety Nurse C, reviewed Resident #5's log and progress notes and stated, It doesn't say what the sexual behavior was but he was known to masturbate. Review of Resident #5's Kardex did not reveal interventions/guidance specific to masturbation or Sexually Inappropriate behavior. Resident #5's care plan included an intervention to Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Review of Resident #5's progress notes did not include documentation of the Sexually Inappropriate behavior or the potential causes of the behavior that occurred on 5/28/2019. Further review of Resident #5's progress notes did not reveal any documentation of sexually inappropriate behavior during his stay (except the incident 5/6/2019) but did reveal a pattern of escalating verbal aggression leading up to the incident on 5/6/2019 and post incident: 4/21/2019: Resident sitting at nurses station visiting being very confrontational with staff and residents. Another resident asked to make a phone call which we directed him that we will help him later. Resident again began to swear telling this resident that he can use his phone. I told him thanks but we can't allow that. Again he became belligerent toward staff and running me and the rest of the staff down to other residents. The behavior note did not include the underlying potential cause, intervention or response to intervention. 5/1/2019 at 13:37: behaviors noted last couple of weeks. Aggression and resistance during care (contracted psychological services) evaluated 4/30/2019, recommended to adjust time of trazadone and take full dose at (bedtime), started on [MEDICATION NAME] (every) am for mood stability. 5/1/2019 at 19:24 detailed the charge nurse reviewed (psychological services) recommendations with Resident #5's doctor, the doctor stated, He won't be happy, He's going to do what he wants. 5/2/2019 at 17:58: Resident at the nurses station complaining about how we changed his medication all around stating I can just [***] ing kill somebody . states I'm going [***] ing crazy .told resident I can relay concerns about meds to the Dr. This note did not include response to intervention used. 5/4/2019 at 04:28: .upset yelling and swearing at staff. This note did not include documentation of potential cause, intervention used or response to intervention. 5/4/2019 at 15:02: Resident asking staff members and other residents, if (resident) could live with them. This note did not include documentation of potential cause, intervention used or response to intervention. 5/6/2019 at 18:45: At 440 pm resident was in 400 hall lounge and (Resident #6) went into the hallway and reported that resident was touching another resident (Resident #4) breast .at 500 pm I borrowed her [***] ing mirror and I might have touch her [***] ing tit. I told him that is not what was reported. He then stated, what that woman that don't even know her [***] ing name . 5/6/2019 at 19:58: .I brushed her tit, don't worry she didn't have much there anyway 5/7/2019 at 10:27: .social services and the resident met .(Resident #5) states I was in there talking with .(Resident #6) .about marriage and I said boy would I love to feel them tits. I asked if I could and she said to go for it. Then all of the sudden she said never mind. I told her you can't do that, she still wouldn't let me so I said forget it. Then there was another old lady in there that had a mirror, I needed it so I went to use her mirror then gave it back.asked if he touched the resident, he said no, not her. 5/7/2019 at 18:13: .cena (certified nurse assistant) that was 1 on 1 with him states that in the dining room resident grabbed her hand and made some statement about her boyfriend . This note did not include documentation of potential cause or response to intervention. 5/7/2019 at 18:43: while resident was 1 on 1 with female cena he grabbed her hand, kissed it and told her she had a beautiful body . This note did not include documentation of potential cause or response to intervention and was not documented on his behavior log. 5/8/2019 at 15:15: Resident was propelling past another resident that was walking past he thought that resident called him a name. He then said [***] you, you [***] ing[***] then went to the front lounge call other people vulgar names. This note did not include documentation of intervention used or response to intervention. 5/8/2019 at 16:47: Resident in room and yelled out to resident (#6) and called her a [***] ing snitch. This note did not include documentation of potential cause or response to intervention. 5/9/2019 at 14:47: (Resident) flipped off someone while going past the activity room when going to happy hour. Cena unsure of who. This note did not include documentation of potential cause or response to intervention. During an Interview with Safety Nurse C on 9/25/2019 at 3:17 PM the facility reported incident report and police report were reviewed. Safety Nurse C stated she reviewed the video footage and put together a detailed report of what she saw because she couldn't record the footage and it self-deletes after a certain number of days. Safety Nurse C stated You cannot see inside the lounge, but you can see who goes in and out of the lounge. Safety Nurse C explained the incident: Resident #4 was lounging on the couch. Resident #6 was sitting in the chair in the lounge. Resident #5 wheeled himself back from the dining room and initiated conversation with Resident #6. He asked Resident #6, Do you want to be my wife and go back to my room? Resident #6 said No. Resident #5 attempted to grab Resident #6 and touched her flannel shirt. Resident #5 told Resident #6 that's okay I'm going to go over to that lady. Resident #5 wheeled over to Resident #4 who always carries around a mirror. He asked Resident #4 if he could use her mirror. Resident #4 gave it to him. According to Resident #6 he ran his fingers through his hair and looked in the mirror. He gave the mirror back to Resident #4. Resident #6 said she witnessed Resident #5 use his hand to go round in circles on her breasts with a squeezing motion. Resident #6 stated she heard Resident #4 say No. Resident #6 also said she saw that Resident #4 kept trying to get up and couldn't because Resident#5's wheelchair was there. Resident #6 got up to get staff and staff immediately separated the residents. During the interview, Safety Nurse C stated that upon post incident interview with Resident #5, he said I brushed her tit when I gave (the mirror) back. Safety Nurse C also stated that Resident #4 initially recalled the incident and demonstrated the action to her upon interview post incident. She took her hand and rubbed it in a circular motion over her breasts. She just kept saying, You're not going to let him do that no more. Upon interview with Resident #4 on 9/26/2019 at 2:45 PM she could not recall the incident. A reasonable person would experience psychological harm from being sexually assaulted. Upon interview with Resident #6 on 9/26/2019 at 3:00 PM she recalled the incident as detailed above. Resident #6 explained that Resident #5 touched her shirt but said she is fine and has been to court once already to tell them what she saw. Facility Abuse Prohibition Policy dated Revised 7/2018 read, Each resident shall be free from abuse .mistreatment .Abuse shall include freedom from verbal, mental, sexual .abuse .it is the responsibility of all staff to provide a safe environment for the residents .Abuse can be resident to resident .Abuse means willful infliction .intimidation .resulting in .mental anguish. It includes verbal abuse, sexual abuse Willful, as used in this definition of abuse means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm .sexual abuse is non-consensual sexual contact of any type with a resident. Examples .A resident forcefully requires another resident to participate in a sexual act Staff will be instructed to report any signs of stress from an other individuals involved with the resident that may lead to abuse .and intervene as appropriate.

This citation pertains to intakes MI 227 and MI 258. Based on observation, interview and record review, The facility failed to 1) ensure 2 residents (Residents #1 & #2) were free from verbal and physical abuse (verbal abuse and physical abuse from staff to resident on 8/10/18 and on 8/11/18), 2) ensure staff reported resident abuse in a timely manner and 3) ensure the safety of Resident #2 after an allegation of staff to resident abuse was reported of 4 residents reviewed for abuse, resulting in an infected skin tear (on Resident #2's left lower leg/skin and bruises on Resident #1's left middle area rib area and left upper arm) with the potential for fear of staff, anger, decreased resident to staff interactions, isolation and sleep disturbances. Findings Include: Resident #1: Review of the Face Sheet, Minimum Data Set ((MDS) dated [DATE], Care Plans dated 7/18, Psychiatric evaluation dated 7/9/18 and Electronic Medical Record (EMR), revealed Resident #1 was a [AGE] year-old resident, confused with a BIMS (cognitive assessment, a score of 15 is alert) of 9, and of 11 7/25/18, had a history of [REDACTED]. The resident's [DIAGNOSES REDACTED]. Review of the facility Incident Report dated 8/12/18, revealed on 8/11/18 at 3:15 a.m., Nursing Assistant/CNA G assisted CNA H to reposition Resident #1 in his bed. In front of Resident #1 CNA G stated to CNA H, you know how much I hate that Mother F-----; lifted the residents legs and intentionally dropped them on the footboard causing a skin tear. Observed fresh skin tear to left shin and red mark to right shin, police report made (Case #1801). Review of the facility nurse's notes dated 8/11/18, stated Informed (Family Member) of residents' skin tears on anterior shins during transfer, (Physician) notified of skin tears to bilateral shins. No nursing assessments or measurements were documented regarding the residents' skin tear and red mark on his shins. Review of the physician order [REDACTED]. Apply steri-strips prn (as needed). Review of the physician order [REDACTED]. Steri-strips prn. Monitor and report any s/s of infection. Review of the physician order [REDACTED]. Steri strips prn. Monitor and report any s/s of infection. Review of the physician order [REDACTED]. Monitor and report any s/s of infection. Observation of Resident #1 was done on 8/22/18 at 12:30 p.m., he was sitting in his wheelchair in his room. The resident had a dark black scabbed area approximately 2 inches in length and ½ inch in width covered with a dressing on his left lower leg/shin area. The area was noted to be slightly red on the outer edges with no drainage noted. NO red marks were noted on the resident's right skin. The resident was un-able to be interviewed due to decreased cognition. During an interview done on 8/22/18 at 8:00 a.m., CNA H stated She (CNA G) came in at 3:00 a.m., early. (Resident #1) was face down on his bed, he self-transferred on to his bed. I asked for help and (CNA G) came in and she stated, you know how much I hate that Mother F-----. She (CNA G) had showered (the resident) prior and (the resident) had punched her in the head weeks prior to this incident. I said this is our job, this is what we do; she (CNA G) didn't say anything. She (CNA G) grabbed (the resident) by the back of the pant legs and swung his legs over his bed and just let go of his legs. (Resident #1's) legs hit the foot board hard. I then said ok, just help me boost (the resident) in the bed, (the resident) was still on his stomach. So, she (CNA G) tried to grab his arms and I said No, use the pink pad (a lift pad). She (CNA G) left a little after 5:00 a.m. (the incident occurred on 8/11/18 at 3:15 a.m.), she worked the floor, she was assigned to (Resident #1) until they (charge nurses) contacted the Administrator. When this surveyor asked CNA H was she did not ask CNA G to leave the residents room when she swore at him she stated, I didn't have anyone to help me and I wanted him safe; now I think I should have asked her to leave. CNA G was observed abusing Resident #1 verbally and physically at 3:15 a.m. and was not sent home until approximately 2 hours later. CNA G continued to work with the resident she had abused (on 8/11/18) after being observed abusing him for approximately 2 hours; the facility did not ensure resident safety after staff to resident abuse was witnessed. Review of the All Staff meeting held on 8/6/18, the Nurse Educator L note's stated, Responding (to an allegation of staff to resident abuse): intervene, ensure the person safety, do not leave with abuser, they must leave, get help, report suspicions and allegations, immediate! (the employee accused of resident abuse must leave the facility immediately and report all abuse allegations immediately). Review of the All Staff meeting (held on 8/6/18) signatures revealed CNA G had attended. During an interview done on 8/22/18 at 10:10 a.m., CNA G stated I heard (CNA H) say we need some help in (Resident #1's room). I went to (the residents) room, I saw (the resident) was laying diagonally face down on his bed, he self-transferred. When I walked in, CNA H was standing over (the resident) laughing at him. I looked up in the air and said, what the F---; I was up-set with her (CNA H) for laughing. I never flipped (the resident) off. I picked up (the residents) legs underneath his calf's and straightened his legs out; I didn't drop his legs. The DON and Administrator never said a word about a skin tear and bruising to me. She (CNA H) got snippy with me and said you know he (the resident) goes to bed at 3:00 a.m. I worked until 5:15 a.m. (on 8/11/18 after being accused of staff to resident abuse at 3:15 a.m.), when (Nurse LPN M) came up to me and said, I talked to (the DON) and you have to leave. I worked 2 hours after the incident (on 8/11/18) on the same hall. When this surveyor asked CNA G if she was burnt out, she stated, probably. Review of CNA G's facility statement dated 8/13/18, stated she (CNA G) walked in room (CNA H) was standing over (Resident #1) laughing, cracking-up. (The resident) was face down, laying diagonally off the bed. Stated she (CNA G) was pissed (CNA H) was laughing at (the resident). Stated, I tilted my head up in the air and stated, what the F---. Stated to her (CNA H said CNA G) he goes to bed at 3 in the morning and you should have had him (the resident) in bed. She (CNA G) grabbed both legs and swung feet on bed. Denied (CNA G) denied swearing and flipping off when asked; did say when asked if (the residents) legs came in contact of (with) foot board, yes. Review of the facility Electronic Clock-In and Clock-Out time record dated 8/11/18, revealed CNA G clocked into work at the facility on 8/11/18 at 2:54 a.m. and clocked out at 5:18 a.m., for approximately 2 hours and 3 minutes after being observed abusing Resident #1, CNA G worked with residents in the facility and was not sent home immediately. During an interview done on 8/22/18 at 1:55 p.m., Nurse LPN M stated The nurse on the other side (Nurse F) came over and asked me what to do at approximately 3:30 a.m. to 4:00 a.m. This was approximately 15 minutes to 45 minutes after CNA G was accused of staff to resident abuse involving Resident #1; a delay in calling the Administrator and removing CNA G from the facility. During an interview done on 8/22/18 at 7:30 a.m., Nurse LPN F stated (Resident #1) had punched her (CNA G) in the forehead when she was giving (the resident) a shower. (CNA H) came to me and told me that they (CNA's G & H) went in the room (the residents room on 8/11/18) and said (CNA G said to the resident), we all know how much I love this Mother F-----. (Resident #1) was hanging off the bed and she (CNA G) flipped him off. Then (CNA G) picked up (the residents) legs and plopped his legs into bed. I interviewed (the resident) and did the body assessment and I found a fresh skin tear on the left skin a quarter size. The right skin had a red mark about the size of a half a dollar, she (CNA G) had dropped his legs on the foot board, now they (the residents skin) have gotten worse. Review of CNA G's facility Termination dated 8/16/18, revealed she was terminated on 8/15/18 due to violation of category III work rule #41. Review oaf the facility Employee Hand Book dated 4/20/18, stated on page 15, Employees may not physically, verbally emotionally, or psychologically abuse a resident. Review of CNA G's facility Disciplinary Action Record dated 1/15/18, revealed the CNA had been given a written Warning regarding an incident on 1/4/18, for not reporting an allegation of abuse made by a resident in a timely manner to management. Resident #2: Review of the Face Sheet, MDS dated [DATE], Care Plans dated 2/1/18 and EMR, revealed Resident #2 was an [AGE] year-old resident, admitted to the facility on [DATE], extremely confused with a BIMS of 1, and requiring staff assistance with all ADL's with close monitoring due to behaviors. The resident's [DIAGNOSES REDACTED]. Review of Resident #2's Mood and Cognitive care plans dated 2/1/18, revealed staff were to make eye contact with all communications, keep routines regular, use engaging approaches with the resident, anticipate needs, assist in decision making and use non-pharmacological interventions to decrease mood exacerbations. Review of the facility Incident Report dated 8/13/18 (the incident occurred on 8/10/18), revealed on 8/10/18 at approximately 1:15 a.m., revealed Nursing Assistant/CNA I had reported an allegation of staff to resident abuse involving Resident #2 and CNA E. CNA E held Resident #2 down on their bed and contained them to their room. As a result, CNA E left bruises on the residents left upper arm and left mid-rib area. The facility Incident report dated 8/13/18, stated There was a large bruise on LT (left) lateral rib area and sm (small) purplish bruise on LT posterior upper arm. (CNA D) observed incident and reported to (Nurse LPN C). (CNA D) informed DONE at 2:40/p (2:40 p.m., the incident occurred on 8/10/18 at approximately 1:15 a.m.) 8/10/18. Conclusion, two bruises noted upon assessment, police report made (Case #1800). (Nurse LPN C and CNA E) employment was terminated 8/14/18. Review of the nurse's notes dated 8/10/18, stated Resident noted to have 1 x 1.4 CM (centimeters) pink/purple bruise to LT (left) bicep (upper arm). LT lower posterior rib noted to have a purple 12 x 13 CM bruise. Review of the facility picture of Resident #1 that was taken on 8/10/18, given to this surveyor on 8/22/18, by the Safety/Rehab Nurse LPN K, revealed a small blue/purplish bruise on an upper arm and an elongated darker blue/purplish bruise on the rib area. Review of the physician order [REDACTED]. Observation of Resident #2 was done on 8/22/18 at 1:30 p.m., she was in her room. The resident had an irregularly shaped light blue/greenish bruise on her upper left arm, approximately 1/2 an inch. The resident also had a 1 inch in length purple bruise on her left mid-rib area. The resident was very confused and was unable to be interviewed. During an interview done on 8/22/18 at 8:50 a.m., Nurse LPN C stated The facility terminated me because I did not call the Administrator when I was told of resident abuse. I could hear (Nursing Assistant/CNA E) and (Resident #2), I could hear (CNA E) raise her voice to the resident. (Nurse LPN I) and I heard (CNA E) raising her voice, yelling at (Resident #2). (Resident #2) had taken some blue booties from another resident and put them on the soiled linen cart in the hallway. (CNA E) took them away from her (the resident). The resident was up-set and (CNA E) got up-set when the resident started hitting her (CNA E), she did hit (CNA E), she did not hurt her. I heard her (CNA E) aggressiveness and say, stop it. I said to (Nurse I), I suppose I should go down there and stop it. I was at the nurse's station with (Nurse I), we were approximately 50 feet away. (Nurse I) said, when they (CNA E) and other staff) take her back to her (the resident) room and sit her on her bed she will eventually go back to sleep. This is the way we do it, (Resident #2) had not been sleeping lately, she had recently fallen and was sent to the hospital. I noticed when (CNA E) was mandated to stay over (facility mandated the CNA E to work an extra 4 hours past her regular schedule on 8/10/18), she was frustrated, it did show-up in her care that night. She (CNA E) was mandated to stay over 4 additional hours and she didn't feel good. (CNA E) did work that night after she tex'd the DON (Director of Nursing/DON) to see if she could go home at the end of her shift. (CNA D) had come up to me and said she thought (CNA E) was rough and abusive to the resident. I had it in my mind that this was between the two CNA's. (CNA D) did ask me if I had talked to (CNA E), I said not yet. I did not talk to (CNA E) because I thought it was a rivalry between the two CNA's. (CNA D) was right across the hallway and witnessed the incident, she told me she saw it. Review of Nurse C's facility statement dated 8/10/18, stated at approx. (approximately) 1:45 a.m., (CNA D) stated to her (CNA E) was abusive, she was hitting (Resident #2) and was yelling at her. Stated (Nurse C) she felt (CNA D) was eager to get (CNA E) in trouble because (CNA D) was up-set that she was moved halls at 11pm. Review of Nurse C's facility Termination dated 8/14/18, stated An allegation of abuse was reported by a CNA (to Nurse C) at approximately 1:30 a.m. on 8/10/18. Facility administration was made aware of the allegation by the reporting CNA on 8/10/18 at approximately 2:40 a.m. Nurse C did not follow facility policy 1:201.00, and immediately send CNA E home following an allegation of abuse, contact the Administrator and begin the investigation, category III Work Rules #63. Review of CNA E's facility Termination dated 8/15/18, revealed she was terminated on 8/14/18 due to violation of category III work rule #41. Review of the facility Employee Hand Book dated 4/20/18, stated on page 15, Employees may not physically, verbally emotionally, or psychologically abuse a resident. Review of the facility Abuse Prohibition Policy dated 7/20/18, stated on page 7, If the accused is an employee of the facility, he/she will be suspended until the investigation has been completed. Review of the facility Employee Hand Book dated 4/20/18, revealed on page 3, the Reporting Resident Abuse and Neglect policy (un-dated) and stated If you believe that a resident's physical, mental or general well-being has been or may be abused or neglected, you must report it immediately to your supervisor, department head or Administrator. The company will not tolerate the physical, verbal or emotional abuse of our residents. Review of the facility Abuse Prohibition Policy dated 7/20/18, stated on page 6, 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. During a phone interview done on 8/22/18 at 1:00 p.m., CNA D stated (CNA E) took (Resident #2) to her room (on 8/10/18), (CNA E) told her (Resident #2) to stay in her room. She (CNA E) was forcing her (the resident) on her bed, she (CNA E) was trying to hold (Resident #2) down on the bed. She (the resident), she was on the bed half-way. When this surveyor asked CNA D why she did not stop CNA E from forcing Resident #2 to stay on her bed, holding her down, she stated I was in there several times to put her (the resident) in her room. Ya, I should have reported it (report resident abuse right away), but who would want to be called in at 3:00 a.m. (another CNA called to work, to replace CNA E). Review of CNA D's statement dated 8/10/18, stated at approximately 1:15 a.m. (on 8/10/18), she (Resident #2) was I her room, stated she heard yelling, you need to stay in your room, you need to go to bed, you need to lay down, you need to stop it, stop it. She (CNA D) observed (CNA E) pushing (the resident) down with her arms and was using her legs to hold (the resident) into bed. During an interview done on 8/22/18 at 9:55 a.m., CNA E stated I was on the 300 hall, I saw (Resident #20) up at the linen cart putting dirty booties on her head. I told her lets go back to her room. I used a stern loud voice yes, I yelled at her. I said, we need to lay down and go to bed. I had sat her down on her bed by the shoulders, I pushed her shoulders down. I did not talk to the Administrator of the DON (regarding the incident of resident abuse on 8/10/18). We (CNA E and CNA I) don't like each other, I try to stay away from her. During a phone interview done on 8/22/18 at 12:35 p.m., Nurse Manager RN J stated, I did the body assessment on (Resident #2 after the allegation of abuse on 8/10/18). There was bruising, I think they were new because they were dark purple, the one on the rib and left upper arm. When this surveyor asked what the facility procedure was when an allegation of staff to resident abuse was known, Nurse Manager J stated First the nurse needs to send the staff out of the building. Then I call my Administrator and assess my resident. When this surveyor asked Nurse Manager J what staff were instructed to do if the nurse they reported an allegation of abuse did nothing, she stated the CNA needs to go to another nurse or call the Administrator. During an interview done on 8/22/18 at 1:30 p.m., Nurse LPN I stated (Nurse C) told me she talked to the CNA (CNA E). I was told we had to report it (resident abuse allegation) immediately. I was not aware I had the right to remove them (an employee accused of resident abuse) from the facility. I thought the other nurse (Nurse C) had taken care of it, I did not ask her what she had done. Review of the facility electronic time record dated 8/9/18 to 8/10/18, revealed CNA E electronically punched out on 8/9/18 at 2:00 p.m. (the incident occurred on 8/10/18 at approximately 1:15 a.m.). CNA E was accused of resident abuse at 1:15 a.m. and continued to care for the resident until 2:53 a.m., when she clocked out for the day. CNA E was allowed by the facility to care for the resident she was accused of abusing for approximately 1 hour and 38 minutes before she left the facility; Resident #2 was not ensured safety after staff abuse. During an interview done on 8/22/18 at 12:00 p.m., this surveyor asked the Safety/Rehab Nurse K what the facility policy was with an allegation of staff to resident abuse; Nurse K stated the first thing they (staff) should do is protect the resident, send the accused staff member home immediately. The second thing is contact the Administrator or DON (Director of Nursing). The third thing is interview the resident and staff. The fourth thing is do a skin assessment as soon as possible on the resident. The fifth thing is to inform the physician and POA (Power of Attorney). During an interview done on 8/22/18 at 2:40 p.m., the Safety/Rehab Nurse LPN K was asked by this surveyor why the facility had terminated both CNA's G and E, and Nurse C, she stated, I wanted to make sure that our residents were safe.

Based on interview and record review, the facility failed to respond, timely, to a change in condition for 1 of 14 sampled residents (Resident #8) reviewed for care and services to maintain the highest practicable physical well-being, from a total of 24 residents reviewed, resulting in the Resident's emergent transfer from one local hospital to a secondary hospital that provided [DIAGNOSES REDACTED]. Findings include: Review of the facesheet revealed Resident #8 was a [AGE] year old man who was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Sets ((MDS) dated [DATE] revealed Resident #8 was cognitively intact, and required extensive assist with activities of daily living (ADL's). The Physician orders [REDACTED]. 1) [MEDICATION NAME] capsule 100 milligrams, give one capsule by mouth, twice daily for constipation (order dated 9/29/2015) 2) Senna tablet 8.6 milligrams, give 2 tablets by mouth, twice daily for constipation (order dated 9/30/2015) 3) Milk of Magnesia 30 milliliters orally, as needed for constipation during afternoon med pass (order dated 9/2/2015). According to the Medication Administration Record [REDACTED] 1) [MEDICATION NAME] capsule 100 milligrams, give one capsule by mouth, twice daily for constipation (order dated 9/29/2015) was administered 9/30/2015 through 10/5/2015 at 9:00 AM and 9:00 PM. 2) Senna tablet 8.6 milligrams, give 2 tablets by mouth, twice daily for constipation (order dated 9/30/2015) was administered 9/30/2015 through 10/5/2015 at 9:00 AM and 9:00 PM. 3) Milk of Magnesia 30 milliliters orally, as needed for constipation during afternoon med pass (order dated 9/2/2015) was administered on 10/1/2015 at 1818 (6:18 PM). Serial bloodwork, completed on Resident #8 revealed the following: - 9/3/2015: Blood Urea Nitrogen 46 (reference range 7-25 mg/dl and Creatinine 2.1 (reference range 0.7 - 1.11 mg/dl) - 9/30/2015: Blood Urea Nitrogen 49 (reference range 7-25 mg/dl and Creatinine 2.48 (reference range 0.7 - 1.11 mg/dl) - 10/5/2015: Blood Urea Nitrogen 77 (reference range 7-25 mg/dl and Creatinine 6.50 (reference range 0.7 - 1.11 mg/dl) According to the Nurses Progress Notes dated 9/30/2015 at 12:38 AM, Resident #8 had 3+ gross [MEDICAL CONDITION] from the hips down and along the sides of his body just above the hips, imprint of hand left in the resident's skin when turning him. According to the Nursing Progress Notes dated 10/3/2015 at 22:30 (10:30 PM), Resident #8's daughter, family member #1 (identified as a Nurse Practitioner; advanced practice nurse) voiced concern about her dad (Resident #8) taking too many laxatives and about the [MEDICAL CONDITION] to his BLE (bilateral lower extremities). Concerns placed on doctor's board for him to review tomorrow. According to the Nursing Progress Notes dated 10/4/2015 at 16:17 (4:17 PM), doctor in to see resident and looked at [MEDICAL CONDITION]; no significant change in weight. Doctor informed of family's (family member #1) concern of loose stools, as that is what the resident (Resident #8) is telling daughters. Explained need to keep stools soft related to bowel stricture and recent bowel obstruction. According to the Nursing Progress Notes dated 10/5/2015 at 23:26 (11:26 PM), Resident's (Resident #8) daughter (family member #1) asked nurse to call doctor and leave him a voicemail re. (regarding) Creatinine and BUN results. According to the Nursing Progress Notes dated 10/5/2015 at 23:38 PM (11:38 PM), daughter (family member #1) called this nurse and asked if doctor was called; nurse explained to her that a voicemail was left and that if resident has any change in condition, doctor would be paged urgently; daughter again expressed concern re. lab results (BUN and Creatinine). According to the Nursing Progress Notes dated 10/6/2015 at 13:26 PM (1:26 PM) Reviewed lab results; orders received to transfer to ER (emergency room ) for eval and treat. Review of the Emergency Department Triage/Initial assessment dated [DATE] revealed Resident #8 received initial evaluation at a local hospital for increased BUN and creatinine levels, also patient is having periods of confusion. The Resident's past medical /surgical history included [MEDICAL CONDITION] and placement of a [DIAGNOSES REDACTED] stent. Resident #8 was identified through labwork performed at the initial hospital with a BUN of 84 and a Creatinine of 7.5, for which he was documented to have been transferred to a secondary hospital for consultation with a nephrologist and a [DIAGNOSES REDACTED]. During a telephone interview on 10/9/2015 at 9:04 AM, Attending Physician L stated, He (Resident #8) came to us with multiple issues; he had [MEDICAL CONDITION] and [MEDICAL CONDITION]. He had multiple co-morbidities. On October 6th (2015) he had a significant change in his creatinine level; it was 7.5. That suggested acute [MEDICAL CONDITION]. Due to a stent in his bowel, we didn't want him to have hard stools but he didn't have profuse loose stools. His increased creatinine was due to hydro[DIAGNOSES REDACTED] and [MEDICAL CONDITION]. During a telephone interview on 10/8/2015 at 5:18 PM, Family Member #1 reported that family members had observed (Resident #8) to have about 11 loose stools, which were reported to facility staff members. Family Member #1 stated, The staff just blew me off when I told them about the stools; they told me his stools were mushy, just as they should be. He had stools with blood on them; they didn't stop his [MEDICATION NAME]. They had gotten labwork on him; I called on 10/5/2015 to check his labwork. I was told his INR was 5.2. I wanted to know about the BUN and creatinine levels. I was told they ended up with a BUN of 77 and a Creatinine of about 6.5. I told a nurse that these were at [MEDICAL TREATMENT] level. His urinary output was decreased. I told the nurse to call his doctor; she told me she left the doctor a voice mail. (Resident #8) has just had a catheter placed and is now receiving [MEDICAL TREATMENT]. I've been told by his nephrologist he is diagnosed with [REDACTED].

Based on observation, interview, and record review, the facility failed to identify and assess a change in the status of an unstagable pressure ulcer in 1 of 8 sampled residents (#3) reviewed for pressure ulcer care, in a sample of 24 residents, resulting in the worsening of the condition of a pressure ulcer and the development of two additional pressure ulcers with the potential for pain and infection of an open wound. Findings include: According to the Admission Record, dated 10/9/2015, Resident #3 was an [AGE] year old male admitted to the facility on [DATE] who was hosptalized on [DATE] and readmitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. According to the National Pressure Ulcer Advisory Panel (NPUAP), a stage 2 ulcer is a loss of partial thickness of the skin that results in a shallow open area. A Skin/Wound Progress Note, dated 9/21/2015, recorded the presence of a new open area, stage 2, on Resident #3's right buttock. The area measured approximately 0.8 centimeters (cm) by 0.8 cm. with the center of the wound dark pink, and a small amount of drainage was present. The documentation on the Skin/Wound Progress Note, dated 9/28/2015, revealed that the stage 2 pressure ulcer on Resident #3's right buttock measured approximately 0.5 cm. by 0.5 cm with a red wound base. It was noted that a small amount of drainage was on the old dressing. The note identified a small abraided area on the right buttock that measured approximately 0.2 cm. by 0.2 cm The Skin/Wound Progress Note, dated 9/28/2015, corrected the previous entry for the abraided area to the left buttock. On 10/5/2015 the Skin/Wound Progress Note, indicated that the wound on the right buttock measured approximately 1.0 cm by 0.5 cm. The skin surrounding the wound was documented as pink/intact and blanchable. The note indicated that the treatment was changed to [MEDICATION NAME] wound dressing on that date because the area had declined. On that date, the note did not mention the abraided area to the left buttock. On 10/6/2015 at 3:30 pm, Licensed Practical Nurse (LPN) staff N was observed in Resident #3's room as she cleansed the open area on his right buttock and applied a topical ointment. The wound appeared larger than the measurement of 1.0 cm. by 0.5 cm. documented on 10/5/2015. In an interview on 10/8/2015 at 9:15 am, Registered Nurse (RN) Staff C , the wound care nurse, was asked to re-measure Resident #3's pressure ulcer. On 10/8/2015 beginning at 9:30 am, RN Staff C was observed in Resident #3's room as she re-measured the stage 2 pressure ulcer on Resident #3's right buttock. RN Staff C stated that the condition of the wound was worse and identified two additional stage 2 pressure ulcers on Resident #3's buttocks. RN Staff C's Skin/Wound Progress Note, dated 10/8/2015, included the following: the measurement of the right buttock was 2.2 cm by 2.0 cm with the center of the wound having white/slough tissue and pinpoint dark spot in the center. The skin around the wound was dark pink/purple and slow to blanch. A stage 2 area was noted below the first area and measured approximately 3.0 cm by 1.0 cm. A third stage 2 area was observed on the left buttock that measured 1.0 cm. by 1.0 cm In an interview on 10/8/2015 beginning at 9:30 am, Certified Nursing Assistant (CNA) staff E, who was also in Resident #3's room when RN Staff C measured the three wounds on Resident #3's buttocks, stated that when she had cared for Resident #3 on Saturday, October 3, 2015, she had notified LPN Staff O when she had observed the new open areas on Resident #3's buttocks. When CNA staff E was asked to clarify, she stated that Resident #3 had three open areas on his buttocks on Saturday when she cared for him and that LPN Staff O had looked at the areas on Saturday. A review of the progress notes revealed no documentation by LPN Staff O related to Resident #3's wounds. A phone call and voice mail were left for LPN O to contact this surveyor, but no return call was received. RN Staff C stated that when she had measured the wound on Resident #3's right buttock on 10/5/2015, she had not noted the additional pressure ulcers and she had not been informed of any new areas. According to the facility's Pressure Area Standing Orders, signed by the medical director on 5/27/2015, the treatment of [REDACTED]. ( )

Based on interview and record review, the facility failed to comply with the physician's order to remove a catheter for 1 of 3 residents (Resident #1) reviewed for catheters out of a total of 24 sampled residents, resulting in an urethral tear. Findings include: Review of the Admission Record dated 9/22/15 reflected Resident #1 was an [AGE] year old female who had resided at the facility since 9/9/15 and readmitted [DATE]. The undated Medical [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Resident #1's skin care plan with a re-admission date of [DATE] reflected additional [DIAGNOSES REDACTED]. According to Resident #1's 5-day Admission Minimum Data Set (MDS) assessment dated [DATE] she was unable to speak, she was always incontinent of bowel and bladder and was on anti-biotic for an infection and pneumonia. The facility's Nursing Comprehensive Evaluation dated 9/9/15 completed for Resident #1's initial admission to the facility, reflected under Indwelling Catheter Evaluation that All questions are checked 'No' and there is no appropriate diagnosis for an indwelling catheter. On 9/9/15 there was a doctor's order to discontinue the Foley catheter for Resident #1. In an interview on 10/9/15 between 2:00 PM and 3:30 PM, Assistant Director of Nursing (ADON) C confirmed the physician's order dated 9/9/15 to discontinue Resident #1's Foley was written for the purpose but was not discontinued until 9/21/15. Review of the Facility's 5 day report (undated) reflected the Foley catheter was in place for urine elimination until discontinued on 9/21/15 by Charge Nurse. Review of the hospital Emergency Department initial nursing assessment dated [DATE] reflected the Chief Complaint was increased resp (respiratory) rate. Pitting [MEDICAL CONDITION] from sternum to bilateral feet. Patient nonverbal, eyes open mumbling, responds to painful stimuli . Foley d/c'd (discontinued) today. See additional notes. Review of the the Inpatient Progress Note dated 9/22/15 at 14:29 (2:29 PM), Hospital Doctor P documented in that there were Concerns raised by Emergency Dept staff regarding possible vaginal trauma with hemorrhage. CSC (criminal sexual conduct) investigation was requested. I have performed an external vaginal examination with nursing staff and social work in attendance. I see no signs of vaginal bleeding or trauma. There is swelling due to the patient have generalized [MEDICAL CONDITION]. There is a small urethral tear at the 12 o'clock position. I suspect this is a result of injury from the previous Foley catheter that was in place from her recent hospitalization and was just removed yesterday. In my opinion the vaginal bleeding which was seen, most likely originated from this tear. There is also [DIAGNOSES REDACTED] of the skin surrounding the vagina which is most likely candidiasis. In an interview on 10/9/15 at 10:20 AM, Administrator A stated she believed the root cause to identified concerns during this survey took place because all paperwork is electronic now and when there was paper charting there were checks and balances in place. For example, when the physician's order was written to discontinue Resident #1's Foley catheter, the paper telephone order was given to the Director of Nursing, and currently there was nothing in place like that with the electronic medical records system. On 10/9/15 at about 2:30 PM, Nurse surveyor stated an urethral tear can cause permanent scaring, resulting in difficulty with urinating. According to the Urology Care Foundation, Trauma to the urethra can cause significant problems. Injury can cause leakage of urine into surrounding tissues and result in swelling, inflammation, infection and abdominal pain. Urethral trauma can also cause the inability to urinate, retention of urine in the bladder and blood in the urine (hematuria). (http://www.urologyhealth.org/urologic-conditions/urethral-trauma) ( )