Every finding on record at Dimondale Nursing Care Center

Based on observation, interview, and record review the facility failed to correctly identify, treat, resulting in worsening and non-healing of pressure ulcers for three residents (R29, R32, R81) out of five residents reviewed for pressure ulcers. Findings Include: Resident #29 (R29) Wounds were reviewed for R29. Review of the medical record reflected R29 was admitted to the facility on [DATE], with diagnoses that included chronic pain, delirium, and reduced mobility. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R29 scored 9 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Terminal Kennedy ulcers (KTU) and pressure ulcers are both types of skin breakdown, but they are different in their cause, appearance, and meaning. A pressure ulcer happens when there is prolonged pressure on one area of the skin, usually over bony parts of the body. This pressure reduces blood flow to the tissue, eventually leading to skin and tissue damage. Pressure ulcers develop gradually and are usually preventable with frequent repositioning, good nutrition, skin care, and pressure-relieving devices. The Centers for Medicare & Medicaid Services (CMS) and the National Pressure Injury Advisory Panel (NPIAP) classify pressure ulcers into stages based on how deep the damage goes, from Stage 1 (reddened, unbroken skin) to Stage 4 (deep tissue loss exposing muscle or bone) (NPIAP, 2016). KTU's, on the other hand, are a specific type of skin breakdown often seen at the end of life. They usually develop very quickly, sometimes in just a matter of hours, and are commonly found on the sacrum or coccyx area. These ulcers tend to have a distinct appearance. They can be shaped like a pear, butterfly, or horseshoe and may have a sudden dark purple or black color. Unlike pressure ulcers, Kennedy ulcers are not caused by pressure alone. Instead, they are believed to result from skin failure during the dying process, when the body is shutting down and blood is being directed away from the skin to protect vital organs (Langemo & Brown, 2006). The rapid onset and worsening of a Kennedy ulcer is often a signal that death is near, sometimes within hours to weeks. On [DATE] at 10:53 AM, R29 was observed in bed. R29's left hand was wrapped in gauze. A Nurse's Note dated [DATE] at 7:07 AM revealed On am (morning) assessment some drainage was noted coming from her (R29's) palm, staff saw that her finger nails were all inside her palm and it was cleaned and finger nails trimmed and the palm was covered with wrapped up. Wound was draining with a very foul smell. wound was cleaned and wrapped up. Review of a Hospice Note dated [DATE] stated new wound to palm of L (left) hand noted d/t (due to) hand contractures and finger nails causing skin break . Review of the Physician Orders revealed an order initiated on [DATE] and revised on [DATE] for Hand Carrot to right and left hands as tolerated. This was initiated after the development of the left palm skin wound. Further review of the Physician order's revealed an order initiated on [DATE] which stated left palm skin concern, cleanse with wound cleanser, pat dry, place AquaCell AG patch (AquaCell Ag is an antimicrobial wound dressing designed to manage wounds at risk of infection or showing signs of infection) over and cover with AquaCell foam. Wrap with Kerlix. Review of the Skin and wound tab revealed no documentation or assessment for the wound on the left palm despite the skin concern clearly being described and treated as an open wound. In an interview on [DATE] at 1:20 PM, Clinical Care Coordinator (CCC) S confirmed that R29's hands were contracted, however, had no information about the left palm wound, such as when and how it occurred, or knew any information about when the hand carrot order was implemented, despite having access to R29's medical record. CCC S stated there should have been photos and assessments for the left hand wound but had no information as to why those were not obtained. Review of the Medical Record showed no evidence of R29's Physician being notified of the left palm wound. Review of the Medical Record showed no evidence of a Change in Condition form being completed for the left palm wound. Review of the Incident report dated [DATE] revealed nursing discovered R29's fingernails inside her palm. Under the section of the Incident Report stated, people notified, only a family member for R29 was listed. No Physician was listed. Record Review revealed on [DATE], it was discovered that R29 developed a sacral wound (just above the tailbone) which was initially identified as a Stage 3 Kennedy ulcer. The wound was noted as in-house acquired. At the time, it measured 6.62 cm², with a length of 4.37 cm and a width of 1.96 cm. The wound bed was 80% epithelial and 20% slough (soft, yellow, white, or greenish dead tissue), showing no signs of granulation (new healthy tissue). Review of the sacral wound photograph in the electronic medical record can be described as an open wound with red, moist tissue. The wound bed contains yellowish slough. The wound borders appear to be irregular and macerated (skin has become soft, wet, and broken down from being in contact with too much moisture for too long), suggestive of prolonged moisture exposure. KTU's are not staged, like pressure ulcers. KTU's are identified through their characteristics rather than through a staging system. No scholarly or regulatory source supports staging KTUS. Record review revealed that on [DATE], R29's sacrum wound area had minimally decreased to 6.56 cm², with a length reduction to 4.05 cm but a slight width increase to 2.34 cm. The wound depth was recorded at 0.1 cm. PUSH (PUSH Tool, Pressure Ulcer Scale for Healing, is a standardized instrument developed by the National Pressure Injury Advisory Panel (NPIAP) to monitor the healing progression of pressure injuries over time. It assigns numerical values to three key wound characteristics: surface area (length × width), exudate amount, and tissue type present in the wound bed. The cumulative score ranges from 0 (completely healed) to 17 (severe), with higher scores indicating more severe wounds) score was 11, with 20% epithelial tissue and 80% granulation. Review of R29's sacral wound photograph on the electronic medical record revealed an open area with bright, red moist tissue, rolled wound edges, and widespread redness surrounding the wound. The wound was described as a Stage 3 [NAME] Ulcer. On [DATE], R29's sacral wound area increased to 11.11 cm² with significant length growth to 7.12 cm. Eschar (necrotic tissue) was first documented at 30%, and slough increased to 50%, suggesting tissue deterioration. PUSH score rose to 14. The wound was classified as an Unstageable (full depth of the wound bed can ' t be seen yet. This is usually because the wound is covered with dead tissue such as slough or eschar) [NAME] Ulcer. Record Review revealed on [DATE], the wound area grew slightly to 11.28 cm², though length decreased to 5.62 cm. The wound now contained 60% eschar and 40% slough. The PUSH score remained at 14. The wound was classified as an Unstageable [NAME] Ulcer. On [DATE], the area expanded to 13.63 cm². While the length further decreased to 4.14 cm, the width had grown to 4.85 cm. Slough and eschar remained stable at 40% and 60%. The wound was classified as an Unstageable [NAME] Ulcer. Review of the photograph of the wound in the electronic medical record revealed R29's wound contained eschar and areas of bright red bleeding tissue. On [DATE], the wound continued to expand, reaching 19.75 cm² with eschar increasing to 80%, signaling significant necrosis. The wound continued to be classified as an Unstageable pressure ulcer. The PUSH score was 16. The photograph depicted a bright, red wound bed and surrounding tissue area, which was a continuation of previous photographs reviewed and indicated profusion to the area, which is uncharacteristic of a KTU. On [DATE], R29's wound measured with an area of 33.87 cm², with a length of 5.59 cm and width of 8.77 cm. Granulation was first noted again at 10%, while slough and eschar accounted for 40% and 50% of the wound bed. The PUSH score maintained at 16. On [DATE], the wound assessment showed a decrease in wound area to 28.09 cm² and eschar reduced to 30%, slough remained at 40% with 30% granulation. The PUSH score maintained at 16. Per the wound assessment, the surrounding tissue was red and blanchable. On [DATE], the area increased again to 33.25 cm². Redness, inflammation, and gangrene were noted, indicating localized infection. Granulation remained at 30%, slough at 30%, and eschar increased to 40%. The wound was being described as Unstageable, however, after review of the photograph, the wound bed was visible, suggesting a depth and stage could have been documented. The wound presented as beefy red. On [DATE], R29's sacral wound area had decreased slightly to 30.09 cm². Granulation improved to 50% and eschar dropped to 20%. The wound was being described as Unstageable, however, after review of the photograph, the wound bed was visible, suggesting a depth and stage could have been documented. The wound presented as beefy red. On [DATE], the sacral wound reached its largest size at 49.28 cm², measuring 6.68 cm in length and 10.23 cm in width. Granulation increased to 70%, while slough and eschar were down to 20% and 10%. On [DATE], the wound slightly decreased to 47.94 cm², with depth reaching 3.0 cm. Epithelial tissue was documented at 30%, granulation at 50%, and slough at 20%. The PUSH score was 15. On [DATE], per the measurements documented in the medical record, R29's wound measurements implied wound improvement, with the wound area reducing to 32.86 cm², though the length increased to 7.15 cm. Depth reduced to 1.0 cm, granulation rose to 70%, and slough remained stable at 20%. The wound bed was beefy read and the wound was being classified as a Stage Four [NAME] Ulcer. On [DATE], the wound area was consistent at 32.89 cm². Granulation increased to 90%, and slough remained at 20%, indicating positive healing progress. The wound was described as stable. The PUSH score remained at 15. On [DATE], the area had decreased to 29.79 cm². Granulation was 60%, slough increased to 30%, and eschar reappeared at 10%. Undermining was documented at 3.0 cm from 7 to 3 o'clock. The PUSH score was 16. Review of the photograph in the medical record depicted a Stage 4 pressure ulcer on the sacral region with a beefy, moist wound bed. On [DATE], the area increased to 34.52 cm², and undermining extended to 3.5 cm from 8 to 4 o'clock. Granulation improved to 80% and slough decreased to 20%. On [DATE], the wound area decreased again to 28.53 cm², with a length of 4.05 cm and a width of 8.76 cm. Depth measured at 2.0 cm. Granulation tissue was at 90%, and slough had decreased to 10%. On [DATE] at 4:35 PM, a request was made to observe wound care the following day. On [DATE], Director of Nursing (DON) B reported that R29's wound care was completed overnight and that R29's wound care was scheduled during night shift. Over the 16-week period, the wound showed consistent progression and regression, a pattern uncharacteristic of a Kennedy terminal ulcer. According to the National Pressure Injury Advisory Panel (NPIAP, 2019) and [NAME] et al. (2019), Kennedy terminal ulcers are rapidly progressing wounds that develop within hours to a few weeks before death, exhibit irregular shapes (such as pear, butterfly, or horseshoe-shaped), and typically do not exhibit healing. This resident's wound demonstrates a gradual and prolonged evolution, improvement in tissue composition, and absence of significant end-of-life status, key factors that clearly align with a diagnosis of a pressure injury. Review of the Physician Order's revealed a treatment order for R29's sacral wound active since [DATE] which stated sacral wound: cleanse with wound cleaner, pat dry, crush Flagyl 500 milligram tab then apply to wound bed, moisten gauze with NS (normal saline), squeeze out excess, lightly pack wound to depth, cover with border foam dressing. Despite the non healing status of the wound, the treatment order remained the same since [DATE]. R29's sacral wound persisted for approximately 16 weeks, which is inconsistent with the expected clinical trajectory of a KTU. Separately, on [DATE], second wound developed on R29's right trochanter (right hip) with an initial area of 4.13 cm² (3.77 cm in length and 1.56 cm in width). Review of the photograph in the electronic medical record revealed a dark colored closed area that presented as a suspected deep tissue injury (dark purple or deep red area, or a blood-filled blister, on skin that may feel firm, mushy, or warmer/cooler than the surrounding skin. Even though the top layer of skin may not be open, the tissue underneath is already damaged from pressure). The assessment noted a PUSH score of 11. Review of the Wound assessment dated [DATE] revealed R29's right trochanter wound area expanded dramatically to 14.02 cm², with full epithelial coverage noted and a PUSH score of 10. Clinical records indicate that a circular implanted pain pump was located under the skin in that area. The wound started to notably mirror the round shape of the underlying medical device. On [DATE], the area decreased to 10.61 cm², showing 80% epithelialization, 10% granulation, and 10% eschar. The wound continued to present in a circular shape mirroring the underlying pain pump. On [DATE], the wound expanded again to 18.7 cm², characterized by 90% slough and only 10% granulation. Review of the photograph located in the medical record revealed that the wound had opened, revealing a wound bed of eschar. The skin surrounding the wound appeared red, and the wound edges were well-demarcated (round and easy to see). Review of the wound assessment dated [DATE] revealed that R29's right trochanter wound nearly doubled in size to 35.9 cm², with tissue breakdown now consisting of 80% slough and 20% eschar. The wound had a PUSH score of 15. On [DATE], the wound had regressed to 19.17 cm², but was now 100% slough, suggesting continued necrotic progression. Review of the photograph revealed that the pain pump was now exposed. On [DATE], the wound size increased to 25.81 cm² with 40% slough. Review of the wound photograph revealed the exposed hardware, specifically a intrathecal pump (a pump that is surgically placed under the skin). A pressure ulcer developed over the surface of the implanted intrathecal pump. The wound edges were rolled and undermined, with black eschar along the margin. On [DATE], R29's wound had an area of 47.87 cm². At that time, the wound presented with 40% granulation and 60% slough. Clinical notes confirmed that the intrathecal pain pump eventually became exposed through the wound bed and ultimately dislodged and fell out of the resident's body, indicating advanced soft tissue destruction due to persistent pressure and device-related trauma. R29's right trochanter wound persisted for about 8 weeks, which is inconsistent with the expected clinical trajectory of a KTU. In an interview on [DATE] at 1:51 PM, Registered Nurse (RN) D stated that she was familiar with R29's care, including her pressure ulcers. RN D reported that she cares for R29 about two times a week under R29's hospice care. RN D reported that KTU'S typically present as a dark discoloration and deteriate rapidly. RN D reported that initially, R29's sacral and right trochanter pressure ulcers were classified as KTU's however, in retrospect, using her professional knowledge she would classify them as pressure injuries due to the long-standing nature of the wounds. In an interview on [DATE] at 11:06 AM, Physician H stated that KTU's come on very quickly and indicate that the patient is terminal with the potential to pass within days or weeks. Physician H stated that KTU's are thought to occur due to perfusion issues, skin failure, or the body shutting down. In an interview on [DATE] at 2:13 PM, Physician LL stated that KTU's were classified as [NAME] Ulcers due to the patients decline and weight loss. Physician LL also reported that [NAME] Ulcers are not stageable. Regarding treatment, Physician LL added if the ulcer is not infected we don't treat them. A review of R29's total body skin assessments revealed that every weekly assessment conducted throughout the duration of her admission consistently documented normal findings. Specifically, R29 was noted to have good skin turgor, skin color appropriate for her ethnic background, warm (normal) skin temperature, normal moisture levels, and overall skin condition described as normal. If R29 had experienced hypoperfusion and/or organ failure to a degree that impacted her skin integrity, such changes would have been reflected in the weekly skin assessments. Review of R29's Blood Pressures revealed the following: [DATE] 12:16 PM 114 / 71 mmHg [DATE] 1:19 PM 121 / 75 mmHg [DATE] 7:17 AM 110 / 78 mmHg [DATE] 2:30 PM 100 / 55 mmHg [DATE] 2:27 PM 100 / 55 mmHg Review of these blood pressure readings show evidence that R29's Mean Arterial Pressure (MAP- the average pressure in a person's arteries during one cardiac cycle. It represents the perfusion pressure delivered to the organs and tissues of the body. Unlike simple systolic or diastolic pressure readings, MAP provides a more accurate reflection of the blood flow and pressure that organs actually experience) was above the normal range of 70-100 mmHg which indicated adequate perfusion. In an interview conducted on [DATE] at 12:37 PM, Licensed Practical Nurse (LPN) D stated that physicians are primarily responsible for reviewing, staging, and initiating wound care orders. When asked whether wounds are assessed in person, LPN D explained that this is not always the case. She noted that if she encounters an issue, she may request the physician to assess the wound in person, otherwise, they typically rely on photographs and documentation in the electronic medical record. They do not round every week, she added. When asked about the process for changing wound treatments, LPN D stated that if a wound is not healing, the physician will usually consider modifying the treatment plan after approximately two weeks. Regarding R29's left palm, LPN D stated the skin was never visibly open, therefore, she did not believe it was necessary to monitor or assess the area further. Per the medical record, there was clear indication that the left palm had in fact, opened. Review of the Physician Order's revealed an order for R29's sacral wound active from [DATE] and discontinued on [DATE]. The order stated to cleanse the sacral wound with normal saline, pat dry, place AquaCell AG over the wound and cover with AquaCell dressing. As mentioned, AquaCell AG is a antimicrobial wound dressing designed to manage wounds at risk of infection or showing signs of infection. AquaCell is utilized for the management of both chronic and acute wounds, such as leg ulcers, pressure injuries (stages 2-4) and diabetic ulcers; surgical wounds (post-operative, donor sites, dermatological); partial-thickness (second-degree) burns . wounds that are prone to bleeding, such as wounds that have been mechanically or surgically debrided and donor sites . (https://www.woundsource.com/product/aquacel-foam-dressing). Per the manufacturer's website, AquaCell is a ConvaTec brand and stands out for its unique gelling action based on Hydrofiber technology. This property allows the dressing to absorb and lock in exudate and bacteria. It is a versatile primary wound dressing indicated for use on moderate to highly exuding chronic and acute wounds. AquaCell supports wound healing by providing a moist wound healing environment. Further review of the wound care orders for R29's sacral and right trochanter wound revealed AquaCell and AquaCell AG were utilized for R29's wound care treatments. Review of the literature provided by the facility states Setting realistic wound management goals that are situated around comfort and odor control rather than healing ([NAME] et al., 2019). Labeling these wounds as Kennedy terminal ulcers misrepresented the clinical scenario and may falsely imply unavoidability. The wound's trajectory, characteristics, and treatments support the conclusion that R29 experienced chronic, in-house acquired pressure injuries. Additionally, Kennedy terminal ulcers (KTUs) are not staged using the standard pressure injury staging system because they are considered a distinct type of skin failure related to the dying process. Unlike traditional pressure injuries, KTUs appear suddenly, often within hours to a few weeks before death, and they progress rapidly. Their unique presentation and association with end-of-life changes make them inappropriate for classification under the National Pressure Injury Advisory Panel's staging guidelines. Instead, KTUs should be described in narrative form, noting their appearance, location, size, and progression, rather than assigning a numerical stage. Applying a pressure injury stage to a Kennedy ulcer can lead to misclassification and clinical confusion (NPIAP, 2016). (https://pubmed.ncbi.nlm.nih.gov/30801349). Additionally, Accurate assessment is vital to distinguish Kennedy terminal ulcers from pressure injuries to ensure appropriate care planning and to avoid misinterpretation of unavoidable skin changes. ([NAME], S., [NAME], J., Hunt, T., [NAME], K., & [NAME], B. M. (2019). Kennedy terminal ulcers: A Scoping Review. Journal of Hospice and Palliative Nursing, 21(3), 202-208). R29 expired in the facility on [DATE]. Based on observation, interview, and record review the facility failed to correctly identify, treat, resulting in worsening and non-healing of pressure ulcers for three residents (R29, R32, R81) out of five residents reviewed for pressure ulcers Findings Include:Resident #81 (R81)Review of the medical record reflected that R81 was admitted to the facility on [DATE], hospitalized on [DATE] and was readmitted to the facility on [DATE]. Diagnoses of Dementia, Pressure-induced Deep Tissue Damage, Pressure Ulcer of Sacral region, unstageable.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] revealed R81 had a Brief Interview of Mental Status (BIMS) of 00 (unable to answer any questions) out of 15.Under section G0100, Activities of Daily Living (ADL) Assistance reveals R81 is dependent for all care. During an interview on [DATE] at 12:29 PM, R81's family member II stated that R81 developed a pressure ulcer after admission to this facility.Physician Order: Clean pressure ulcer on the coccyx with wound cleanser, pat dry apply Aquacel AG (used for managing moderate to heavily exuding wounds, including pressure ulcers, to be changed every 3-5 days for proper usage,), cover with Aquacel foam (AQUACEL® Ag Foam may be used for the management of both chronic and acute wounds, such as leg ulcers, pressure injuries (stages 2-4) to be changed every 3-5 days for proper usage,) and cover with bordered form every shift for Skin integrity, ordered on [DATE], discontinued on [DATE]. Record review revealed a nursing progress note dated [DATE] 1:43 PM, Nurse's Progress Note, Note Text: During routine care resident was noted to have a Pressure Ulcer on the coccyx. The nurse cleaned the area with a wound cleaner, patted dry covered with Aquacel form. Family, on call and provider were notified. A change in condition was initiated.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury- Unstageable- Sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 9.11 cm x 3.24 cm x 5.57 cm with a push score of 14 and 0% change.Record review of an Skin and Wound Evaluation dated [DATE] revealed R81's type of wound was Pressure-Kennedy terminal ulcer, unstageable due to slough and eschar, in house acquired on [DATE]. Wound measurements were 3.2cm x 5.6cm depth unknown with area 9.1cm. Granulation of 50% of wound bed filled and eschar of 50% of wound bed.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury- Unstageable- Sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 9.44 cm (+4%) x 5.94 cm (+83%) x 2.38 cm (-57%) with a push score of 14, with a push score of 14 and -4% change.Physician Order: Clean Pressure Ulcer on the coccyx with wound cleanser, pat dry apply aquacel AG (used for managing moderate to heavily exuding wounds, including pressure ulcers, to be changed every 3-5 days for proper usage, cover with Aquacel foam (AQUACEL® Ag Foam may be used for the management of both chronic and acute wounds, such as leg ulcers, pressure injuries (stages 2-4)and cover with bordered foam every evening shift every 3 day(s) for Skin integrity, ordered on [DATE] and discontinued on [DATE].Record review revealed a nursing progress note dated [DATE] 12:45 PM, Nurse's Progress Note, Note Text: Family requesting resident be sent to emergency department for ulcer to sacrum. Education given to family regarding Pressure Ulcer being a [NAME] Ulcer which is terminal and not curable. Resident sent for further evaluation on the ulcer per family request; physician notified. Transfer packet sent with bed hold policy and ombudsman information.Physician Order: Clean Pressure Ulcer on the coccyx with wound cleanser, pat dry apply aquacel AG (used for managing moderate to heavily exuding wounds, including pressure ulcers, to be changed every 3-5 days for proper usage, cover with Aquacel foam (AQUACEL® Ag Foam may be used for the management of both chronic and acute wounds, such as leg ulcers, pressure injuries (stages 2-4)and cover with bordered foam every evening shift every 3 day(s) for Skin integrity, ordered on [DATE] and discontinued on [DATE].Physician Order Clean Pressure Ulcer on the coccyx with wound cleanser, pat dry apply Aquacel AG (used for managing moderate to heavily exuding wounds, including pressure ulcers to be changed every 3-5 days for proper usage,), cover with Aquacel foam (AQUACEL® Ag Foam may be used for the management of both chronic and acute wounds, such as leg ulcers, pressure injuries (stages 2-4), and cover with bordered form every evening shift every 3 day(s) for Skin integrity AND every 24 hours as needed. Ordered on [DATE] and discontinued on [DATE].Physician Order Clean pressure ulcer on the coccyx with wound cleanser, pat dry apply Medi honey (Medi honey is used for wound care and has several benefits: Pulls moisture from wounds and reduces bacterial growth. Has an anti-inflammatory effect that speeds up healing time and reduces pain. Stimulates blood flow and oxygen release, aiding wound healing. Reduces swelling and has an antibacterial effect.Safe and effective for various types of wounds, including diabetic foot ulcers, pressure ulcers, burns, and surgical wounds. and cover with bordered form every evening shift every 3 day(s) for Skin integrity AND every 24 hours as needed, ordered on [DATE] and discontinued on [DATE].Physician Order: Kennedy terminal ulcer on sacrum: cleanse with wound cleanser, pat dry, apply Medi honey (Medi honey is used for wound care and has several benefits: not a treatment for a [NAME] Ulcer Pulls moisture from wounds and reduces bacterial growth. Has an anti-inflammatory effect that speeds up healing time and reduces pain. Stimulates blood flow and oxygen release, aiding wound healing. Reduces swelling and has an antibacterial effect. Safe and effective for various types of wounds, including diabetic foot ulcers, pressure ulcers, burns, and surgical wounds. cover with bordered form everyday shift for wound care AND as needed Ordered [DATE] 9:45AM, discontinued on [DATE].Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 5.47 cm (-42%) x 2.77 cm (+53%) x 2.92 cm (+23%) with a push score of 12 and 40% change.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 4.41 cm (-19%) x 2 cm (-28%) x 2.83 cm (-2%) with a push score of 12 and 52% change.Physician Order Kennedy terminal ulcer on sacrum: cleanse wound with wound cleanser or NS, pat dry, apply Santyl (Santyl works by breaking down damaged collagen in wounds, helping to clear away dead tissue and allowing new, healthy skin to grow) to wound bed, cover wounds with dry fluffy gauze then bordered foam dressing every day shift for wound care AND as needed. Ordered [DATE] discontinued on [DATE]. Physician Order: Kennedy terminal ulcer on sacrum: cleanse wound with wound cleanser or NS (normal saline), pat dry, apply Santyl (Santyl works by breaking down damaged collagen in wounds, helping to clear away dead tissue and allowing new, healthy skin to grow) to wound bed, cover wounds with dry fluffy gauze, skin prep, then bordered foam dressing every day shift for wound care AND as needed. Ordered [DATE], discontinued on [DATE].Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 6.21 cm (+41%) x 2.44 cm (+22%) x 3.58 cm (+26%) with a push score of 13 and 32% change.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 8.73 cm (+1%) x 2.86 cm (+8%) x 3.96 cm (+1%) deepest point .3 cm and undermining 1cm with a push score of 12 and 4% change.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacrum. The wound evaluation has a picture of the sacrum showing measurements of area 8.71 cm x 2.76 cm (-4%) x 4 cm (+1%) deepest point 1cm and undermining 1cm with a push score of 12 and 4% change.Record review revealed a document labeled Wound Evaluation on [DATE] labeling #2 Pressure-Kennedy terminal ulcer-Deep Tissue Injury-sacr

Based on observations, interviews, and record reviews, the facility failed to effectively create and maintain the Water Management Plan effecting 144 residents, resulting in the increased likelihood for development of Legionellosis and other opportunistic waterborne pathogens.Findings include:On 07/01/25 at 09:30 A.M., Record review of the facility Water Management Plan was reviewed with Director of Maintenance (DM) K. The following items were noted:The facility Water Management Plan was observed missing the following content:1. A clear definition of the current Water Management Team Members.2. A written narrative of the potable water supply system from headwork's to sanitary discharge.3. A clear identification of increased and/or high-risk areas within the potable water supply for legionella bacterium development.4. Failure to utilize and follow an accepted industry standard reference resource (American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) 188, Centers for Disease Control and Prevention (CDC), etc.).On 07/01/25 at 10:55 A.M., An interview was conducted with Infection Preventionist (IP) L regarding any cases of Legionellosis since the last annual survey. (IP) L stated: No.On 07/02/25 at 10:06 A.M., An environmental tour of the second-floor unoccupied area was conducted with (DM) K. The following item was noted:The hand sink potable water supply was observed discolored (amber colored) for at least 5-10 seconds upon actuation flushing.On 07/02/25 at 10:25 A.M., An interview was conducted with (DM) K regarding the last time the second-floor unoccupied area was occupied. (DM) K stated: The area has not been occupied for at least 12 years.On 07/02/25 at 11:20 A.M., Record review of the Legionella Prevention potable water supply flushing logs for the last three months revealed a statement notated on the form that read: All areas above need to run for 1 minute each to properly flush stagnant standing water from pipes in low use areas.On 07/02/25 at 11:33 A.M., An interview was conducted with Senior Maintenance Technician (SMT) M regarding how long ago the second-floor unoccupied area was occupied. (SMT) M stated: Since the early 90's. (SMT) M also stated: The unoccupied space is considered 2-East and 2-South.On 07/02/25 at 02:30 P.M., An interview was conducted with [NAME] President of Clinical Services (VPCS) I regarding the second-floor unoccupied area potable water supply. (VPCS) I stated: We have plumbers on-site to disconnect and drain the water pipes.On 07/02/25 at 02:42 P.M., An interview was conducted with (Company Name) Plumbing Vendor Technician (PVT) N regarding the potable water separation plan between the facility unoccupied areas and occupied areas. (PVT) N stated: We plan to cut and cap 48 water supply risers on Monday (7-7-25).On 07/03/25 at 09:00 A.M., Record review of the Centers for Disease Control and Prevention (CDC) publication entitled: Controling Legionella in Potable Water Systems dated 1-3-2025 revealed under Flushing: Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) for at least 5-minutes regularly as needed to maintain water quality parameters within control limits.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 144 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.Findings include:On 07/01/25 at 11:47 A.M., A common area environmental tour was conducted with Director of Housekeeping and Laundry Services (DHLS) J. The following items were noted:1 East (149-170)Soiled Utility Room: The room was observed heavily malodorous from limited return-air exhaust ventilation. (DHLS) J indicated he would contact maintenance for necessary repairs.Shower Room: The return-air-ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. (DHLS) J indicated he would have staff thoroughly clean and sanitize the return-air ventilation grill as soon as possible.1 South (300-324)Nursing Station: 1 of 5 chairs were observed (etched, scored, particulate). The damaged area measured approximately 3-inches-long by 1-inch-wide twice.Pantry/Clean Utility Room: The plaster surface was observed (etched, scored, particulate), adjacent to the entrance door. The damaged area measured approximately 2-inches-wide by 18-inches-long. (DHLS) J indicated he would contact maintenance for necessary repairs as soon as possible.1 North (122-147)Nursing Station: 1 of 4 chairs were observed (etched, scored, particulate). The damaged area measured approximately 2-inches-wide by 4-inches-long. (DHLS) J indicated he would contact maintenance for necessary repairs as soon as possible.Oxygen Room: The utility sink atmospheric vacuum breaker was observed leaking water during faucet actuation. (DHLS) J indicated he would contact maintenance for necessary repairs as soon as possible. 1 [NAME] (100-121)Nursing Station: The oscillating wall fan was observed soiled with accumulated and encrusted dust/dirt deposits.Shower Room: 2 of 2 privacy curtains were observed soiled with bodily fluids and human waste. The commode base perimeter rim was also observed severely (etched, scored, worn). The commode base caulking was additionally observed (etched, scored, stained, particulate). (DHLS) J indicated he would contact maintenance for necessary repairs as soon as possible.Beauty Shop: The desk fan was observed soiled with accumulated and encrusted dust/dirt deposits.Staff Breakroom: The utility sink atmospheric vacuum breaker was observed leaking water upon faucet actuation. (DHLS) J indicated he would contact maintenance for necessary repairs as soon as possible.2 [NAME] (200-225)Soiled Utility Room: The hand sink faucet handles were observed loose-to-mount. The hot and cold handles were also observed to separate completely from the valve stem assembly upon upward force. (DHLS) J indicated he would contact maintenance for necessary repairs as soon as possible.2 North (Memory Care Unit) (226-251)Shower Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. (DHLS) J indicated he would have staff thoroughly clean and sanitize the return-air ventilation grill as soon as possible.Soiled Utility Room: The (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. The hand sink faucet cold water handle was also observed loose-to-mount. (DHLS) J indicated he would contact maintenance for necessary repairs as soon as possible.Oxygen Room: The utility sink faucet atmospheric vacuum breaker was observed leaking water upon actuation. (DHLS) J indicated he would contact maintenance for necessary repairs as soon as possible.On 07/02/25 at 10:15 A.M., An interview was conducted with Director of Maintenance (DM) K regarding the facility work order system. (DM) K stated: We have the TELS system.On 07/03/25 at 10:00 A.M., Record review of the Policy/Procedure entitled: Housekeeping Policies & Procedures Check List dated (no date) revealed under (12) Discharge Room Clean: (p) Check privacy curtains & replace if needed. (q) Wall vents & heat/AC unit vent cleaned.On 07/03/25 at 10:30 A.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observation, interview, and record review the facility failed to ensure 9 out of 10 resident's (Residents #'s 11, 37, 42, 65, 94, 108, 124, 134, & 242) allegations of abuse were reported to the state agency.Findings Included:Per the facility face sheet R11 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 was cognitively intact. Record review of a concern form dated 5/17/2025, revealed R11 had documented on the concern form that she had run out of oxygen, and Certified Nurse Aid (CNA) JJ told her that she had to wait, and proceeded the leave to attend to another resident leaving R11 with no oxygen. R11 documented on the concern form that CNA JJ made her sit in urine soak brief for over six hours, until a nurse made CNA JJ change her. R11 documented that CNA JJ was being rude, R11 told CNA JJ she needed her labia washed due to the soap had not been washed out of that area yet, and it was burning. The concern form further revealed that R11 stated CNA JJ started to scream at her, and was then asked to leave her room, but CNA JJ stated that she did not have to leave and then slammed R11's room door. The concern form revealed that R11 did not want CNA JJ in her room, and this was the third time that this type of incident had happened, and she was not going to be an abused patient. The concern form revealed that the facility's response was that R11 and CNA JJ were spoken to, and CNA JJ was provided with education. The allegations of abuse were not identified as allegations of abuse, nor reported to the state agency upon checking the state agency reporting system. In an interview on 7/08/2025 at 1:35 PM, Administrator A stated that he went and talked to R11 to see what happened. Administrator A said R11 leaves her window open the wind pushes the door shut, CNA JJ is new, and stated that he asked CNA EE if the incident that had taken place was abuse or customer service, in which Administrator A stated that the decision was made by CNA JJ, CNA EE, and R11 that is was not abuse; just a customer service concern, despite the fact that R11 specifically stated on the concern form that she was not going to be an abused patient. Therefore, Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R11 had to be costumer service concerns and not abuse allegations. Resident #37 (R37): Per the facility face sheet R37 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R37 had a BIMS score of 15 out of 15 which indicated R37 was cognitively intact. Review of a documented concern on a concern form dated 6/1/2025, revealed that R37 did not get her meds on time, and when she asked the nurse (did not state name) when she could get her meds the nurse said to R37 I'll get to you when I get to you with an attitude. The concern form documentation revealed that the facility’s response to R37's concern was that Administrator A spoke with both R37 and the nurse, and it was determined that R37 would go outside to smoke during medication administration times. Education was provided to nurse regarding customer service, spoke with residents about letting staff/nurse know when she is going outside so staff know where she is. The facility did not identify, nor address R37's statement that the nurse had an attitude, and told her, I'll get to you when I get to you In an interview on 7/08/2025 at 1:21 PM, Administrator A was asked about the allegation of abuse R37 documented on the concern form regarding the nurse. Administrator A stated that she spoke with R37 who said the nurse was close to her room and she asked if it was time for her medications, and the nurse said I will get to you when I get to you. Administrator A said he asked R37 how she felt about it, whether she felt it was abuse or customer service concern. Administrator A said R37 stated she felt the nurse could have said it in a different way. Administrator A also said he asked R37 to let staff know when she was leaving and coming, because she was frequently outside, and he would talk to the nurse about customer service. Administrator A stated R37 had no abuse concerns, however nowhere on Administrator A's follow-up documentation was that documented. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R11 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, not reported to the state agency upon checking the state agency reporting system. Resident #42 (R42): Per the facility face sheet R42 was admitted on [DATE]. Review of the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/17/25 revealed R 42 was [AGE] years old, admitted to the facility with diagnosis that included cerebral vascular accident (stroke). R42 scored 12 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Section B of the MDS reflected R42 had clear speech and adequate hearing, was usually understood and usually understood others Review of a concern form that R42 filled out revealed Licensed Practical Nurse (LPN) E spoke to R42 in a mean way on 1/21/2025, and that R42 had to wait for her morning meds, in a very mean way, when R42 asked for her meds. The concern form revealed that R42 stated this type of behavior from LPN E happened often. R42 wrote on the concern form that she had asked for her medications before breakfast, but as of 9:45 AM, R42 still had not received her medications. R42 also documented on the concern form that LPN E treats other residents the same way. The concern form revealed that the facility's response was that R42 was frustrated that she had to wait for her blood pressure to be taken before receiving her meds, and it was documented that R42 now changed her mind and made a statement that LPN E was not mean to her. The documented action to be taken was that the CNAs will attempt to get R42's vital signs at the start of the day shift. However, R42 requested on the concern form that LPN E be spoken to about the way she talks to residents, and needs to talk kindly, as LPN E does this often to many patients. The concern form did not document any education or speaking to LPN E about how she spoke to R42 in a very mean way. In an interview on 7/08/2025 at 1:15 PM, Administrator A stated that R42 had to be interviewed by the Speech Therapist (ST) because R42 had expressive dysphasia (cannot speak whole sentences), so someone had to assist R42 with getting her words out. Administrator A said the only thing R42 could do was nod yes and no so the ST had to guess what R42's frustration was telling her. So, ST felt R42 was trying to say LPN E was rude. Review of another concern form dated 6/18/2025, revealed R42 made a complaint that a CNA (did not name the CNA) was very rude while serving her breakfast, and CNA ignored her and had a rude tone. The facility's response was that a nurse spoke with R42 and the CNA an both stated it must have been a misunderstanding. In an interview on 7/08/2025 at 1:05 PM, Administrator A said, regarding the 6/18/2025 concern, R42 felt the CNA was ignoring her. Administrator A said he spoke with the CNA who did not understand where the resident’s frustration was coming from so it must of been a misunderstanding, Review of another concern dated 1/7/2025 revealed when R42 would lay down after lunch and then wanted to get back up at 2:00 PM for group, staff would not get her up, but would tell her to go to sleep I can't get you up and down. None of these allegations of abuse were identified as allegations of abuse, nor were they reported to the state agency. Resident #65 (R65): Per the facility face sheet R65 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R65 had a BIMS score of 10 which indicated R65 had only a moderate cognitive impairment. Review of a concern form dated 6/17/2025, revealed LPN MM got upset with R65, and refused to give R65 her pain medication, and it was not until the night shift arrived that R65 then received morphine because her pain was so bad. The concern form further stated that LPN MM was very rude. Facility resolution was educating the resident on the process of obtaining a narcotic to administer. The concern did not identify the allegation of abuse regarding LPN MM being very rude. Under FACILITY RESPONSE and ACTION TO BE TAKEN revealed no documentation of LPN MM receiving any education, or anything else regarding the allegation. In 7/08/2025 at 12:54 PM, Administrator A said he went and talked with R65, and the process was explained to R65 for obtaining a controlled substance. Administrator A said he told R65 the definition of abuse, then asked R65 if he believed LPN MM was abusive versus a customer service concern. Administrator A said he did ask R65 what he meant by LPN MM being rude, and R65 said he meant he felt misunderstood. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R11 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, not reported to the state agency upon checking the state agency reporting system. Resident #94 (R94): Per the facility face sheet R94 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R94 had a BIMS score of 12 out of 15 which indicated a moderate cognitive impairment. Review of a concern form, date unknown, revealed an allegation that R94 was being sex trafficked. In an interview on 7/08/2025 at 1:00 PM, Administrator A stated that the police received an anonymous call that R94 was being sex trafficked. So, Administrator A said he spoke to R94 who denied it, so that was why he did not report the allegation to the state agency. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R11 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, not reported to the state agency upon checking the state agency reporting system. Resident #108 (R108): Per the facility face sheet R108 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R108 had a BIMS score of 12 out of 15. Review of a concern form dated 6/30/2025, revealed CNA OO had an unfriendly and gruff personality. The form revealed CNA OO could be rough when providing care, and the problem was ongoing. The action to be taken was to talk to CNA OO In an interview on 7/08/2025 at 12:41 PM, Administrator A stated he did not consider abuse with R108's concern. Administrator A said R108 told him that CNA OO was unfriendly and gruff. Administrator A said he asked R108 if CNA OO was acting intentionally and/or willfully, if he should provide coaching, and if it was customer service concern. Administrator A stated that he defined abuse to R108 and told him to let him talk to CNA OO, and then he would come back and ask R108 what his recommendations would be for what he should do with CNA OO. Administrator A said after he defined abuse to R108, R108 said it was a customer service concern. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R108 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, not reported to the state agency upon checking the state agency reporting system. Resident #124 (R124): Per the facility face sheet revealed R124 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R124's BIMS score was 14 out of 15. R124 was the roommate of R108. Both residents filled out a concern form on 6/30/2025 which were identical concerns. Review of a concern form dated 6/30/2025, revealed CNA OO had an unfriendly and gruff personality. The form revealed CNA OO could be rough when providing care, and the problem was ongoing. The action to be taken was to talk to CNA OO In an interview on 7/08/2025 at 12:41 PM, Administrator A stated he did not consider abuse with R124's concern. Administrator A said R124 told him that CNA OO was unfriendly and gruff. Administrator A said he asked R124 if CNA OO was acting intentionally and/or willfully, if he should provide coaching, and if it was customer service concern. Administrator A stated that he defined abuse to R124 and told him to let him talk to CNA OO, and then he would come back and ask R124 what his recommendations would be for what he should do with CNA OO. Administrator A said after he defined abuse to R124, R124 said it was a customer service concern. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R124 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, not reported to the state agency upon checking the state agency reporting system. Resident #134 (R134): Per the facility face sheet R134 was admitted the facility on 5/23/2025. Review of an MDS dated [DATE], revealed R124 had a BIMS score of 15 out of 15. Review of a concern form dated 5/30/2025, revealed Physical Therapy Assistant (PTA) QQ spoke to R134 in a way that left her feeling upset. The facility's action was that R134's physical therapy would be provided by another PTA. In an interview on 7/08/2025 at 12:50 PM, Administrator A stated that he had no concerns with R134's concern being an allegation of abuse, because R134 said PTA QQ went into her room while she had an IV antibiotic running, and because of that R134 did not want to start therapy until the antibiotic was completed. PTA QQ stated R134 that she was not going to get any better if she did participate in therapy. Administrator A said R134 did not want PTA QQ to treat her anymore because his comments made her feel bad. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R124 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, not reported to the state agency upon checking the state agency reporting system. Resident #242 (R242): Per the facility face sheet R242 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R242 had a BIMS score of 12 out of 15. Review of a concern form dated 1/30/2025, revealed CNA KK had an attitude every time R242 opened her mouth CNA KK would respond rudely, and when she asked a question CNA KK would come back with a sarcastic attitude/response. The concern form revealed that on 1/30/2025 CNA KK got pissed, and upon leaving R242's room, hid R242's remote (call light) turned off all lights, and shut the door on R242. The concern form further revealed that when R242 would call for CNA KK, CNA KK would get mad at her and she was tired of it. The concern form revealed that the facility's response was to provide education to CNA KK in regard to satisfactory customer service practices. CNA KK signed the concern form on 2/12/2025 that she received the education to ensure resident care spoken to with respect and professionalism, and residents will be treated with professionalism. In an interview on 07/08/2025 at 8:09 AM, via phone R242's daughter (Dtr) RR stated that R242 was not available for interview, however stated she was very familiar with the incident. Dtr RR stated that the situation with CNA KK went on for several days, then she requested a concern form. Dtr RR said CNA KK was sarcastic, had an attitude when R242 asked for anything, would shut R242's door and hide her call light. Dtr RR said R242 would have to yell out for help because she did not have her call light. Dtr RR stated that this had happened twice, and said she was on the phone with R242 one of the times that it happened. She told me the CNA KK hid her remote (call light) and shut her door. Dtr RR said R242 had started screaming out, help me help me, and said they (staff) were not coming. Dtr RR said she then called the nursing desk over and over until someone answered. Dtr RR said she wrote the incident on a concern form, and gave the form to LPN SS, but did not know where the form went from there. On 7/08/2025 at 8:43 AM, an attempt was made to contact LPN SS” but was unsuccessfully. In an interview on 7/08/2025 at 8:55 AM, CNA KK stated that she did not recall R242, did not recall the incident, and did not recall receiving a one-to-one Inservice that she signed on 2/12/2025, asked if she wanted to change anything about her statement in which CNA KK stated No In an interview on 7/08/2025 at 1:25 PM, Administrator A stated that he would say the allegations could be abuse, and that he would have spoken to R242 and got her statement, talked to staff, and done a thorough investigation. Administrator A said based on what is written on the concern form, those are allegations of abuse, and said yes he would do an investigation and report it to the state agency. However. Administrator A was not able to explain why the allegations were not reported to the state agency. In an interview on 7/08/2025 at 2:01 PM, LPN U, who was the Unit Manager for the one south unit, stated that the concern form was given to her by Administrator A. LPN U said she spoke with R242, and CNA KK about the incident, but stated she had no documentation of those interviews. Upon asking LPN U stated that she had no concerns with allegations of abuse, and no concerns with allegations of involuntary seclusion in R242's concern that was written on the concern form. In an interview on 7/08/2025 at 238 PM, Director of Nursing (DON) B, after reading R242's concern form, stated yes and also stated that she had a concern with CNA KK shutting the door on R242, and allegations of abuse. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R124 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, not reported to the state agency upon checking the state agency reporting system.

Based on interview, and record review the facility failed to ensure 9 out of 10 residents (Residents #'s 11, 37, 42, 65, 94, 108, 124, 134, & 242) allegations of abuse were thoroughly investigated, assure prevention of further potential abuse, and report the finding within five working days to the state agency. Findings Included:Per the facility face sheet R11 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 was cognitively intact. Record review of a concern form dated 5/17/2025, revealed R11 had documented on the concern form that she had run out of oxygen, and Certified Nurse Aid (CNA) JJ told her that she had to wait, and proceeded the leave to attend to another resident leaving R11 with no oxygen. R11 documented on the concern form that CNA JJ made her sit in urine soak brief for over six hours, until a nurse made CNA JJ change her. R11 documented that CNA JJ was being rude, R11 told CNA JJ she needed her labia washed due to the soap had not been washed out of that area yet, and it was burning. The concern form further revealed that R11 stated CNA JJ started to scream at her, and was then asked to leave her room, but CNA JJ stated that she did not have to leave and then slammed R11's room door. The concern form revealed that R11 did not want CNA JJ in her room, and this was the third time that this type of incident had happened, and she was not going to be an abused patient. The concern form revealed that the facility's response was that R11 and CNA JJ were spoken to, and CNA JJ was provided with education. The allegations of abuse were not identified as allegations of abuse, no investigation was done, CNA JJ was not removed from continuing to provide resident care, and the allegations were not reported to the state agency, nor was a 5-day investigation upon checking the state agency reporting system. In an interview on 7/08/2025 at 1:35 PM, Administrator A stated that he went and talked to R11 to see what happened. Administrator A said R11 leaves her window open the wind pushes the door shut, CNA JJ is new, and stated that he asked CNA EE if the incident that had taken place was abuse or customer service, in which Administrator A stated that the decision was made by CNA JJ, CNA EE, and R11 that is was not abuse; just a customer service concern, despite the fact that R11 specifically stated on the concern form that she was not going to be an abused patient. Therefore, Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R11 had to be costumer service concerns and not abuse allegations. Resident #37 (R37): Per the facility face sheet R37 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R37 had a BIMS score of 15 out of 15 which indicated R37 was cognitively intact. Review of a documented concern on a concern form dated 6/1/2025, revealed that R37 did not get her meds on time, and when she asked the nurse (did not state name) when she could get her meds the nurse said to R37 I'll get to you when I get to you with an attitude. The concern form documentation revealed that the facility’s response to R37's concern was that Administrator A spoke with both R37 and the nurse, and it was determined that R37 would go outside to smoke during medication administration times. Education was provided to nurse regarding customer service, spoke with the resident (R37) about letting staff/nurse know when she is going outside so staff know where she is. The facility did not identify, nor address R37's statement that the nurse had an attitude, and told her, I'll get to you when I get to you In an interview on 7/08/2025 at 1:21 PM, Administrator A was asked about the allegation of abuse R37 documented on the concern form regarding the nurse. Administrator A stated she spoke with R37 who said the nurse was close to her room and she asked if it was time for her meds, and the nurse said I will get to you when I get to you. Administrator A said he asked R37 how she felt about it, whether she felt it was abuse or customer service concern. Administrator A said R37 stated she felt the nurse could have said it in a different way. Administrator A also said he asked R37 to let staff know when she was leaving and coming, because she was frequently outside, and he would talk to the nurse about customer service. Administrator A stated R37 had no abuse concerns, however nowhere on Administrator A's follow-up documentation was that documented. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R11 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, no investigation was done, no identified staff member (nurse) was not removed from continuing to provide resident care, and the allegations were not reported to the state agency, nor was a 5-day investigation upon checking the state agency reporting system. Resident #65 (R65): Per the facility face sheet R65 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R65 had a BIMS score of 10 which indicated R65 had only a moderate cognitive impairment. Review of a concern form dated 6/17/2025, revealed LPN MM got upset with R65, and refused to give R65 her pain medication, and it was not until the night shift arrived that R65 then received morphine because her pain was so bad. The concern form further stated that LPN MM was very rude. Facility resolution was educating the resident on the process of obtaining a narcotic to administer. The concern did not identify the allegation of abuse regarding LPN MM being very rude. Under FACILITY RESPONSE and ACTION TO BE TAKEN revealed no documentation of LPN MM receiving any education, or anything else regarding the allegation. In 7/08/2025 at 12:54 PM, Administrator A said he went and talked with R65, and the process was explained to R65 for obtaining a controlled substance. Administrator A said he told R65 the definition of abuse, then asked R65 if he believed LPN MM was abusive versus a customer service concern. Administrator A said he did ask R65 what he meant by LPN MM being rude, and R65 said he meant he felt misunderstood. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R11 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, no investigation was done, LPN MM was not removed from continuing to provide resident care, and the allegations were not reported to the state agency, nor was a 5-day investigation upon checking the state agency reporting system. Resident #94 (R94): Per the facility face sheet R94 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R94 had a BIMS score of 12 out of 15 which indicated a moderate cognitive impairment. Review of a concern form, date unknown, revealed an allegation that R94 was being sex trafficked. In an interview on 7/08/2025 at 1:00 PM, Administrator A stated that the police received an anonymous call that R94 was being sex trafficked. So Administrator A said he spoke to R94 who denied it, so that was why he did not report the allegation to the state agency. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R11 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, no investigation was done, and the allegations were not reported to the state agency, and no 5-day investigation results were reported upon checking the state agency reporting system. Resident #108 (R108): Per the facility face sheet R108 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R108 had a BIMS score of 12 out of 15. Review of a concern form dated 6/30/2025, revealed CNA OO had an unfriendly and gruff personality. The form revealed CNA OO could be rough when providing care, and the problem was ongoing. The action to be taken was to talk to CNA OO In an interview on 7/08/2025 at 12:41 PM, Administrator A stated he did not consider abuse with R108's concern. Administrator A said R108 told him that CNA OO was unfriendly and gruff. Administrator A said he asked R108 if CNA OO was acting intentionally and/or willfully, if he should provide coaching, and if it was customer service concern. Administrator A stated that he defined abuse to R108 and told him to let him talk to CNA OO, and then he would come back and ask R108 what his recommendations would be for what he should do with CNA OO. Administrator A said after he defined abuse to R108, R108 said it was a customer service concern. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R108 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, no investigation was done, CNA OO was not removed from continuing to provide resident care, and the allegations were not reported to the state agency, nor was a 5-day investigation upon checking the state agency reporting system. Resident #124 (R124): Per the facility face sheet revealed R124 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R124's BIMS score was 14 out of 15. R124 was the roommate of R108. Both residents filled out a concern form on 6/30/2025 which were identical concerns. Review of a concern form dated 6/30/2025, revealed CNA OO had an unfriendly and gruff personality. The form revealed CNA OO could be rough when providing care, and the problem was ongoing. The action to be taken was to talk to CNA OO In an interview on 7/08/2025 at 12:41 PM, Administrator A stated he did not consider abuse with R124's concern. Administrator A said R124 told him that CNA OO was unfriendly and gruff. Administrator A said he asked R124 if CNA OO was acting intentionally and/or willfully, if he should provide coaching, and if it was customer service concern. Administrator A stated that he defined abuse to R124 and told him to let him talk to CNA OO, and then he would come back and ask R124 what his recommendations would be for what he should do with CNA OO. Administrator A said after he defined abuse to R124, R124 said it was a customer service concern. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R124 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, no investigation was done, CNA OO was not removed from continuing to provide resident care, and the allegations were not reported to the state agency, nor was a 5-day investigation upon checking the state agency reporting system. Resident #134 (R134): Per the facility face sheet R134 was admitted the facility on 5/23/2025. Review of an MDS dated [DATE], revealed R124 had a BIMS score of 15 out of 15. Review of a concern form dated 5/30/2025, revealed Physical Therapy Assistant (PTA) QQ spoke to R134 in a way that left her feeling upset. The facility's action was that R134's physical therapy would be provided by another PTA. In an interview on 7/08/2025 at 12:50 PM, Administrator A stated that he had no concerns with R134's concern being an allegation of abuse, because R134 said PTA QQ went into her room while she had an IV antibiotic running, and because of that R134 did not want to start therapy until the antibiotic was completed. PTA QQ stated R134 that she was not going to get any better if she did participate in therapy. Administrator A said R134 did not want PTA QQ to treat her anymore because his comments made her feel bad. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R124 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, no investigation was done, and the allegations were not reported to the state agency, nor was a 5-day investigation upon checking the state agency reporting system. Resident #242 (R242): Per the facility face sheet R242 was admitted to the facility on [DATE]. Review of an MDS dated [DATE], revealed R242 had a BIMS score of 12 out of 15. Review of a concern form dated 1/30/2025, revealed CNA KK had an attitude every time R242 opened her mouth CNA KK would respond rudely, and when she asked a question CNA KK would come back with a sarcastic attitude/response. The concern form revealed that on 1/30/2025 CNA KK got pissed, and upon leaving R242's room, hide R242's remote (call light) turned off all lights, and shut the door on R242. The concern form further revealed that when R242 would call for CNA KK, CNA KK would get mad at her and she was tired of it. The concern form revealed that the facility's response was to provide education to CNA KK in regard to satisfactory customer service practices. CNA KK signed the concern form on 2/12/2025 that she received the education to ensure resident care spoken to with respect and professionalism, and residents will be treated with professionalism. In an interview on 07/08/2025 at 8:09 AM, via phone R242's daughter (Dtr) RR stated that R242 was not available for interview, however stated she was very familiar with the incident. Dtr RR stated that the situation with CNA KK went on for several days, then she requested a concern form. Dtr RR said CNA KK was sarcastic, had an attitude when R242 asked for anything, would shut R242's door and hide her call light. Dtr RR said R242 would have to yell out for help because she did not have her call light. Dtr RR stated that this had happened twice, and said she was on the phone with R242 one of the times that it happened. she told me the CNA KK hid her remote (call light) and shut her door. Dtr RR said R242 had started screaming out, help me help me, and said they (staff) were not coming. Dtr RR said she then called the nursing desk over and over until someone answered. Dtr RR said she wrote the incident on a concern form, and gave the form to LPN SS, but did not know where the form went from there. On 7/08/2025 at 8:43 AM, an attempt was made to contact LPN SS” but was unsuccessfully. In an interview on 7/08/2025 at 8:55 AM, CNA KK stated that she did not recall R242, did not recall the incident, and did not recall receiving a one-to-one Inservice that she signed on 2/12/2025, asked if she wanted to change anything about her statement in which CNA KK stated No In an interview on 7/08/2025 at 1:25 PM, Administrator A stated that he would say the allegations could be abuse, and that he would have spoken to R242 and got her statement, talked to staff, and done a thorough investigation. Administrator A said based on what is written on the concern form, those are allegations of abuse, and said yes he would do an investigation and report it to the state agency. However. Administrator A was not able to explain why the allegations were not reported to the state agency. In an interview on 7/08/2025 at 2:01 PM, LPN U, who was the Unit Manager for the one south unit, stated that the concern form was given to her by Administrator A. LPN U said she spoke with R242, and CNA KK about the incident, but stated she had no documentation of those interviews. Upon asking LPN U stated that she had no concerns with allegations of abuse, and no concerns with allegations of involuntary seclusion in R242's concern that was written on the concern form. In an interview on 7/08/2025 at 238 PM, Director of Nursing (DON) B, after reading R242's concern form, stated yes and also stated that she had a concern with CNA KK shutting the door on R242, and allegations of abuse. Administrator A did not report the allegations of abuse to the state agency, because he considered the concerns R124 had to be costumer service concerns and not abuse allegations. The allegations of abuse were not identified as allegations of abuse, no investigation was done, CNA KK was not removed from continuing to provide resident care, and the allegations were not reported to the state agency, nor was a 5-day investigation upon checking the state agency reporting system. Resident #42 (R42) R42 review of the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/17/25 revealed R 42 was [AGE] years old, admitted to the facility with diagnosis that included cerebral vascular accident (stroke). R42 scored 12 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Section B of the MDS reflected R42 had clear speech and adequate hearing, was usually understood and usually understood others. Review of a facility concern form dated 1/21/25 revealed R42 went to the nurse's station requesting her morning medications and License Practical Nurse (LPN) E responded to her in a very mean way and told her she had to wait. The form went on to say LPN E often responds like this. The section of the same form asks how the concern can be resolved in which R42's response was Talk to her about talking to residents kindly, she does this often and to many patients. The facility response to R42's allegation of abuse was that R42 was frustrated and inpatient from having to wait for her medication and LPN E was not mean. There was no investigation done by the facility, no statements, no interviews with other residents, no interviews with other staff, no protection placed to ensure R42 was safe, so suspension for LPN E pending an investigation. On 07/08/25 10:39 AM, during an interview with R42, it was queried if she recalled talking to the form Director of Nursing and recanting on the statements about LPN E talking mean to her and other residents. R42 stated she did not recant her statement and LPN E still was mean and had a nasty attitude. In an interview on 7/08/2025 at 1:15 PM, Administrator A stated that R42 had to be interviewed by the Speech Therapist (ST) because R42 had expressive dysphasia (cannot speak whole sentences), so someone had to assist R42 with getting her words out. Administrator A said the only thing R42 could do was nod yes and no so the ST had to guess what R42's frustration was telling her. So, ST felt R42 was trying to say LPN E was rude. Review of another concern form dated 6/18/2025, revealed R42 made a complaint that a CNA (did not name the CNA) was very rude while serving her breakfast, and CNA ignored her and had a rude tone. The facility's response was that a nurse spoke with R42 and the CNA and both stated it must have been a misunderstanding. In an interview on 7/08/2025 at 1:05 PM, Administrator A said, regarding the 6/18/2025 concern, R42 felt the CNA was ignoring her. Administrator A said he spoke with the CNA who did not understand where the resident’s frustration was coming from so it must of been a misunderstanding, Review of another concern dated 1/7/2025 revealed when R42 would lay down after lunch and then wanted to get back up at 2:00 PM for group, staff would not get her up but would tell her to go to sleep I can't get you up and down. The allegations of abuse were not identified as allegations of abuse, no investigation was done, LPN E nor a CNA was removed from continuing to provide resident care, and the allegations were not reported to the state agency, nor was a 5-day investigation upon checking the state agency reporting system.

Based on interview and record review, the facility failed to ensure grievances were promptly documented, investigated, tracked and resolved for one resident of one resident reviewed for grievances (Resident #8). Findings include:Review of the clinical record reflected R8 was admitted to the facility for long term care with diagnoses that included diabetes and hemiplegia. Review of the Minimum Data Set (MDS) dated [DATE], R8 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 07/01/25 11:25 AM, during an interview with R8, he reported multiple missing clothing items that have not been replaced despite multiple complaints. R8 reported this had been an ongoing issue and since his most recent hospitalization from 5/03/25 to 5/08/25 additional items were missing. R8 reported due history of former facility administration rummaging through his personal property and discarding items at will, R8 did not trust facility staff and reached out to the local Ombudsman to get involved in effort to assist in recovering the missing items. Review of the facility grievance log from January 2025 to June 2025, revealed there were no grievance/concern forms from R8. On 07/03/25 at 10:43 AM, during a phone interview with Ombudsman HH it was reported that R8 reported that in April of 2024 while hospitalized the multiple items were missing. An interim Nursing Home Administrator (NHA) was aware and attempting to work with R8 on recovering the items, then the Interim NHA left and current NHA A took over. Ombudsman HH stated she had met with NHA A and R8 and NHA A was agreeable to replacing some items but not all since the list provided by R8 went back to April of 2024. R8 went to the hospital (May 2025) reported additional missing items and no resolutions have occurred. On 07/03/25 12:06 PM, during an interview with NHAA he reported he started at the facility in January of 2025 and was aware of R8 concerns regarding missing items and reported he had multiple conversations and a meeting with R8 and Ombudsman HH in March or April. NHA A during the meeting R8 did not want staff to look for the missing items and did not want to be reimbursed. When asked if perhaps R8's history and lack of trust may have been a reason for declining housekeeping to search his room, NHA A stated he didn't know. When queried why R8 would pursue the issue of missing items, get the Ombudsman involved then decline wanting items found or items to reimbursed, NHA A stated he could not respond to the question. Documentation related the meeting held with R8 and Ombudsman HH was requested. When queried why the missing items were not tracked in the grievance log and missing item/concern form filled out, NHA A stated because R8 didn't want to file a complaint. When queried why NHA A wouldn't want to track, monitor and resolve issue to identify patterns for the facility, NHA A did not respond. On 07/03/25 12:11 PM during a follow up interview with Ombudsman HH she reported at no time did R8 say that he didn't want to be reimbursed for the lost items, R8 did say he did not want staff to search his room and go through belongings but had no objections for staff to search laundry. By the close of the survey on 7/08/2025 there was no documentation provided by the facility that R 8 did not want resolution, that laundry had been searched, there was no documentation of the meeting that was held with NHA A, R8 and Ombudsman HH.

Based on interview and record review the facility failed to ensure for two out of two residents (Resident #11 and #242) the right to be free from abuse, and involuntary seclusion. Findings Include: Resident #11 (R11) Per the facility face sheet R11 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 was cognitively intact.Record review of a concern form dated 5/17/2025, revealed R11 had documented on the concern form that she had run out of oxygen, and Certified Nurse Aid (CNA) JJ told her that she had to wait, and proceeded the leave to attend to another resident leaving R11 with no oxygen. R11 documented on the concern form that CNA JJ made her sit in urine soak brief for over six hours, until a nurse made CNA JJ change her. R11 documented that CNA JJ was being rude, R11 told CNA JJ she needed her labia washed due to the soap had not been washed out of that area yet, and it was burning. The concern form further revealed that R11 stated CNA JJ started to scream at her, and was then asked to leave her room, but CNA JJ stated that she did not have to leave and then slammed R11's room door. The concern form revealed that R11 did not want CNA JJ in her room, and this was the third time that this type of incident had happened, and she was not going to be an abused patient.In an interview on 7/07/2025 at 12:22 PM, CNA EE stated he went into R11's room to assist CNA JJ with R11's care when CNA JJ started to yell at R11, and then they both yelled back and forth. CNA EE stated that she told CNA JJ to leave R11's room, and at first CNA JJ would not want to leave, but when she finally did she slammed the room door. CNA EE said CNA JJ told R11 that she could not be this rude to be people who took care of her. CNA EE said he reported the incident to Administrator A immediately, along with R11. CNA EE said Administrator A asked him if there was any abuse involved, and then said he told Administrator A the same thing he just stated in this interview. CNA EE also said CNA JJ told R11 that she did not have to do a damn thing, and it was an argument that got out of control. CNA EE did state that CNA JJ did tell R11 that she did not have to leave the room and R11 said yes you do. CNA EE said he told CNA JJ that she did have to leave the room. In an interview on 7/07/2025 at 12:38 PM, R11 stated that CNA JJ had come into her room to help with care and just started yelling and getting angry. R11 said she asked CNA JJ to leave the room, and CNA JJ said she did not have to, then slammed her room door. In interview with R11 on 7/08/2025 at 10:45 AM, R11 stated that she did ask to be cleaned in her peri area because it burned, but the CNA JJ just began to verbalize how she can find another job, and went on and on, and then she asked her to leave, but CNA JJ she said she did not have to, and then slammed her room door. In an interview on 7/07/2025 at 1:00 PM, CNA JJ stated that she went in to provide care for R11, when R11 started to talk badly to her, and yelled at me and told me to get. CNA JJ said she the door just closes as if it slams. The concern form revealed that the facility's response was that R11 and CNA JJ were spoken to, and CNA JJ was provided with education. However, R11's right to be free from abuse was not maintained due to the fact that CNA JJ was not removed from providing care to R11 and other residents, because the facility did not perform an abuse investigation.Resident #242 (R242):Per the facility face sheet R242 was admitted to the facility on [DATE].Review of an MDS dated [DATE], revealed R242 had a BIMS score of 12 out of 15. Review of a concern form dated 1/30/2025, revealed CNA KK had an attitude every time R242 opened her mouth CNA KK would respond rudely, and when she asked a question CNA KK would come back with a sarcastic attitude/response. The concern form revealed that on 1/30/2025 CNA KK got pissed, and upon leaving R242's room, hide R242's remote (call light) turned off all lights, and shut the door on R242. The concern form further revealed that when R242 would call for CNA KK, CNA KK would get mad at her and she was tired of it.The concern form revealed that the facility's response was to provide education to CNA KK in regards to satisfactory customer service practices. CNA KK signed the concern form on 2/12/2025 that she received the education to ensure resident care spoken to with respect and professionalism, and residents will be treated with professionalism. In an interview on 07/08/2025 at 8:09 AM, via the phone R242's daughter (Dtr) RR stated that R242 was not available for interview, however stated she was very familiar with the incident. Dtr RR stated that the situation with CNA KK went on for several days, then she requested a concern form. Dtr RR said CNA KK was sarcastic, had an attitude when R242 asked for anything, would shut R242's door and hide her call light. Dtr RR said R242 would have to yell out for help because she did not have her call light. Dtr RR stated that this had happened twice, and said she was on the phone with R242 one of the times that it happened. she told me the CNA KK hid her remote (call light) and shut her door. Dtr RR said R242 had started screaming out, help me help me, and said they (staff) were not coming. Dtr RR said she then called the nursing desk over and over until someone answered. Dtr RR said she wrote the incident on a concern form, and gave the form to LPN SS, but did not know where the form went from there. On 7/08/2025 at 8:43 AM, an attempt was made to contact LPN SS, but was unsuccessfully. In an interview on 7/08/2025 at 8:55 AM, CNA KK stated that she did not recall R242, did not recall the incident, and did not recall receiving a one to one In-service that she signed on 2/12/2025, asked if she wanted to change anything about her statement in which CNA KK stated No In an interview on 7/08/2025 at 1:25 PM, Administrator A stated that he would say the allegations could be abuse, and that he would have spoken to R242 and got her statement, talked to staff, and done a thorough investigation. Administrator A said based on what is written on the concern form, those are allegations of abuse, and said yes he would do an investigation and report it to the state agency. However. Administrator A was not able to explain why the allegations were not reported to the state agency. In an interview on 7/08/2025 at 2:01 PM, LPN U, who was the Unit Manager for the one south unit, stated that the concern form was given to her by Administrator A. LPN U said she spoke with R242, and CNA KK about the incident, but stated she had no documentation of those interviews. Upon asking LPN U stated that she had no concern's with allegations of abuse, and no concern's with allegations of involuntary seclusion in R242's concern that was written on the concern form. In an interview on 7/08/2025 at 238 PM, Director of Nursing (DON) B, after reading R242's concern form, stated yes and also stated that she had a concern with CNA KK shutting the door on R242, and allegations of abuse.

Based on observation, interview, and record review the facility failed to label and store medication in accordance with accepted professional principles, for one resident (#111) of seven residents during observation of medication administration, one of eight medication carts (to include medication for resident #342), and one medication refrigerator (one east refrigerator) of six refrigerators reviewed. Findings Included:Resident #111 (R111)Review of the medical record revealed R111 was admitted to the facility 02/16/2024 with diagnoses that included type 2 diabetes, congestive heart failure (CHF), atherosclerotic heart disease (build up of substances in artery walls), hypertension, sleep apnea, insomnia, bilateral cataracts, depression, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/09/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (intact cognition) out of 15. During observation of medication administration on 7/03/2025 at 08:24 a.m. Licensed Practical Nurse (LPN) Q was observed entering R111's room to provide prepared medication. R111 was observed sitting up in bed eating her breakfast. LPN Q was observed providing an insulin injection to R111. LPN Q asked R111 if she would like to take her medication (9 different medications in a medication cup) at this time. R111 responded that she would like to take her medication once she had completed her breakfast. LPN Q was observed leaving the medication cup (with 9 different medications) on R111's overbed table and then leaving R111's room. During observation and interview on 07/02/2025 at 08:27 a.m. R111 was observed lying down in bed. The medication cup (with medication) was observed sitting on the over bed table. When inquired if nursing staff left medication with her to take without their supervision, R111 explained that usually staff do leave the medication with her to take later because she does not like to consume her mediation until after she has eaten.Review of R111's medical record did not demonstrate a physician order that she as able to take her medication independently. R111's medical record did not demonstrate that and assessment for self-administration of medication had been conducted. R111's medication record did not have a plan of care specifying that she could self-administer medication. During an interview on 07/03/2025 at 09:17 a.m. Director of Nursing (DON) B explained that the process of self-administering of medication required an assessment by the interdisciplinary team, a physician order, and the residents plan of care would include self-administering of medication. DON B confirmed that R111's medical record did not include the required assessment, physician order, or plan of care for self-administration of medication. Resident #342 (R342) Review of the medical record revealed R342 was admitted to the facility 06/13/2025 with stroke, cognitive communication deficit, left sided hemiplegia (weakness or paralysis), type 2 diabetes, dysphagia (difficulty swallowing), malnutrition, hyperlipidemia (high fat content in blood), history of seizures, and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference [NAME] (ARD) of 06/19/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 03 (severe cognitive impairment) out of 15.On 07/03/2025 at 10:56 a.m. during inspection of 1 [NAME] back medication cart, it was observed that the second drawer contained a medication cup with medication present. The unlabeled medication cup contained three white pills, one light orange pill, one yellow pill, and one dark orange pill. Licensed Practical Nurse (LPN) E explained that the cup contained R342's morning medication. LPN E explained that she was unable to provide R342 with his morning medication because care was being provided. LPN E explained that she had placed the medication cup, with the medication, in the medication cart at an earlier time. LPN E could not list the names of the medication and could not explain why the medication cup was not labeled with R342's name or the names of the medications.During an interview on 07/08/2025 at 10:59 a.m. Director of Nursing (DON) B explained that it was not acceptable to leave mediation in a medication cup without the cup being labeled with the resident name and the names of the medication. DON B' explained that medication should only be stored in packaging from the pharmacy or medication company. During review of one east medication refrigerator June temperature log it was observed to not have temperatures recorded for 06/25/2025, 6/26/2025, 06/28/2025, and 06/30/2025. During an interview on 07/03/2025 at 09:57 a.m. with Infection Preventionist (IP) R explained that it is the responsibility of the midnight nurses to record the temperature of the medication refrigerator on the log. IP R also explained that it was her responsibility to review the logs daily. IP R could not explain why the dates, list above, did not have recorded temperatures.

Based on interview and record review, the facility failed to notify the physician and PACE((Program of All-Inclusive Care for the Elderly) of a change in condition for 1 resident (R104) of three residents reviewed for change of condition, resulting in R104 being hospitalized . Findings included: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 [AGE] year-old female admitted to the facility on [DATE] from the hospital for respite care, with diagnoses that encephalopathy, seizure disorder, chronic obstructive pulmonary disease, respiratory failure, diabetes, kidney failure, anxiety, and depression. The MDS reflected R104 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for bed mobility, transfers, dressing, bathing and toileting. Review of the complaint received by the State Agency alleged the facility failed to prevent a significant medication error for R104. During a telephone interview on 5/5/25 at 3:23 p.m. Complainant C reported R104 was admitted to the facility, from the hospital, for respite care (temporary break for primary caregivers) on 4/18/25 as ongoing patient of PACE (Program of All-Inclusive Care for the Elderly). Complainant C reported PACE authorized R104 to be admitted to participating facility from 4/18/25 through 4/24/25 post hospitalization . Complainant C reported the facility had a contract with organization to coordinate care including to provide all medications and R104 had received narcotic medications on 4/23/25 that organization had not prescribed and was unaware R104 was taking. Complainant C reported R104 was transferred to the hospital on 4/23/25 related to unresponsive, acute respiratory failure and continued to be on life support in the Intensive Care Unit. Review of R104 Nursing Progress Note, dated 4/23/25 at 1:42 p.m., reflected, Resident was transferred to [named] Hospital at 1:00pm Via stretcher, doctor was called after resident was unresponsive, Respirations were 6, HR[heart rate] was 30 and o2[oxygen] stat[saturation] was 57. Doctor instructed Nurse and author of this note to send resident out. Nurse called 9-11 and EMT [emergency medical technician] came. While EMT was here Wrap[Licensed Practical Nurse D] nurse disclosed to nurse and author of this note that when she was given report before this resident was transferred over to this unit that the previous nurse stated that she had to sternum rub resident in order to give her medication. Nurse and author of this note then relayed that to the EMT, Resident was administered one round of Narcan, she became responsive but was taken to [named hospital] for observation. Review of R104 Service Authorization, received by facility from PACE provider 4/18/25 according to fax transmission located on top of page, reflected R104 was authorized to receive service from 4/18/25 through 4/24/25 by the facility. Continued review of the document revealed, Consultant Please Note: referral is authorized for this Visit, Procedure, and/or Tests indicated ONLY, unless otherwise noted. Call immediately for medication orders and/or changes in patient condition . Review of R104 Nurse Progress Note, dated 4/18/25 at 4:00 p.m., reflected, [named R104] arrived via ambulance on a stretcher. She was hospitalized for a Seizure . Review of R104 Social Service Note, dated 4/21/25 at 10:27 a.m., reflected, Resident is [AGE] years old, able to make eye contact when completing assessment. Resident scored a 15/15 BIMS, resident is cognitively intact and able to make her own decisions . Review of R104 Physician Progress Note, dated 4/21/25, reflected, She was seen today for admission assessment in a room .PLAN: [AGE] year-old female with history of morbid obesity, remote, seizure, disorder, atrial fibrillation, hypothyroid, sleep apnea and chronic respiratory failure who had multiple hospitalization in the past is admitted for skilled care after having ? hypoglycemic seizure, atrial fibrillation and acute/chronic respiratory failure. - Goal of rehabilitation is to return home where, she was helped by family for IADL[instrumental activities of daily living] and used a wheel chair at home. - Goal is to improve transfer with SBA[stand by assist] and min assist to transfer and monitor for progress - Pain control, morbid obesity and Pulmonary HTN[hypertension] are limiting factors and prognosis at this time is guarded - Pain control assessed and will schedule Oxy bid, which she has been taking in past with good results - Pain goal is reviewed with her, including side effects and interactions in detail - Will reassess pain control and titrate with goal to help improve transfer and keep pain at mild to tolerable - Keep O2 24 hours and inhalers as needed and use of CPAP[continuous positive airway pressure] and BIPAP[bilevel positive airway pressure] use and compliance discussed with her - Keep anticoagulation and monitor heart rate and BP[blood pressure] - History of seizure with CT head not significant for any finding. Rule out hypoglycemia as likely trigger - Check blood sugar BID[two times daily] and sliding scale. Check A1c and follow up - Keep Keppra dose unchanged and reassess - kidney function monitoring and recheck BMP - Stop Statin for few weeks to avoid muscle side effects at this time - RD[registered dietician] consult for nutrition and caloric needs - Monitor bladder and bowel function - Keep Foley for now and reassess bladder function - Keep antidepressant and monitor sleep, mood and behaviors - Check TSH - Skin care as outlined in the care plan - Hospital records reviewed and medications reconciled - Care plan discussed with her and care team. Will follow up in few days to assess the progress. Review of R104 vitals signs, dated 4/21/25 through 4/23/25, reflected vitals that included: 4/21/25 at 7:44 p.m. -Pulse - 41 beats/minute (no evidence reported to physician). Blood pressure - 99/68 (no evidence reported to physician). Review of R104 Care Plan, dated 4/19/25, reflected, Observe for s/sx of respiratory distress and report to MD PRN: Abnormal respiratory rate, pulse ox, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color . Review of R104 Change of Condition document, dated 4/23/25 and completed 4/24/25, reflected R104 had sudden change in responsiveness and physician notified at 12:00 on 4/23/25. The document included vitals from 8:54 a.m. as most recent. Review of R104 transfer form, dated 4/23/25, reflected R104 had unplanned transfer to the hospital related to unresponsive with vitals that included blood pressure of 89/56, heart rate 30 beats per minute, respirations of 6 per minute, and oxygen level of 57%. Review of R104 hospital documents, dated 4/23/25 through 5/5/25, reflected R104 continued to be on ventilator in the ICU. The documents included. This is a 67 y.o.[year old] female with PMHx[past medical history] of COPD, chronic hypercapnic respiratory failure on 4L O2[4 liters oxygen] at baseline, congestive heart failure, DM2[diabetes], Afib (Xarelto), HTN[hypertension], hypothyroidism, GERD[reflux], possible seizures (Keppra), anxiety, depression, OSA[osteoarthritis], opioid dependence (low back pain) who was admitted to [named hospital] on 4/23/2025 1339 due to decreased level of consciousness. As she was on Oxycontin, she was given Narcan in ED[emergency department], initially followed commands and answered questions appropriately but was on BiPAP, became more somnolent and required intubation. She was started on Bumex for acute on chronic HF[heart failure], treated with antibiotics for possible pneumonia. She required pressors. She was treated for shock, severe cardiomyopathy, AKI, EF is 20-25%. EEG showed moderate nonspecific encephalopathy. She required CRRT[continuous renal replacement therapy] starting 4/25. She was extubated on 4/29 to BiPAP. On 5/1 she was off CRRT and off pressors and transferred to floor. GI was consulted as she had marked transaminitis with cholestatic component, thrombocytopenia and echogenic liver. They recommended RUQ[right upper quad] ultrasound, liver panel in outpatient setting, trend labs and supportive care. They felt it was NAFLD/NASH with superimposed injury, drug induced liver injury or ischemic hepatitis. Cardiology recommended IV heparin for Afib. She was treated with metoprolol for idiopathic cardiomyopathy. They recommended to do a repeat ECHO in a week. Bumex was recommended for HFrEF[heart condition]. She uses a NG[nasal gastric] for feedings as she was NPO[nothing by mouth] status per SLP[thera[y]. On 5/3 she was transferred back to ICU for persistent and worsening hypoxemia, hypotension. She will not tolerate conventional HD[dialyisis] nor can tolerate any meaningful UF and she was started again on CRRT (5/3 nephrology note). She was re-intubated and palliative care was consulted . During a telephone interview on 5/6/25 at 10:50 a.m. Licensed Practical Nurse (LPN) D reported worked on 4/23/25 and assisted with R104 after transfer from 1 South unit to 1 North unit around 11:30 a.m. prior to lunch time. LPN D reported LPN E was R104's nurse on 4/23/25 prior to transfer to 1 north from 1 south. LPN D reported was assisting 1 North nurse and took report from LPN E who told her R104 needed sternal rub prior to giving morning medications on 4/23/25. LPN D reported had cared for R104 prior to 4/23/25 and reported significant change in resident baseline including unresponsive and change in level of consciousness when first observed when R104 arrived on 1 North. LPN D reported as soon an R104 was transferred from 1 South unit to 1 north unit informed 1 North nurse they may need to send R104 to hospital related to change in condition including abnormal vital signs. LPN D reported assisted with R104 transfer to the hospital and Emergency Medical Team administered Narcan (medication that reverses effects of narcotics) and R104 became responsive and returned to the resident she recalled from baseline. LPN D reported did not recall R104 having order for Oxycodone 20mg when she had cared for R104 days prior and was surprised and stated, seemed like large dose. LPN D reported nurses are expected to monitor residents with new Narcotic orders for pain level, sleepiness, change in function, change in level of consciousness and should be reported to Physician related to change in condition immediately and documented. LPN D stated, When you have to sternal rub someone, something in wrong. During a telephone interview on 5/6/25 at 11:34 a.m., LPN E reported was R104 on 4/23/25 day shift starting around 7:00 a.m. LPN E reported night shift did not report anything unusual for R104 and was told took medications whole in pudding, used oxygen and BIPAP with diagnosis of chronic obstructive pulmonary disease. LPN E reported first observed R104 around 7:30 a.m. and appeared to be resting comfortably and continued to pass medication on hall and reported usually passed medications to new residents like R104 at end of medication pass. LPN E reported got to R104 for morning medications late that day between 10:30 a.m. and 11:00 a.m. and reported R104 appeared groggy, tapped on chest and would open eyes, smile then fall back to sleep. LPN E told R104, Lets get medications down, we need to move you, and R104 swallowed medications in pudding. LPN E reported administered several medications including Metoprolol Tartrate (beta-blocker blood pressure medication), and Oxycodone 20 mg. LPN E reported did not check R104 blood pressure prior to administering medications and should have. LPN E reported Certified Nurse Aid had checked vitals at start of shift around 8:00 a.m. on 4/23/25 and reported R104 systolic blood pressure was under 90 and should not have administered Metoprolol and verified did not verify R104 blood pressure prior to administering medications. LPN E reported transferred R104 from 1 South unit to 1 North unit prior to lunch on 4/23/25 and told nurse during report had to really work to get R104 to take medication related to being lethargic an should be reported to physician. LPN E reported was approached by Director of Nursing (DON) B couple hours after and asked if LPN E had administered Metoprolol with low blood pressure and verified. LPN E reported received education related to verifying blood pressure prior to administering blood pressure medications and to hold if less than 100 systolic blood pressure (top number). LPN E reported all nurses received same education after R104 incident. LPN E reported should not have administered R104 medication and stated, they wanted her[R104] moved, and she was in a hurry. LPN E reported not aware of specific required documentation to monitor side effects of narcotics and reported was nursing judgement to report change in condition including increased lethargy. LPN E verified she did not notify physician related to R104 condition. During a telephone interview on 5/6/25 at 1:59 p.m., Registered Nurse (RN) G reported cared for R104 on 4/22/25 day shift and reported R104 was alert and slightly confused that with no change in baseline. RN G reported if resident had change in consciousness including lethargy nurse expected to obtain vitals, report to physician, follow orders and hold medication until verified with physician. During a telephone interview on 5/6/25 at 2:15 p.m. Certified Nurse Aid (CNA) H reported worked on 1 South unit the evening of 4/22/25 into 4/23/25. CNA H reported R104 oxygen level was below 60% when found without BIPAP in place sleeping and was reported to nurse. CNA H reported assisted another CNA I around 5:00 a.m. with R104 who was not acting like herself. CNA H reported R104 was not talking, appeared to have jerking movements that was not normal for R104 after oxygen levels had been reported to nurse earlier in shift. During a telephone interview on 5/6/25 at 2:44 p.m. Licensed Practical Nurse (LPN) F reported was working 4/23/25 day shift on 1 North when R104 was transferred from 1 South and was on lunch. LPN F reported another nurse LPN D was also on the unit and received report from LPN E. LPN F reported returned from lunch about 12:25 p.m. was introduced to R104, who was slouched over in broda chair with BIPAP on, with no response from R104. LPN F reported was unsure what R104 baseline was but reported oxygen saturation was 57% and should be greater than 90% and heart rate was low. LPN F verified R104 was a full code and requested assistance to transfer to bed and R104 vitals improved, and LPN F remained at bedside to monitor. LPN F reported R104 never woke up, opened eyes or responded to staff during transfer from chair to bed. LPN F reported R104 heartrate went down to 30 beats per minute with respirations 6 to 8 per minute and low oxygen and physician was notified and orders given to transfer to hospital. LPN F verified was told that morning nurse had reported R104 was administered morning medications after sternal rub require to wake R104. LPN F reported R104's documented blood pressure was 89/56 on 4/23/25 morning prior to receiving blood pressure medication and oxycodone at 11:00 a.m. LPN F reported EMS staff administered Narcan to R104 and R104 immediately woke up and was responsive and verified had been non-responsive entire time on 1 North unit. LPN F reported facility provided education to nurse staff related to monitoring blood pressure prior to administering blood pressure medications or narcotics after R104 incident. During a telephone interview on 5/6/25 at 3:30 p.m., CNA J reported worked on 4/23/25 starting at 7:00 a.m. on 1 South. CNA J reported had cared for R104 prior to 4/23/25 and reported significant change in R104 baseline noticed at 7:00 a.m. CNA J reported R104 did not look right and was having trouble breathing. CNA J R104 BIPAP machine was alarming when she had arrived to shift and night shift nurse RN K entered R104 room and adjusted machine and alarm stopped. CNA J informed LPN E about R104 including concerns with breathing, less responsive and overall did not look good. CNA J reported by the time they transferred R104 to 1 North R104 CNA J was really concerned and reported to LPN D. CNA J reported R104 BIPAP was making noise again during transfer around 12:00 p.m. During a telephone interview on 5/6/25 at 3:59 p.m., CNA I reported was familiar with R104 and had cared for R104 on 4/22/25 night shift into 4/23/25. CNA I reported had reposition R104 in bed at start of shift between about 11:00 p.m. and 12:00 a.m. and R104 was talking and making jokes. CNA I reported during next rounds observed R104 who appeared less responsive, weak, and out of it that was a change for R104. CNA I reported informed RN K something was wrong with R104 and RN K asked if CNA I had obtained vitals. CNA I then obtained R104 vitals, including low oxygen, and reported back to RN K. CNA I reported RN K did not go to R104 until CNA I returned with vitals to observe R104. CNA I stated, nothing going on unless vitals say according to that nurse. CNA I reported R104 was completely different on second and third rounds during that night and stated, she was not ok. CNA I reported did not feel like nurse responded to reported changes for R104, however, advised to report concerns to immediate supervisor, who was 1 South nurse and that was done. CNA I reported had cared for R104 the evening prior and had similar incident with low oxygen levels and reported to nurse who immediately assessed R104 and adjusted BIPAP and encouraged R104 with breathing and improved. CNA I reported R104 never improved from second and third rounds on 4/22/25 night shift. During a telephone interview on 5/6/25 at 4:44 p.m., CNA L reported cared for R104 on 4/23/25 morning shift starting about 7:00 a.m. CNA L reported did not receive report from night shift and entered R104 room to obtained vitals around 7:00 a.m. and R104 appeared to be in really bad shape with oxygen saturation of 54% and encouraged R104 to take deep breaths for about seven minutes and came up to 90% on BIPAP machine. CNA L reported R104 blood pressure was low as well. CNA L reported R104 was lethargic, eyes would open and close, skin had poor color and was twitching and struggled with breathing. CNA L reported both RN K and LPN E entered R104 room and RN K reported R104 needed sternal on and off during shift to awaken. CNA L reported asked RN K, how could you not notice her[R104] in this shape? CNA L reported assisted R104 to transfer from 1 South to 1 North between 10:30 a.m. and 11:00 a.m. on 4/23/25 and refused to transfer R104 in wheel chair and requested broda chair because was not safe related to R104 was non-responsive at the time. CNA L reported Physician entered R104 room at time of transfer to 1 North and advised staff to transfer R104 to hospital and appeared was not aware of R104's change in condition until that moment. CNA L reported would report to Unit Manager if nurse did not respond to staff reports of resident change in condition. During a second interview on 5/7/25 at 8:27 a.m., LPN E reported no knowledge of low oxygen reading for R104 on 4/23/25 at start of shift with exception of providing CNA staff personal oximeter to use and re-check post bad reading. During an interview on 5/7/25 at 8:34 a.m., Director of Nursing (DON) B reported R104 was admitted [DATE] for PACE respite care. DON B reported recent collaboration team meeting with PACE within past two weeks and learned that residents admitted with PACE services require all changes in care including medications or change of conditions should be communicated with PACE. DON B verified was not aware prior to meeting that facility had to communicate and changes and was unsure if facility had contract with PACE. DON B reported R104 change of conditions was not communicated to PACE and they were not informed of medication changes made on 4/21/25 when Oxycodone was added and should have been. DON B reported PACE basically manages whole person and everything goes through them. DON B reported would expect CNA staff to report anything abnormal to nurse, nurse to assess, complete Change of Condition(COC) documentation if needed or at least Nurse Progress Note. DON B reported would expect abnormal vitals to be documented as well as normal after adjustments/assessments and COC would include physician notification. DON B reported would expect nurse staff to use nurse judgement or follow blood pressure parameters prior to medication administration including use of [NAME] blockers. DON B reported would have expected nurse to hold R104 Metoprolol dose on 4/23/25 morning with blood pressure of 89/56 and notify physician. DON B reported the facility completed a Past Non-Compliance for R104 incident and all nurse staff were educated related to blood pressure parameters and facility was in compliance by 4/26/25. During a telephone interview on 5/7/25 at 9:34 a.m., Medical Director (MD) M reported would expect to be notified by facility staff of change in resident condition including systolic blood pressure less than 100, and definitely oxygen less than 70%, and increase lethargy. MD M reported did not receive call from facility for R104 for change of condition prior to order to transfer to hospital. MD M reported blood pressure perimeters are nursing judgement but wound expect to be notified if systolic blood pressure less than 100 prior to administration of blood pressure medications or Oxycodone (Narcotic). During an interview and record review on 5/7/25 at 10:01 a.m., RN K reported had worked at facility for about two years and typically work on south hall. RN K reported cared for R104 7p to 7a night shift 4/22/25 into 3/23/25. RN K reported R104 had COPD and used BIPAP while sleeping. RN K reported R104 was awake and alert at start of shift and around 5am CNA I did rounds and reported something was wrong with R104 and asked if nurse could come check. RN K asked CNA K, what is problem? RN K reported had asked if CNA I had obtained full vitals and instructed to do so. RN K reported CNA staff should have knowledge to obtain vitals before telling informing nurse something is wrong. RN K reported CNA I returned to nurse with vitals including low oxygen level and stated, this was a teaching moment for CNA I. RN K reported entered R104 with CNA I around 5:00 a.m. and R104 was sleeping and woke her up by shaking and opened eyes for moment and closed and reported taught CNA I to assess capillary refill prior to monitoring oxygen level. RN K reported would expect CNA staff to first obtain accurate data prior to asking nurse to assess residents. RN K was asked where to locate vitals, and RN K reported should be documented in Electronic Medical Record(EMR) and verified was unable to locate full set of vitals for R104 including no blood pressure or heart rate for 12 hour shift and stated did not document them. RN K reported was unsure why R104 vitals were not documented and reported maybe CNA staff add vitals. This surveyor asked RN K why R104 6:00 a.m. medications were not given and marked with, SL. RN K verified Medication Administration Record(MAR) reflected R104 Levothyroxine Sodium(thyroid medication) was marked as SL(sleeping according to codes on MAR) because resident was sleeping and medications not given. This surveyor asked RN K if nurse notified physician thyroid medication was not administered and RN K reported was unsure and reported Physician was not notified of missed dose. RN K reported did not notice change in R104 baseline mostly because was not familiar with R104. RN K reported was unable to recall if he had reported to oncoming staff on 4/23/25 that sternal rub was required to wake R104. RN K reported staff were educated recently related to blood pressure parameters and was unable to report when to report to physician. After review of provided staff education reported recalled did get education that included to notify physician if systolic blood pressure under 100. During a second interview on 5/7/25 at 12:15 a.m., LPN D verified facility management provided education for blood pressure parameters within past 2 week and verified did not receive education related to narcotic side effect monitoring. LPN D reported nursing judgement to monitor for sleepiness, lethargic, and change of condition, follow policy and procedures. LPN D reported would wake resident for 6:00 a.m. thyroid medication and would not document on MAR as sleeping. LPN D reported if thyroid medication not given would notify physician dose not given. LPN D reported would not administer narcotic to resident if sleeping or lethargic. During a interview and record review on 5/7/25 at 12:26 p.m., Unit Manager (UM) N reported did not observe R104 on 4/23/25 but was notified by telephone that R104 was nonresponsive that was not R104 baseline. UM N reported was familiar with R104 when resident was on 1 west for short while but moved related to roommate issues and reported was very talkative and alert. UM N reported would expect nurse staff to check blood pressure prior to administration of beta blocker because if too low can bottom out resident and they will end up in ICU on ventilator. UM N reported facility staff not required to document monitoring for narcotic use side effects and reported was nursing judgement. UM N reported would not expect nursing staff to administer beta blocker and/or narcotic with low blood pressure or sleep/lethargic. UM N reported completed R104 Change of Condition document on 4/24/25 by review of records because identified staff had not completed and should have. UM N reported would not expect nurse to document sleeping as reason for missed dose thyroid medication and would expect physician to notified of missed dose. During second interview on 5/7/25 at 1:35 p.m., DON B verified Plan of Correction was 4/26/25 and focused on staff failed to monitor blood pressure prior to administration of blood pressure medication and verified no education was provided for monitoring of side effects of narcotics. DON B reported R104's blood pressure medication and narcotic should have been held and physician notified as well as staff should have completed Change of Condition documentation prior to administering R104 morning medications.

Based on interview and record review the facility failed prevent a significant medication error as evidenced by administration of Metoprolol (beta-blocker blood pressure medications) without monitoring blood pressure prior to administration for resident (R104), resulting in hospitalization . Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 [AGE] year-old female admitted to the facility on [DATE] from the hospital for respite care, with diagnoses that encephalopathy, seizure disorder, chronic obstructive pulmonary disease, respiratory failure, diabetes, kidney failure, anxiety, and depression. The MDS reflected R104 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for bed mobility, transfers, dressing, bathing and toileting. Review of the complaint received by the State Agency alleged the facility failed to prevent a significant medication error for R104. During a telephone interview on 5/5/25 at 3:23 p.m. Complainant C reported R104 was admitted to the facility, from the hospital, for respite care (temporary break for primary caregivers) on 4/18/25 as ongoing patient of PACE (Program of All-Inclusive Care for the Elderly). Complainant C reported PACE authorized R104 to be admitted to participating facility from 4/18/25 through 4/24/25 post hospitalization . Complainant C reported the facility had a contract with organization to coordinate care including to provide all medications and R104 had received narcotic medications on 4/23/25 that organization had not prescribed and was unaware R104 was taking. Complainant C reported R104 was transferred to the hospital on 4/23/25 related to unresponsive, acute respiratory failure and continued to be on life support in the Intensive Care Unit. Review of R104 Nursing Progress Note, dated 4/23/25 at 1:42 p.m., reflected, Resident was transferred to [named] Hospital at 1:00pm Via stretcher, doctor was called after resident was unresponsive, Respirations were 6, HR[heart rate] was 30 and o2[oxygen] stat[saturation] was 57. Doctor instructed Nurse and author of this note to send resident out. Nurse called 9-11 and EMT[emergency medical technician] came. While EMT was here Wrap nurse disclosed to nurse and author of this note that when she was given report before this resident was transferred over to this unit that the previous nurse stated that she had to sternum rub resident in order to give her medication. Nurse and author of this note then relayed that to the EMT, Resident was administered one round of Narcan, she became responsive but was taken to [named hospital] for observation. Review of R104 transfer form, dated 4/23/25, reflected R104 had unplanned transfer to the hospital related to unresponsive with vitals that included blood pressure of 89/56, heart rate 30 beats per minute, respirations of 6 per minute, and oxygen level of 57%. During a telephone interview on 5/6/25 at 11:34 a.m., LPN E reported was R104 on 4/23/25 day shift starting around 7:00 a.m. LPN E reported night shift did not report anything unusual for R104 and was told took medications whole in pudding, used oxygen and BIPAP with diagnosis of chronic obstructive pulmonary disease. LPN E reported first observed R104 around 7:30 a.m. and appeared to be resting comfortably and continued to pass medication on hall and reported usually passed medications to new residents like R104 at end of medication pass. LPN E reported got to R104 for morning medications late that day between 10:30 a.m. and 11:00 a.m. and reported R104 appeared groggy, tapped on chest and would open eyes, smile then fall back to sleep. LPN E told R104, Lets get medications down, we need to move you, and R104 swallowed medications in pudding. LPN E reported administered several medications including Metoprolol Tartrate (beta-blocker blood pressure medication), and Oxycodone 20 mg. LPN E reported did not check R104 blood pressure prior to administering medications and should have. LPN E reported Certified Nurse Aid had checked vitals at start of shift around 8:00 a.m. on 4/23/25 and reported R104 systolic blood pressure was under 90 and should not have administered Metoprolol and verified did not verify R104 blood pressure prior to administering medications. LPN E reported transferred R104 from 1 South unit to 1 North unit prior to lunch on 4/23/25 and told nurse during report had to really work to get R104 to take medication related to being lethargic an should be reported to physician. LPN E reported was approached by Director of Nursing (DON) B couple hours after and asked if LPN E had administered Metoprolol with low blood pressure and verified. LPN E reported received education related to verifying blood pressure prior to administering blood pressure medications and to hold if less than 100 systolic blood pressure (top number). LPN E reported all nurses received same education after R104 incident. LPN E reported should not have administered R104 medication and stated, they wanted her[R104] moved, and she was in a hurry. LPN E reported not aware of specific required documentation to monitor side effects of narcotics and reported was nursing judgement to report change in condition including increased lethargy. LPN E verified she did not notify physician related to R104 condition. During a telephone interview on 5/6/25 at 2:44 p.m. Licensed Practical Nurse (LPN) F reported was working 4/23/25 day shift on 1 North when R104 was transferred from 1 South and was on lunch. LPN F reported another nurse LPN D was also on the unit and received report from LPN E. LPN F reported returned from lunch about 12:25 p.m. was introduced to R104, who was slouched over in broda chair with BIPAP on, with no response from R104. LPN F reported was unsure what R104 baseline was but reported oxygen saturation was 57% and should be greater than 90% and heart rate was low. LPN F verified R104 was a full code and requested assistance to transfer to bed and R104 vitals improved, and LPN F remained at bedside to monitor. LPN F reported R104 never woke up, opened eyes or responded to staff during transfer from chair to bed. LPN F reported R104 heartrate went down to 30 beats per minute with respirations 6 to 8 per minute and low oxygen and physician was notified and orders given to transfer to hospital. LPN F verified was told that morning nurse had reported R104 was administered morning medications after sternal rub require to wake R104. LPN F reported R104's documented blood pressure was 89/56 on 4/23/25 morning prior to receiving blood pressure medication and oxycodone at 11:00 a.m. LPN F reported EMS staff administered Narcan to R104 and R104 immediately woke up and was responsive and verified had been non-responsive entire time on 1 North unit. LPN F reported facility provided education to nurse staff related to monitoring blood pressure prior to administering blood pressure medications or narcotics after R104 incident. During a telephone interview on 5/6/25 at 4:44 p.m., CNA L reported cared for R104 on 4/23/25 morning shift starting about 7:00 a.m. CNA L reported did not receive report from night shift and entered R104 room to obtained vitals around 7:00 a.m. and R104 appeared to be in really bad shape with oxygen saturation of 54% and encouraged R104 to take deep breaths for about seven minutes and came up to 90% on BIPAP machine. CNA L reported R104 blood pressure was low as well. CNA L reported R104 was lethargic, eyes would open and close, skin had poor color and was twitching and struggled with breathing. CNA L reported both RN K and LPN E entered R104 room and RN K reported R104 needed sternal on and off during shift to awaken. CNA L reported asked RN K, how could you not notice her[R104] in this shape? CNA L reported assisted R104 to transfer from 1 South to 1 North between 10:30 a.m. and 11:00 a.m. on 4/23/25 and refused to transfer R104 in wheelchair and requested broda chair because was not safe related to R104 was non-responsive at the time. CNA L reported Physician entered R104 room at time of transfer to 1 North and advised staff to transfer R104 to hospital and appeared was not aware of R104's change in condition until that moment. CNA L reported would report to Unit Manager if nurse did not respond to staff reports of resident change in condition. During an interview on 5/7/25 at 8:34 a.m., Director of Nursing (DON) B reported R104 was admitted [DATE] for PACE respite care. DON B reported recent collaboration team meeting with PACE within past two weeks and learned that residents admitted with PACE services require all changes in care including medications or change of conditions should be communicated with PACE. DON B verified was not aware prior to meeting that facility had to communicate and changes and was unsure if facility had contract with PACE. DON B reported R104 change of conditions was not communicated to PACE and they were not informed of medication changes made on 4/21/25 when Oxycodone was added and should have been. DON B reported PACE basically manages whole person and everything goes through them. DON B reported would expect CNA staff to report anything abnormal to nurse, nurse to assess, complete Change of Condition (COC) documentation if needed or at least Nurse Progress Note. DON B reported would expect abnormal vitals to be documented as well as normal after adjustments/assessments and COC would include physician notification. DON B reported would expect nurse staff to use nurse judgement or follow blood pressure parameters prior to medication administration including use of [NAME] blockers. DON B reported would have expected nurse to hold R104 Metoprolol dose on 4/23/25 morning with blood pressure of 89/56 and notify physician. DON B reported the facility completed a Past Non-Compliance for R104 incident and all nurse staff were educated related to blood pressure parameters and facility was in compliance by 4/26/25. During a telephone interview on 5/7/25 at 9:34 a.m., Medical Director (MD) M reported would expect to be notified by facility staff of change in resident condition including systolic blood pressure less than 100, and definitely oxygen less than 70%, and increase lethargy. MD M reported did not received call from facility for R104 for change of condition prior to order to transfer to hospital. MD M reported blood pressure perimeters are nursing judgement but wound expect to be notified if systolic blood pressure less than 100 prior to administration of blood pressure medications or Oxycodone (Narcotic). During an interview and record review on 5/7/25 at 10:01 a.m., RN K reported had worked at facility for about two years and typically work on south hall. RN K reported staff were educated recently related to blood pressure parameters and was unable to report when to report to physician. After review of provided staff education reported recalled did get education that included to notify physician if systolic blood pressure under 100. During a second interview on 5/7/25 at 12:15 p.m., LPN D verified facility management provided education for blood pressure parameters within past 2 week and verified did not receive education related to narcotic side effect monitoring. LPN D reported nursing judgement to monitor for sleepiness, lethargic, and change of condition, follow policy and procedures. LPN D reported would wake resident for 6:00 a.m. thyroid medication and would not document on MAR as sleeping. LPN D reported if thyroid medication not given would notify physician dose not given. LPN D reported would not administer narcotic to resident if sleeping or lethargic. During a interview and record review on 5/7/25 at 12:26 p.m., Unit Manager (UM) N reported would expect nurse staff to check blood pressure prior to administration of beta blocker because if too low can bottom out resident and they will end up in ICU on ventilator. UM N reported facility staff not required to document monitoring for narcotic use side effects and reported was nursing judgement. UM N reported would not expect nursing staff to administer beta blocker and/or narcotic with low blood pressure or sleep/lethargic. During second interview on 5/7/25 at 1:35 p.m., DON B verified Plan of Correction was 4/26/25 and focused on staff failed to monitor blood pressure prior to administration of blood pressure medication and verified no education was provided for monitoring of side effects of narcotics. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included interventions and actions to correct monitoring of blood pressure parameters the past noncompliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview and record review, the facility failed to assess, monitor, document, and provide appropriate and timely treatment per professional standards of practice for one (#9) of one Residents reviewed for management of known Congestive Heart Failure (CHF-inability of the heart to pump blood efficiently, causing shortness of breath, fatigue, leg and foot swelling, and weakness), resulting in a 44 pound weight gain, shortness of breath, acute respiratory failure with hypoxia, acute pulmonary edema and acute re-hospitalization for acute exacerbation of CHF. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R9 was a [AGE] year old female admitted to the facility on [DATE] with re-admission post hospital stay 1/24/25 related to exacerbation of Congestive Heart Failure(CHF), with diagnoses that included hypertension (HTN, high blood pressure), chronic CHF, chronic kidney disease, diabetes mellitus and depression. The MDS reflected R9 had a Brief Interview of Mental Status (BIMS assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for toileting, bathing, dressing, hygiene, bed mobility, and transfers. The MDS reflected no behaviors including refusal of care. During an observation and interview on 2/12/25 at 1:10 p.m., R9 door laying in bed with very strong odor of urine in room with ( a brand name external urinary catheter system) in place on floor at the bedside. R9 was observed with noted edema in bilateral hands and legs. R9 reported they were admitted to facility at the end of November 2024 after hospital admission and readmitted to the hospital in January 2025 related to increased swelling. R9 reported does not refuse care or weights. Review of R9 Electronic Medical Record, dated 11/26/24 through 2/12/25, reflected R9 admission weight on 11/27/24 was 356 pounds(lbs). Continued review of R9's weight summary reflected R9 weight was consistently measured by mechanical lift and reflected the following weights: 12/9/24 = 362.2 lbs.(6.2 lbs gain in 12 days) 12/27/24 = 389.5 lbs.(33.5 lbs gain in 30 days)(no documented weight between 12/9/24 and 12/27/24). 1/3/25 = 386.3 lbs. 1/8/25 = 396.1 lbs.(40.1 lbs gain in 42 days) 1/14/25 = 400.4 lbs(44.4 lbs gain in 48 days) 1/25/25 = 329 lbs(re-admission post hospital stay related to exacerbation of CHF) 1/28/25 = 357.7 lbs 2/2/25 = 364.1(35 lbs gain in 8 days) Review of R9 Hospital Discharge Summary, date printed 11/26/24, reflected, R9 had a hospital admitted [DATE] for Hyperkalemia (elevated potassium) and Acute Kidney Injury (AKI). The Discharge Summary reflected, AKI/hyperkalemia, baseline creatinine 1. On presentation 3.43. -Likely etiology prerenal with component of ATN[acute tubular necrosis]. Nephrology was consulted. -Lisinopril 10mg daily discontinued, Lasix 20 mg p.o.[by mouth] daily discontinued Resume Lasix after BMP check in 1 week. -Amlodipine can be added for blood pressure control if needed outpatient .NP[Nurse Practitioner] Follow up in 1 week[contact details included] . Review of R9 Hospital After Visit Summary, dated 1/26/24, reflected the following: If admitted for Heart Condition: I understand .Weighing myself daily and reporting a gain of 2-3 pounds a day/or 5-6 pounds a week to my physician is important . Review of R9 Nurse Progress, dated 11/26/2024 at 9:48 p.m., reflected, Resident arrived at the facility about 1706[5:06 p.m.] on a stretcher and staff assisted the paramedics with transfer to bed. Resident has history of HTN, diabetes type 2, acute kidney failure, CHF, Morbid Obesity, Vitamin D and B12 deficiency. Resident alert and oriented. Review of R9 Social Service Note, dated 11/27/2024 at 3:47 p.m., reflected, Patient is a [AGE] year old female, who admitted to ( facility) with an admitting dx of ACUTE KIDNEY FAILURE, UNSPECIFIED and she plans to return to her group home upon discharge. Patient made eye contact with writer and had answered all questions appropriately. Patient had scored 15/15 on the BIMS assessment, indicating her cognition remains intact. Patient is their own responsible party and is able to make decisions in their own day to day care. Review of R9 Physician Note, dated 12/10/2024 at 4:43 p.m., reflected, She was seen today for a follow up visit on nursing request for a lump in her right breast and edema of hands .No SOB [short of breath], cough, dyspnea, chest pain or other associated symptoms reported. She has been keeping her hands on pillow to raise it, which has been helping the swelling a lot. She still has the catheter to prevent her sacral area and continues to be NWB[non-weight bearing]. EXAMINATION She was comfortable in her bed, resting BP[blood pressure]:: 130/81 12/10/2024 Temp: 97.3 Pulse: 69 bpm[beats per minute] Weight: 362.9 Lbs [6.9 lbs gain since admission] Resp: 18 Breaths/minute BS[blood sugar]: 132 O2[oxygen]: 95 % . Hand edema is dependent. ACE wrap if needed, keep moving hands and keep it elevated. Check albumin with CMP[comprehensive metabolic panel] . Review of R9 Nursing Progress Notes, dated 12/30/2024 at 5:23 a.m., Resident had her call light and responded she complained of SOB asking Staff for an inhaler and she does have any order. She was reassessed after giving her 02 on 2L[liter]. V/S[vital signs] were WNL[within normal limits] BS was 95 she was given milk to help sustain BS before breakfast. Resident stated that she can breath better with the O2. The on call Dr[doctor] was tiger text and phone call was tried with no answer up this morning. But resident is filling better. Review of the Nursing Progress Notes, dated 1/5/2025 at 3:46 p.m., reflected, Resident now noted to have coarse rhonchi throughout lungs and persistent non productive cough. Current VS BP 94/65, T-98.0, Pulse-74, Resp-18 and Oxygen at 95% with 2L of oxygen in place via NC[nasal cannual]. I have administered her PRN albuterol inhaler x 2 so far today with little effect. Denies chest pain or discomfort, respirations are even and unlabored. On call provider notified of clinical condition. Awaiting direction. (No mention of R9's 30 pound weight gain in past 39 days). Review of R9 Nursing Progress Note, dated 1/5/2025 at 7:07 p.m., reflected, New orders from provider for Duo nebs via nebulizer every 6 hours x 5 days. LN[licensed nurse] notified [named family] of clinical condition. Orders entered and oncoming nurse to be notified. (No mention of R9's 30 pound weight gain in past 39 days). Review of R9's Weight Change Note, dated 1/8/2025 at 2:19 p.m., reflected, DATA: WEIGHT WARNING: Value: 396.1 Vital Date: 2025-01-08 10:14:00.0 MDS: +5.0% change over 30 day(s) [ 9.1% , 33.0 ] +3.0% change over 30 day(s) [ 9.1% , 33.2 ] +5.0% change [ 9.1% , 33.2 ] +7.5% change [ 11.3% , 40.1 ] +10.0% change [ 11.3% , 40.1 ] NOTES: Nutrition follow up: Current weight 1/8 396.1#[pounds], 1/3 386.3#, 12/27 389.5# up from 12/9 362.9#. Resident is not receiving any diuretics. She was eating very well then had SOB and was positive for covid with a cough and had a decline in oral intakes and has since recovered some and eating better. She is being treated for unstageable wound to left heel which is improving and typically she accepts liquacel well for additional protein. Will review resident in complex for weight gain. Review of R9 Weight Change Note, dated 1/15/2025 3:00 p.m., reflected, DATA: WEIGHT WARNING: Value: 400.4 Vital Date: 2025-01-14 14:23:00.0 MDS: +5.0% change over 30 day(s) [ 10.2% , 37.0 ] +3.0% change over 30 day(s) [ 10.3% , 37.5 ] +5.0% change [ 10.3% , 37.5 ] +7.5% change [ 12.5% , 44.4 ] +10.0% change [ 12.5% , 44.4 ] NOTES: Nutrition follow up: Current weight is 400.4# 1/14, 391.3# 1/13, 1/8 396.1#, 1/3 389.5#. Weights are up from 362.9# 12/9. Resident has been eating excellent at meals. Wound to her heel is healed. Will recommend to d/c liquacel supplement. MD[medical director] wanted to watch the weights when discussed at complex. (R9 had documented 44.4 pound weight gain(12.5%) in past 48 days since admission with orders for continue to monitor). Review of R9 Nursing Progress Note, dated 1/15/2025 7:27 p.m., reflected, Resident voiced c/o[complaint of] weight gain and feeling SOB O2 at 95% and v/s wnl. Edema is noted. MD made and awaiting response. Note completed by Licensed Practical Nurse (LPN) S. Review of the facility Change of Condition assessment, dated 1/15/25, reflected R9 had increased or worsening edema and shortness of breath. The assessment indicated R9 had CHF and diabetes as pertinent diagnoses and was marked for, Recently progressive or persistent minor SOB without other symptoms, OR with progressive leg edema. and, Persistent unilateral or bilateral edema. The assessment included notes that reflected, Resident voiced c/o weight gain and feeling SOB O2 at 95% and v/s wnl. Edema is noted. Review of R9 Nurse Progress Note, dated 1/16/2025 at 7:07 p.m., reflected, Resident voiced concerns r/t[related to] ring being stuck on left index finger. Resident would like ring removed if possible, discussed possibility of using ring cutter to remove. Will continue to monitor. The record had no mention of communication with physician related to continued edema or follow up from 1/15/25 Change in Condition with no documented response from Provider. Review of R9 Nurse Progress Note, dated 1/17/2025 at 7:02 p.m., reflected, Resident noted to have significant edema and weight gain. Resident's daughter in to visit and discussed with nurse and resident current clinical condition. Provider notified and all above in agreement to send resident to ED [emergency department] for eval/tx[evaluation/treatment] . During an interview on 2/12/25 at about 5:00 p.m., LPN S reported did complete Nurse Progress note on 1/15/15 about R9 edema and weight gain and completed Change in Condition Assessment and sent tiger text to physician with note waiting response at end of shift. LPN S verified did not speak with physician or receive response back prior to end of shift and reported was unsure if physician responded and verified no new orders added 1/15/25. LPN S reported facility new admission weight policy was usually to obtain weight on admission then weekly times four weeks and follow physician orders. LPN S reported would be the same for residents with CHF. LPN S reported had been off for past five days and was currently R9's nurse. LPN S verified R9 had documented refusal of physician ordered weight on 2/11/25 and verified was not aware. LPN S verified R9 primary diagnosis was CHF and verified re-admission to facility 1/24/25 post hospital admission for exacerbation of CHF. LPN S reported R9 had physician orders for weekly weights with last documented weight 2/2/25(10 days prior) of 264 pounds and verified re-admission weight was 329 lbs which indicated significant weight gain. LPN S reported if resident with CHF has over five pound gain physician should notified and documented in medical record. During an interview on 2/12/25 at 5:15 p.m., Clinical Care Coordinator Registered Nurse (CCC) R reported had worked at the facility for about two months with prior work experience on acute care hospital setting. CCC R reported was facility policy to perform admission weight on all residents then weekly to monthly depending on physician orders. CCC R reported would expect nurse to notify physician of weight gain of more than five pound for resident with diagnosis of CHF. CCC R reported nursing best practice would be to monitor resident with diagnosis of CHF weight daily especially with recent re-hospitalization for exacerbation of CHF. CCC R reported was R9's Clinical Care Coordinator and reported was not aware of R9 prior weight gain and not aware of current weight gain. CCC R reported would expect nurse to follow physician orders and verified R9 had physician order for weight on 1/10/25 that was not completed and indicated refused on 1/11/25. CCC R reported would expect nurse to continue to reapproach resident, document in medical record and report to CCC. CCC R verified was not notified of R9 weight refusal. CCC R reported would expect nursing staff to continue to reach out to physician if no response and document in medical record and inform CCC and verified was not aware physician did not respond to R9 change of condition notification. CCC R verified was unable to locate physician response in R9 EMR for 1/15/25 change in condition. CCC R verified R9 admission weight was 356 lbs on 11/27/24 with physician orders for weekly weights. CCC R reported was unsure why R9's weight was not obtained weekly but should have been. CCC R verified R9 weight on 12/27/24 was 389 lbs and verified 33 lbs weight gain in one month should have been reported to physician and documented in EMR. CCC R reported was unable to locate that R9's significant weight gain had been reported to physician. During an interview on 2/12/25 at 5:27 p.m., Director of Nursing (DON) B reported would expect new admission residents to be weighted on admission then evaluated by Registered Dietician who would decide frequency. DON B reported would expect the same with resident with diagnosis of CHF unless physician ordered otherwise including if resident had recent hospital re-admission for exacerbation of CHF. DON B reported would expect nurse to notify physician of resident weight gain of over five pounds and document in medical record. DON B reported would expect nurse to follow physician orders. Review of R9 Weight Change Note, dated 1/27/2025 at 6:58 a.m., reflected, Readmit Nutrition Assessment Diagnosis: CHF, resp failure, morbid obesity, DM, UTI, depression, CKD, HTN, hypothyroidism,GERD Medication trt for dx :novolog,senokot, duloxetine, pantprazole,levothyroxine, Lasix (40mg BID) Ht:67 Current weight: 329 # BMI:51 Usual/Desired Wt: Weight at initial admission was 356# and this increased to 400# 1/14 .Nutrition Diagnosis/Assessment:Resident was sent to the hospital with significant edema. She was noted to have chest pain,hyperkalemia, CHF exacerbation,UTI. Cardiology seen resident and noted borderline cardiomegaly with acute pulmonary edema. She was noted to have CKD stage 3B (follow potassium and fluids). She was not previously on Lasix but was started on IV Lasix and transitioned to oral. This most likely resulted in her weight loss as edema has improved. She was also started on a CPAP and UTI was treated with antibiotics. Nutrition Interventions: 1. Diet as ordered by physician-Regular (follow for need to restrict sodium or fluids) 2. Follow weights- new diuretic in place 3. Follow for TSH improvement 4. Will honor food preference 5. Monitor weight/labs/physical parameters to evaluate that diet and intake meet actual nutrition needs and resident goals . Review of R9 Physician Note, dated 2/3/2025 at 7:05 p.m., reflected, Resident was seen today for a readmission back into the facility. She was sent to the ER [emergency room ] for significant edema and weight gain. The resident was complaining of chest pain and SOB. Chest X-ray revealed cardiomegaly and right side pleural effusion. She was diagnosed with HF[heart failure] exacerbation .Resident's weight has increased significantly, Check weight in 1 week[2/10/25] . Review of R9 Hospital Physician Discharge Summary, dated 1/24/25, reflected, Admission Diagnosis: Hyperkalemia, Chest Pain, Acute UTI[urinary tract infection], Acute exacerbation of CHF .CHF exacerbation, AKI(acute kidney injury), Supratherapeutic INR .Discharge Diagnoses: Principal Problem: CHF exacerbation, Active Problems: Hypoxia, Current long-term us of anticoagulant medications with history of deep vein thrombosis, HFrEF (heart failure with reduced ejection fracture), Acute pulmonary edema, Acute respiratory failure with hypoxia and hypercapnia, Acute on chronic respiratory failure wit hypoxia and hypercapnia, Mood disorder due to known physiological condition .Hospital Course .Chest pain of 1 week duration, central, gripping, 7/10, worse with leaning forward .CXR[chest X-ray significant for cardiomegaly with central vascular prominence and right-sided pleural effusion. admitted for AHRF[acute hypoxemic respiratory failure] 2/2[secondary to] HFrEF exacerbation .Rapid response called on 1/18 for hypoxia and chest pain .ABG[arterial blood gas] suggestive of respiratory acidosis. Bedside echo suggesting IVC[inferior vena cava] dilation >2; noted small pericardial effusion. Patient was started on bipap[bilevel positive airway pressure] with Lasix IV 40 mg with improvement .Due to respiratory acidosis, and acute hypoxic hypercapnic respiratory failure, patient was started on nightly CPAP[continuous positive airway pressure]. Previously on CPAP, but pt was not using at facility. Case manager spoke with facility and facility stated they will re-order CPAP. Recommend to continue nightly CPAP. Cardiology recommended lasix IV[intravenous] 40 mg BID[twice] daily until patient reached dry weight. On day of discharge transitioned to PO[by mouth] lasix 40 mg BID. Continue on hydralazine 10 mg three times daily and Toprol XL 50 mg . Review of R9 Hospital After Visit Summary, dated 1/24/25, If admitted for Heart Condition: I understand .Weighing myself daily and reporting a gain of 2-3 pounds a day/or 5-6 pounds a week to my physician is important . Review of R9 Care Plan, dated 11/27/24, reflected, CHF: Assess/Document/Report to MD PRN for any s/sx dependent edema of legs/feet, perioribtal edema, SOB upon exertion, cool skin, dry cough, distended neck veins, weakness, wt. gain unrelated to intake, wheezes upon auscultation, increased heart rate, leathargy, disorientation. During a telephone interview on 2/13/25 at 9:59 a.m., R9's family member T reported R9 was her own responsible party and R9 family member T was listed as emergency contact and Care Conference person. R9's family T reported had alerted nurse staff two weeks prior to Christmas of concern with R9's increased edema with no response and was present on 1/17/25 when R9 was transferred from the facility to the hospital. R9's family T reported other family member U had reported concerns of R9 increased edema to nurse staff on 1/15/25 with no follow up response. R9's family T reported on 1/17/25 had insisted R9 be sent to the hospital. R9's family T reported staff tried to tell her that 40 lbs weight gain was related to poor food intake. R9's family reported R9 had prior history of CHF with history of exacerbation requiring hospitalization prior to admission to facility with recent hospital stay between 11/16/24 and 11/26/24 diuretics placed on hold related to kidney function. During an interview on 2/13/25 at 11:18 a.m., DON B reported reviewed R9 medical record and reported completed time line. DON B reported located email communication between Registered Dietician and physician about R9 dated 1/15/25 through 1/17/25 related to possible weight gain related to poor food choices.(40 lbs in 48 days since admission). DON B was asked if information was documented in R9 medical record and DON B responded, no, staff could do better about documentation. DON B reported was unsure if weight alerts existed and reported was unsure why staff did not receive weight alert for R9 33 pound gain from admission to 12/27/24. DON B reported staff document by exception only and reported would expect staff to complete assessment for weight gain but only document if abnormal. DON B reported if residents refuse care would expect staff to document if resident was educated on possible outcomes of choices. DON B reported if resident requests to go to hospital facility would send them. DON B reported would provided timeline of information. No timeline was received prior to to survey exit. During a telephone interview on 2/13/25 at 12:13 p.m, R9 family U reported was present at facility visiting R9 on 1/15/25 and reported to LPN S concern with R9 increased edemas, and shortness of breath. R9's family U reported LPN S had reported R9 had 40-50 pound weight gain since admission and reported was not aware of any follow up. R9's family U reported returned to visit next day on 1/16/25 and again reported concern to nursing staff related to R9's increased edema and shortness of breath and R9's reported concern of needing wedding band cut off because hands were so swollen. R9's family U reported R9 had not removed wedding band in over [AGE] years and was upset as husband had recently past away. R9 family U reported other family T arrived the next day on 1/17/25 and insisted R9 be sent to the hospital and reported was told by hospital medical staff that R9 would not have made it if they had waited much longer to be treated. During an interview on 2/13/25 at 2:12 p.m., LPN L reported CCC has schedule of monthly resident weights for first week of month and reported otherwise order was located on Medication Administration Record. During a telephone interview on 2/13/25 at 3:51 p.m., Registered Dietician (RD) D reported she monitored R9 weekly weights and alerts go to her and she documented in progress notes. RD D reported had communicated with physician 1/15/25 about 44 lbs gain since admission who wanted to continue to monitor R9 weight. When asked if she had received weight alert on 12/27/24 for R9's 33.5 lbs gain in 30 days RD D reported she must have and reported she must have cleared the alert and was unable to answer why and verified was not able to located in R9's EMR and should have been reported to physician and documented. RD D reported R9's weight on 1/25/25 at re-admission was not an accurate weight after comparing to hospital discharge weight and re-weight was completed on 1/28/25 as 357.7. Review of the facility, CHANGE OF CONDITION - RESIDENT PHYSICIAN/NP NOTIFICATION policy, dated 10/29/14, reflected, POLICY: The attending physician /physician extender or on-call physician/physician extender will be notified with changes in a resident ' s condition or health status .PROCEDURE: 1. Seven (7) days a week, attending physicians or physician/NP on call is to be notified of all condition or health status changes .Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received . A policy/procedure was requested, but not received by the conclusion of the survey, pertaining to monitoring of Residents with CHF.

This citation refers to intake MI00145124. Based on observation, interview and record review, the facility failed to competently assess and monitor for changes in condition and notify the physician of pertinent findings in a timely manner for 2 residents (Resident #103 and Resident #104) resulting in the potential for and actual harm from unrecognized, clinically significant changes in condition and uncontrolled pain. Findings: Resident #103(R103) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R103 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included aftercare arthroplasty right hip removal prosthesis and insertion of antibiotic spacer post hip infection, muscle weakness, need for assistance with person care, cardiomyopathy, hypertension (high blood pressure), anemia, atrial fibrillation, and congestive heart disease. The MDS reflected R103 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required partial to moderate assist with transfers. During a telephone interview on 6/26/24 at 3:19 p.m. complainant C reported Certified Nurse Aid(CNA) D was very rough with R103 during a transfer on 5/9/24 around 7:30 p.m. and threw legs into bed followed by extreme pain. Complainant C reported R103 was post right hip reconstruction surgery on 4/25/24 and surgical follow up appointment on 5/8/24. Complainant C reported R103 was sent to the emergency room after X-ray showed right hip dislocation on 5/10/24 and returned to the facility on [DATE] around 2:00a.m. Complainant C reported facility ran out of pain medications and R103 went over 24 hours without. Complainant C reported R103 was seen by surgeon on 5/16/24 and sent to the hospital for emergency surgery related to damaged right hip and hardware was removed and unable to replace hardware for six months. Review of the Orthopedic Physician Consult, dated 5/8/24, reflected R103 was seen in the office for a two week post-operative right total hip arthroplasty revision removal prosthesis and insertion antibiotic spacer. The consult note reflected R103 had a current pain scale of 4/10 and indicated since the last office visit the pain had become better for the patient and decrease since surgery on 4/25/24. The note reflected the surgical incision demonstrated acceptable healing and no drainage. Continued review of Consult reflected X-ray of hip with Remedy long femoral stem hemiarthroplasty with was well aligned. Review of the Orthopedic Center X-Ray Report, dated 5/8/24, reflected R103 had X-Ray 73502-hip, unilat, 2-3 views Right completed. The report reflected, Hip/Pelvis X-ray: Remedy long femoral stem hemiarthroplasty. Well aligned. Review of R103's Physician Note, dated 5/10/24 at 2:44 p.m., reflected, Note Text: In today for an urgent visit on his request for pain in his right hip after he was transferred into the bed, and he fears that he might have dislocated his hip. He is a [AGE] year-old man with history of osteoarthritis, atrial fibrillation, and GERD. He is admitted for skilled care after he developed infection in his right hip prosthesis. The right hip was replaced initially in 2018. It was later replaced due to chromium toxicity two years ago. He had a fall recently and that required revision of the hip, but later developed prosthesis infection and was admitted for skilled care. He is currently receiving IV abx. He had a wound clinic follow up appointment and his wound back[vac] has been removed. He reports that last night, while being transferred into the bed nursing aid lift his leg to transfer him in the bed. He feels that right after the transfer, he developed significant pain in his right leg and his right leg appears externally rotated. His wife is also present and concerned if it has dislocated. Is it recent lab labs reviewed and currently his Vancomycin is being held based on his trough levels. He reports pain seven out of 10 currently, worse with slight movement. He requesting if a stronger pain medication can be given to him until the x-ray is done. Nursing staff, but also interviewed to complete this assessment .PLAN - [AGE] year old man with infection of prosthetic right hip, IV antibiotics status I& D developed worsening pain with extra rotated right tip after transferring into the bed - X ray right to rule out dislocation - is assessed. Increase PRN and Norco to every four hours - awaiting x-ray of hip, if this[dis] location is confirmed will transfer to emergency room for orthopedic intervention, if recommended - family, including wife and granddaughter was explained the care plan in detail and they agreed - nurse will call as soon as the stat x-ray report are available. Care plan is discussed with the nurse and nursing Director. Review of of R103 Nurse Progress Notes, dated 5/10/2024 at 4:47 p.m., reflected, Received STAT x-ray results and reviewed with [named physician]. Noted dislocation of spacer/femur. Physician gave order to send resident to ED with hope he can be seen by ortho to have the hip reset. Daughter and wife updated on resident's status and notified of order to transfer resident. Will send to [named hospital], which is where resident was originally treated . Review of the Physician orders, dated 5/9/24 through 5/10/24 reflected no evidence of order for STAT X-ray for R103 on 5/10/24. Review of R103 Radiology Results Report, dated 5/10/24 at 3:06 p.m., reflected, Conclusion: 1. Post right hip with superior dislocation of the prosthetic femur. Suspected additional underlying malrotation. Correlate with prior imaging. 2. Questionable minute fracture deformities at the acetebular fossa versus expected postsurgical change . Review of the Hospital Records, date 5/10/24 through 5/11/24, reflected R103 was seen in the Emergency Department on 5/10 at 6:21 p.m. The record reflected, Chief Complaint: Pt comes from [named facility] after right hip sx[surgery] in April, last night staff threw his legs into bed and pt had significant pain, x-ray was obtained today showing R femur dislocation . Continued review of the ED Note Physician/Provider, dated 5/10/24 at 7:19 p.m., reflected, History of Present Illness: [named R103] a [AGE] year-old man with past history of right hip replacement complicated by infection presented to ED today wit complaint of right hip pain. The patient's wife and daughter were at bedside and provided additional history. The patient and his family state that nurses in the facility center were trying to put him in bed when they pulled his right leg out and the hip got dislocated .The patient and his wife did note that they are concerned that there was a caregiver abuse at the patients SAR that resulted in dislocation of the hip. They already spoke with the manager of the SAR and the nurse responsible has been placed on leave. They also made a police report. Review of R103 Nurse Progress Note, dated 5/11/2024 5:22 p.m., reflected, Resident has been pleasant and cooperative with cares. A/Ox4. VSS. Skin W/D. Takes medications as ordered. Has taken one PRN pain medication for pain in right hip. Has been resting in bed most of shift with call light in reach and safety maintained. Skin well approximated at S/P surgical site. No noted S/SX of infection present. Attends therapy per recommendations. Able to verbalize wants and needs. Needs met at this time. Review of R103 Nurse Progress Notes, dated 5/14/2024 at 7:55 a.m., reflected, spoke with resident's daughter who shared concerns about resident's pain management and hydration .Resident's daughter also expressed that she feels like his current rx for Oxycodone 5mg q4h prn is not enough to management resident's current pain level and requested that nurse asked the Dr for fentanyl patches for resident. Nurse spoke with resident and encouraged fluids through PM/midnight shift and offered OTC pain management which resident accepted. Dr notified . Review of the Physician Progress Note, dated 5/14/2024 at 11:10 a.m., reflected, Resident is a [AGE] year old male who was seen today for a follow-up of pain and need for fluids. He was admitted into the facility for rehab following a revision of his hip post fall. He was also treated for an infection of his prosthesis in the hospital. The attending visited with the resident on the 10th of May for pain and pain medications were increased. The notes reviewed and the daughter is concerned that the resident is not receiving adequate hydration and is requesting IV fluids. She also feels that the pain regimen is not covering his pain and she is requesting fentanyl patches. Spoke with the nurse and she reported that the resident does drink independently and does not feel he needs more fluids, but labs were ordered. Visited with the resident at bedside with the family present. The resident reported that he does have a lot of pain, but feels the oxycodone does provide him with relief. I spoke with him about the plan for the oxycodone and we also talked about adding a lidocaine patch in addition and both he and his family agreed. I spoke with the resident about his fluid intake. He said that he doesn ' t drink very much because he doesn ' t like the water, but has been drinking Gatorade. I let him know because of his history, we will check his labs first and go from there. I also let him know that I had the nurse to consult dietary for additional fluids with his IV ABX and to continue to drink what he likes. The resident does see ortho tomorrow. He has not been working with PT because he had to go back to the hospital because his hip popped out and he has been in a lot of pain .Plan: 1. Right hip pain 2. Dehydration Receiving oxycodone 5mg QID and PRN q 6 hours. Had the nurse split up order and new C2 completed Has ibuprofen as needed for breakthrough pain, will continued Added lidocaine patch to right hip q 24 hours BMP ordered to check hydration status. Consult dietary for possibly fluids with ABX, continue to encourage fluids Plans discussed with the nurse . Review of the Medication Administration Note, dated 5/15/2024 at 12:36 p.m., reflected R103 was sent to hospital from doctors appointment. Review of the Hospital Discharge Summary, dated 5/22/2, reflected R103 was admitted [DATE] and taken to the Operating Room for an open irrigation and debridement of his right hip and removal of antibiotic spacer. Patient has no hip prosthesis in. The Summary included, Discharge Diagnosis and Plan: 1. Infection of right prosthetic hip joint .Pt is to remain nonweightbearing on his rt lower extremity as he has no hip joint currently. PT Must work with patient today to at least stand and transfer and get him off his pack so as not to develop bed sores .Will leave incisional drain on for another 10 days and DC sutures in 3 weeks post op .cefepine 2g and vacomycin .for total of 4 weeks .end date at 6/17/24 .Dislocated hip .heart failure .cardiomyopathy .atrial fibrilation .anemia . Review of the Nursing Schedules, dated 6/27/24, reflected CNA D was working South Hall(rehab unit) at 3:00 p.m. During an interview on 6/27/24 at 9:59 a.m. CNA E reported had worked at the facility for about [AGE] years and often on the rehab unit. CNA E reported facility did not provide any training related to post operative hip precautions including transfers with exception to follow kardex. CNA E reported worked with R103 on 5/10/24 on day shift. CNA E reported R103 had reported he could not get out of bed that morning for group therapy related to elevated pain and stated, was not like him. CNA E reported he always participated in therapy and had not seen him in that much pain in past. CNA E reported R103 told her about incident night prior(5/9/24) with staff assisted transfer being rough with extreme pain and reported wife and daughter were very upset. CNA E reported had informed nurse because allegation of rough care. CNA E reported prior to 5/10/24 R103 was doing well with controlled pain and staff knew to be careful related to new hip surgery. Nursing Home Administrator(NHA) A provided three abuse allegations investigations on 5/27/24 at 10:18 a.m. including one for R103, dated 5/10/24 at 4:45 p.m. Review of the Facility Reported Incident(FRI), dated 5/10/24 at 4:45 p.m., reflected NHA A submitted FRI for R103 on 5/10/24 at 5:51 p.m.(for incident that occurred 5/9/24 at 7:00 p.m.) The Incident Report included, Incident Summary: Residents family alleges nurse aid was rough when transferring residents' legs into bed. Nurse Aide has been suspended pending investigation . The FRI reflected there was no witnesses.(investigation reflected R103 wife was present at time of incident on 5/9/24). The FRI included investigation notes that reflected, 5/10/24(no time): [named R103 wife] interview with [named Director of Nursing(DON) B]. I [name DON B] was called to room regarding concern with CNA from the night before. The wife and daughter were in the residents room. I introduced myself and asked the resident and family what had occurred the previous night. The residents wife and daughter reported they had concern with an employee named [named CNA D] .who seemed to have an attitude the previous night when she came in to answer the call light. Family stated, [named CNA D]came in and asked what was needed. [Named R103] said he needed to get up and get into bed. The wife stated she told [named CNA D] that R103 wanted to do as much as he could without assistance, and the aide would need to take her time because of the situation with his hip. The wife stated [named R103]was able to stand up slowly, turn around, and sit slowly on the edge of the bed. At that point the aide asked if he needed help getting his legs into bed, and he said yes. The aide grabbed the residents ankles, counted to 3 and swung his legs up into bed quickly. The wife reported her husband then yelled out in pain. The wife the stated she couldn't believe what just happened, because she had told the CNA to go slowly. Continued review of the FRI investigation notes reflected, 5/10/24(no time): [named R103] and [named R103 wife] interview with [named NHA A]. DON requested that I speak with the family. I went down to the room to speak with the wife and daughter. They stated the previous night they were upset with how a CENA transferred [named R103] into bed. [named wife] lead off with the aide already had a bad attitude .[named R103 wife] explained how the transfer happened, included that the aide counted to three and then quickly lifted his legs onto the bed. [named R103 wife] states that she thought that it could almost be intentional during initial interview but seemed unsure. Continued review of the FRI investigation notes reflected, 5/10/24(no time): [named R103] and [named R103 wife]Second interview with [named DON B]. This writer notified wife and daughter that resident hip was dislocated per the x-ray, the physician was notified, and was ordering [named R103] to be transferred to the hospital . Continued Review of the FRI investigation notes reflected, 5/10/24(no time): [Named CNA D] .I entered the room as the call light was on and I went to check on the resident. The resident requested to be put in bed, after I transferred him to the bed, he requested that I put his legs up. I counted to three and then picked his legs up to transfer them onto the bed. After the transfer, the resident made a grunting noise and stated that his leg hurt, I then notified the nurse that he was in pain .5/14/24: [named CNA F] Sometimes I think that she needs to slow down to show the residents more empathy .The family member reported the situation to me, I then notified the nurse .5/17/24: [named Registered Nurse(RN) H] I do feel that she should slow down at times when providing care . During an interview on 6/27/24 at 12:25 p.m., Physical Therapy staff(PT) I reported had worked at the facility for about five months and was not involved in training staff including hip precautions. PT I reported post hip precautions included no hip flexion over 90 degrees, no abduction and need for careful staff assist with transfers if residents request with support of both ankles at same time to keep body alignment. PT I reported had worked with R103 prior to 5/9/24 incident and reported had been progressing well with therapy including short ambulation with use of walker. PT I reported after 5/9/24 R103 was unable to get out of bed related to uncontrolled pain so only able to perform limited range of motion exercises until discharged [DATE]. PT I reported completed one on one education with CNA D post incident with R103 that included safe transfer with hip precautions on 5/21/24. Review of the Physical Therapy Treatment Encounter, dated 5/6/24 through 5/14/24, reflected R103 was progressing toward goals and compliant with treatment 5/6/24 through 5/9/24 with noted ambulation with 2 wheel walker 5 feet on 5/9/24 at 12:48 p.m Review of therapy on 5/13 and 5/14 reflected pain with leg immobilize in place with sessions in bed. During an interview on 6/27/24 at 12:48 p.m., Licensed Practical Nurse(LPN) G reported nurse expected to report assess resident if staff report change of condition to nurse and report to physician in document on change of conditions documents or progress notes. LPN G reported if CNA staff report resident with increased pain, nurse expected to assess resident first then determine what options available for pain control and if no medication or treatments available or pain not controlled to contact physician and document. LPN G reported expect that pain medications should be available within no more than 4 hours from pharmacy if narcotics orders. LPN G reported worked day shift on 5/9/24 and was giving report to RN H about 7:00 p.m. when CNA staff reported R103 had requested pain medications. LPN G reported during day shift R103 pain was controlled and was able to go outside with family and participate in therapy. LPN G reported worked next on 5/11/24 and 5/12/24 and R103 did not get out of bed related to increased pain. LPN G reported investigation was completed. LPN G reported if residents have increased uncontrolled pain nurse should assess and notify physician and document. During an interview on 6/27/24 at 1:30 p.m., CNA J reported had worked at the facility over three years. CNA J reported if change in resident baseline with either oral intake of resident reports of pain expected to report to nurse and reported not able to document that information as CNA. CNA J reported knows how to care for residents by following the Kardex. Review of the Physician orders, dated 5/9/24 through 5/10/24, reflected R103 had orders that included Oxycodone 5mg every 6 hours as needed for pain and Tylenol 1000mg every 6 hours as needed for pain. Review of the Electronic Medical Record(EMR), dated 5/9/24 through 5/10/24, reflected R103 requested as needed Oxycodone 5mg on 5/19/24 at 4:06 pm for pain 5/10 on pain scale and with effective pain control at 6:55 p.m. of 2/10 on pain scale. R103 was given as needed dose of Tylenol for patient complaint of 8/10 on pain scale at 7:38 p.m. R103 was given as needed dose of Oxycodone 5mg for R103 complaint of severe pain. R103 was given additional dose of Tylenol 1000mg on 5/10/24 at 1:17 a.m. related to prior Tylenol and Oxycodone dose ineffective with pain 7/10 on pain scale. R103 was administered as needed dose of Oxycodone 5mg 5/10/24 at 4:10 a.m. related to R103 report of pain 7/10 on pain scale. R103 requested additional as needed dose of Oxycodone 5mg on 5/10/24 at 10:32 for pain of 6/10 on pain scale and requested increased pain medication when seen by physician.(order changed from Oxycodone 5mg every 6 hours to every 4 hours on 5/10/24 at 11:45 a.m.). Continued review of the EMR reflected no mention of nursing assessment of R103 post reported incident at 7:00 p.m.(including right hip physical assessment/positioning) or no evidence of physician notification of change in pain level.(prior to reported incident R103 pain level documented between 0 to 6 on pain assessment). During an telephone interview on 6/27/24 at 4:09 p.m., LPN K reported R103 was a pleasant man with a pleasant family. LPN K reported worked on 5/10/24 with R103 after family reported concerns about R103 right hip pain. LPN K stated, Resident was in excruciating pain. LPN K reported R103 was assessed by physician on 5/10/24 who suspected R103's right hip was dislocated. LPN K reported R103's wife did not want to wait for X-ray to arrive and DON B was notified and shortly after mobile X-ray arrived. LPN K reported even with changes in R103 pain medications pain was no controlled and X-ray came back positive for dislocation and R103 was transferred to the hospital. During an interview on 6/27/24 at 4:51 p.m., CNA L reported had worked at the facility for about one year and worked with R103 on the evening on 5/9/24 from 11:00 p.m. through 6:30 a.m. CNA L reported R103 told her was transferred into bed with staff assist and transfer did not go right. CNA L reported later that night attempted to change R103 and he refused care because hip was, in bad condition and hurting really bad. CNA L reported R103 reported did not want to end up in hospital with worse injury. CNA L reported to to Registered Nurse(RN) H. During an interview on 6/27/24 at 5:10 p.m. LPN M reported was not present for at time of R103 incident on 5/9/24. LPN M reported R103 was alert and oriented and able to make needs known. LPN M reported worked 5/14/24 when R103 daughter reported concerns that R103 pain medications were not controlling pain and reported had notified physician. LPN M reported R103 did not return after orthopedic appointment the next day. LPN M reported if CNA staff reported to her that resident with recent post hip replacement complained of increased pain with transfer would assess resident, notify NHA and Physician because possible allegation of abuse. During an interview on 6/27/24 at 5:20 a.m., CNA D reported worked with R103 on second shift on 5/9/24. CNA D reported R103 used call light and report she answered call light on 5/9/24 around 7:00 p.m. CNA D reported R103 was sitting in a wheelchair with left side against the bed and stood up with use of walker and pivoted to turn and sit on edge of bed without assist. CNA D reported R103 requested assistance to get legs into bed. CNA D reported she lifted R103 ankles after counting to 3 to the bed and R103 made a noise that made her think he was in pain.(CNA D acted out wheelchair position and had reported did not move wheelchair to place legs in bed, however wheelchair would have been in the way to pivot legs in bed with smooth motion. CNA D changed story and reported maybe she did move wheelchair prior to assisting R103 position legs in the bed.) CNA D reported R103 requested pain medication, CNA D reported to LPN G and RN H during shift report at around 7:00pm that after transferring R103 to bed R103 complained on increased right hip pain(surgical hip) and requested pain medications. CNA D reported R103 pressed his call light three additional times in next 45 minutes to ask for pain medications related to elevated pain. CNA D reported to RN H again that R103 requested pain medication. CNA D reported after R103 got pain medications did not hear from him again during the shift that ended at 11:00 p.m. CNA D reported R103 was a one person assist with transfers and had not received specific teaching related to post hip precautions but now after incident they have a binder at the nurse station with post hip precautions. CNA D reported hip precautions were not on R103 kardex at the time but now have been added after incident. CNA D reported worked 5/10/24 first shift 7:00 a.m. to 3:00 p.m. and was questioned at the end of the shift about R103 transfer on 5/9/24 evening. CNA D reported was later called by Human Resources and informed she would be on suspension pending investigation and was off for about two weeks. CNA D reported received education from PT I prior to return to work. During an observation on 6/28/24 at 9:45 a.m. observed transfer precautions binder located at the south nurse station included post hip precautions. During a telephone interview on 6/28/24 at 11:01 a.m., CNA F reported had worked second shift on 5/9/24 at the time of the incident around 7:00 p.m. with R103. CNA F reported R103 was very upset and dis-[NAME], R103 wife was upset because R103 had requested assistance from another CNA to transfer into bed. CNA F reported wife was angry because she asked CNA D to be genital because of recent hip surgery and CNA D quickly transferred legs on bed and caused R103 immediate pain in right hip. CNA F reported consoled R103 and wife and reported to RN H that R103 complained of immediate right hip pain after CNA D transferred him. CNA F reported R103 was a pleasant man who was alert and oriented and was clearly in severe pain after incident related to reported pain, significant facial grimacing, and stated, looked like he was in pain because he was board stiff. CNA F reported worked with R103 in the past and pain was controlled and would go outside in wheelchair with family or to Dining Room but not after incident, he remained in bed. During a telephone interview on 6/28/24 at 11:30 a.m., RN H reported had worked with R103 on 5/9/24. RN H reported was told by CNA D had pain after transfer from wheelchair to bed. RN H reported R103 had recently received as needed Oxycodone for pain so was not due at that time so gave as needed dose of Tylenol. RH H spoke with R103 who reported pain was, pretty high and reported CNA D staff was rough and moved little too fast when assisting with transfer. RN I reported he then spoke with CNA D about R103 complaint. RN I verified did not document in the medical record about the reports from staff of R103 increased pain during transfer. RN I later learned from someone else that R103 right hip was dislocated and had to be transferred to the hospital. RN I reported did not contact physician or assess R103 right hip including palpation or observe for external rotation. RN I continued to administer as needed pain medication through out night shift. RN I reported did not report incident as allegation of abuse because did not think CNA D intended to hurt R103. During an interview on 6/2824 at 12:08 p.m., Physician Medical Director(MD) N reported had been the Medical Director at the facility for several years. MD N reported did not receive call from the facility on 5/9/24 related to R103 pain post staff assisted transfer around 7:00 p.m. MD N reported staff requested R103 to be seen on 5/10/24 and reported was unsure when. MD N reported ordered x-ray to rule out dislocation. MD N reported x-ray came back positive for dislocation and order to send R103 to the hospital. MD N reported did not feel staff deliberately caused injury. MD N reported would expect nurse to give ordered medication. MD N was queried if he would expect nurse to call if aware of knowledge that R103 reported rough transfer followed by increased pain. MD N reported was not able to answer that question. MD N reported assessed R103 on 5/10/24 and wife and daughter were upset after increased pain related to transfer night prior. During a telephone interview on 6/28/24 at 1:07 p.m., R103 wife O reported was present on 5/9/24 and observed CNA D assist R103 transfer to bed around 7:00 p.m. that caused R103 immediate pain. R103 wife O reported she had been outside with R103 for about one hours prior to both returning to R103 room and used the call light to assist R103 into bed. R103 wife O reported CNA D entered the room alone. R103 wife O reported told CNA D R103 needed two people to transfer and CNA D responded, they were busy, and R103 reported he would try. R103 wife O reported took several minutes but R103 stood from wheelchair and sat on bed slowly. R103 wife reported told CNA D needed to be very careful and CNA D asked if R103 needed help with legs and R103 reported yes. CNA D grabbed both legs near heels and threw R103's legs on the bed and R103 screamed in pain. R103 wife O told CNA D she could not believe she just did that and told R103 wife O she would tell the nurse what had happened. R103 wife O reported did not see CNA D prior to leaving for the evening. R103 wife O reported also went to nurse desk and reported to nurse what had happened to R103 and need for pain medications prior to leaving on 5/9/24. During a telephone interview on 6/28/24 at 1:28 p.m., R103 reported recalled very clearly what happened on 5/9/24. R103 reported had reconstructive surgery on right hip after complications including infection on 4/24/25. R103 reported admitted to facility on 5/3/24 and had been working with therapy and progressing well with good pain control around 4/10 on pain scale. R103 reported on 5/9/24 CNA D assisted him into bed. R103 reported was sitting on side of bed and stated, she tossed my legs onto bed. R103 reported it cause him so much pain at 10/10 he could not even say what happened next. R103 stated, I was trying to keep it together. R103 reported RN H asked about pain several times during the night and reported told RN H CNA D threw R103 legs in bed. R103 reported CNA D came in room after R103 told RN H what had happened and CNA D apologized and asked, how should I have done that? R103 reported did not assess R103 right after the incident or move the covers to observe right leg. R103 reported told everyone he could what happened because he was in so much pain and worst pain he had ever been in and reported everyone knew what had happened. R103 reported no relieve from pain medications and remained 10/10 on pain scale through the night and next day. R103 reported daughter called the physician who came right in and ordered an X-ray that took about four hours to arrive and was later sent to the hospital. During a telephone interview on 6/28/24 at 1:48 p.m., R103 daughter C reported she called Physician Medical Director N on 5/10/24 at about 10:30 a.m. and informed him of transfer on 5/9/24 evening that caused uncontrolled pain to R103 post operative right hip. R103 daughter C reported MD N came to assess R103 right away and was mad and suspected hip was dislocated. R103 daughter C reported at least four hours before mobile X-ray arrived and results came back about one hour later and R103 was sent to the hospital. R103 daughter C reported R103 had additional right hip surgery on 5/15/24 to remove hardware and R103 currently does not have hip and was told by surgeon could not re-attempt prosthesis for 6 months which means no weight to right leg. During an interview on 6/28/24 at 4:30 p.m., DON B reported was first made aware of R103 incident on 5/9/24 on 5/10/24 at around 10:00 a.m. DON B reported CNA J reported R103 family was upset related to interaction from prior day. DON B reported R103 room and R103 on in bed and R103 wife and daughter were present when she got there. DON B reported R103 was assisted into bed by CNA D on 5/9/24 evening and R103 yelled out when legs assisted into bed. DON B reported R103 family had already called MD N and verified. DON B reported would expect nursing staff to assess residents if staff reported acute pain during transfer. DON B reported MD N ordered stat X-ray after assessed on 5/10/24 and verified was unable to located order. DON B reported verified mobile X-ray order was called in on 5/10/24 at 11:40a.m., mobile X-ray arrived at 3:06 p.m. and notified facility at 3:52 p.m. of R103 right hip dislocation. DON B reported STAT X-rays are obtained within 4 hours and reported R103 should have had an order for STAT X-ray in the EMR. During an interview on 6/28/24 at 5:26 p.m., NHA A reported was first aware of R103 allegation of abuse on 5/10/24 at 4:45 p.m. wh [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide timely, appropriate care and services to meet the needs of three of 27 residents reviewed for quality of care (Resident #11, Resident #15 and Resident #121), from a total of 27 sampled residents, resulting in these residents potentially not receiving adequate and/or appropriate care required for them to maintain or achieve their highest practicable physical well-being. Findings Include: Resident #11 (R11) Review of the medical record reflected R11 was an initial admission to the facility on [DATE] with a readmission on 04/25/24. Diagnoses of Acute and Chronic Respiratory Failure with Hypoxia, Muscle Weakness, Chronic Obstructive Pulmonary Disease, Acute on Chronic Systolic (congestive) Heart Failure, Hemiplegia and Hemiparesis following Cerebral Infarction (stroke) affecting the right side and Peripherial Vascular Disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/06/2024, revealed R11 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R11 requires assistance with care provided for his lower extremities. During an interview and observation on 06/12/24 at 08:12 AM, R11, stated he wanted to go to the hospital because he was short of breath, he also stated the nurse working that shift checked his vital signs including the O2 sats. He stated that he ended up calling 911 to come and get him, because the facility did not help get him transferred to the hospital. R11 stated the EMS called the facility to see if he really needed to be transferred because he had called 911 before. R11 stated he finally was sent out to the hospital and was admitted on [DATE] through 04/25/24. Record review revealed R11 was admitted to the hospital on 04/14/24 due to acute hypoxic respiratory failure and decompensated ejection fraction (heart failure with reduced ejection fraction) as well as lower extremity cellulitis. R11 required increased oxygen requirements of 4 liters per minute (lpm) with a baseline of 2 lpm. R11 received IV diuresis (kidneys filter too much fluid from the body) and oxygen requirements helped with dyspnea (shortness of breath) and peripheral edema (accumulation of fluid causing swelling). On-call provider was notified on 04/14/24 at 02:44 AM and no new orders received. On 06/14/24 at 08:40 AM During an Interview with Clinical Care Coordinator (CCC) D Stated they had checked his vitals, a provider came in and checked him, checked his lungs, O2 sat's. Provider went to nurses' station to writer orders, the emergency Medical Service (EMS) walked by the station to pick him up. R11 stated he wasn't feeling well, she called provider came in and assessed him. CCC D stated she did not see a progress note for the provider on 04/14/24. CCC D stated she was standing there with provider during his assessment and the orders given. CCC D stated unfortunately, he did not put in a progress note. During an interview on 06/14/24 at 02:18 PM, CCC D stated she had called the provider regarding the hospital visit with no progress note. CCC D stated R11 had went out to the hospital on 03/25/24 first, and that was the visit that provider stated he saw the resident. Provider looked through his draft notes and he found his note and scanned it in the medical record. 34705 Resident #121(R121) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R121 was a [AGE] year old male admitted to the facility on [DATE], with recent re-admission post new onset diabetes mellitus on 4/4/24 with prior diagnoses that included traumatic brain injury with left craniotomy, pelvic fracture, hypertension (high blood pressure), diabetes insipidus, seizure disorder, hypopituitarism, hypothyroidism, speech and language deficits following brain injury, weakness, difficulties walking and depression. The MDS reflected R121 a BIM (assessment tool) score of 7 which indicated his ability to make daily decisions was severely impaired. The MDS reflected R121 had no behaviors including rejection of care. During a telephone interview on 6/11/24 at 11:59 a.m., R121's father and Durable Power of Attorney (DPOA) Z verified was R121 responsible party. R12's DPOA Z reported concerns that facility did not notify him of changes in R121 care at times. R121's DPOA Z reported on 3/29/24, when R121 was transferred to the hospital R121 DPOA Z had requested R121 be transferred to the hospital on day shift related to change in condition several times. R121 DPOA Z reported he noticed the change in R121 condition during a visit and informed the day shift nurse several times who reported the physician had not returned their call. DPOA Z reported had asked for R121 to be sent to hospital at 3:00 p.m. and did not receive return call from the facility until 11:00 p.m. informing him R121 was being transferred to the hospital. DPOA Z reported was very upset because he had requested R121 be sent around 3:00 p.m. and should not need to wait for physician if he was the responsible party. DPOA Z reported R121 blood sugar was over 900 when he arrived to the hospital which was dangerously high and should have been sent much earlier. DPOA Z reported elevated blood sugar was new for R121 but staff should have recognized that he looked ill on the day shift during his visit and listened when he requested R121 be sent to the hospital several times. Review of the Physician Discharge Summary, dated 9/26/23(43 days after hospital admission 8/15/23), reflected R121 had discharge diagnoses that included hypernatremia, diabetes incipidus, head trauma, intraparenchymal hematoma of brain due to trauma, central hypothyroidism, anemia, mixed origin delirium and traumatic brain injury. Continued review reflected, Hospital Course: [AGE] year mal who was admitted to [named hospital] on 7/31/23 to trauma services .Hyperglycemia and A1c of 5.9[elevated], started on insulin gtt[drip], transitioned to subcutaneous . Review of R121's History and Physical, dated 8/15/23, reflected, Assessment and Plan .Hyperglycemia Hemoglobin A1C 8/11/23 5.9(H) .comment: increased risk for diabetes .Levemir 43 units BID . Review of the facility History and Physical, dated 9/27/23, reflected, History of Present Illness: The patient had significant head injuries. The patient was admitted to the prolonged hospitalization , ventilation, PEG tube placement, multi specialty intervention. Later, the patient is stabilized. After stabilizing his condition today on 09/27/2023, the patient desired to be transferred to the subacute rehabilitation .Past Medical History: Including acquired problems in the hospital including status post craniotomy,hypernatremia, hypokalemia, central hypothyroidism, hyperglycemia,thrombocytosis, respiratory failure,status post tracheostomy,craniotomy, multiple surgical intervention, status post EGD with PEG tube placement, head trauma,motor vehicle non-traffic accident injury, traumatic subdural hematoma,occipital skull fracture, thrombosis of superior sagittal sinus, GI bleed,status post PRBC transfusion Review of R121 Nutritional Note, dated 12/28/2023 at 8:03am, reflected, DOCUMENT CHANGES IN DIET, INTAKE AND HYDRATION STATUS,PERTINENT LABS::QUARTERLY:Nutrition Note Ht: 70 Current weight:222.8 # BMI:32 Resident has triggered for significant weight gain X 1 month. Weight increased from 193#. Resident has made tremendous improvements since admission. He came in NPO with tube feeding and then started an oral diet with was upgraded and now he has no tubefeeding and weight has increased. Diet is Regular, regular texture, thin liquids- large portions . Review of the Weight Change Notes, dated 3/8/24, for R121, reflected, March weight is 265# 3/6, resident continues to gain weight. Weight 2/26 260#, 2/20 256.6#, 2/13 251# . Review of the Nutritional Note, dated 3/21/2024 at 10:37am, for R121, reflected, Nutrition followup .Residents oral intakes continue to increase. This morning resident ate100% of breakfast and then told aid that he didn't eat. They knew he did eat and encouraged him to just tell them that he wanted more to eat. He then did ask for more so aid got him more to eat this morning. PM aid reported that he ate dinner and had 2 sloppy joes with bag of chips and did snack during the night. Aid did report that his weight gain is impacting how his clothes are fitting. Will review this again with MD to discuss any changes that could be made to meds. Review of R121 Nutritional note, dated 3/29/2024 at 7:39am, reflected, INTAKE AND HYDRATION STATUS,PERTINENT LABS:: QUARTERLY:Nutrition Note Ht:70 Current weight:265 # BMI: 38 Resident has had 10% weight increase X 1 month and 23% weight gain from 6 months ago. Resident had weight gain from 200-231# Sept to Feb. Resident then had bone flap replaced 2/5 and since that time weight has increased to 265#. Over this past month he is constantly hungry, asking for food, snacking all day resulting in significant weight gain .Discussed this with team and it was also stated that since bone flap replaced his behaviors have changed resulting in more anger and trashing his room . Review of the Provider Notes dated 9/2023 through 3/29/24 with no mention of weight gain mentioned or addressed. Continued review of the Provider notes with no mention of glucose monitoring related to history of documented hyperglycemia. Review of the Nursing Progress Notes, dated 3/30/24 at 1:23 a.m., for R121, reflected, Resident had a fall earlier today, noted the resident was sleepy and drowsy during the bedtime med pass, about 9pm resident had a right-side weakness, and activity level was below his baseline. Family members were notified and requested him to be sent out. Resident sent out a few minutes to 11pm. resident was tachycardiac and could not feed himself which he normally does. Dr and on call supervisor were notified. Resident transferred out to [named] Hospital with all the paperwork and documentation relating to ombudsman and bed hold policy.(last documented Nursing Progress Note was dated 3/18/24). Review of the Fall Incident/Accident Report, dated 3/29/24 at 2:20p.m., reflected R121 had an unwitnessed fall in the room and was found by aide laying on floor face down. The report reflected R121 was unable to give description. The reported reflected immediate action that was taken included,Resident was assessed for injuries none were noted, neuros were initiated, DON and family notified. The report appeared incomplete with no documentation under pain, mental status, mobity or predisposing factors were blank. (No evidence that investigation or follow up was provided as requested including neurological assessments.) Review of the Electronic Medical Record(EMR), dated 3/29/24, reflected no evidence of neurological checks as indicated on Fall Report until 8:00p.m. on 3/29/24.(Fall was at 2:20p.m.) Further review of the EMR reflected no evidence pain assessment or vitals signs post fall. Review of the SBAR Communication Form and Progress Notes for Change of condition, dated 3/29/24, reflected nurse had notified physician at 8:00 p.m. of R121 decreased level of consciousness. Review of the Nursing Home to Hospital Transfer Form, dated 3/29/24, reflected R121 report was called to the hospital at 12:00 a.m. and the form was completed by DON B on 4/1/24. Review of the Hospital Discharge Summary, dated 4/4/24, reflected R121 was admitted on [DATE] at 12:22a.m. The summary reflected, Admission Diagnosis DKA (diabetic ketoacidosis) .Hyperosmolar hyperglycemic state .HPI, as per admitting provider .On arrival to the ED, stroke team was called to evaluate the patient .Lab work was remarkable for .glucose (985) .He was treated with 2 L normal saline, given a dos of ceftriaxone and placed on an insulin drip according to the e DKA HHS protocol. He was admitted to the ICU for further treatment and management of AMS [altered mental state] likely from hyperglycemia. Hospital Course: Patient is a [AGE] year-old gentleman with TBI and a resident at a nursing home who comes to the hospital with altered mental status and lethargy. Found to have finding concerning for HHS[hyperosmolar hyperglycemic syndrome]. A1c 9.5. 2 months ago was 5.4. Started on aggressive IV fluids and insulin regimen subcutaneously .New onset diabetes likely due to autoimmune diabetes . Attempts were made to contact all day shift staff and transferring nurse (8 staff members) with no answer and no return calls. During an interview on 6/14/24 at 2:03 PM, Facility Nurse Consultant U verified no physician or provider notes were located that mentioned knowledge of R121 significant weight gain prior to change of condition and transfer to the hospital with blood sugars greater than 900 on 3/29/24. 46954 Resident #15 (R15) Review of the Admission Record reflected R15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis which included mood disorder, anxiety disorder, diverticulosis (a condition where small pouches form in the walls of the large intestine), chronic respiratory failure, and pain in left shoulder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/17/24, reflected R15's Brief Interview for Mental Status (BIMS) was scored 15 out of 15, indicating cognitively intact. Review of the same MDS reflected R15 was experiencing pain almost constantly. Review of the Physician Order's revealed R15 was prescribed Oxycodone HCl 5 milligrams (mg) (a opioid containing medication) as needed for pain. The order was activated on 4/18/24. Review of the May Medication Administration record revealed R15 was administered the Oxycodone 5mg two to four times daily. Review of the June Medication Administration record revealed R15 was administered the Oxycodone 5mg two to three times daily. According to the National Center for Biotechnology Information website, opioid drugs affect receptors in the gastrointestinal (GI) tract. These receptors control the contraction of the muscles in the GI tract which leads to a decrease in gastrointestinal motility. Review of a Nurses Note dated 5/25/2024 at 12:32 PM revealed Resident [R15] complaining of constipation. Refused MOM (milk of magnesia). Agreed to take Bisacodyl 5mg (laxative tablet) one tablet today and one tonight. Review of an Alert Note dated 5/26/24 at 12:20 PM revealed R15 had a bowel movement. Review of the Physician's Orders revealed a new order for Senna Plus Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth in the morning for constipation. Review of the Bowel Task revealed R15 did not have bowel movement 5/30/24 through 6/4/24 and 6/6/24 through 6/11/24. Review of the May and June Medication Administration Records revealed that no as needed constipation relief medications were offered, refused or administered to R15. Review of the Progress Notes revealed no indication that R15 was offered and refused the as needed constipation relief medications. In an interview on 06/13/24 05:14 PM, Director of Nursing (DON) B stated that the Bowel Protocol should be initiated after a resident does not have a bowel movement after nine shifts. The nurse would initiate the as needed standing orders and administer according to Physician instructions. If the medications do not provide relief, the physician should be notified. DON B reviewed the medical record and confirmed the absence of bowel movements for R15 and the absence of the constipation relief medication being ordered or offered.

Based on observation, interview and record review, the facility failed to ensure their rights to self determination were honored for three residents (resident #15, #63 and #97) of six residents reviewed and facility census of 135 for self determination. Findings Include: On 6/11/24 at approximately 8:30 am, upon entering the facility entrance door, 2 separate typed signs were observed in clear plastic protector and posted on the main entrance door, the first sign read !!ATTENTION!! RESIDENTS & FAMILY DOORS LOCK AT 8 PM ALL RESIDENTS MUST BE INSIDE BY 8 PM The second sign, also in a plastic protector and taped to the door read Resident Visiting Hours Monday-Sunday 8:00 AM - 8:00 PM Resident #15 (R15) Review of the clinical record including the Minimum data Set (MDS) dated [DATE] reflected Resident # 15 (R15) was a admitted to the facility 09/09/23 with diagnosis that included lung cancer, depression and anxiety, further review of the clinical record reflected R15 was receiving hospice care. R15 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 06/11/24 at 12:29 PM, R15 was interviewed at bedside and reported being admitted to the facility several times (returning home ) and normally has no issues, however upon the most recent readmission in September of 2023, R15 reported the doors are locked at 8:00pm. R15 reported her family was not allowed to visit and she was not allowed to go outside past 8:00pm. R15 elaborated that she felt like she was treated like a child, Do you know how many nights I sit in this room looking at sky and its still daylight and I think I will go outside but I cant because I am locked in here. R15 stated she did report this concern with Nursing Home Administrator A (NHA) A last fall but didn't get a response. R15 voiced concern of the the Fourth of July coming and not being allowed to see fireworks for the holiday due to the rule of being made to stay in after 8:00 pm. Resident #63 (R63) Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] reflected Resident # 63 (R63) was admitted in 2018, R63 scored 15 out of 15 (cognitively intact) . On 06/11/24 at 11:54 AM Resident # 63 (R63) was interviewed in her room, she was observed to have tanned skin and verbalized that she liked to spend her days outside in the fresh air. R63 stated she wanted to make a complaint about the curfew and elaborated that she would like to sit on the patio in the evening and enjoy the summer weather especially since it was still daylight past 8:00 PM, but had to be in by 8:00 PM per the facility rule. 34705 Resident #97(R97) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R97 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included lung cancer with secondary cancer to liver and bone, hypertension (high blood pressure), history of falls with fractures, blood clots, anxiety and depression. The MDS reflected R97 BIM (assessment tool) score of 15 which indicated her ability to make daily decisions were cognitively intact. The MDS reflected no behaviors including unsafe wandering. During an observation on 6/11/24 at approximately 8:45 am, upon entering the facility entrance door, 2 separate typed signs were observed in clear plastic protector and posted on the main entrance door, the first white sign read !!ATTENTION!! RESIDENTS & FAMILY DOORS LOCK AT 8 PM ALL RESIDENTS MUST BE INSIDE BY 8 PM. The second green sign, also in a plastic protector and taped to the door read Resident Visiting Hours Monday-Sunday 8:00 AM - 8:00 PM. During an observation on 6/11/24 at 10:42 AM, the white sign that read, !!ATTENTION!! RESIDENTS & FAMILY DOORS LOCK AT 8 PM ALL RESIDENTS MUST BE INSIDE BY 8 PM had been removed and green visitation sign remained posted on the entry door. During an observation and interview on 6/11/24 at 4:45 PM, R97 was in room with family and appeared calm, pleasant and able to answer questions without difficulty. R97 reported was upset that facility residents, including herself had to be inside the building by 8:00 p.m. every night because the doors locked. R97 reported liked to go outside and during the summer it is daylight much later than 8:00 p.m. R97 reported signs on the doors that reflected rules of when to be back inside the facility. R97 reported this was her home and she should not be locked in or out of her home. R97 reported the same rules apply to visitors with posted sign on door of visiting hours between 8:00 a.m. and 8:00 p.m. and had been same rules since she admitted to facility. R97 reported their are times that residents are outside after 8:00 p.m. and the doors are locked. R97 daughter reported there had been several times they would have liked to keep R97 out past 8:00 p.m. but that was the rules so they comply but difficult with evening schedules. During an interview on 6/13/24 at 3:01 PM, R97 reported two residents were locked out of facility last evening at 8:00 p.m. R97 reported not aware of any system to get back in facility similar to door bell. R97 stated, They treat us like we are prisoners that pay a good amount of money to stay hear. During an interview on 6/14/24 at 2:01 PM, Nursing Home Administrator (NHA) A removed sign from the main entry door and reported the facility did not have rules for visiting hours or that residents had to be in the facility by 8:00 p.m. NHA A reported the doors are locked from 8:00 p.m. until 8:00 a.m. but system in place that staff can be alerted to open the doors but no reception staff at those times. NHA A reported was unaware residents were under the impression they had a curfew and could see that by the posted signs they might think that. NHA A reported planned to provide staff, resident and family re-education related no visitation or resident hours rules. NHA A reported was unsure who removed the white posted sign on 6/11/24 after survey entrance.

Based on observation, interview and record review, the facility failed to act promptly on grievances and or concern forms reported in resident council meetings and provide responses and resolutions to 52 grievances filed in the last six months, as reported during a confidential resident council interview, in a total sample of 27 residents and a total census of 135 residents, resulting in unresolved resident concerns and decreased quality of life. Findings include: During a confidential interview with resident council group on 06/12/24 at 11:19 AM where 11 residents attended. The last six-months concern forms were reviewed and discussed for resolution. Concerns shared during private meeting. 1) Wheelchair concerns needed repair for over a month. 2) Call light response time. 3) Male resident had a female shirt put on him. 4) Female had a fall in her bathroom, pulled the call light for help, the floor was slippery was the reason she fell . 5) They are always told its the states fault, 6) Facility staff will go into residents' room and look through their things without permission and remove personal things from their rooms. 7) Not using dining room, not enough staff, must eat in their rooms. 8) Food- cold food on west hall, not receiving meals on time, they are late daily. 9) If they order a chef salad, must wait a long time to get it. Concern forms reviewed from the last 6 months. 1) Female missing showers 2) Missing hearing aides 3) Roommate woke up screaming in the night. 4) Room not put back together after cleaning 5) Miscommunication at shift change 6) Glasses need adjusted 7) Missing red bra. 8) Missing clothes 9) Male missing showers 10) Receiving food late 11) Male driving wheelchair too fast in hall 12) Requested roommate change 13) Does not want to be wake up in the night 14) Lab comes too early to draw blood. 15) Male missing clothes 16) Neighbor's TV is loud 17) Does not want to be woke up during the night/early morning. 18) Male missing items 19) Staff talking loud in the hallway 20) Lost DVD movie 21) Male missing items 22) Wheelchair nears repair 23) Female missing items 24) Missing personal wheelchair 25) People coming in his room at night 26) Missing laptop 27) Trash can missing 28) Call light respond time 29) Broken pepper grinder 30) Needed a different bed 31) Male not getting showers 32) Smokers sit by the front door 33) Glasses broken 34) Missed scheduled appt 35) Needs help with shower 36) Urinal not emptied at night 37) Missing money 38) Trash not getting emptied 39) Assist with standing 40) Missing/faulty lamp 41) Evening activities 42) Food choices 43) Mattress needs replaced 44) Not getting food and fresh water 45) Male missing shower- ongoing 46) Missing alarm clock 47) Male missing clothes 48) Computer not working 49) Call light not answered/missed shower- ongoing 50) Resident living in the dining room 51) Facility not addressing concerns 52) Roommate TV is load During an interview on 06/14/24 at 08:34 AM, Laundry Manager (LM) Ostated the inventory sheets for all of the personal belongings are kept in the soiled utility room with the labeling sheets. RN P stopped during this interview and stated she would find out where they are kept as she doesn't think they have ever been in the medical record. During an interview on 06/14/24 at 08:57 AM, Executive Director in Training (EDIT) Q stated they receive the concern forms, and he logs them. EDIT Q stated he follows up with the resident, offers a solution, if residents are satisfied then he will ask them to sign off on the concern form. Writer asked EDIT Q what they were doing to track these concerns and audit to see if there are repeated concerns being reported. EDIT Q stated he takes them to QA meetings; specific managers ask the residents about their concerns. EDIT Q also stated they had started a new program called support and services form. Writer asked to see the process and audits for this program. EDIT Q stated they had a four-week cycle to look for all grievances. Writer asked EDIT Q to provide this data. Record review revealed EDIT Q has provided blank copies of the support and service form at 0913 AM on 06/14/24. On 06/14/24 at 2:42 PM, Writer emailed NHA A requesting the completed support and service forms that they had been using. Writer asked NHA A what he did to correct the problems and what was the root cause? Writer received this email on 06/14/24 at 02:50 PM from NHA A stating, part of the idea/inception of this new program for us is to have immediate resolution. In essence to take care of a problem before it's a problem. With that said managers are supposed to address issues right there at the bedside. If for some reason they were unable to do so then they were instructed to complete a grievance form. Record review of the completed support and service forms revealed two forms were not dated, one was dated 05/30/24, 06/03/24, 06/06/24, 06/07/24, 06/11/24 over the course of 12 days. It revealed there were still concerns identified during this time and the forms did not reveal any follow up, correction or identifying the root cause to these concerns. This new program appears to have been started during the last month, but did not address the ongoing concerns over the course of the last year leaving residents with ongoing concerns, potential for unmet needs and dissatisfaction with the facility.

Based on observation, interview, and record review the facility failed to ensure a medication error rate less than five percent when 8 medication errors were observed from a total of 28 opportunities for one resident (R121) of eight residents observed during medication administration, resulting in a medication error rate of 28.57%. Findings include: During an observation and interview on 6/13/24 at 7:54 a.m., Licensed Practical Nurse (LPN) R prepared several medications for R121 at the medication cart. LPN R crushed several oral medications including Keppra 750 mg one tablet and Ferrous Sulfate 325 mg one tablet. LPN R crushed eight total medications(keppra, ferrous sulfate, zoloft, metformin, Tamsulosin HCl, Prilosec, Glycopyrrolate and Carbamazepine) and added to orange juice and administered to R121. R121 observed with facial grimacing and shaking head during administration. LPN R reported crushed medications and placed in orange juice because R121 does not like to take medications. Review of the Pharmacy Recommendations Progress Notes, dated 3/5/2024 at 11:06 a.m., for R121, reflected, PHARMACIST RECOMMENDS:: This patient has an order for crushed meds. Keppra and ferrous sulfate are not to be crushed. Please add do not crush to each order OR change each order to oral solution. Review of R121 Physician orders, dated 4/5/24 to current, reflected, Ferrous Sulfate Oral Tablet 325 (65 Fe)MG (Ferrous Sulfate) Give 1 tablet by mouth in the morning for supplement DO NOT CRUSH .levETIRAcetam[Keppra] Oral Tablet 750 MG(Levetiracetam)Give 1 tablet by mouth two times a day for seizure prophylaxis DO NOT CRUSH . Review of the Medication Not To Be Crushed, located inside the narcotic binder on the top of each medication cart, reflected Keppra and Ferrous Sulfate should not be crushed. During an interview on 6/14/24 at 10:38 AM, LPN S reported staff nurses know which medication not to crush because of resource document located in narcotic binder on each medication cart. LPN S verified both Keppra and Ferrous Sulfate were on the document labeled, Medication Not To Be Crushed, dated 7/19. During an interview on 6/14/24 02:05 PM, Nurse consultant U reported verified R121 Keppra and Ferrous Sulfate should not have been crushed and verified order reflected that.

Based on observation, interview, and record review the facility failed to insure that one resident (R121) was free from significant medications errors out of eight residents reviewed during medication pass task, resulting in the potential for adverse physical reactions/outcomes to residents. Findings Included: Resident #121(R121) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R121 was a [AGE] year old male admitted to the facility on [DATE], with recent re-admission post new onset diabetes mellitus on 4/4/24 with prior diagnoses that included traumatic brain injury, pelvic fracture, hypertension (high blood pressure), diabetes insipidus, seizure disorder, hypopituitarism, hypothyroidism, other speech and language deficits following brain injury, weakness, difficulty walking and depression. The MDS reflected R121 a BIM (assessment tool) score of 7 which indicated his ability to make daily decisions was severely impaired. The MDS reflected R121 had no behaviors including rejection of care. During an observation and interview on 6/13/24 at 7:54 a.m., Licensed Practical Nurse (LPN) R prepared several medications for R121 at the medication cart. LPN R crushed several oral medications including Keppra 750 mg one tablet and Ferrous Sulfate 325 mg one tablet. LPN R crushed eight total medications(keppra, ferrous sulfate, zoloft, metformin, Tamsulosin HCl, Prilosec, Glycopyrrolate and Carbamazepine) and added to orange juice and administered to R121. R121 observed with facial grimacing and shaking head during administration. LPN R reported crushed medications and placed in orange juice because R121 does not like to take medications. Review of the Pharmacy Recommendations Progress Notes, dated 3/5/2024 at 11:06 a.m., for R121, reflected, PHARMACIST RECOMMENDS:: This patient has an order for crushed meds. Keppra and ferrous sulfate are not to be crushed. Please add do not crush to each order OR change each order to oral solution. Review of R121 Physician orders, dated 4/5/24 to current, reflected, Ferrous Sulfate Oral Tablet 325 (65 Fe)MG (Ferrous Sulfate) Give 1 tablet by mouth in the morning for supplement DO NOT CRUSH .levETIRAcetam[Keppra] Oral Tablet 750 MG(Levetiracetam)Give 1 tablet by mouth two times a day for seizure prophylaxis DO NOT CRUSH . Review of the Medication Not To Be Crushed, located inside the narcotic binder on the top of each medication cart, reflected Keppra and Ferrous Sulfate should not be crushed. During an interview on 6/14/24 at 10:38 AM, LPN S reported staff nurses know which medication not to crush because of resource document located in narcotic binder on each medication cart. LPN S verified both Keppra and Ferrous Sulfate were on the document labeled, Medication Not To Be Crushed, dated 7/19. During an interview on 6/14/24 02:05 PM, Nurse consultant U reported verified R121 Keppra and Ferrous Sulfate should not have been crushed and verified order reflected that.

Based on observation, interview, and record review the facility failed to ensure proper storage of medications for 1 of 3 medication rooms reviewed, resulting in the increased likelihood for decreased medication efficacy and adverse side effects in a current facility census of 135 residents Findings include: During an observation on 6/12/24 at 3:40 PM, Licensed Practical Nurse (LPN) V reported Registered Nurse (RN) W was orienting with her that day unlocked the south hall medication room. LPN V reported medication room had two refrigerators and one was for resident overstock medications and the other was for vaccines. This surveyor opened the closed vaccine refrigerator and LPN V verified the thermometer read 60 degrees. Several single dose flu and pneumonia vaccines and 2 bottles of tuberculin were observed along with an ice pack. LPN V reported the night shift monitored the refrigerator temperatures and was unsure where they were located. LPN V was asked what the refrigerator temperature should be at she pointed to sign on the wall that reflected under 40 degrees. LPN V was observed attempting to locate temp log in medication room and nurse station and was unable to locate. During an interview and record review on 6/12/24 at 2:45 PM, Clinical Care Coordinator (CCC) X reported was responsible for first floor south unit and reported refrigerator temperatures were monitored by night staff and was unsure where they were documented. CCC X asked the Director of Nursing (DON) B who reported the frig temp log was located at the South Nurse Station in binder. DON B located the binder that included one incomplete frig log last documented on 6/11/24 at 41 degrees. DON B reported would expect staff to monitor both refrigerators and document temps daily and verified several missing temps 6/3/24-6/10/24. DON B reported did not locate temp log for vaccine frig and verified temp was too warm and removed vaccines and reported plan to dispose. DON B reported frig temp should be between 36 and 41 degrees and verified was over 50 degrees. Review a typed document temperature log titled, Medication Fridge Temps, dated 6/1/24 through 6/12/24, provided by the DON B on 6/12/24 at 4:24 p.m., reflected temps for one vaccine refrigerator twice daily all under 42 degrees. During an interview on 6/14/24 at 8:51 AM, Registered Nurse Infection Control Nurse(RNIC) C reported facility vaccines were stored in a south hall medication room refrigerator that she observed temps in daily Monday to Friday.(Provided log was completed 6/1/24 through 6/12/24). RNIC C reported provided June log to DON B but did not have prior record past current month because was not aware she needed to keep records and deleted at the end of the month. RNIC C reported had not observed vaccine fridge with elevated temps.

Based on observation and interview, the facility failed to display current nurse staffing information that was readily accessible for all 135 residents, as well as visitors in the facility, resulting in the likelihood of necessary staffing information not being available to residents and visitors. Findings include: During an observation on 6/11/24 at 11:17 AM, posted staffing was located in a staff only area, behind doors with 2 large stop signs that reflected staff only. The posting was dated 6/10/24 with census 133. During an observation on 6/12/24 at 8:00 AM, posted staffing continued to be posted in staff only area, dated 6/10/24. During an observation on 6/13/24 at 9:45 AM, posted staffing continued to be posted in staff only area dated 6/10/24. During an observation, interview and record review on 6/13/24 at 2:25 PM, Human Resource(HR) Staff Y reported had been in position about one month and was responsible for posting staffing. HR Y reported was instructed to post staffing for previous day for staff review. HR verified printed 6/11/24 and 6/12/24 and posted that day after review of posting observed and verified was staff only area. HR Y reported was not aware staffing posting had to be in public area or current day staffing.

This citation pertains to intake MI00135574 Based on observation, interview, and record review, the facility failed to provide advanced written or spoken notice prior to a room change for one Residents (#1), of three residents reviewed for room changes. This deficient practice resulted in the potential for increased anxiety, misunderstanding of the reasons for the room change, actual arguments, and the lack of opportunity for resident questions or concerns. Findings include: Resident #1 (R1) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with medical diagnosis which included chronic pain, neuromuscular dysfunction of bladder, adjustment disorder with depressed mood, anxiety, and quadriplegic. The MDS reflected R1 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact. The same MDS revealed R1 was unable to ambulate or perform most activities of daily living including toileting and personal hygiene and lacked the ability to feed himself. During an interview on 6/28/23 at 8:53 AM, R1 was observed in bed. R1 had a semi-private room and no roommate at the time of interview. R1 appeared calm and able to answer questions appropriately. R1 reported a roommate change without prior notice and was upset that a roommate with no compatibility with R1 was moved into his room. R1 verified that he did not receive written notice, sign anything, discuss with social work, see or meet the roommate prior to the roommate moving in. R1 reported that the roommate was only in his room for one day. R1 reported troubles over television volume, R1 felt that R13's television was turned up too loudly which resulted in R1's inability to sleep. R1 reported the issue to Social Worker (SW) H as well as other staff members. R1 reported that he was told that they could not move R13 and provided facility transfer information for R1. R1 reported on one occasion, R13 lifted the curtain that separates the roommates from eachother and said fu*k you, mother fu*ker after R1 had reported the loud television to staff. R1 admitted that he felt threated. R1 reported that staff did not believe that this altercation occurred because R13 lacked the capability to speak. R1 stated his vocab was good when it came to swear words. R1 also reported that there was no discussion or proper notification prior to R13 moving into the shared place. R1 stated housekeeping just came in and started cleaning room and said oh you're getting a roommate. R1 stated that he has asked in the past how do you determine who gets a roommate? He was told that normally the facility rooms people that have same personality traits. R1 reported he was upset and very concerned about new roommate because the new roommate did not have any capatibilty with him. Review of a Behavior Note dated 3/7/23 revealed Resident (R1) voiced concerns about roommate to this writer. He stated that his roommate watches tv (television) very loudly which doesn't allow him to rest. Also stated that roommate made threats to him because he reported the loud tv to. Review of a Social Service Note dated 3/7/23 revealed that R1's Family Member had called the Social Worker to discuss the complaint of the roommate's loud television. SW H stated to R1's family member that the situation with resident had already been addressed. As there is not currently an open bed in this facility, resident (R1) was given options for facilities to transfer to. Review of a Social Services Note dated 3/8/23 revealed checked in with resident after receiving notice that another incident happened last night. Resident stated that he does not feel safe with current roommate. Residents roommate was being moved to another room during conversation . Review of the Social Work Progress Notes, dated 3/5/22 through 3/9/22 revealed that there was no mention R1 was notified that he was getting a roommate, including, notes about being able to meet the new roommate and ask questions prior to the roommate move in. Review of the State Operations Manual (Rev. 173, 11-22-17), reflected, The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. Moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes .The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. A resident receiving a new roommate should be given as much advance notice as possible. In an interview on 6/27/23 at 1:58 PM Social Worker (SW) H reported when considering roommate placement, it is discussed in morning meetings. Social Work is usually the one who communicates the room changes to residents or the responsible party to confirm if the move is agreed upon. SW H reported she would assume someone would have had the discussion with R1 before moving R13 into the room. The information would be documented in the electronic medical record as a Progress Note. R13 moved in the room with R1 in March. R1 accused R13 of saying some words that at the time I personally hadn't seen him demonstrate the ability of. R1 had stated that R13 threw back the curtain and said something along the lines of hurting R1. R1 and R13 had an argument about the television being too loud. SW H reported that R13 did not have behaviors prior to rooming R13 with R1. Record Review for R13 revealed R13 had behaviors which included being combative and verbally abuse. Two Behavior Notes dated 1/29/23 revealed R13 was cursing at staff while care was being provided and being verbally and physically combative to Certified Nursing Assistant staff. R13 was refusing used to comply with direction . Resident (R13) has had behaviors with aggression all weekend . has also yelled and is swearing at staff to get the hell or fu*k out of his room and leave him alone. In an interview on 6/28/23 at 10:44 AM, Director of Nursing (DON) B stated when determining room placement for residents, the Interdisciplinary Team will review what rooms are available and who we think would be a good fit that person. The team takes into consideration resident personalities, similar traits, and likes and dislikes. DON B stated that the resident would generally be notified that they are getting roommate at the time when housekeeping goes in. Housekeeping will notify the resident. If the Resident has a concern, it is housekeeping's responsibility to bring it to the Nursing staff. has problem, generally assume speak up to housekeeping team and bring the concern to nursing.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and safe transfers to prevent falls in 5 of 7 residents (Resident #101, #48, #10, #86, and #110) reviewed for falls, resulting in falls with majory injury (fracture(s)) for Resident #48 and #10, fall with injury needing outside medical intervention for Resident #101, and the potential for falls with injury for Residents #86 and #110. Findings include: Resident #101 Review of an Admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and age related physical debility. Review of a Brief Interview for Mental Status (BIMS) assessment for Resident #101, dated 1/29/2022, revealed a score of 3, out of a total possible score of 15, which indicated that the resident was severely cognitively impaired. Review of a Nurses Note dated 1/29/2022 at 11:24 p.m. revealed .Resident (Observed on floor) without injury around 20:00 (10:00 p.m.) . Pt poor safety awareness, poor historian r/t dementia .resident known to self transfer . Review of a Nurses Note dated 3/29/2022 at 4:19 p.m. revealed .Resident was observed on the floor . Review of a Nurses Note dated 4/18/2022 at 7:35 p.m. revealed .Writer was called into room by worker that resident was observed on floor in between her and roommates bed. Writer went into residents room and observed resident on the floor in between beds . Skin assessment complete lump and laceration on left side of forehead . Doctor notified agreed that resident should be sent to hospital for evaluation . Resident picked up .at 1140 . Review of local hospital emergency department notes from 4/18/2022 visit revealed that Resident #101 was evaluated after suffering a fall and diagnosed with an acute head injury and traumatic hematoma of her forehead. In an observation on 4/20/2022 at 12:13 p.m., Resident #101 was noted to have a protruding bruise on her left forehead. Review of a Nurses Note on 4/22/2022 at 7:37 p.m. revealed .Resident was observed on the floor in room . Will continue to monitor . In an interview on 4/28/2022 at 1:11 p.m., Registered Nurse (RN) ZZ reported that Resident 101 would benefit from one on one observation because falls happen when no one is around within a couple minutes. RN ZZ reported that she has discussed Resident 101's need for one on one observation with the clinical care coordinator. Review of policy/procedure Falls Reduction Program, revised 9/25/2016, revealed .PURPOSE: To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury . Implement and indicate individualized interventions . Resident #48 (R48) According to the Minimum Data Set (MDS) dated [DATE], R48 scored 3/15 (severely cognitively impaired) on her BIMS (Brief Interview Mental Status), had unclear speech rarely making her needs known, rarely understanding others, required extensive assistance of physical support for ADLs (Activities-of-Daily-Living), had impairment in one leg, received antipsychotics, anti-anxieties, opioids, was receiving hospice services, with diagnoses that included having an ostomy, [CONDITION(S)], hip fracture, dementia, malnutrition, anxiety, and depression. Review of R48's Care Plan Date Initiated 6/3/2021 (admission) reported risk of falls related to history or repeated falls with very poor safety awareness and attempts to get up independently. Frequently self-removes footwear .Goal Resident safety will be maintained .minimize risk for injury related to falls 6/3/2021 .Intervention date initiated 6/3/2021 I will wear non-skid footwear for all transfers . Review of Incident Report (IR) #6374 dated 8/11/2021 at 17:39 (5:39 PM) revealed R48 was on the floor of the Day Room (2 North unit) with an Immediate Action Taken . Staff will check for placement on non-skid footwear throughout the shift to ensure placement and replace if needed .Predisposing Situation Factors .Footwear not in place . resident plan of care followed . Review of R48's IR #6376 dated 8/12/2021 at 11:00 a.m revealed R48 was on the floor of the Day Room (2 North unit) in bare feet and had removed her non-skid socks with an Immediate Action Taken . TED hose have been dc'd (discontinued) to decrease res (resident) attempts to remove socks .resident was confused, impaired memory, gait imbalance, incontinent, wanderer . Review of R48's IR #6416 dated 9/9/2021 at 11:00 a.m. revealed R48 was sleeping on the floor of her room covered in a blanket. Immediate Action Taken Medication adjustments have been made as fall intervention. Review of R48's Fall assessment dated [DATE] at 11:00 a.m. revealed R48 had a history of falls, an unsteady gait, received narcotic and antianxiety medications, had pain and bladder incontinence, the overall Care Plan was to minimize risks. The fall assessment summary reported R48 had impaired cognition, poor safety awareness while having increased behaviors. Review of R48's Care Plan Intervention revised on 9/9/2021 Medication review by Pharmacist PRN (as needed) .Frequent rounds to ensure resident safety and make sure she is in her own appropriate w/c (wheelchair) . Review of R48's IR #6440 dated 9/23/2021 at 11:30 a.m. revealed R48 was sitting on the floor of the hallway next to her wheelchair not wearing non-skid socks. Review of R48's Care Plan Intervention for IR #6440 reported Staff will offer resident to lay down in bed throughout the day if she appears sleepy . Review of R48's IR #6441 9/23/2021 at 18:30 (6:30 PM) reported the resident was observed on the floor of her room next to her wheelchair and non-skid sock next to her. According to the IR, Resident #48 had impaired memory and poor safety awareness, was a wanderer and exit seeker with footwear not in place. Review of R48's Care Plan Intervention for IR #6441 did not reveal an intervention had been updated to reflect two falls in one day. Review of R48's IR #6450 dated 10/4/2021 at 12:48 p.m. revealed R48 was found on the floor of the back hallway by the dining/activity room during the passing of meal trays. R48 was holding herself up with right arm, legs flexed, near a window. Her wheelchair was on the other side of the room. Resident was not wearing socks. The assessment reported the resident was confused with impaired memory and gait imbalance while ambulating without assistance. Review of R48's Care Plan for IR #6450 reported no immediate intervention was updated for R48 on 10/4/2021. Review of R48's IR #6454 dated 10/6/2021 at 16:00 (4:00 PM) revealed R48 was found laying on her back on her bathroom floor. She had an abrasion to the top of her scalp with blood in her hair and on the floor. The wheelchair was near the heater. Immediate Action Taken was for staff to offer toileting assistance prior to leaving the room. R48 was described as confused with impaired memory, with poor safety awareness, history of falls, and non-compliant with using wheelchair. Review of R48's Fall assessment dated [DATE] 16:00 reported the resident had a history of falls related to responding to bladder urgency, standing still/walking, and reaching up/down. She had difficulty maintaining a standing position with impaired balance during transitions. The resident received narcotic and antianxiety medications. The resident had walked across room into bathroom and fell . New Care Plan intervention dated 10/7/2021 was to offer toileting assistance prior to leaving room. Review of Care Plan verified update. Review of R48's IR #6511 dated 11/9/2021 at 11:50 a.m. revealed R48 was found on the floor in the dining room with wheelchair cushion slid out of chair. A towel had been stuffed underneath the cushion. Immediate Action Taken wheelchair cushion to be removed risk of skin breakdown was low. Review of R48's IR #6550 dated 12/4/2021 at 11:45 a.m. revealed a nurse responded to what sounded like a crying infant. Upon entering R48's room, the nurse observed resident sitting on the floor in doorway, sideways, head leaning against the front of dresser, legs extended out in front of her. Resident reported I hit my head. Resident unable to explain what she was trying to do. Possible intervention: Gripper blocks installed on floor. Review of R48's Care Plan for IR #6550 reported no immediate intervention (gripper blocks as indicated in IR #6550) was updated for the resident on 12/4/2021. Review of R48's IR #6575 dated 12/29/2021 at 11:45 a.m. revealed R48 was found laying in another's resident's room (other resident not present) on her back with legs extending outwards in front of wheelchair. Resident noted having increased weakness post-Covid infection. Ambulating without assistance. Review of R48's Care Plan for IR #6575 did not reveal an immediate intervention had been updated. Review of R48's IR #6576 dated 12/30/2021 at 04:30 (4:30 AM) reported the resident had fallen out of bed resulting in a one-inch laceration her forehead. Review of R48's Fall assessment dated [DATE] at 04:30 reported the resident had a history of falls. The assessment's summary indicated the resident rolled out of bed different circumstance from previous fall with new intervention of a perimeter mattress. Review of resident's Care Plan verified update. Review of R48's IR #6599 dated 1/21/2022 at 00:00 (midnight) reported the resident was found on the floor in her room near the window on her back clinging to the side of the bed. Resident not wearing any type of footwear. Fall resulted in a 4 cm length x 3 cm width hematoma on rear left side of head. Immediate Action Taken intervention was for the resident to wear non-skid footwear at all times. A bariatric perimeter mattress was requested. Resident was described as confused, drowsy, with impaired memory. Predisposing Situation Factors included the resident to be ambulating with assist. Review of R48's Care Plan for IR #6599 did not reveal an immediate intervention on 1/21/2022 had been updated. Review of R48's IR #6612 dated 2/2/2022 at 01:30 a.m. revealed R48 was found on the floor in her room in a fetal position. Resident was reported to be confused with impaired memory and gait imbalance. Review of R48's Fall assessment dated [DATE] at 01:30 (AM) reported the resident had a history of falls. Had difficulty maintaining standing position, gait, and musculoskeletal problems. The IDT reviewed for root cause analysis with r/t poor safety awareness with impaired balance and BLE (bilateral lower extremity(legs)) weakness. Day 1 2/2/22 New intervention: medication review. Day 2 2/3/22 new intervention: bed low level mattress to right side of bed. Review of R48's Care Plans for IR #6612 dated 2/2/2022 did not reveal an immediate intervention to ensure resident's safety during a fall on 2/2/2022. Review of R48's IR #6623 dated 2/7/2022 at 10:40 a.m. revealed R48 was found laying on the floor in the hall close to the dining room door on 2North. Another resident stated R48 was walking and was holding onto the railing and fell . R48's wheelchair was in the dining room. Resident had poor safety awareness, with impaired memory and gait imbalance. Predisposing Situation Factors included ambulating without assist and footwear not in place. There was poor lighting due to lack of power in facility at time of the incident. Review of R48's Fall Timeline provided by DON C revealed, 2/7/22 1040 (AM) .isolated incident r/t (related to) temporary power outage with diminished emergency lighting in place No intervention put in place. During an interview on 4/26/22 at 3:42 PM RN XXX stated, I remember the day (R48) fell (2/7/2022). The power was off so only some of the lights were on in the unit (2 North). The lighting in the hall (R48) was found in was dim. She was close to the dining room door towards the last resident door to the right. (R48) would try to get up and walk on her own. I know (CNA D) was there because she told me (R48) had fallen. I reviewed (R48's) Care Plans after the fall and called (CCC VV) to see if anything needed changed. (CCC VV) did not update (R48's) Care Plan because she felt the fall was due to the unit being dim. Maintenance personnel told us a half-hour prior to the power being turned down so staff on the unit knew the power was going to be turned down. (R48) could not walk on her own at this time. However, in this incidence she did walk on her own because her wheelchair was found in the dining room. The staff and I tried to keep the residents at the nursing station while the power was to be turned down but (R48) took off. She would self-propel. (CNA D) saw (R48) five (5) minutes prior to the fall. I feel like at the time of the fall it was only (CNA D) and myself on the unit. We did not see (R48) trying to get up to walk. There was only the two of us trying to watch all the residents at that time. During an interview on 4/22/22 at 2:31 PM, Maintenance Director DDD stated, There was a planned shutdown with the energy company on 2/7/2022 around 10:00 am for about 35 minutes to service a transformer. Lights would not go off. The generators would be fired up and power would go off at main breaker. I don't remember any lighting go off. During an interview on 4/26/22 at 4:16 PM CNA XXXX stated, The power was turned off the day (R48) fell in the hall. She kept getting up out of her wheelchair. I looked up and she was in her wheelchair. I went another room, came out and she was on floor. The lighting was not very good. I don't think our residents should have been up at the time of the power outage. It was hard for me to see who it was lying on floor with the lighting. We were told by Maintenance the power was going to be turned off but didn't know what the lighting was going to be like. (R48) was not injured at that time, she got right back up and told me she flew there. Review of R48's IR #6625 dated 2/8/2022 at 10:00 (AM) revealed R48 was heard screaming for help. Staff went to her room and found her lying on the floor. R48 had a laceration on upper forehead, scattered bruising on right side of the body, and bilateral knees. Unable to move right hip. Rotated right shoulder with pain and right knee with pain. Provider ordered STAT x-rays. Resident was confused with impaired memory. Predisposing Situation Factors included wanderer and ambulating without assist. Findings: fracture involving the right femoral neck with displacement (hip fracture). IR revealed, 2/8/2022 Investigative summary: Interviewed staff on unit this morning prior to event. Per CNA's resident was awake and up in chair when they arrived on floor for start of shift. Resident was then taken into her room and assisted into bed. Nurse administered scheduled medications at approximately 0809. CNA went to check on resident at approximately 0830 to see if resident wanted breakfast. CNA states resident appeared asleep, so she was not disturbed. Nurse then heard resident yelling for help just before 0930. Nurse entered room and observed resident on the floor . Review of R48's eInteract Transfer Form 2/8/2022 at 11:48 (AM) revealed, Sent to (name of hospital) 2/8/2022 11:50 (AM) .reason for transfer: fall . Review of R48's Orthopedic Consultation Note dated 2/8/2022 at 14:52 (2:52 PM) revealed, .Right hip pain s/p fall from standing height .report she only gets out of bed with assistance, otherwise ambulates minimally .Assessment R (right) hip fracture . During an interview on 4/22/22 at 9:03 AM Clinical Care Coordinator (CCC) VV stated, (R48) fell and fractured her hip February 8 (2022). She fell out of the bed to the left side and her Care Plan was revised at that time. (R48) was sent to the hospital and had an x-ray. She has had a lot of falls. She used to be highly mobile and ambulate without assistance. (R48) has a whole gambit of therapy screens. Right now, she is a two-person pivot. She would transfer by self. (R48's) transfers and interventions were changed each time in her Care Plan which reflected on the Kardex (guide to direct resident specific care). If (R48) was up you wanted people with her. She had [CONDITION(S)] and wouldn't go to bed. (R48's) February 7th (2022) fall was related to with poor lighting because the electrical system was on the generator and she went off into a corner in the hall. Another fall she had was when she rolled off the left side of the bed and was holding onto to the side of the bed. At that time, a mattress was put on the left side of bed. During an interview and record review on 4/26/22 at 1:52 PM CNA D reviewed schedules to verify she was working on 2/7 and 2/8, 2022. Verified she worked 2/7 2/8/2022. I work the back of the unit and do not remember (R48) falling. Surveyor reviewed CNA D's schedule to verify she was working on 2/7/2022 and 2/8, 2022. CNA D verified she worked 2/7/2022 and 2/8/2022 stating, I work the back of the unit and do not remember (R48) falling. During an interview on 4/26/22 at 4:08 PM CNA G stated, I was there on the day (R48) fell but I was doing something else. All staff were aware of her being a fall risk. We did the best we could to keep her falling. She was not to be walking on her own. During an interview on 4/26/2022 at 4:33 PM RN RR stated, (R48) was very disoriented and did things on her own. Staff could put her in her wheelchair, and she would get right back up. RN RR did not indicate what the care plan intervention frequent monitoring meant or how it applied to R48. During an interview and record review on 4/27/22 at 1:01 PM CCC VV stated while reviewing R48's medical records with Surveyor, (R48's) ADL (activities-of-daily living) Care Plan stated she was a 2 PA (person assist) transfer pivot .the intervention to prevent self-transfers (had a history of self-transfers). I cannot restrain her in any way. Residents have certain rights, and I cannot restrain her physically or chemically. She did not really call for staff. Knowing that she was going to self-transfer, I put interventions in place to make her safer knowing she was going to self-transfer. Yes, I would like to have someone next to the resident all the time, but the resident has rights. Surveyor reviewed R48's medical records with CCC VV who stated, (R48's) Fall Care plan . history of repeated falls .frequently removes her footwear. CCC VV stated, Staff frequently monitored (R48) at night. Frequently depends on situation, time of day, and resident's mood. The meaning of frequently takes so much into account. If I read it as a healthcare worker, I need to look at the resident more than usual. I cannot give you a definition of more than usual. I'm going to check on her more than usual. I do not want to say check on her every 30 minutes because staff might be with another resident and cannot get the resident. During an interview on 4/27/22 at 2:20 PM Director of Nursing (DON) C stated, Monitoring frequently means any time you are walking around. During an interview on 4/27/22 at 3:01 PM Hospice Director of Clinical Services UUU stated, Our company received a fall report on 2/8/22 regarding (R48's) fall. The report stated (R48) had a laceration above right eye, right shoulder, and right hip pain. Her right knee was bruised and painful. We were notified via telephone she had a right femoral neck fracture without displacement and was being sent to the hospital to have hip put in placement. Family wanted her on comfort care with no surgical repair. The facility had her on a 1:1 that night but I do not know how long that lasted. Her plan of care regarding safety interventions, included checking on her frequently. I do not see the frequency in a time frame. I would think checking on the resident hourly for someone that has had quite a few falls. Our company always want to make sure there were new interventions with every fall. I think after the fall with fracture on 2/8/22 (R48) stayed in bed and did not do much after. During an interview on 4/28/22 at 9:03 AM Licensed Practical Nurse (LPN) QQ stated, I believe there would be falls on that unit (2 North) because the residents there need reminders to be careful. Staff had to remind (R48) constantly to be safe. Her falls were caused from her walking out of her chair. She would stand up and take a step and fall. R10 According to the Minimum Data Set (MDS) dated [DATE], R10 scored 10/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status), had clear speech usually making needs known, usually understood others, her bed mobility/positioning required extensive assistance of two-plus persons, did not transfer out of bed, ADLs (Activities-of-Daily Living) required extensive assistance including eating, both legs had impairment, always incontinent of bowel/bladder, received hospice services, received anti-anxiety, antidepressant, and opioid medications with diagnoses that included heart arrhythmia, hypertension, diabetes mellitus, arthritis, hip fracture, dementia, malnutrition, anxiety, and depression. Review of R10's Incident Reports dated dated 6/22/2021 at 18:23 (6:23 PM), 6/24/2021 16:45 (4:45 PM), 8/1/2021 at 11:10 (AM), 8/8/2021 at 05:30 AM, 10/19/2021 at 17:30 (5:30 PM), 10/27/2021 at 17:20 (5:20 PM), 10/27/2021 at 02:15 (AM), 12/30/2021 at 11:15 (AM) revealed R10 had 8 falls in 6 months. Review of R10's IR #6357 8/1/2021 at 11:10 (AM) reported a nurse heard what sounded like pounding on a door. The resident was found on the floor just inside her room flat on her back, legs extended out in front of her. Walker was on other side of room. Not wearing footwear. Resident was reported as saying, I was trying to go out to the office. Immediate Action Taken reported R10 complained of soreness and right hip pain. Frequent checks throughout the day to ensure proper footwear was in place. Review of R10's Progress Note 8/1/ 7:01 (5:01 PM) indicated the resident exited the facility with 2 EMS (emergency medical service) personnel. 17:04 Progress Note indicated the resident was sent to the hospital. Review of R10's Progress Note 8/2/2021 04:10 (AM) indicated the resident returned from hospital with no new orders. Review of R10's IR #6591 dated 1/14/2022 at 08:30 (AM) reported staff heard loud noise/yelling from resident's room. R10 was observed in doorway of her room on her left side with her back to the closet. Resident stated she was looking out the window. Immediate Action Taken 1.5 cm superficial abrasion on back left side of head, left shoulder abrasion, resident holding left hip stating I can't move it. Resident described as confused, impaired memory and had gait imbalance. Review of R10's Fall Assessment 1/14/2022 08:30 (AM) reported the resident had a history of falls with difficulty maintaining standing position and gait problems. Assessment summary indicated resident had poor safety awareness and needed frequent reminders to use walker. Guardian stated resident fell a lot at home. IDT Day 1: 1/14/2022 New intervention signs in room and bathroom with picture of walker and reminder to use walker. IDT Day 2: 1/17/2022 X-ray completed with noted acute left femoral neck fracture. Pain medication increased to manage pain and keep resident comfortable. No further interventions. Review of R10's INTERACT 1/14/2022 at 9:10 (AM) revealed, .fracture of left femur head .resident has history of poor safety awareness and falls . Review of R10's Progress Note 1/14/2022 at 10:47 AM revealed, .x-ray ordered for left hip . Review of R10's Order Audit Report 1/27/2022 revealed, 10:43 (AM) Transfer 2P (2 person) Hoyer (mechanical lift), 10:46 (AM) revealed, LOCOMOTION 1PA (person assist) with wheelchair. During an observation and interview on 4/20/22 at 10:32 AM R10 was supine in bed with a wheelchair and walker across the room out of reach of resident. Air mattress on bed. On the floor to either side of the bed were mattresses. R10 stated, I hurt myself from falling down. During an interview on 4/21/22 at 1:44 PM Certified Nursing Assistant (CNA) N and GGGG were providing a brief change for R10. CNA GGGG stated, (R10) fell a few months ago and broke her hip and has not got up very much since then. (R10) is a fall risk and tries to get out of bed. During an interview and record review on 4/22/22 at 8:43 AM Clinical Care Coordinator (CCC) VV stated, (R10) had an x-ray on 1/14/22 for a fall that resulted in a fractured hip. R10 had a history of falling and breaking hip. On 1/14/22 (R10) was up walking independently at night in her room, it was dark, and fell . She is not to walk independently. (R10) did not use her walker and required cueing to use it. She was to have standby-assist with a history of transferring without asking for help. At one time she tried using the bedside table for a walker and fell . (R10) had a history of falling prior to admission. She was at risk for falling upon admission. During an interview on 4/27/2022 at 7:40 AM Registered Nurse (RN) RR stated, (R10) was a fall risk. She could be in her wheelchair right next to staff, and she would just get up and drop to the floor. During an interview on 4/27/22 at 10:00 AM Family Member (FM) VVV stated, My mother had falls before coming into the facility. She has had many trips to the ER (emergency room /hospital) while with two hip fractures here at the facility from falls. I blame it on her dementia. My mother used to walk six (6) miles a day. She liked to walk. During an interview and record review on 4/27/22 at 10:08 AM Licensed Practical Nurse (LPN) GG stated, (R10) used to walk with a walker. Her cognition is impaired. She had a fractured hip in August 2021 and one in January 2022. (R10) would walk with a walker when she was first admitted . Prior to (R10's) coming to this facility, she did a lot of walking. Review of R10's IR #6637 2/17/2022 at 16:52 (4:52 PM) reported the resident was found on the floor of her room on her back. Resident was moaning with a slight abrasion on left knee. Review of R10's Fall Assessment 2/17/2022 16:52 reported the resident had a history of falls with difficulty maintain standing position, gait problems, and musculoskeletal problems. Received medications that can cause lethargy or confusion ([MEDICATION(S)]). Assessment summary indicated the resident had severe dementia and was receiving palliative hospice care. History of frequent falls. Had a healing left hip fracture from her last fall (1/14/2022). IDT reviewed for root cause analysis: Resident had significant cognitive deficits related to advanced dementia. Resident terminally ill on hospice with terminal restlessness noted on anti-anxiety medication, also air mattress ordered from hospice for skin protection. Hospice approved inadvertently an air mattress overlay. Root cause poor safety awareness with terminal restlessness and use of overlay. IDT Day 1 2/18/2022 new intervention removal of overlay and order of new low air loss mattress from hospice. Review of R10's Care Plan for IR #6637 did not reveal a low air mattress had been documented as an intervention. Review of R10's IR #6658 dated 3/3/2022 dated 3/3/2022 16:243 (4:23 PM) reported the resident was found on floor in the hallway lying next to her wheelchair. R10 had been up in her wheelchair for approximately 1 hour. Review of R10's Fall assessment dated [DATE] 16:23 reported the resident had a history of falls. Assessment summary indicated resident had increased restlessness and had been getting out of her bed at times. Staff had been putting her in her wheelchair to assist with restlessness. fell in front of chair in front of nurse's station. New intervention medication review. Antianxiety increased to four times a day. During an interview on 4/27/2022 at 7:40 AM, RN RR stated, Both (R48 and R10) were fall risks. There would usually be two CNAs and myself on 2 North. Could the unit use more than two aides? Yes, depending on resident behaviors. Some residents took two staff to toilet or brief change and maybe another staff would be helping a resident in a room. Staff cannot be everywhere at once. Resident #86 Review of an Admission Record revealed Resident #86 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: muscle weakness, muscle spasms, and cervical (neck) spine fusion. Review of a Minimum Data Set (MDS) assessment for Resident #86, with a reference date of 3/18/22 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #86 was cognitively intact. Review of the Functional Status revealed that Resident #86 required extensive assistance with 2 people for transfers, bed mobility, dressing and toileting. During an interview on 4/23/22 at 12:14 PM., Resident #86 reported she cannot walk unassisted at all, and at this time she is non-weight bearing, does not walk, and cannot stand on legs. Resident #86 reported she had a fall about 2 weeks ago. Resident #86 reported the staff were rushing to get her up and staff are always rushing because of the staffing shortage. Resident #86 reported she was being lifted by 2 staff using an easy stand/sit to stand lift as the staff were raising her up, she (Resident #86) felt her legs start to spasm. Resident #86 reported she told the staff to stop, and to lower her back down from the lift, the staff did not stop when she (Resident #86) asked and they continued to lift her. Resident #86 reported at that time her arms were stuck in the sling, and she was left hanging by her armpits. Resident #86 reported she was yelling please stop, please stop, you're hurting my neck and arms. Resident #86 reported she finally screamed STOP STOP STOP. and the staff lowered her to the floor. Resident #86 reported since her accident (car accident) her legs spasm, and they go up and back from the knees, up towards her buttocks. Resident #86 reported staff are suppose to make sure her (Resident #86's) feet are securely and properly planted on the base of the lift. Resident #86 reported neither staff placed her feet on the base of the lift, nor did staff listen to her once she (Resident #86) started to express she wanted to be lowered back to her seated position. Resident #86 reported she thought her arms were going to come out of socket. Once she (Resident #86) was lowered to the floor the 2 staff working blamed her (Resident #86) for not holding on, or lifting herself with her arms. Resident #86 reported she is weak from her accident, and if she could lift herself, she wouldn't be in the facility. Resident #86 stated I was laying on the floor like a baby, it was the worst experience I've ever had. Review of Resident #86's Care Plan revealed Focus: ADL's: I (Resident #86) have a potential/actual ADL deficit R/T: recent urinary tract infection . [CONDITION(S)], Hx MVA (motor vehicle accident) with bilateral leg weakness, cervical disc disease weakness, reduced mobility muscle spasms Date Initiated: 03/12/2022 Interventions: Transfer 2 PA (person assist) with Ez Stand. Second person to keep the legs in place Date Initiated: 03/12/2022 Review of a facility Incident/Accident report dated 4/5/2022 at 10:20 AM revealed: Nursing Description: Resident (Resident #86) had to be lowered to the ground from the E-Z stand, r/t (related to) her legs spasms and she (Resident #86) would not stand up and would not use her arms to pull up and just kept screaming to put her on the floor Resident Description: (Resident #86) my legs buckled and I needed to laid on the floor Review of a Residnet #86's Electronic Medical Record (EMR) revealed: on 4/6/2022 at 10:33 Unusual Occurrence Note Late Entry: Document follow-up on (Resident #86) status in relation to incident/unusual occurrence: (Resident #86) is AAO (alert and oriented) x4 and able to make her (Resident #86) needs known. She (Resident #86) is care planned to be a E-Z s [TRUNCATED]

Based on observation, interview, and record review, the facility failed to maintain resident dignity and meet the needs of residents in 4 of 6 residents (Resident #90, Resident #86, Resident #325 and Resident #28) reviewed for dignity resulting in residents having extended wait times for toileting, episodes of incontinence, and feelings of being burdensome. Findings include: Review of a facility Policy with a Revision Date: of 7/15/15 revealed: POLICY STATEMENT: Our (facility name omitted) and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being PROCEDURE: .1. Accommodation of Individual Needs and Preferences 1.1. The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered 4. Staff Interaction with Residents 4.1. In order to accommodate individual needs and preferences, staff interactions must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the resident's wishes. 4.1.1. Staff shall interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity. (For example, staff shall face the resident and speak to him or her at eye level if the resident is hearing impaired and can read lips.) Resident #90 Review of an Admission Record revealed Resident #90 was originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #90, with a reference date of 3/21/22 revealed a Brief Interview for Mental Status (BIMS) score of 03/15. Review of the Functional Status revealed that Resident #90 required extensive assistance with 2 people for transfers, dressing and toileting. During an observation/interview on 4/20/22 at 10:15 AM., observed Resident #90 in her bed laying on her back, with Family Member (FM) TTTT at bedside. FM TTTT reported Resident #90 was wet and had a bowel movement. FM TTTT reported he turned the call light on, staff came in turned it off and said they would be back. FM TTTT reported that was at least a half hour ago. FM TTTT reported he comes in most days, and it is very typical that Resident #90 is not up, clean and dressed for rehab. FM TTTT reported it's sad to see a loved one left sitting like that. During an interview/observation on 4/20/22 at 10:45 AM., Certified Occupational Therapy Assistant (COTA) JJJJ in Resident #90's room for therapy. COTA JJJJ reported Resident #90 is seen for therapy 5 times a week. COTA JJJJ reported the therapy department has what is called a set up a get up list for staff to ensure residents who are receiving therapy are up and ready to go for their therapy time slot. COTA JJJJ reported most days for Resident #90, and many other residents are left in bed, in nightgown or pajamas, and Residents dependent on staff for toileting, and residents who wear adult briefs are wet and soiled. COTA JJJJ reported throughout the day staff make little to no attempts to decrease pressure on residents' bottoms, and high-risk pressure ulcer areas. COTA JJJJ stated It's unfortunate that I see the residents left in their soiled briefs. During an interview/observation 4/20/22 at 12:13 PM., FM TTTT reported at times before coming to the facility (FM TTTT) calls ahead and asks to have Resident #90 up and in her chair so he can visit. FM 'TTTT reported most times she is still in her bed, and food on her face. FM TTTT reported visiting Resident #90 daily and for long lengths of times, staff will not enter the room when FM TTTT is present. FM TTTT reported when he asks for Resident #90 to be changed staff are rude, loud and disrespectful to him, and in front of Resident #90. FM TTTT stated I don't think I should have to ask to have (Resident #90) changed they (nursing staff) asked me how do I (FM TTTT) know if she (Resident #90) has wet her pants staff are always are on the defense. During this interview CNA S entered the room, and quickly exited, without saying a word. This surveyor approached CNA S and inquired who/which CNA was assigned to Resident #90. CNA S reported she was assigned to Resident #90 and the reason she did not come into the room was FM TTTT was there, and she wanted to provide privacy. CNA S reported she should have asked if Resident #90 or FM TTTT needed anything. CNA S reported she should have also check Resident #90 to ensure her brief was dry. CNA S re-entered Resident #90's room walked over to Resident #90 and checked her brief which was visibly soiled with urine, and feces which was visible on the backside of Resident #90's upper thigh area. CNA S reported she had to go get another staff to assist her with changing Resident #90's brief. Resident #86 Review of an Admission Record revealed Resident #86 was originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #86, with a reference date of 3/18/22 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #86 was cognitively intact. Review of the Functional Status revealed that Resident #86 required extensive assistance with 2 people for transfers, bed mobility, dressing and toileting. During an observation/interview on 4/20/22 at 11:45 AM., Resident #86 was observed in her room sitting up in her wheelchair. This surveyor noted a strong smell of urine. Resident #86 reported her adult brief is soaked with urine right now. Resident #86 reported she has been waiting almost an hour for staff to come get her changed and she is to leave in 15 minutes to go home for the afternoon. Resident #86 reported if she is not changed before 12:00 PM., she will go home wet and smelling of urine until she returns late afternoon. Resident #86 became very tearful and wanted to finish the interview for now. During an interview on 4/26/22 at 11:41 AM., Resident #86 reported she has missed showers, been left wet and soiled for hours, been dropped from a sit to stand lift, and missed rides to go home. Resident #86 stated .I hate this place its horrible the only reason managers and more staff are here is because you guys (state surveyors) are here . I sit in my urine and feces all the time. I have to wait a half hour or more sitting in my sh** .while they look for someone .I hear the intercom staff call asking for assistance saying can we get some assistance .on whatever unit .these people literally do not care about us at all it makes me feel sick to myself. Resident #86 reported a few CNA's are so rude to her it makes her cry, and that she has mentioned going to management about it but the staff just laugh and respond with go ahead I don't care, they will get some new people for a day or so and it will be back to normal another CNA said do you think yelling out is [NAME] to make us move any faster. Resident #325 Review of an Admission Record revealed Resident #325 was originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for Resident #325, with a reference date of 4/12/22 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated Resident #325 was severely cognitively impaired. Review of the Functional Status revealed that Resident #325 required extensive assistance with 2 people for transfers, bed mobility, dressing and toileting. During an observation and interview on 4/22/22 at 10:00 AM., Resident # 325 was in his bed, awake and Certified Occupational Therapy Assistant (COTA) JJJJ was present at bedside. Resident #325 was non-verbal and used a communication board to point to boxes that had pictures of things such as (including but not limited to) a smiley face, sad face, medications, thumbs up, thumbs down, pain, shower, and clothing. Resident #325 pointed to thumbs down when asked how he was doing, thumbs down when asked if he felt staff was taking good care of him, thumbs down when asked if he was happy, and a thumbs up when asked if he was left wet and soiled regularly. COTA JJJJ reported he came in approximately 10 minutes ago to complete therapy. COTA JJJJ reported Resident #325 should be up in wheelchair, clean and ready for therapy. COTA JJJJ reported he turned the call light on 10 minutes ago, because Resident #325 was in bed soaked with urine and feces in his adult brief up to his mid back (this surveyor observed adult brief soaked with feces on back). COTA JJJJ reported he had come down to the unit approximately 45 minutes ago to complete therapy on another resident and requested staff have Resident #325 up and ready by 10:00 am-10:15 am. COTA JJJJ stated .this is absolutely not okay, yesterday I came in to work with (Resident #325) and he was covered in feces (Resident #325's) clothing was soaked, the wheelchair had feces running down the seat, sides, and frame. There was feces on his feeding tube pole and base, the bed frame, and all over the floor . COTA JJJJ reported Resident #325 has been recovering from C-diff (C-Diff -Clostridioides difficile or C. difficile is a germ/bacteria that causes severe diarrhea and inflammation of the colon). COTA JJJJ reported yesterday Resident #325 was a mess. It was terrible. I don't know how long (Resident #325) had been sitting like that. COTA JJJJ reported he cleaned Resident #325 up after informing the nurse on duty of the condition (Resident #325) was in. COTA JJJJ reported during the nearly 45 minutes it took him (COTA JJJJ) to clean him (Resident #325) no staff came in to help Resident #325, and COTA JJJJ had left the call light on during that time. COTA JJJJ reported he had left the room, again informing the nurse as well as housekeeping to ensure the floor and equipment was properly sanitized. During this observation and interview at 10:20 AM., Registered Nurse (RN)-Clinical Care Coordinator (RN-CCC) L entered Resident #325's room (the call light had been on) RN-CCC L looked at this surveyor, walked to the wall, turned call light off and asked us (this surveyor and COTA JJJJ) what we needed. At no time did RN-CCC L approach Resident #325, ask him if he needed anything, or check his positioning/brief. RN-CCC was asked by this surveyor when she was about exit the room if the call call light should remain on if the residents needs are not met .RN-CCC L responded to this surveyor and stated I'll go get someone to assist (Resident #325) and walked out of Resident #325's room. During an interview on 4/22/22 at 10:27 AM., RN-CCC L was seated at the nurses station and asked if she (RN-CCC L) had found staff to assist Resident #325. RN-CCC L reported no, staff are in with another resident. RN-CCC L further reported she was pulling up the call light time log for Resident #325's room. RN-CCC L was asked if there was any reason she could not assist staff, call for help or ask COTA JJJJ to assist her with care for Resident #325 who had a bowel movement. RN-CCC L did not answer the question and proceeded to tell this surveyor the average call light response time for Resident #325. Resident #28 Review of an Admission Record revealed Resident #28 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Brief Interview for Mental Status (BIMS) assessment for Resident #28, dated 1/27/2022, revealed a score of 12, out of a total possible score of 15, which indicated that the resident was moderately cognitively impaired. In an observation and interview on 4/21/2022 at 1:33 p.m. in Resident #28's room, Resident #28 reported that when she pushes the call light to request help with toileting, she is told that it is not time and that she needs to wait for the 3 hour scheduled time. Resident #28 stated that this makes her feel Awful. In an observation and interview on 4/26/2022 at 1:22 p.m. in Resident #28's room, Resident #28 reported that 3 hour checks for toileting are not frequent enough and cause her to attempt to transfer herself to the bathroom. Resident #28 that reported that staff called her behavioral because she needed to use the bathroom frequently. Resident #28 reported having Irritable Bowel Syndrome, causing her to need to use the bathroom frequently. Resident #28 reported that the day before she asked for staff to help her use the bathroom during meal time and she was required to wait for about 20 minutes before staff had time to help her. Resident #28 stated that this made her feel frustrated, and it made her stomach upset. In a telephone interview on 4/27/2022 at 9:13 a.m., Family Member of Resident #28 QQQ verbalized one concern regarding care. Family Member QQQ reported that Resident #28 is focused on her bowel patterns, and staff need to offer toileting often enough that Resident #28 will not feel anxious about this. Review of Resident #28's current care plan revealed .Interventions .toileting program, offer and assist to bathroom frequently .

Based on interviews, and record review the facility failed to obtain outside pain management services in a timely manner for 1 of 1 resident (Resident #40) reviewed for pain management, resulting in Resident #40 having uncontrolled pain. Findings include: Review of an Admission Record revealed Resident #40 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #40, with a reference date of 2/2/22 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #40 was cognitively intact. Review of the Health Conditions Pain Management revealed, Resident #40 required scheduled pain management, PRN pain management, non-medication pain intervention, the pain frequency was almost constantly, the pain made it hard to sleep at night, the pain limited day to day activities and the pain intensity was very severe, horrible. Review of Resident #40's Pain Management Care Plan revealed, Chronic BLE (bilateral lower extremity), whole lower body, muscle spasms. Intermittent discomfort top front teeth. Intermittent pain to neck, shoulders. At risk for pain r/t (related to) surgical amputations, h/o (history of) left rib fracture, RLS (restless leg syndrome), reflex sympathetic dystrophy (chronic pain after injury), [CONDITION(S)] (pain from nerve damage) .broken/carious teeth Date Initiated: 04/27/2021. INTERVENTIONS: Assess for verbal & non-verbal s/sx (signs and symptoms) of distress or pain unrelieved by ordered meds (medications). Date Initiated: 04/27/2021. INTERVENTIONS: .Discuss concerns regarding pain management with the MD (medical doctor) & consulting pharmacist PRN (as needed) Date Initiated: 04/27/2021. Identifying precipitating factors of pain & evaluate effectiveness, side effects of Meds PRN Date Initiated: 4/27/2021. Medications as ordered Date Initiated: 04/27/2021 . During an interview on 4/20/22 at 2:00 P.M., Resident #40 reported that he has constant pain and stated .I take multiple pain medication around the clock .my base level pain is still 9 out of 10 .I can barely move .I need to get into the pain clinic .the doctor recommended the pain clinic in December 2021 .but I still don't have an appointment . Resident #40 reported that the facility staff do not follow through with making appointments and stated, .when I ask about it, they (facility staff) always say that they are working on it . Resident #40 reported that the last information that he received was that the pain clinic wanted an MRI (medical imaging of the body) before they would schedule an appointment. During an interview on 4/22/22 at 11:05 A.M., Medical Records Staff (MR) DD reported that she received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . MR DD reported that on 1/25/22 (7 weeks later), when she had not heard back, she faxed the referral again. MR DD reported that on 3/8/22 (6 weeks later) the pain clinic called with questions about the referral and stated, .I know they called a couple times .I think someone called them back . MR DD reported that on 3/22/22 (2 weeks later) she received a packet from (Registered Nurse (RN) EE) that the pain clinic had sent requesting an MRI prior to scheduling the office visit, and on 3/28/22 we call and scheduled the MRI. MR DD reported that Resident #40's MRI was scheduled for next week, 4/27/22, and after the MRI is done the resident will be scheduled for an appointment at the pain clinic. During an interview on 4/26/22 at 10:26 A.M., Resident #40 reported that he had still not heard anything about his MRI appointment. During an interview on 4/26/22 at 10:32 A.M., Registered Nurse (RN) EE reported that she was going to talk to Resident #40 today about his MRI appointment that is scheduled for 4/27/22 (tomorrow). Review of Resident #40's Nurses Note dated 4/26/2022 at 10:46 A.M. revealed spoke with resident today informed him that his MRI will be tomorrow . Review of Resident #40's Physician Note dated 3/14/22 at 16:21 (4:21 P.M.) revealed, . Fair pain control. Patient states he has chronic leg and feet pain that will spread to upper extremities if pain not controlled, RSD (a type of complex regional pain syndrome in which the patient feels persistent pain in a limb or extremity). He tells me he has had a pain pump in the past .the increased dose of [MEDICATION(S)] (medication for depression and anxiety) is effective for leg/foot area pain. States he still has pain in his legs at times .Pt needs to be seen at pain clinic . Review of Resident #40's Physician Note dated 2/14/22 13:32 (1:32 P.M.) revealed, .Complex regional pain syndrome .Staff reminded to make appointment at pain clinic .states medication helpful for leg discomfort most of the time but states some leg cramping . Review of Resident #40's Physician Note dated 1/26/22 at 16:41 (4:41 P.M.) revealed, .Pt requesting [MEDICATION(S)] dose to be increased to 120mg daily, states he feels it is helping with nerve pain in his legs and would like to have increased dose for more beneficial effects. Pt informed that [MEDICATION(S)] (pain medication) is now reduced .we are beginning the weaning process. Orders given to have patient attend pain clinic however he has not yet . Review of Resident #40's Physician Note dated 12/6/21 at 16:40 (4:40 P.M.) revealed, Pt asking for referral to pain clinic, pt has been there in the past. This would likely benefit him greatly . Referral to pain clinic .

This citation has two Deficient Practice Statements (DPS A and DPS B) DPS A) Based on observation, interview and record review the facility failed to ensure staff were comprehensively screened and not entering with signs and symptoms of COVID-19, resulting in immediate jeopardy when symptomatic staff entered the facility and provided direct care to residents. This deficient practice resulted in the facility widespread infection of COVID-19 and the likelihood for further cross contamination of COVID-19 to other residents and staff, thereby putting all 114 residents at risk for infection, hospitalization , and/or death. Findings include: On [DATE] at 8:15 AM, Director of Nursing (DON) B reported the facility had a total of 19 positive residents; 11 remained in the facility, 3 recovered, 3 were hospitalized , and 2 died in the hospital. DON B reported the facility had a total of 19 positive staff; 2 no longer worked in the facility, 10 recovered, and the others were active. At approximately 8:25 AM, DON B clarified there were 12 residents on the COVID-19 unit. Review of the CMS 672 revealed the facility had a census of 114 on [DATE]. According to the facility's timeline, the facility's first COVID-19 positive staff member was tested on [DATE] and results were reported on [DATE]. The timeline revealed the facility's first COVID-19 positive resident was tested on [DATE] and results were reported [DATE]. The facility's COVID-19 status updates provided throughout the survey by DON B and Assistant Director of Nursing (ADON) C revealed the following: [DATE]: 12 COVID-19 positive residents in the facility (19 cumulative) and 5 suspected COVID-19 residents that were tested on [DATE] [DATE]: 15 additional residents and 6 staff tested positive for COVID-19 [DATE]: 23 additional residents and 7 staff tested positive for COVID-19 The cumulative totals as of [DATE] were 31 staff and 57 residents who tested positive for COVID-19. According to the Centers for Disease Control and Prevention (CDC), People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear ,[DATE] days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19. (https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html) Review of the facility's Pandemic Response Plan updated [DATE] revealed If a team member becomes ill at work: 1. Team members who become ill at work should immediately exit the facility and contact their supervisor. 2. Ill team members will be assessed for symptoms and may be sent home allowing for further evaluation of symptoms. 3. Team member should monitor themselves for fever and symptoms of respiratory infection and contact their doctor. 4. If the symptoms are in line with COVID-19, the Employer will test the employee for COVID-19 or provide guidance for making testing arrangements outside of the facility if necessary. 5. The Medical Director and Regional Clinical Director should be notified. 6. The facility Infection Preventionist should begin tracking the team member's illnesses using the Respiratory Surveillance Log. During COVID-19, track the team member's symptoms two times per day. An individual log should be used to document the team member's self-reported temperature and symptoms and results of testing. If a Team Member is sick they should stay home: 1. COVID-19 affects different people in different ways. Infected people have had a wide range of symptoms reported-from mild symptoms to severe illness. Symptoms of COVID-19 include: Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea. Symptoms in the elderly may present as a low-grade fever, altered mental status, decline in physical functioning and poor appetite. 2. Team Members with new onset of fever (subjective or temperature of >100.0) OR symptoms of possible COVID-19 syndrome (cough OR shortness of breath OR sore throat and other current symptoms of COVID-19), you MUST stay HOME and immediately notify your supervisor . Review of the Prevent COVID-19 Employee Screening Logs and the Prevent COVID-19 Visitor Screening Logs (provided as staff screening logs) dated [DATE] through [DATE] revealed greater than 75 staff screening entries with documented signs and symptoms of COVID-19 and greater than 5 incomplete staff screening entries. According to the logs, these staff were not asked to go home. The COVID-19 Employee Screening Log reflected on [DATE], Staff Member (SM) G answered yes to cough or sore throat and was not sent home. On [DATE], SM G answered yes to muscle pain or headache and was not sent home. On [DATE], SM G answered yes to muscle pain or headache and was not sent home. Review of SM G's time punch detail reflected they worked from 8:13 AM to 4:34 PM on [DATE]. SM G worked from 8:15 AM to 3:49 PM on [DATE]. On [DATE], SM G worked from 8:06 AM to 10:52 AM. The facility's timeline reflected that on [DATE], the facility received notification of SM G's positive COVID-19 test that was collected on [DATE]. The timeline reflected that SM G was asymptomatic and was sent home. During a phone interview that began on [DATE] at 11:00 AM, SM G reported if they answered yes to two or more screening questions, they were to contact a nurse. SM G reported they tested positive for COVID-19 on [DATE] and did not have any symptoms. SM G reported when they got sent home (on [DATE]), the only symptom they had was brain fog and their head felt out of it. SM G reported they developed a cough and shortness of breath a few days later but nothing while they were at work. Regarding answering yes to cough or sore throat on [DATE], SM G reported every morning they had a sinus thing, so they coughed in the morning. Regarding answering yes to muscle pain or headache on [DATE] and [DATE], SM G reported their legs were sore from being up and down, which they believed to be from painting. Review of the facility's timeline revealed on [DATE], the facility was notified of two additional staff who tested positive for COVID-19. The timeline revealed CNA N was tested on [DATE] and became symptomatic [DATE] while at work. There was no indication that CNA N was sent home due to becoming ill while at work. Further review of the Prevent COVID-19 Employee and Visitor Screening Logs revealed on [DATE], Certified Nursing Assistant (CNA) J signed in and answered yes to cough and sore throat. CNA J was not asked to go home. Review of the time clock punch details revealed CNA J worked on [DATE] from 2:52 PM until 11:03 PM. Review of the facility's timeline revealed CNA J was tested on [DATE] and symptoms began on [DATE]. The timeline did not reference the cough and sore throat that were documented on the Employee Screening Log on [DATE]. The facility received notice on [DATE] that CNA J tested positive for COVID-19. In a telephone interview on [DATE] at 1:19 PM, CNA J reported on [DATE], she also had a runny nose prior to showing up to work. CNA J reported while at work on [DATE], she also experienced a headache and asked the nurse for [MEDICATION NAME] at approximately 8:00 or 9:00 PM. The Prevent COVID-19 Employee and Visitor Screening Log revealed on [DATE], CNA K signed in and marked yes to headache and was asked to go home. On [DATE], CNA K signed in and marked yes to cough, but was not asked to go home. Review of the time clock punch details revealed CNA K worked on [DATE] from 6:57 AM until 9:54 PM. On [DATE], CNA K signed in and marked yes for shortness of breath/difficulty in breathing, muscle pain/body aches, headache, and sore throat. CNA K was asked to go home. Review of the facility's timeline revealed CNA K's symptoms began [DATE] and CNA K was tested outpatient for COVID-19 on [DATE]. The results were positive. In a telephone interview on [DATE] at 9:35 AM, CNA K stated about 10 days ago right before I tested positive, I wasn't feeling well that Saturday ([DATE]). CNA K reported she notified the nurse manager and explained that she had a really bad migraine, really, really bad headache, feeling overly tired. I didn't have a fever but felt my body temperature was warm. I felt really, really warm. CNA K reported she was sent home on [DATE]. CNA K reported she worked the next day, [DATE]. CNA K stated it was my weekend to work. I came in, still didn't feel 100 percent, had the headache. I worked Sunday. Monday is when I tested positive. When asked if she notified anyone on [DATE] that she was not feeling well, CNA K reported she again notified the nurse manager because she still had a headache and also had a cough that day .I wasn't really sure about the cough. I just noticed one was starting, but it wasn't that bad .I figured if I got sent home Saturday for symptoms, I thought I would have to stay home Sunday. CNA K reported the cough was new and the nurse manager told her the facility would wait for the COVID-19 test results and play Sunday ([DATE]) by ear. CNA K reported she worked 16 hours on [DATE]. CNA K reported on Monday, [DATE] she felt worse and that's when the facility sent her for a rapid COVID-19 test, which was positive. In a second telephone interview on [DATE] at 11:37 AM, CNA K reported on [DATE], she worked the 2 North unit, which was not a COVID-19 unit. Review of the Prevent COVID-19 Employee and Visitor Screening logs revealed on [DATE], CNA L signed in with a cough, chills and/or repeated shaking with chills, muscle pain/body aches, and sore throat. CNA L was not asked to go home. Review of the time clock punch details revealed CNA L worked on [DATE] from 2:50 PM until 11:09 PM. On [DATE], CNA L signed in with cough, chills and/or repeated shaking with chills, and muscle pain/body aches. Review of the time clock punch details revealed CNA L worked [DATE] from 6:51 AM until 9:56 AM. Review of the facility's timeline revealed CNA L's COVID-19 test that was performed on [DATE] was reported as positive on [DATE]. In a telephone interview on [DATE] at 10:21 AM, CNA L reported the thermometer at the employee screening station doesn't seem very accurate because every person has a 97.2 or 97.6 temperature. CNA L stated, I actually came in (on [DATE]) and it said I had a 97.2 temp. Then I checked it with the residents' thermometer, and it said 99.8 so it's a huge difference. CNA L reported on [DATE] she also had muscle soreness, headache, cough, sore throat, and fatigue .all the symptoms of COVID and worked an eight-hour shift. CNA L reported she talked to someone .a staff member on the floor and that person told her she was fine to work. CNA L reported she felt bad a couple days prior but was not scheduled to work until [DATE]. CNA L reported the next day ([DATE]) the facility notified her that she tested positive for COVID-19 during the routine staff testing that was performed twice per week. In a telephone interview on [DATE] at 11:39 AM, CNA L reported on [DATE], she worked the 1 West unit which was not a COVID-19 unit. Review of the Prevent COVID-19 Employee and Visitor Screening Logs revealed on [DATE], CNA M signed in with a cough and was not asked to go home. Review of the time clock punch details revealed CNA M worked [DATE] from 11:06 PM until 7:29 AM on [DATE] and worked on [DATE] from 11:02 PM until 7:17 AM on [DATE]. Review of the facility's timeline revealed CNA M was tested for COVID-19 on [DATE] and the results were reported as positive on [DATE]. In an interview on [DATE] at 8:48 AM, Assistant Director of Nursing (ADON) C reported she was the facility's Infection Preventionist. ADON C reported staff self-screen upon entering the building by having their temperature taken by the facial recognition scanner and then answering the questions for signs and symptoms of COVID-19. When asked what happened to the completed paper screening logs, ADON C reported they were placed in a binder. When asked how the logs were monitored, ADON C reported in October, the facility realized there were some holes in the logs and the facility began working on correcting that. ADON C reported staff education was performed, and the logs were reviewed daily to catch any holes, inconsistencies, or if any staff were answering yes to any sign/symptom question. ADON C reported staff were supposed to notify the on-call manager if they answered yes to any one sign or symptom of COVID-19. ADON C reported for a period of time, staff were supposed to notify the on-call manager if two or more signs/symptoms were present, but as of approximately two weeks ago, the facility changed the requirement to one sign/symptom. On [DATE] at 12:38 PM, ADON C reported she did not believe the facility educated staff when they changed the requirement from two symptoms to one symptom. ADON C reported CNA K called her on [DATE] and [DATE]. ADON C reported she sent CNA K home on [DATE] due to a headache and not feeling well. ADON C reported CNA K did not notify her of the cough on [DATE]. When asked about CNA L, ADON C reported CNA L worked the entire shift on [DATE] and a partial shift on [DATE]. ADON C reported she was not aware CNA L was experiencing signs/symptoms of COVID-19. ADON C reported she was the on-call manager on [DATE] and [DATE] and was not notified. According to the CDC's Preparing for COVID-19 in Nursing Homes, Evaluate and Manage Healthcare Personnel. - Implement sick leave policies that are non-punitive, flexible, and consistent with public health policies that support HCP to stay home when ill. - Create an inventory of all volunteers and personnel who provide care in the facility. Use that inventory to determine which personnel are non-essential and whose services can be delayed if such restrictions are necessary to prevent or control transmission. - As part of routine practice, ask HCP (including consultant personnel and ancillary staff such as environmental and dietary services) to regularly monitor themselves for fever and symptoms consistent with COVID-19. - Remind HCP to stay home when they are ill. - If HCP develop fever (T=100.0oF) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace. Have a plan for how to respond to HCP with COVID-19 who worked while ill (e.g., identifying and performing a risk assessment for exposed residents and co-workers). - HCP with suspected COVID-19 should be prioritized for testing. - Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. - Actively take their temperature* and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace . (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fprevent-spread-in-long-term-care-facilities.html) Immediate Jeopardy began on [DATE] and was identified on [DATE]. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on [DATE] due to the failure to ensure staff were comprehensively screened and not entering with signs and symptoms of COVID-19. The Immediate Jeopardy was removed on [DATE] when it was verified that the facility had the following in place: 1. Current residents were tested for COVID-19 on [DATE] and one resident with new onset of symptoms has been re-tested today ([DATE]). Current residents remain in Transmission Based Precautions with staff wearing PPE as appropriate. 2. A one-time audit was completed on [DATE] of screening for staff from ,[DATE] to present to identify reported symptoms that were consistent with COVID-19. Staff members documenting symptoms in the past 14 days were evaluated to determine if a negative COVID test has been received since symptoms were reported. This audit was completed by the Infection Preventionist and Regional Support RN. If symptoms were within the past 14 days and no negative test available since onset of symptoms staff were removed from schedule or evaluated by DON to determine if symptoms were consistent with COVID-19. 3. Re-education for all staff was initiated on [DATE] regarding completion of screening log and follow up required if symptoms are present. 1 or more of the following symptoms including Fever, Cough, New shortness of breath or difficulty breathing, Vomiting, Diarrhea, Chills/Shaking, Muscle Pain/Body Aches, Headache, Sore Throat, or New loss of Taste or Smell will be reported prior to the start of the shift and prior to entering the resident care areas to the on Call RN with number available at screening locations. Staff not receiving education by 7AM on [DATE] will receive education prior to next shift worked 4. Staffing shortages will be addressed per the Pandemic plan and may include use of Agency, Sister Facility Staff, Resident Aides, Feeding Assistants, or utilization of 8-hour CENA training course for non-certified aides. 5. DON and Executive Director reviewed the screening log which was determined as appropriate. DON and Executive Director reviewed Pandemic Plan, in particular areas related to Staff Screening and found it to be appropriate. Instructions for screening log completion were posted near each staff screening location within the facility on [DATE]. 6. System Change: DON/designee will review screening logs daily to include symptoms evaluation. Staff with symptoms relative to COVID-19 will be further screened by a member of the clinical team to determine if symptoms are consistent with COVID-19 and would require follow up testing and/or for staff member to be removed from schedule. Notations regarding discussion with staff member may be documented on the back of screening log or on a separate tracking log. Follow up needs will be referred o (sic) Infection Preventionist or designee. Upon survey exit on [DATE], it was determined the Immediate Jeopardy was removed on [DATE] and the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. DPS B) Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices during a COVID-19 outbreak for 9 (Resident #2, #3, #4, #5, #6, #7, #8, #9, #10) of 13 residents reviewed, resulting in the potential for further spread of COVID-19 to all 114 facility residents and staff. Findings include: Resident #10 (R10) Review of the medical record revealed R10 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed R10 had severely impaired cognitive skills for daily decision making. R10's care plans revealed potential for infection r/t (related to) exposure to covid-19 individuals. Droplet precautions initiated. The care plans revealed droplet precautions were initiated on [DATE]. On [DATE] at 8:33 AM the 1 south unit was observed to be on full transmission- based precautions for observation of COVID-19 status. R10 was walking down the hallway with a staff member. R10 was not wearing a mask and the staff member was not wearing a gown. At 8:51 AM, R10 was still ambulating in the hallway without a mask. The staff member was not wearing a gown and was walking with R10. An observation on [DATE] at 9:29 AM revealed Resident #2 (R2) was seated in her wheelchair in the hallway, wearing a cloth face mask that was not fully covering her nose and mouth. R2 wandered into Resident #3's (R3) room. R3 was not wearing a face mask. R2 and R3 were observed approximately three to four feet apart, talking to each other for a few minutes. R2 was redirected to her own room after she exited R3's room. On [DATE] at 9:36 AM, R2 wandered into Resident #9's (R9) room. A nurse approached R2 and told R2 which room number was hers. An observation on [DATE] at 12:45 PM revealed R2, Resident #8 (R8), and R9 sitting in the common area across from the nurse's station. R8 and R9 were spaced approximately two feet apart. R9 was wearing a mask. R2 was approximately four feet away from R9. R2 was not wearing a mask. R2 and R8 were both observed coughing into their hands multiple times. R2 stated I'm getting sick .I was eating my dinner and I felt my stomach turning. I was feeling sick then. Registered Nurse (RN) O was observed in the vicinity and did not encourage the three residents to separate nor encourage mask use. A few minutes later, RN O walked back down the hallway, asked R2 to don her mask, and moved R9 into the day room. At 12:50 PM, R8 was observed coughing into her hands again. R2 then asked RN O for something to blow her nose on. RN O gave R2 a tissue. RN O asked R8 to put a mask on while you're sitting out here coughing. RN O then assisted R8 with donning a face mask. At 12:54 PM, R2 and R8 were observed approximately two feet apart, facing each other. R8 had her mask below her nose and was coughing. In an interview on [DATE] at 12:55 PM, RN O reported R8's cough was chronic. Resident #2 (R2) Review of the medical record revealed R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R2 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review or R2's Progress Notes through [DATE] revealed no documented signs or symptoms of COVID-19. Review of the medical record, care plan, and physician's orders [REDACTED]. Review of R2's COVID-19 test performed on [DATE] revealed results were reported as positive on [DATE]. Resident #3 (R3) Review of the medical record revealed R3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R3 scored 11 out of 15 (moderate cognitive impairment) on the BIMS. Review of the medical record, care plan, and physician's orders [REDACTED]. Review of R3's COVID-19 tests revealed the test performed on [DATE] was reported as negative on [DATE]. The COVID-19 test performed on [DATE] was reported as positive on [DATE]. Resident #8 (R8) Review of the medical record revealed R8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R8 scored 3 out of 15 (severe cognitive impairment) on the BIMS. Review of R8's medical record and care plans revealed no documentation of a chronic cough. Review of R8's COVID-19 test performed on [DATE] revealed the results were reported as negative on [DATE]. The COVID-19 test performed on [DATE] was labeled as an invalid sample on [DATE]. Resident #9 (R9) Review of the medical record revealed R9 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R9 scored 3 out of 15 (severe cognitive impairment on the BIMS and required extensive assistance of one person for locomotion on the unit in his wheelchair. An observation on [DATE] at 10:25 AM revealed four blue bags of isolation gowns on the floor inside the entrance of the 1 North Unit. At 10:31 PM, a staff member asked LPN P to call laundry because the unit needed a bin for the soiled gowns. On [DATE] at 12:23 PM, the 1 North Unit was observed with a clear plastic bag of gowns on the floor. An observation on [DATE] at 12:26 PM revealed one staff member wearing goggles, mask, and a gown, inside of Resident #4's (R4) room. The staff member was not wearing gloves. From the hallway, a second staff member handed a meal tray to the staff member inside R4's room. While not wearing gloves, the staff member was observed touching R4's silverware to cut up food and touching the drink cups. The staff member then doffed her gown and sanitized her hands before entering Resident #5's (R5) room. The staff member sanitized her hands, donned a new gown, and took another tray from the staff member in the hallway. The staff member again was not wearing gloves and observed touching and moving R5's overbed table before placing the tray on the table. An observation on [DATE] at 12:32 PM revealed CNA R entered Resident #6 (R6) and Resident #7's (R7) room. CNA R sanitized her hands and donned a gown and gloves. CNA R then took a tray from the other staff member in the hallway and delivered the tray to R6. CNA R then removed her gloves and held the gloves wadded up in her hand while she obtained a meal tray for R7. CNA R then set R7's meal tray on R6's television stand/dresser, threw the wadded gloves away, sanitized her hands, and donned new gloves. CNA R then delivered the meal tray to R7. Resident #4 (R4) Review of the medical record revealed R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R4 scored 13 out of 15 (cognitively intact) on the BIMS. Review of the physician's orders [REDACTED]. Review of the facility's COVID-19 update, R4 was tested for COVID-19 on [DATE] with positive results reported [DATE]. Resident #5 (R5) Review of the medical record revealed R5 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R5 scored 7 out of 15 (severe cognitive impairment on the BIMS. Review of the physician's orders [REDACTED]. Per the facility's COVID-19 update, R5 was tested for COVID-19 on [DATE] with positive results reported [DATE]. Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R6 scored 8 out of 15 (moderate cognitive impairment on the BIMS. Review of the physician's orders [REDACTED]. Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R7 scored 13 out of 15 (cognitively intact) on the BIMS. Review of R7's physician's orders [REDACTED]. In an interview on [DATE] at 11:02, CNA Q reported she was not familiar with contact time for the disinfectant wipes used on shared resident care equipment. CNA Q reported she did not know how long the products needed to remain visibly wet. In an interview on [DATE] at 11:12 AM, CNA R reported the facility used bleach or purple (PDI sani cloth, purple top wipes) to shared resident care equipment. When asked about how the products were used and about contact time, CNA R stated let it sit for at least a minute to dry .I would say a minute for both to let it air dry. In an interview on [DATE] at 11:23 AM, CNA S reported she was not educated on contact time of the disinfectant products used for shared resident care equipment. CNA S stated I think it's a minute for both the bleach wipes and the purple top PDI sani wipes. In an interview on [DATE] at 1:38 PM, ADON C reported staff should change their gown and gloves in between residents during meal delivery service. When asked about contact time of the disinfectant wipes used in the facility, ADON C reported the bleach (orange top) wipes were one minute and the purple top wipes were four minutes. ADON C reported bagged soiled linen should be placed in the soiled utility room. ADON C reported staff should wear a gown when ambulating with R10 in the hallway since R10 was on transmission-based precautions. ADON C reported she was not aware that R2 and R8 had a cough and that neither resident had been identified of having any signs/symptoms of COVID-19. The surveyor informed ADON C that R2 was observed coughing and complained of her stomach turning over. ADON C reported these were new symptoms. During a phone interview on [DATE] at 12:26 PM, Certified Nurse Aide (CNA) E reported they used germicidal wipes on shared resident care equipment and mechanical lifts. CNA E reported they especially wiped the parts that the residents touched, as well as the screens they touched on the equipment. When queried about the contact time (the amount of time the surface or object needed to stay wet for disinfection), CNA E reported the just heard this, and it was four minutes. Regarding if the surface dried before the four minutes, CNA E reported staff should probably wait another couple of minutes before taking someone else's temperature or vital signs. When asked if they had to reapply the solution or just wait, CNA E replied they would just wait until the time was up. According to the label for Super Sani-Cloth Germicidal Disposable Wipes, the Environmental Protection Agency (EPA) number was ,[DATE]. The label reflected, .SPECIAL INSTRUCTIONS FOR CLEANING AND DECONTAMINATION AGAINST HIV-1, [MEDICAL CONDITION] VIRUS (HBV) AND [MEDICAL CONDITION] VIRUS (HCV) OF SURFACES/OBJECTS SOILED WITH BLOOD/BODY FLUIDS .Contact time: Use second germicidal wipe to thoroughly wet surface. Allow surface to remain wet two (2) minutes, let air dry . According to the label for Microdot Bleach Wipes, the EPA numbe (TRUNCATED)

This citation pertains to intake MI 0356. Based on observation, interview, and record review, the facility failed to ensure timely administration of significant medications for 1 (Resident #3) of 5 reviewed for neglect, resulting in immediate jeopardy when Resident #3 did not receive medications as ordered on [DATE] at 7:00 PM, 8:00 PM, and 9:00 PM, resulting in Resident #3 being found not breathing, without a pulse, unresponsive, and was hospitalized with [DIAGNOSES REDACTED]. This deficient practice places 143 residents at risk for untimely medication administration and potential for serious medical decline. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 was admitted to the facility on [DATE], with a [MEDICAL CONDITION] (opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube; Breathing is done through the [MEDICAL CONDITION] rather than through the nose and mouth) and with [DIAGNOSES REDACTED]. The MDS revealed Resident #3 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and required extensive assistance with activities of daily living (ADLs). Review of Resident #3's Short Term Antibiotic care plan dated [DATE], revealed administer my antibiotic as ordered by my doctor, monitor my lung sounds and respiratory status, monitor my temperature and vital signs as ordered every shift while I'm on my antibiotic and for 3 days after I've finished treatment. The medical record revealed Resident #3 was receiving antibiotics. Review of the Diabetes care plan dated [DATE], revealed administer my scheduled long-active insulin as ordered. Review of the Respiratory care plan dated [DATE], revealed administer my respiratory treatments as ordered, monitor me for any s/sx (signs/symptoms) respiratory distress/infection and report to MD PRN (physician as needed); respiration, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color. Resident #3 had a history of [REDACTED]. -Review of Resident #3's Admission assessment dated [DATE] revealed he had an occasional cough, yellow/green sputum, and abnormal lung sounds (rales, rhonchi, wheezing, diminished, and absent on both sides). -Review of the Change In Condition dated [DATE] at 2:05 AM, revealed Unable to place inner cannula [MEDICAL CONDITION]. Hardened secretions at insertion site. -Review of the Nurse's Note dated [DATE] at 3:15 AM, revealed Resident transferred via ambulance to (name of hospital) for eval and treatment of [REDACTED]. -Review of the Nurse's Note dated [DATE] at 11:24 AM, revealed Resident had difficulty with breathing/choking on clear thick secretions. Residents lips turned light shade of blue. Resident suctioned at trach, without difficulty, o2 sats (oxygen saturation, normal is ,[DATE] percent) checked low 80's, increased O2 to 8 liters, gave breathing treatment, respirations very shallow, 8 per minute. Suctioned x3, large amount of clear sections returned . -Review of the Physician's Progress Note dated [DATE], revealed the plan was to continue suctioning, oxygen, nebulizer treatments, and monitoring. Review of Resident #3's vitals, revealed no documentation of respirations, pulse, or blood pressure on [DATE] or [DATE]. Review of the Nurse Note dated [DATE] at 4:39 AM, revealed Throughout evening shift resident calling out being transferred from bed chair to bed helped for about 2 hours, he then requested to be transferred back to chair which was done. He continued to call out which is WNL (within normal limits) for resident at times. Tube feed bottle changed around 0120 (1:20 AM) r/t (related to) prior bottle empty. Interactions at baseline. Around 0141 (1:41 AM) resident stopped calling out, this RN (Registered Nurse) entered his room to assess him and blood sugar per orders. He was slumped over in his wheelchair and his skin tone pale, attempted to obtain biox (blood oxygenation) reading using his personal machine which was at bedside, no reading. This RN observed his breathing cease at 0143 (1:43 AM). No palpable pulse, no cardiac or lung sounds auscultated (heard). Had CNA (Certified Nursing Assistant) call nurse stat. This RN obtained crash cart. CNAs transferred resident to bed backboard was in place. CPR (Cardiopulmonary Resuscitation) initiated at 0146 (1:46 AM). Another staff member called 911. Rescue breathing [MEDICAL CONDITION] (automated external defibrillator) applied no shocks advised, BCLS (Basic Cardiac Life Support) continued. EMS (Emergency Medical Services) arrived at 0200 (2:00 AM), pulse returned at 0203 (2:03 AM), spontaneous breathing returned at 0210. Transferred to (name of hospital) . Resident #3's blood sugar was documented at 1:40 AM as 458 (mg/dl, greater than 300 indicates diabetes out of control, greater than 400 indicates a dangerous situation). Review of Resident #3's Medication Administration Record [REDACTED]. [MEDICATION NAME] (long acting insulin) 28 units was not administered at 8:00 PM. At 9:00 PM, the following medications were not administered: blood sugar check with sliding scale [MEDICATION NAME] (short acting insulin), [MEDICATION NAME] (breathing treatment), and [MEDICATION NAME] suspension. At 12:00 AM on [DATE], Resident #3's PEG (Percutaneous Endoscopic Gastrostomy-a tube passed into a patient's stomach through the abdominal wall) tube was not flushed with 350 milliliters of water as ordered. Review of the Treatment Administration Record (TAR), revealed the following treatments were not completed: evening and night [MEDICAL CONDITION] care, night change of inner cannula, and night oxygen saturation. Each medication and treatment was marked as TO indicating Resident #3 was transferred out (to the hospital). Resident #3 was transferred to the hospital on [DATE] at 2:20 AM. According to https://www.accessdata.fda.gov/drugsatfda_docs/label/,[DATE]s037lbl.pdf, [MEDICATION NAME]® is a combination of two medicines called [MEDICATION NAME][MEDICATION NAME]. [MEDICATION NAME]® contains [MEDICATION NAME] sulfate, which is a beta-adrenergic agonist, and [MEDICATION NAME], which is an [MEDICATION NAME]. These two medicines work together to help open the airways in your lungs. [MEDICATION NAME]® is used to help treat airway narrowing ([MEDICATION NAME]) that happens with [MEDICAL CONDITIONS] in adult patients who need to use more than one [MEDICATION NAME][MEDICATION NAME] medicine. According to https://www.accessdata.fda.gov/drugsatfda_docs/label/,[DATE]lbl.pdf, Patients should take [MEDICATION NAME] at regular intervals once or twice a day as directed, since its effectiveness depends on regular use. The patient should not alter the prescribed dosage unless advised to do so by the physician. According to https://www.accessdata.fda.gov/drugsatfda_docs/label/,[DATE]s037lbl.pdf, Patients who require twice-daily dosing (of [MEDICATION NAME]) can administer the evening dose with the evening meal, at bedtime, or 12 hours after the morning dose .Glucose monitoring is essential for all patients receiving insulin therapy. Review of Resident #3's MAR, revealed he was ordered to receive [MEDICATION NAME] twice daily and the last dose of [MEDICATION NAME] was administered at 8:00 AM on [DATE]. In a telephone interview on [DATE] at 11:38 AM, Registered Nurse (RN) D reported on [DATE], her shift began at 6:30 PM. RN D reported Resident #3 did not receive his bed time medications as ordered and stated I imagine I was just running behind. In a telephone interview on [DATE] at 10:49 AM, when asked if she realized Resident #3's medications were due at 7:00 PM, 8:00 PM, and 9:00 PM, RN D stated probably not. RN D reported she usually started at room [ROOM NUMBER] and worked her way to the end of the hall. Resident #3 was in a room at the end of the hall. When asked if the electronic medical record notified staff of late medications, RN D stated In a way yes, it will let you know meds are due during a certain time. When you have 20 residents due at the same time, it's hard to differentiate which is which .It doesn't send a certain alert, but the meds appear red (indicating late medications). RN D was unable to explain why Resident #3's physician ordered medications were not administered. RN D also reported any vital signs would be documented in the electronic medical record. On [DATE] at approximately 2:30 PM, video surveillance was observed with Nursing Home Administrator (NHA) A. On [DATE] at approximately 12:30 AM, RN D was observed with her medication cart parked near the nurses' station. She appeared to be stocking the cart with medications delivered from pharmacy. RN D's computer screen had red boxes (indicating medications were late). NHA A agreed the screen was red and that indicated late medications. NHA A reported she watched surveillance for RN D's entire shift and there was nothing out of the ordinary that would have explained why Resident #3's medications were not administered. Review of RN D's personnel file, revealed a history of medication errors. RN D received One To One In-Services on [DATE] for two missed bed time medications, [DATE] for a medication administered at the incorrect time, an Employee Disciplinary Warning on [DATE] for two medication errors (incorrect dose and another medication given without obtaining labs as ordered by the physician), and a One To One In-Service on [DATE] for administering two doses of a medication when it should have been discontinued as ordered. Review of the EMS (Emergency Medical Services) Patient Care Report dated [DATE], revealed We were dispatch (sic) to (address of facility) for a [MEDICAL CONDITION]. On our arrival nursing staff was doing CPR on a 74 YM (year old male) that was in [MEDICAL CONDITION]. Pt (Patient) nurse said that pt was yelling most of the night and they went to check on him and found him unresponsive in his wheel chair. They had moved pt to his bed started CPR at 0145 with an AED. On our arrival pt was place (sic) on our cardiac monitor and pulse check was dune (sic) at 0200 pt had a pulse at rate of 98 (beats per minute). Rescue breathing was continued through out transport at a rate of 20 bpm (breaths per minute). Resident #3's blood sugar was 475. Review of the hospital History and Physical dated [DATE], revealed He (Resident #3) was brought to (name of hospital), continues to be unresponsive. His [MEDICAL CONDITION] was found to be completely occluded; ABG c/w (consistent with) respiratory acidosis (happens when lungs cannot move enough carbon [MEDICATION NAME]) with hypoxemia (low oxygen in the blood)-this was suctioned with improvement in oxygenation to low 90's while on 10 lpm (liters per minute) via trach. Pt continues to be obtunded with myoclonic jerks (involuntary muscle jerks) .Pt requires ICU admission . The hospital Progress Note dated [DATE], revealed Patient had respiratory arrest had likely leading to PEA (pulseless electrical activity) arrest, now status [REDACTED]. Now patient transitioned to comfort measures only. Resident #3 died on [DATE]. In an interview on [DATE] at 2:02 PM, NHA A and Director of Nursing (DON) B reported they first became aware on [DATE] that Resident #3 did not receive his medications on [DATE]. Review of the facility's Medication Administration policy dated ,[DATE], revealed Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center . NHA A was presented with Immediate Jeopardy Notification on [DATE] at 4:38 PM, due to the facility's failure to ensure timely administration of significant medications for Resident #3 who did not receive medications and was not properly assessed as ordered on [DATE] at 7:00 PM, 8:00 PM, and 9:00 PM, resulting in Resident #3 being found not breathing, without a pulse, unresponsive, and hospitalized with [DIAGNOSES REDACTED]. A corrective action plan was requested from the facility to remove the immediate jeopardy. Immediate Jeopardy was removed on [DATE] when the facility had the following in place: 1) A one-time audit was completed on [DATE] by the Assistant Director of Nursing (ADON) of all resident's currently residing at the facility to ensure that residents were receiving medications as prescribed. Medications were reviewed from [DATE] to current to ensure they were being given as prescribed by the physician. All medications charted as not given had supportive documentation present in the medical records. 2) Licensed Nurses were re-educated on the medication administration including timely administration of significant medications. This was initiated on [DATE] with Licensed Nurses who were working 6:30pm to 7am by the Nurse Managers. Staff will be educated by the Nurse Managers continuing on [DATE] to ensure that staff are re-educated on the administration of medication especially significant medications. 3) The facility policy for Medication Administration was reviewed by the Director of Nursing and the Administrator on [DATE] and no changes were needed. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

This citation pertains to intake MI 0356. Based on observation, interview, and record review, the facility failed to ensure proper respiratory assessment, monitoring, and treatment for one (Resident #3) of one reviewed for respiratory treatment, resulting in immediate jeopardy when Resident #3 was found not breathing, without a pulse, unresponsive, and was hospitalized with [DIAGNOSES REDACTED]. This deficient practice places respiratory care residents at risk for improper assessment, monitoring, and treatment. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 was admitted to the facility on [DATE], with a [MEDICAL CONDITION] (opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube; Breathing is done through the [MEDICAL CONDITION] rather than through the nose and mouth) and with [DIAGNOSES REDACTED]. The MDS revealed Resident #3 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and required extensive assistance with activities of daily living (ADLs). Review of Resident #3's Short Term Antibiotic care plan dated [DATE], revealed administer my antibiotic as ordered by my doctor, monitor my lung sounds and respiratory status, monitor my temperature and vital signs as ordered every shift while I'm on my antibiotic and for 3 days after I've finished treatment. The medical record revealed Resident #3 was receiving antibiotics. Review of the Diabetes care plan dated [DATE], revealed administer my scheduled long-active insulin as ordered. Review of the Respiratory care plan dated [DATE], revealed administer my respiratory treatments as ordered, monitor me for any s/sx (signs/symptoms) respiratory distress/infection and report to MD PRN (physician as needed); respiration, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color. Review of Resident #3's Admission assessment dated [DATE] revealed he had an occasional cough, yellow/green sputum, and abnormal lung sounds (rales, rhonchi, wheezing, diminished, and absent on both sides). Review of the Change In Condition dated [DATE] at 2:05 AM, revealed Unable to place inner cannula [MEDICAL CONDITION]. Hardened secretions at insertion site. Review of the Nurse's Note dated [DATE] at 3:15 AM, revealed Resident transferred via ambulance to (name of hospital) for eval and treatment of inability to place inner cannula into trach. Review of the Nurse's Note dated [DATE] at 11:24 AM, revealed Resident had difficulty with breathing/choking on clear thick secretions. Residents lips turned light shade of blue. Resident suctioned at trach, without difficulty, o2 sats (oxygen saturation) checked low 80's (normal is ,[DATE]%) increased O2 to 8 liters, gave breathing treatment, respirations very shallow, 8 per minute. Suctioned x3, large amount of clear sections returned . Review of the Physician's Progress Note dated [DATE], revealed the plan was to continue suctioning, oxygen, nebulizer treatments, and monitoring. Review of Resident #3's vitals, revealed no documentation of respirations, pulse, or blood pressure on [DATE] or [DATE]. Review of Resident #3's medical record, revealed no further full nursing respiratory assessments documented after the admission assessment done on [DATE]. The Progress Notes revealed the following: [DATE] 6:24 PM biox (oxygen saturation) 93, low of 94 exceeded, no distress noted [DATE] 3:30 AM biox 93, low of 94 exceeded, no signs or symptoms of distress, difficulty in breathing, shortness of breath at this time. Will continue to monitor [DATE] 4:01 AM no s/sx of respiratory distress at this time [DATE] 11:40 AM physician's note: RESP: Clear to Auscultation. Normal effort. No accessory muscle use. No respiratory distress. [DATE] 8:23 PM no complaints of shortness of breath or difficulty in breathing, breathing treatment [MEDICAL CONDITION] , no s/sx distress noted [DATE] 4:36 AM no s/sx respiratory distress at this time [DATE] 9:44 AM physician's note: no c/o (complaints of) SOB/DIB (shortness of breath/difficulty in breathing), breathing tx (treatment) [MEDICAL CONDITION], no s/sx respiratory distress at this time [DATE] 19:50 no c/o SOB/DIB, breathing ts tolerated, no s/sx distress [DATE] 4:22 AM no s/sx of respiratory distress at this time [DATE] 1:37 PM [MEDICATION NAME] (medicated breathing treatment) PRN (as needed) given-no respiratory assessment documented [DATE] 12:41 AM biox 91%, low of 94 exceeded. notes: res has no s/sx of distress, difficulty in breathing or shortness of breath, will continue to monitor [DATE] 2:57 AM suctioned-no respiratory assessment documented, no description of secretions noted [DATE] 4:09 AM no s/sx of respiratory distress at this time .trach suctioned once this shift, clear thick sputum removed [DATE] 4:18 AM suctioned times one this shift-no respiratory assessment [DATE] 12:06 AM [MEDICATION NAME] dose missed, given noon dose. There was no explanation why the morning dose was missed. [DATE] 5:54 PM suctioned x 1 for increased secretions was effective, no s/sx distress [DATE] 3:40 AM biox 92%, low of 94 exceeded, notes: res has no s/sx of distress at this time. will continue to monitor [DATE] 4:54 AM suctioned-no respiratory assessment documented [DATE] 11:37 AM suctioned-no respiratory assessment documented In an interview on [DATE] at 11:47 AM, Registered Nurse (RN) G reported she suctioned Resident #3 on [DATE] at 11:37 AM. RN G reported Resident #3 had been in therapy and requested to be suctioned so therapy brought him back to his room. In a telephone interview on [DATE] at 11:11 AM, Certified Nursing Assistant (CNA) F reported on the night of [DATE], Resident #3 was not listed to have his vital signs checked, therefore Resident #3's vital signs were not checked. In a telephone interview on [DATE] at 11:52 AM, Licensed Practical Nurse (LPN) E reported she cared for Resident #3 during night shift on [DATE] into the morning of [DATE]. LPN E reported Resident #3 required suctioning at least twice and changed cannula once because he would have thick secretions. LPN E reported all vital signs would be documented in the electronic medical record. In a telephone interview on [DATE] at 1:00 PM, LPN H reported Resident #3's vital signs were checked every other day. LPN H reported there were no full respiratory assessments documented because the facility charted by exception. LPN H reported Resident #3 required [MEDICAL CONDITION] suctioning whenever he requested. LPN H stated if we kept up with the treatments, there was never a problem with him clogging up. LPN H reported Resident #3 often coughed up sputum into his oxygen mask, which had to be cleaned off. In an interview on [DATE] at 3:12 PM, CNA BB reported Resident #3 would get secretions built up in his trach. In an interview on [DATE] at 9:12 AM, Assistant Director of Nursing (ADON) CC reported vital signs were only documented in the electronic medical record and respiratory assessments should be included in the progress notes. Review of the Nurse Note dated [DATE] at 4:39 AM, revealed Throughout evening shift resident calling out being transferred from bed chair to bed helped for about 2 hours, he then requested to be transferred back to chair which was done. He continued to call out which is WNL (within normal limits) for resident at times. Tube feed bottle changed around 0120 (1:20 AM) r/t (related to) prior bottle empty. Interactions at baseline. Around 0141 (1:41 AM) resident stopped calling out, this RN entered his room to assess him and blood sugar per orders. He was slumped over in his wheelchair and his skin tone pale, attempted to obtain biox reading using his personal machine which was at bedside, no reading. This RN observed his breathing cease at 0143 (1:43 AM). No palpable pulse, no cardiac or lung sounds auscultated (heard). Had CNA (Certified Nursing Assistant) call nurse stat. This RN obtained crash cart. CNAs transferred resident to bed backboard was in place. CPR (Cardiopulmonary Resuscitation) initiated at 0146 (1:46 AM). Another staff member called 911. Rescue breathing [MEDICAL CONDITION] (automated external defibrillator) applied no shocks advised, BCLS (Basic Cardiac Life Support) continued. EMS (Emergency Medical Services) arrived at 0200 (2:00 AM), pulse returned at 0203 (2:03 AM), spontaneous breathing returned at 0210. Transferred to (name of hospital) . Resident #3's blood sugar was documented at 1:40 AM as 458 (mg/dl, greater than 300 indicates diabetes out of control, greater than 400 indicates a dangerous situation). Review of Resident #3's Medication Administration Record [REDACTED]. [MEDICATION NAME] (long acting insulin) 28 units was not administered at 8:00 PM. At 9:00 PM, the following medications were not administered: blood sugar check with sliding scale [MEDICATION NAME] (short acting insulin), [MEDICATION NAME] (breathing treatment), and [MEDICATION NAME] suspension. At 12:00 AM on [DATE], Resident #3's PEG tube (Percutaneous Endoscopic Gastrostomy-a tube passed into a patient's stomach through the abdominal wall) was not flushed with 350 milliliters of water as ordered. Review of the Treatment Administration Record (TAR), revealed the following treatments were not completed: evening and night [MEDICAL CONDITION] care, night change of inner cannula, and night oxygen saturation. Each medication and treatment was marked as TO indicating Resident #3 was transferred out (to the hospital). Resident #3 transferred to the hospital on [DATE] at 2:20 AM. According to https://www.accessdata.fda.gov/drugsatfda_docs/label/,[DATE]s037lbl.pdf, [MEDICATION NAME]® is a combination of two medicines called [MEDICATION NAME][MEDICATION NAME]. [MEDICATION NAME]® contains [MEDICATION NAME] sulfate, which is a beta-adrenergic agonist, and [MEDICATION NAME], which is an [MEDICATION NAME]. These two medicines work together to help open the airways in your lungs. [MEDICATION NAME]® is used to help treat airway narrowing ([MEDICATION NAME]) that happens with [MEDICAL CONDITIONS] in adult patients who need to use more than one [MEDICATION NAME][MEDICATION NAME] medicine. According to https://www.accessdata.fda.gov/drugsatfda_docs/label/,[DATE]lbl.pdf, Patients should take [MEDICATION NAME] at regular intervals once or twice a day as directed, since its effectiveness depends on regular use. The patient should not alter the prescribed dosage unless advised to do so by the physician. In a telephone interview on [DATE] at 11:38 AM, Registered Nurse (RN) D reported on [DATE], her shift began at 6:30 PM. RN D reported Resident #3 did not receive his bed time medications as ordered and stated I imagine I was just running behind. In a telephone interview on [DATE] at 10:49 AM, when asked if she realized Resident #3's medications were due at 7:00 PM, 8:00 PM, and 9:00 PM, RN D stated probably not. RN D reported she usually started at room [ROOM NUMBER] and worked her way to the end of the hall. Resident #3 was in a room at the end of the hall. When asked if the electronic medical record notified staff of late medications, RN D stated In a way yes, it will let you know meds are due during a certain time. When you have 20 residents due at the same time, it's hard to differentiate which is which .It doesn't send a certain alert, but the meds appear red (indicating late medications). RN D was unable to explain why Resident #3's medications were not administered. RN D also reported any vital signs would be documented in the electronic medical record. On [DATE] at approximately 2:30 PM, video surveillance was observed with Nursing Home Administrator (NHA) A). On [DATE] at approximately 12:30 AM, RN D was observed with her medication cart parked near the nurses' station. She appeared to be stocking the cart with medications delivered from pharmacy. RN D's computer screen had red boxes (indicating medications were late). NHA A agreed the screen was red and that indicated late medications. NHA A reported she watched surveillance for RN D's entire shift and there was nothing out of the ordinary that would have explained why Resident #3's medications were not administered. Review of RN D's personnel file, revealed a history of medication errors. RN D received One To One In-Services on [DATE] for two missed bed time medications, [DATE] for a medication administered at the incorrect time, an Employee Disciplinary Warning on [DATE] for two medication errors (incorrect dose and another medication given without obtaining labs as ordered by the physician), and a One To One In-Service on [DATE] for administering two doses of a medication when it should have been discontinued as ordered. Review of the EMS Patient Care Report dated [DATE], revealed We were dispatch (sic) to (address of facility) for a [MEDICAL CONDITION]. On our arrival nursing staff was doing CPR on a 74 YM (year old male) that was in [MEDICAL CONDITION]. Pt (patient) nurse said that pt was yelling most of the night and they went to check on him and found him unresponsive in his wheel chair. They had moved pt to his bed started CPR at 0145 with an AED. On our arrival pt was place (sic) on our cardiac monitor and pulse check was dune (sic) at 0200 pt had a pulse at rate of 98. Rescue breathing was continued through out transport at a rate of 20 bpm (beats per minute). Resident #3's blood sugar was 475. In a telephone interview on [DATE] at 2:51 PM, Fire Department Chief/Paramedic R reported EMS would not have a way of knowing if a [MEDICAL CONDITION] was occluded as their standard protocol was not to remove an inner cannula and it was not noted on the EMS run report. In a telephone interview on [DATE] at 3:57 PM, Paramedic S reported EMS would never remove the inner cannula of a [MEDICAL CONDITION]. Paramedic S reported the facility did not say anything about Resident #3's [MEDICAL CONDITION] possibly being plugged and reported when Resident #3 arrived to the Emergency Department, hospital staff called for suction. Review of the hospital History and Physical dated [DATE], revealed He (Resident #3) was brought to (name of hospital), continues to be unresponsive. His [MEDICAL CONDITION] was found to be completely occluded; ABG c/w (consistent with) respiratory acidosis (happens when lungs cannot move enough carbon [MEDICATION NAME]) with hypoxemia (low oxygen in the blood)--this was suctioned with improvement in oxygenation to low 90's while on 10 lpm (liters per minute) via trach. Pt continues to be obtunded with myoclonic jerks .Pt requires ICU admission . The hospital Progress Note dated [DATE], revealed Patient had respiratory arrest had likely leading to PEA (pulseless electrical activity) arrest, now status [REDACTED]. Now patient transitioned to comfort measures only. Resident #3 died on [DATE]. In an interview on [DATE] at 2:02 PM, NHA A and Director of Nursing (DON) B reported they first became aware on [DATE] that Resident #3 did not receive his medications on [DATE]. Review of the facility's Medication Administration policy dated ,[DATE], revealed Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center . Review of Resident #3's MAR indicated [REDACTED]. Review of the facility's Nebulizer policy dated [DATE], revealed Obtain and document post treatment data (pulse, breath sounds and any side effects) in the electronic medical record. This was not done consistently. Review of the facility's Suctioning, Endotracheal and [MEDICAL CONDITION] policy dated [DATE], revealed Document reason for suctioning, time of suctioning, amount, appearance and consistency of secretions and any reaction of resident to procedure. This was not done consistently. NHA A was presented with Immediate Jeopardy Notification on [DATE] at 4:38 PM due to the facility's failure to ensure proper respiratory assessment, monitoring, and treatment for Resident #3, resulting in Resident #3 being found not breathing, without a pulse, unresponsive, and hospitalized with [DIAGNOSES REDACTED]. A corrective action plan was requested from the facility to remove the immediate jeopardy. Immediate Jeopardy was removed on [DATE] when the facility had the following in place: 1) A one-time audit was completed on [DATE] of all resident's currently residing at the facility to ensure that residents who have tracheostomies were receiving care as prescribed. There are no patients currently residing at the facility that have a [MEDICAL CONDITION]. 2) A respiratory assessment including vitals was completed on [DATE] of all residents currently residing at the facility. These assessments were completed by the Nurse Managers. 3) A one-time audit was completed on [DATE] of all current residents to ensure that residents who are on oxygen, nebulizer treatments, [MEDICAL CONDITION] and [MEDICAL CONDITION] are receiving orders as prescribed by the physician. Current residents residing in the facility on [DATE] had care plans reviewed to ensure they were meeting the needs of the residents regarding proper assessment, monitoring and treatment for patients with Oxygen, nebulizers, [MEDICAL CONDITION] and [MEDICAL CONDITION]. 4) Licensed Nurses were re-educated on the proper assessment and treatment of residents with a [MEDICAL CONDITION], or receiving oxygen, nebulizers, and utilizing [MEDICAL CONDITION] and [MEDICAL CONDITION]. Education was initiated on [DATE] with Licensed Nurses who were working 6:30pm to 7am. Staff will be educated by the Nurse Managers continuing on [DATE]. 5) The facility policies for Respiratory Care: NRS-230-B, NRRS-224, NRS-200-C, NRS-210-A, NRS-123A, NRS-143, NRS-194-B, were reviewed on [DATE] by the Director of Nursing and Administrator. No changes were identified. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

This citation pertains to Intake MI 102. Based on observation, interview, and record review, the facility failed to prevent abuse and/or mistreatment for 7 of 11 residents reviewed for abuse (R #4, R #9, R #15, R #16, R #17, R #18, R#19), from a total of 24 sampled residents, resulting in these residents not being free from abuse and/or mistreatment, resulting in psychological harm for Resident #4 (severe cognitive impairment) who was deeply disturbed, emotional pain and/or emotional discomfort for (based on the reasonable person standard) for R #9, R #16, R #17, and R #18 (all had severe cognitive impairment), and emotional discomfort and mistreatment for [REDACTED].#15 and R #19. Findings include: According to an Incident Summary, dated 10/31/17, but not timed, (CNA E) was training by observing (CNA's C and D). (CNA E) reported .(CNA C and D) were assisting (R #4), in the bathroom .(CNA C) was questioning (Res #4) by placing her face close to him and saying, 'are you racist (R #4)?' she questioned him multiple times and then said, 'you don't like me because I'm a nigger. (R #4) had asked for his wife .and he was told by both (CNA C and D) that (his wife) was having sex with (a man named Bob) .(CNA C) asked (R#4) if he cheated on his wife .of course you did because you are stupid .(CNA D) said, 'I am your daughter .(CNA C) said, 'do you want to do something dirty with (CNA D)?' .(CNA E) reported that (CNA C) took blankets and grabbed them from the bottom of the bed and folded them up and covered her (a different resident: R #9's) face . According to the same Incident Summary, on 10/25/17 at approximately 5:00 pm, (CNA E) contacted the administrator by phone and shared that she was concerned and uncomfortable with the interactions that she observed between (CNA C and D) and the residents. She described the behavior as sexually inappropriate conversations between (CNA C and D) in the presence of residents . Review of the Facility Investigation Summary, entered into MI-ACTS 10/31/17, but not timed, revealed Administrator A did not document the time of her interviews with CNA E on 10/26/17, or CNA C and CNA D (each interviewed on both 10/26/17 and 10/27/17). The Summary revealed CNA C and CNA D did not admit to all of the alleged abuse, but Administrator A documented CNA C admitted to saying to her, 'I asked R #4 if he wanted (CNA D) to help because she sucks. I asked (R #4) if he wanted this sucker to help .' and Administrator A documented CNA D admitted , 'Me and (CNA C) helped (R #4). Me and her (CNA C) were talking about the incident that has been going on in my personal life .I told her about Saturday evening my ex (husband) tried to run me off the road like a fu**ing a**hole, I was explaining to her that the guy I was messing with was way better than my ex now. I was cussing but it wasn't toward the resident . In a telephone interview, on 10/31/17 at 4:20 PM, CNA E reported she was in training with 2 other experienced CNAs (C and D) on the 1 North Hallway on midnight shift from 11:00 PM on 10/24/17 - 7:00 AM on 10/15/17 when she (CNA E) witnessed CNA C and D abusing residents from the beginning of the shift at 11:00 PM on 10/24/17, and it not stopping until around 6:45 AM on 10/25/17. CNA E said CNAs C and D were calling each other derogatory names such as slu* and [***] in front of residents, talking about sexual acts they had performed on men, and making fun of residents in their presence. CNA E reported at times, throughout the night CNA C and D would close the door and not allow her into some of the residents' room with them, and the first time this happened, around 11:00 PM, a female resident (who CNA E later identified as R/Resident # 16) screamed at them to stop .I was in the hallway. CNA E said she was present, (time unknown) during a bed check on R #9 and R #17 (roommates), when CNA C folded a blanket and placed it over R #9's face, and CNA C and D were picking on (R #17) for crying. CNA E said, They (CNA C and D) were talking dirty in (R #18's) room, and asked him if he wanted a blow job. CNA E reported she was present when CNA C and D were giving R #4 his shower, and witnessed them aggressively and intentionally emotionally abusing him (see details below). CNA E reported, at the time, she did not know the residents well enough to know most of their names. CNA E said, I regret not telling them (CNA C and D) to stop. CNA E said she knew she was supposed to report immediately but she thought she could not trust the nurse on duty (LPN/Licensed Practical Nurse F) because, during the middle of the shift, she witnessed CNA D showing LPN F and CNA C a video on her phone of her (CNA D's) boyfriend, and assumed they were all friends, because LPN F did not correct her. Also CNA C said she was afraid because CNA C threatened her during R #4's shower, telling CNA E not to say anything and made a throat slicing motion. CNA C reported she did not know where to locate the Administrator's phone number, but got it the next day from a co-worker. CNA C said she called Administrator A twice on 10/25/17, after she got home from work, and was unable to reach her the first time she called, early in the afternoon, but made contact with her later that day and told her everything that happened during the midnight shift. During an interview, on 11/01/17 at 6:05 AM, Nurse Aide E showed this Surveyor the rooms where the alleged abuse occurred and gave more details. CNA E reported she was in the hallway while CNA C and D were in the room of R #16 around 11:00 PM (on 10/24/17) when she heard R #16 scream, 'If you guys don't stop right now, you can get out of my room. During the same interview CNA E reported, They (CNAs C, D and E) walked into (R #9 and R #17's room). (R #9) told them she didn't want to be changed. (CNA C) looked disgusted, and folded the covers, and threw the blankets over (R #9's) head. (R #9) yelled 'Stop it'. I went to her (R #9), comforted her, and took over changing her. They (CNA C and D) were picking on (R #17), which brought a tear to (R #17's) eye. (R #17's) has fragile skin and her arm was bleeding; she was saying 'Oh God it hurts'. (CNA C) said, God's not going to help you, and (CNA D) chimed in. (CNA C) told (R #9) that the devil was there, that the devil was (CNA D). (R #17) said she was going to walk away, and they told her 'Let's see you walk.' They (CNA C and D) were laughing at her (Res #17). They told her to stop crying, and (CNA C told R #17), 'It's not a good look for you.' During the same interview, CNA E reported, (R #4) was last one of that night. CNA E said, In his face, over and over again, inches from his ear (CNA C) yelled at him, asking if he was a racist. He would think about it. CNA C asked him if he thought she was a nigger, and asked him if he cheated on his wife, and said 'Of course you do. All men are stupid. Did you repent? Did you ask for forgiveness?' Then (CNA C) told (R #4) that (CNA D) was his daughter. They told (R #4) his wife was cheating on him. CNA D told him she cheated on her husband, and that she had just had (describing a sexual act) with a man in the parking lot on her lunch break that night. During the same interview, CNA E reported during the night, CNA C and D were in R #18's room when CNA C told R #18 CNA D liked to do dirty things with guys, and asked him if he wanted (then described a sexual act). CNA E said, (R #18) didn't say anything, but he seemed to understand. Review of Intake information revealed Administrator A did not report alleged abuse until 10/26/17 at 5:43 PM (greater than 24 hours after CNA E reported it to her). During an interview, on 11/01/17 at 7:20 AM, Administrator A stated she suspended CNA C and D immediately after her phone discussion with CNA E on 10/25/17 at approximately 5:00 PM, and stated she did not report the alleged abuse regarding R #4 and R #9 until 10/26/17, until after she spoke with CNA E in person. Administrator A stated she did not report to the State agency the incidents regarding R #17 or R #18 because, They were not the same level of concern .They were not abuse. Administrator A stated CNA E reported to her that CNA C and D were taunting R #17 and said, (R #17) was crying, asking for god, and they told her the devil was right there, that (CNA D) was the devil. Administrator A reported The girls (CNA C and D) were calling each other a slu* in front of R #18. It's just inappropriate behavior. Administrator A reported that the facility's discovered additional allegations of mistreatment from staff from R #15, #16 and R #19 during a resident audits conducted on 10/26/17. In addition to not having reported allegations of potential staff abuse from R #17 or R #18, Administrator A had not reported the allegations related to R #15, R #16, or R #19 to the State agency at that time either. In a telephone interview, on 11/01/17 at 9:04 AM, CNA C was interviewed about the incident that began on 10/24/17 at 11:00 PM, and she stated, My understanding is I'm being fired for verbal abuse. I don't abuse no one, no way. I don't know why someone would say that, or whatever . When interviewed about R #4, CNA C denied yelling at, calling him a racist, or abusing R #4 in any way. CNA C said, I can make (R #4) do things, others can't .(CNA D) was talking about her personal life in front of R #4 .I told (CNA D) she sucked .(in front of R #4) I said, do you want this sucker (CNA D) taking care of you? (R #4) said, 'No'. CNA C confirmed that CNA D came back from her break and showed LPN F and CNA E a video, but said, I didn't see it. When interviewed about placing a blanket over R # 9's face, CNA C said, (CNA D) had the light on in (R #9's) room. I took the cover. We take the cover from the bottom. I mean she always ends up - whatever - I'm like this, I'm not going to leave my resident nasty. She (R #9) was wet .She (R #9) will let us, regardless of what she tells us. Regarding R #17, CNA C said, (R #17's) skin is real thin and was asking for god .I told (R #17) 'You tell us this all the time, we know you're hurting'. When CNA C was interviewed about R #18, she said, 'If I talked about sex around a resident, it would be wrong, period. When asked about calling other staff derogatory names in front of residents, CNA C said, Everybody does it. No one said it was wrong. When interviewed about R #16 (the Resident CNA E heard scream at CNA C and D from behind closed doors, CNA C said, O yeah, she did say something cuz we were fussing, something, I can't recall, she felt .like we were mad at each other. (R #16) is, I don't know, like . I don't know. She was trying to be a peacemaker between us. (R #16) is not the type of person, I can't explain. In a telephone interview, on 11/01/17 at 12:30 PM with CNA D, when interviewed about each alleged abuse (R #4, R #9, R #15, R #16, R #17, R #18, and R#19), she denied all abuse allegations, saying, It's all hearsay. CNA D said We will talk .I talk to (CNA C) about my personal life. CNA D said the staff call each other names, on a friend level .No, not inappropriate. CNA D denied showing any videos to CNA C, CNA E, and LPN F during the shift. In a follow up interview with CNA E, via phone on 11/01/17 at 4:09 PM, she again confirmed she told had told Administrator A what happened during the previous shift during her first phone conversation with Administrator on 10/25/17 around 5:00 PM, and specifically about what happened with the blanket (R #9) and to (R #4) comments regarding his wife. CNA E recalled Administrator A telling her in that first conversation with her, 'I'm sorry you had to see that, and she asked why I didn't call her immediately. In an interview with Administrator A, with two surveyors present, on 11/02/17 at 8:40 AM, Administrator A reported her notes from her telephone conversation, with CNA E on 10/25/17 at approximately 5:00 PM, revealed CNA E told her about CNA C and D were 1.) talking disgusting to R #18, calling R #4 a racist, asking him if he cheated on his wife, and telling him all men are stupid; 2.) threatening CNA E by saying, 'If you say anything we'll know it is you; 3.) telling R #17, 'why are you crying. Jesus is not here. The devil is here. You're not going to walk. Stop crying. Not a cute look'. When interviewed as to why there was not mention of the incidents in any of the residents' charts, and no mention of the impact it had on these residents, Administrator A reported the Social Work follow-up interviews with alleged staff to resident abuse were always placed in the Incident Report, and not in the Residents' medical records. Administrator A stated, We've all come to the conclusion that it was significant to (R #4). In a telephone interview, on 11/02/17 at 10:09 AM, LPN F reported she had been told about the alleged abuse but denied any knowledge of CNA C and D abusing/mistreating residents on that midnight shift. LPN F said CNA D showed it (the video) to me and (CNA C) .I did not see them goofing around .not to my knowledge, were they calling each other names. Resident #4 According to the MDS/Minimum Data Set, dated dated [DATE], R #4 was admitted to the facility on [DATE]; he was a [AGE] year old man, who had severe cognitive impairment, no behaviors, was totally dependent on staff for transfers, dressing, eating, and bathing, had [DIAGNOSES REDACTED]. In an interview, on 11/01/17 at 9:45 AM, R #4 was observed laying in a reclining Broda chair near the Nurses' station. Although unable to state who or when it happened, when interviewed about whether he had been mistreated he clearly replied, Yes, I remember they were talking about my wife. Said I didn't pay good attention to her. In a telephone interview, on 11/1/17 at 1:43 PM, Res #4's RP/Responsible Party/Son I stated the facility had reported to him the allegations of abuse. When told what R #4 said to Surveyor (above paragraph), RP I said, (R #4) has had [MEDICAL CONDITION] for [AGE] years, but is sometimes lucid (expresses himself clearly/understands clearly). If he remembers them saying those negative things about my mother, it has unsettled him (R #4). It means it was deeply disturbing to him (R #4). Review of an audit sheets, dated 10/26/17/not timed, revealed residents were queried on 4 points: 1.) Have you heard employees having conversations that were sexual in nature?; 2.) Have any employees teased or taunted you?; 3.) Are you treated with respect and dignity by the employees?, and 4.) Do you have any concerns about things you have heard employees say to other people (residents or employees) or yourself? According to the audit sheet, R #4 answered Question #1, Yes, I have. 2 or 3 women, but could not say where or when, and for Question #3 R #4 answered, .Verbal tear downs, but was unable to explain further . Resident #9 According to the MDS, dated [DATE], R #9 had severe cognitive impairment, was dependent on staff for transfers, dressing, and hygiene, and had [DIAGNOSES REDACTED]. In an interview, on 11/01/17 at 9:50 AM, R #9 was observed sitting in a wheelchair in the hallway and was interviewed regarding staff being unkind to her; she replied, I don't remember. Resident #17 According to the MDS, dated [DATE], R #17 had severe cognitive impairment, was dependent on staff for transfers, dressing, and hygiene, and had [DIAGNOSES REDACTED]. According to a Resident Assistance Form, dated 10/27/17, R #17 reported, Yes, they hurt me, said some bad things, they were not very nice, they were making me feel awful. In a interview, on 11/01/17 at 9:55 AM, R #17 was observed sitting in bed with glasses on, and her left forearm was wrapped with bloody gauze. R #17 was interviewed regarding staff being unkind to her; she replied, Some pull your arm, hit you in the back .not long ago (could not specify when it occurred or which shift). They really hurt me before. They are young (could not further describe them). Resident #19 According to the MDS, dated [DATE], R #19 had no cognitive impairment, was dependent on staff for transfers and dressing, and had [DIAGNOSES REDACTED]. According to the audit sheet, R #19 responded to Question #1 by saying, Some of the girls. They talk about boys; what they do and what they don't. In an interview, on 11/01/17 at 10:02 AM, R #19 who was observed sitting in a wheelchair near her bed reported, I wanted to tell them to quit. It's been happening off and on since I've been here (1 North Hall). They do a lot of talking, fuss about their pay, their feelings. They don't realize the resident is in the room. R #19 said she did not want to hurt anyone's feelings or get anyone in trouble, so she would not say who or when this occurred, but did say, There are a couple I don't want them to come in here .Their attitude is like I'm not even in here. I'm a person, you know. It's things I shouldn't hear. They did it just the other day. I really liked it on South, it didn't happen there. Resident #15 According to the MDS, dated [DATE], was a [AGE] year old man who had no cognitive impairment, was dependent on staff for transfers, dressing, and hygiene, and had [DIAGNOSES REDACTED]. In an interview, on 11/01/17 at 10:25 AM, R #15 reported, I really liked (CNA C), she's one of my favorite Aides, but she doesn't work here anymore .They don't clean people up that good at night. In an interview, on 11/01/17 at 10:50 AM, CNA H reported she worked day shift on 1 North on 10/25/17 and said, (R #4) said he was hungry because they didn't let him eat last night . (R #15) had a BM (bowel movement); said he had been holding it all night. R #15 said, '(CNA D) comes in, does her job half-as*ed and is mean to me'. CNA H reported R #15 appeared to be serious about his response. Resident #16 According to the MDS, dated [DATE], R #16 had severe cognitive impairment, was dependent on staff for transfers, dressing, and hygiene, and had [DIAGNOSES REDACTED]. According to the audit sheet, R #16 responded Yes .I try not to pay attention; usually is not good anyway to Question #1 and #4. In an interview in the dining room, on 11/01/17 at 10:30 AM, R #16 was interviewed about staff behaviors and about a time when she screamed for them to stop and she replied, They act like friends just lipping off; their mouths are running, speaking bad things. Running their damn mouths. Makes me feel like kicking as*es .every damn day they can do it. R #16 was unable to give the names or describe the staff that she was speaking about. Resident #18 On 11/01/17 at 10:39 AM, R #18 was observed sitting in a wheelchair near the nurses' station with his eyes closed and was not awake to answer questions. According to the MDS, dated [DATE], R #18 was severely cognitively impaired, was dependent on staff for transfers, dressing, eating, and hygiene, and had [DIAGNOSES REDACTED]. According to a Resident Assistance Form, dated 10/27/17, R #18 reported, Yes, I hear staff laughing and joking. It is wrong what they are doing. Staff were joking about a (then described a sexual act) .I wish they would stop laughing and joking when customers need help.

This citation pertains to intake MI 695. Based on observation, interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned interventions, and 3.) ensure that those interventions were functional and in place in 1 of 3 sampled residents (Resident #101) reviewed for falls, from a total sample of 4 residents, resulting in Resident #101's fall with injuries that included right scalp hematoma and concussion, during a staff assisted transfer on 2/18/17. Findings include: The facility Falls Reduction Program policy and procedure, dated 9/25/16, reflected, Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall related injury .Procedure .2. Implement and indicate individualized interventions on Care Plan/Kardex. 3. If falls occurs Charge Nurse to complete the following: Physical assessment of resident and observation of environment. Immediate interventions as identified by physical assessment and environmental observation .Neurological Assessment, as applicable with any known or suspected head trauma .3.2. Charge nurse to monitor for delayed consequences of incident utilizing the following: Physical assessment and documentation. Neurological Assessment per directions, as applicable . The facility Gait Belt (Use of) policy and procedure, dated July 1, 2008, reflected, Purpose: To assure the safety of the residents and staff when assisting with a transfer or ambulation a gait belt will be used. Equipment .3. Appropriate assertive devices .5. Gait (Transfer) belt. Procedure: 1. The facility will supply gait belts per protocol. 2. Residents who require assist with transfers and do not require an electric lift will utilize a gait belt with all transfers . The facility Neurological Assessment policy and procedure, dated 5/10/16, reflected, Purpose: To provide professional nursing assessment and interventions with possible head injuries or change in neurological function .Procedure .3. Implement neurological check assessment form with the following minimum frequency: a. Every 15 minutes x 4. b. Every 1 hour x 4. c. Every 2 hours x 4. d. Every shift x 24 . Review of the Face Sheet and the Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS reflected Resident #101 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated her ability to make daily decisions was moderately impaired. The MDS indicated Resident #101 required the extensive assistance of 2 staff members with transfers, ambulation, and toileting, and one person physical assistance with dressing, personal hygiene and bathing. The MDS indicated Resident #101 was unsteady with staff assistance when moving from a seated to a standing position. Review of the fall care plan, dated 1/6/17, revealed that Resident #101 was at risk for falls. Interventions included please remind me often to use call light for assist for transfers .See my ADL(Activities of Daily Living) care plan for my current transfer status. Review of the ADL care plan, dated 1/13/17, revealed Resident #101 had 11 unresolved interventions in place at the time of Resident #101's fall during staff assist times including one transfer that resulted in an injury. The interventions included, I transfer with the use of Ez-stand x 2PA. I may needing extra time to process cueing. Please don't rush me through the process .I transfer with the use of Ez-stand x 2PA. When I am fully awake/alert, I prefer to transfer with 2WW, x 1P extensive/minimal assist, needing extra time to process cuing, Please don't rush me through the process .When I am sleepy or my blood pressure is low. I transfer with the use of Ez-stand x2PA. When I am fully awake/alert, I prefer to transfer with 2WW, x1P extensive/minimal assist, needing extra time to process cueing. Please don't rush me through this process .When I am sleepy; I transfer during the night and first time in the morning (when trying to get to the bathroom with urgency), with the use of Ez-stand x2PA. When I am fully awake, I transfer during the day with 2WW, x1P extensive/minimal assist, needing extra time to process cueing. Please don't rush me through this process .I transfer with use of Ez-stand with help of 2 persons .I transfer with use of Ez-stand with help of 2 persons due to the disease process . Review of the facility, Fall Assessment, dated 2/17/17, reflected that Resident #101 had difficulty maintaining standing position, impaired balance during transitions, fatigue, weakness, and bladder incontinence. Review of the Incident Report, dated 2/18/17 at 6:45 a.m., revealed Resident #101 had a fall with hematoma to the top of the scalp when Certified Nursing Aide (CNA) C attempted to self transfer Resident #101 with no gait belt from the bed to the wheelchair. The incident reported revealed Resident #101 lost her balance during the transfer and CNA C was unable to stabilize Resident #101 before Resident #101 fell foreword and stuck her head on the wall and fell to the floor. The incident report reflected Resident #101 was alert and oriented to person and situation and described the incident as, she was in a hurry and I fell . The report revealed predisposing physiological factors that included; confused, drowsy, impaired memory, recent change in condition, weakness/fainted, and gait imbalance. The report indicated the bed was not locked and a gait belt was not used during a transfer. The report revealed CNA C received education regarding use of a gait belt during transfers and was suspended pending investigation from 2/18/17 through 2/20/17. The report revealed under notes, IDT reviewed incident: RCA Resident has multiple contributing factors including history of falls related to MS. During transfer bed slipped. CNA was not using gait belt. In an interview on 3/13/17 at 1:20 p.m. CNA C reported she had been employed at the facility for about one year as a CNA and was caring for Resident #101 on 2/18/17 at the time of the fall. CNA C reported she changed Resident #101's brief and put her pants on up to knees, positioned Resident #101 on the edge of the bed, attempted to stand Resident #101 by placing one hand under Resident #101's arm and the other arm around Resident #101 and CNA C reported the bed moved and Resident #101 lost her balance, fell forward and hit her head on the wall and fell to the ground. CNA C reported she did not use a gait belt to transfer Resident #101 because she had never used one before. CNA C reported after Resident #101 fell , she was crying uncontrollably and holding her head. CNA C reported she left Resident #101 on the floor alone and exited the room and went to the nurses' station and informed Registered Nurse (RN) D. CNA C reported RN D immediately the went to Resident #101's bedside with her and began to assess Resident #101. CNA C reported Resident #101 was not crying at that time and with the help of CNA E and RN D the three assisted Resident #101 off the floor into a wheelchair with the use a gait belt and transported her to the nurses' station. CNA C reported she then performed the first set of vitals and noticed at that time a large goose egg above Resident #101's right eye less than five minutes after transferring Resident #101 to the wheelchair. CNA C reported she had spoke with RN F, the nurse coming in for the next shift, and gave a statement related to the fall. CNA C reported she was suspended. CNA C reported she spoke with Director of Nursing(DON) B on 2/20/17 and was told she was suspended because she did not use a gait belt with transfer and did not follow the Kardex (CNA care guide). CNA C reported she should have used a gait belt to transfer Resident #101 on 2/18/17. CNA C reported Resident #101 was a difficult 1-person transfer prior to the fall on 2/18/17 and reported that Resident #101 should have had a 2-person transfer or Ez-stand according to the Kardex. CNA C reported she did not check the Kardex at the start of the shift on 2/18/17 and reported it is the expectation that CNA's check the Kardex at the start of the shift. In an observation on 3/14/17 at 9:28 a.m. CNA G entered Resident #101's room. Resident #101 was noted to be laying in bed covered with blankets and reported she did not have pants on. CNA G placed Resident #101's pants up to knees and assisted Resident #101 sit up to edge of the bed. CNA G placed the gait belt around Resident #101 and placed the walker in from of resident. CNA G stood Resident #101 up at the bedside while Resident #101 held onto the walker CNA G pulled up the pants keeping a hand on the gait belt. CNA G ambulated with Resident #101 with the use of the gait belt and the two wheeled walker from the bedside to the bathroom about 25 feet onto the toilet. CNA G transferred Resident #101 with use of gait belt and 2 wheeled walker back to the wheelchair about 25 feet after person care performed. Resident #101 appear to have poor balance during transfer and CNA G was providing strong support. In an interview on 3/14/17 at 9:55 a.m., directly after exiting Resident #101's room, CNA G reported Resident #101's current transfer orders are for assist times one. This surveyor asked how she knows what current transfer orders are? CNA G reported because that was what the Kardex had on it. CNA G was observed signing into the monitor on the wall and reviewing Resident #101's Kardex. CNA G stated, Yesterday I swear it said assist times one with gait belt. I should have checked this morning. CNA G reported that she did not have time to check that morning and did not receive change in report. CNA G reported she was unsure when transfer status changed. CNA G reported Resident #101's Kardex reflected EZ stand with assist times one for transfers. In an interview on 3/14/17 at 1:15 p.m. Registered Nurse (RN) E reported that on 2/18/17 she arrived for her shift at about 6:30 a.m. and was receiving a report from RN D at the nurses' station when CNA C came and reported Resident #101 had fallen in the room. RN E reported RN D went to the room with CNA C and performed an assessment but did not document assessment on the incident report for Resident #101's record. RN E reported CNA C transported Resident #101 from the room to the nurses' station in a wheel chair. RN E reported Resident #101 had a large raised knot that was purple to blue in color on Resident #101's right scalp/forehead area that was large already. RN E reported she did an assessment and included a neurological assessment that revealed sluggish pupil response of the left eye. RN E reported she called the doctor and the DON B at about 7:15 a.m. and reported the incident. RN E reported she had interviewed Resident #101 immediately and when Resident #101 was asked what happened, she responded, the girl was in a hurry and I fell . RN E reported she started to complete an Incident Report and gathered required items needed to transfer resident to hospital per doctor request. RN E reported Resident #101 remained at the nursing station while the documents were completed, including the Nursing notes in the medical record. RN E reported she did not document the neurological assessments with the exception of the initial assessment. RN E reported that EMS arrived about 7:45 a.m. In an interview on 3/14/17 at 3:40 p.m. Unit Manager(UM) F reviewed the ADL care plan and reported Resident #101's transfer status on 2/18/17 was, I transfer with the use of Ez-stand x2PA. I may needing extra time to process cueing. Please don't rush me though this process. UM F reported she had initiated that intervention on 1/13/17 after she first initiated an intervention that stated, I transfer with the use of Ez-stand x 2PA. When I am fully awake/alert, I prefer to transfer with 2WW, x1P extensive/minimal assist, needing extra time to process cueing. Please don't rush me through this process. UM F reported she made the change because she realized the CNA staff can not be expected to be able to determine if Resident #101 is awake and alert. UM F reported reported Resident #101's current transfer status was, I prefer to transfer with the EZ stand and 1PA. I am inconsistent at times r/t my MS. UM F reported the CNA staff are expected to review assigned resident Kardexes at start of each shift. Review of the hospital, Trauma History & Physical/Consult Note, dated 2/18/17, revealed Resident #101 was admitted to the hospital on [DATE] at 8:48 a.m. with chief complaint of fall and hit head on the wall and currently on Plavix(blood thinner) with complaint of 10/10 pain to right forehead with associated hematoma. The document revealed loss of consciousness for less than one minute and round hematoma on right superior forehead measured approximately 2 inches across and right pupil with minimally reactive. The eight page document revealed a problem list that included, Right scalp hematoma .concussion with loss of consciousness of 30 minutes or less. Review of the hospital Discharge Summary, dated 2/20/17, revealed that Resident #101 had discharge [DIAGNOSES REDACTED]. The Discharge summary revealed under follow-up information, Schedule an appointment as soon as possible for visit with (Named group): Why: or with your established PCP for hospital follow up. please finish bactrim for UTI and recheck U/A on 2/22 to ensure resolution. PLEASE BE CAREFUL DURING PATIENT TRANSFERS TO NOT DROP PATIENT . Review of the facility Admission Assessment, dated 2/20/17 at 6:42 p.m., revealed Resident #101 returned to the facility from the hospital post fall with extensive assistance for transfers from surface to surface and was not ambulatory. In an interview on 3/14/17 at 4:15 p.m., Assistant Director of Nursing (ADON) H reported Resident #101's current transfer orders were to use EZ stand with staff assist times one, related to unpredictable strength. ADON H reported she initiated the order on 3/8/17 after communicating with the DON B and Resident #101's family who had requested EZ stand use related to MS(muscular sclerosis). ADON H reported it was her expectation that staff follow the Kardex and use an EZ stand with assist times one for transfers for Resident #101. Review of the CNA Follow Up Question Report related to Resident Care Guide, dated 3/14/17 at 2:13 p.m., revealed CNA G documented, Yes care was provided according to Resident Care Guide for Resident #101. In an interview on 3/14/17 at 5:21 p.m. DON B reported it was his expectation that facility staff check the Kardex before providing resident care including transfers and use gait belts properly. DON B reported after Resident #101's fall on 2/18/17 CNA C was suspended and education was provided for CNA C and all staff related to proper use of gait belts and checking Kardexes prior to resident care. Review of facility document labeled, In-service Roster, dated 2/18/17 at 12:30 p.m., with topics that included, re-education safe transfer and gait belt use, revealed CNA G had signed in for the education. Review of the facility document labeled, Gait Belt Agreement, dated 2/18/17, revealed CNA G signed and dated the document that included an education outline for expectations for proper gait belt use, review verification of plan of care/Kardex. The document revealed, The plan of care/Kardex must be followed. Mechanical Devices, Ambulation, Number of persons required During the transfer. In a second interview on 3/15/17 at 9:40 a.m., DON B reported Resident #101's current transfer status was EZ stand with 1-person assist including on 3/14/17. DON B reported it was his expectation that staff follow Kardex for the most current transfer status for residents. DON B reported after reviewing Resident #101's ADL Care Plan that there were 11 transfer statuses in the system on 2/18/17 with none marked as resolved, when revisions were made. DON B reported if you look in the system the most current transfer status is the first one listed, but the system does not time stamp updates.

This citation pertains to MI 557. Based on observation, interview and record review the facility failed to provide adequate supervision to prevent falls for 1 of 9 residents reviewed for falls (Resident #107), from a total of 9 sampled residents and 7 supplemental residents, resulting in repeated falls; one fall resulted in hospitalization and stitches. Findings include: According to the Minimum Data Set, dated dated [DATE], Resident #107 had severe cognitive impairment, and according to another MDS, dated [DATE], Resident #107 had a recent significant change, and [DIAGNOSES REDACTED]. Review of Resident #107's medical record revealed a Hospice Care Plan was initiated on 8/04/14. Resident #107's Falls Care Plan revealed, "I have a history of frequent falls since admission and continue to be at risk for falling. I have vascular dementia and poor safety awareness, this increases my chances of falling. I also am on a blood pressure medication and I have psychotropic medications that have potential side effects that could cause me to fall..." According to Nurse's Notes (reviewed for the period 6/11/14 through 6/21/14) at 3:00 PM on 6/11/14, "(Resident #107) arrived (was admitted to the facility)." The resident had 13 documented falls in 52 days (6/21/14-8/11/14). According to a Psychiatric Discharge Summary, dated 6/11/14, "(Resident #107) was sent to the emergency room and was admitted and a psych consult was done and then was brought back here...He is ambulatory and with the medications, he needs more assistance with this..." Unusual Occurrence Reports for Resident #107 were reviewed, revealing falls were documented in Nurse's Notes and on the Unusual Occurrence Reports on 6/21/14, 6/23/14, 7/06/14, 7/15/14, 7/18/14, 8/03/14, (2 falls) 8/04/14, 8/06/14, and 8/11/14. Nurse's Notes revealed Resident #107 was also found on the floor on 7/22/14 and 8/09/14, but there were no Unusual Occurrence forms for these falls. According to Nurse's Notes, dated 7/18/14 at 8:30 PM, "(Resident #107) observed face down on floor at (7:30 PM) in doorway of room 227. Laceration noted between (L) left eye and brow. Laceration bleeding. (Resident #107) grimaced and was clenching fists...Physician...gave orders to t/f (transfer) (Resident #107) to hospital..." According to Nurse's Notes, dated 7/20/14 at 2:30 PM (2 days after the fall on 7/18/14), "(Resident #107) arrived on unit approx (approximately) 1400 (2:00 PM)...(Resident #107) has 9 stiches in L eyebrow, 7 cm long, bruise on L eye 7 cm, R (right ) FA (forearm) small bruise; R brachial back of arm bruise; dorsal side of R hand L skin abrasion with scab 1 cm..." Review of Resident #107's Falls Care Plans revealed no new interventions were put into place after the falls on 6/21/14, 6/23/14, 8/03/14, the 2 falls on 8/04/14, and 8/09/14. On 7/15/14, "15 min (minute) checks" were first added to the Falls Care Plan for only "24 hours". Review of Resident #107's Medical Record revealed 15 minute checks were not re-initiated until 8/03/14, and this intervention was not care planned. ( )

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to prevent new sores from developing for 1 of 4 residents (#5) reviewed for pressure ulcers from a total 24 sampled residents, resulting in the recurrent right buttock pressure ulcer and the left heel pressure ulcer both of which were unstageable ( undetermined depth of skin loss covered by either slough or necrosis). Findings include: According to the undated face sheet, Resident #5 was a [AGE] year old female first admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. In addition, Resident #5 was listed as having a history of osteo[DIAGNOSES REDACTED], stage 4 ( full thickness tissue loss with exposed bone, tendon or muscle) ischial (lower portion of hip bone) decubitus, [MEDICAL CONDITIONS], depression, [MEDICAL CONDITION], dementia with behaviors. The minimum data set ((MDS) dated [DATE] reflected Resident #5 had a BIMS (brief interview for mental status) score of 3 out of 15, meaning she had a significant cognitive impairment. The CAA (care area assessment) worksheet dated 8/11/13 reflected Resident #5 had no pressure ulcer although she was at an increased risk for skin breakdown due to multiple contributing factors such as incontinence (bowel), immobility, conginitive loss, bed/chair bound, and required staff assistance to move sufficiently to relieve pressure and needed special mattress or seat cushion. The most recent "Braden" scale for predicting pressure sore risk was dated 7/24/13 with a total score of 13, representing she was at moderate risk. The nurse's notes dated 6/7/13 through 4/26/14 reflected Resident #5 had episodes of skin breakdowns that were documented vaguely and non-descriptiving in detail on several occasions. The first entry noted on 8/22/13 of nurse's note. The note reflected, Resident #5 had " 0.5 cm x 0.3 cm reddened non-blanchable area on right buttock..." The next entry nurse's note dated 9/30/13 reflected, Resident #5 was "observed 1.2 cm x 1.0 cm non-blanchable area on right buttock, new order for "Sensi care three times daily for 7 days and re-evaluate." The third nursing note entry of skin breakdown was dated 11/10/13. The note described, " Resident #5 combative with care, left lower leg wound resolved, discontinue '[MEDICATION NAME]'...bilateral buttocks (Sigc) in area with breakdown present, red blanchable..." The nurse's note dated 12/27/13 reflected Resident #5 "had small reddened area on right side buttock..." The nurse's note dated 2/6/14 reflected, " late entry from 1/29/14 'DuoDerm' sponge replaced, red blanchable area CNA (certified nurse aide) reported 'DuoDerm' off area approximately quarter coin size (no location)..." The nurse's note dated 3/8/14 reflected "...wound on right buttock observed with no slough, center of wound is beefy red, 'Santyl' applied to wound bed only..." The nurse's note dated 3/16/14 reflected Resident #5 was "observed 1.5 cm x 1.0 cm fluid filled blister on her left shin and 0.8 cm x 0.8 cm blood filled blister on her left heel, 'Barrier Wipe' to be applied three times daily..." The nursing note dated 4/2/14 reflected, "changed dressing to right bottom, no drainage, 100 % pink non-granulating tissue, surrounding skin blanchable redness, left heel no change..." The nurse's note dated 4/23/14 reflected, "open area on left buttock crease." The nurse's note dated 4/26/14 reflected, "...left heel is black with leathery layer covering..." The "Pressure" ulcer care plan dated 8/24/11 reflected Resident #5 had a history of [REDACTED]. The interventions included 1) daily skin check by CNA, 2) treatment as ordered, 3) peri-care after episodes of bowel incontinence, 4) pressure reducing cushion in wheelchair, 5) alternating pressure mattress, 6) reposition every 2 hours in bed, every hour in chair, 7) float heels in bed, 8) in chair for more than 2-4 hours at a time, 9) weekly skin check by licensed staff. The additional hand-written interventions included 10) abductor pillow between legs dated 3/18/14, 11) "Roho" cushion dated 2/7/14, 12) "Roho" cushion on foot of wheelchair behind heels while up in wheelchair dated 3/18/14, 13) low air loss mattress dated 3/18/14. During the survey (4/29/14 -5/2/14) Resident #5 was not observed being out of bed. The "Licensed Nurse Weekly Hydration and Skin Assessment" form dated January through April 2014 (these were only ones found in the clinical record) reflected Resident #5 had skin assessment done on 1/3, 10, 17, 24, 2/7, 14, 21, 3/7, 21 and 4/11/14; 10 times out of 16 possible days. The "Wound Assessment Details Report" dated 2/6/14 through 4/28/14 reflected Resident #5 had the following pressure ulcers: Right ischial Date Stage 2/6/14 Suspected deep tissue injury Size (in centimeters) 3.3 x 1.5 x 0.0, 50 % slough and 50 % necrotic 2/13/14 Suspected deep tissue injury Size (in centimeters) 3.0 x 2.5 x 0.0, 50 % slough and 50 % necrotic 2/28/14 Suspected deep tissue injury Size (in centimeters) 2.2 x 1.8 x 0.0, 10 % slough and 90 % necrotic 3/5/14 Suspected deep tissue injury Size (in centimeters) 2.1 x 1.0 x 0.0, 5 % slough and 95 % necrotic 3/18/14 Suspected deep tissue injury Size (in centimeters) 3.0 x 1.8 x 0.0, 0 % slough and 100 % necrotic 4/2/14 Suspected deep tissue injury Size (in centimeters) 1.6 x 0.3 x 0.0, 0 % slough and 0 % necrotic 4/28/14 Suspected deep tissue injury Size (in centimeters) 1.0 x 0.4 x 0.0, 0 % slough and 0 % necrotic On 4/30/14 at 9:00 a.m., dressing change to Resident #5's right buttock pressure ulcer was observed in her room. The Licensed Practical Nurse, (staff "P") performed the procedure assisted by the nurse aide, (staff "Q). The right buttock wound was red, shaped like butterfly (irregular) with dark brown scab in the center. Staff "P" cleansed the wound, applied "Safgel" and covered with "[MEDICATION NAME]" foam dressing. Resident #5 was combative, restless and uncooperative. Resident #5 also had severe contractures of both legs, drawn to her abdomen, and it was extremely difficult to position her properly. Staff "P" confirmed that the wound was still covered with hard necrotic tissue, contradicting the most recent wound report ( 0 % necrosis). Resident #5's left heel dressing was noted to be off and the wound had 100 % black eschar (dead tissue), measuring approximately 3.0 cm x 4.0 cm with unknown depth. Left heel Date Stage Size 3/18/14 Suspected deep tissue injury Size (in centimeters) 1.6 x 1.6 x unknown, 100 % necrosis 3/24/14 Suspected deep tissue injury Size (in centimeters) 1.6 x 1.6 x unknown, 100 % necrosis 4/7/14 Suspected deep tissue injury Size (in centimeters) 1.8 x 1.5 x unknown, 100 % necrosis 4/21/14 Suspected deep tissue injury Size (in centimeters) 3.0 x 4.0 x unknown, 100 % necrosis 4/28/14 Suspected deep tissue injury Size (in centimeters) 3.0 x 3.5 x unknown, 100 % necrosis Left ischial (left buttock) Date Stage 4/28/14 Healing stage 2 Size (in centimeters) 0.2 x 0.3 x 0.0 On 4/29/14 at 10:00 a.m., Resident #5 was observed lying on her back with her head of bed elevated at semi-Fowler's position in her room. However, her whole body had been slid down to the middle of the bed, causing more pressure to her bottom. On 4/30/14 at 8:30 a.m., Resident #5 was observed lying on her right side (where the ulcer is), facing the door. At 1:00 p.m. and 2:00 p.m. on same day, Resident #5 was again observed lying on her right side, facing the door. At 2:10 p.m.,the nurse aide, (staff "Q") was asked when she was planning on turning the resident. Staff "Q" stated, "I know she is on her right side now, but I will turn her to left side next time." On 5/1/14 at 9:15 a.m., Resident #5 was observed lying on her back with her face turned facing the door. She had been slid down to the middle of the bed, it was difficult to verify her position. The nurse aide, (staff "R") who was assigned to Resident #5 stated, " I turned her to right side around 8-8:30 a.m. We have to turn her from side to side." At 10:00 a.m. on same day staff "R" turned the resident to left side. Staff "R" was reminded that Resident #5 had a pressure ulcer on her right buttock, thus leaving her on her right side may not promote healing. Staff "R" did not seem to understand the rationale. On 5/1/14 at 1:45 p.m., Director of Nursing, (staff "B") and the facility consultant, (staff "Y") were asked what may be the causes of Resident #5's recurrent pressure ulcers. Staff "Y" stated Resident #5 had a history of [REDACTED]. Staff "Y" also stated Resident #5 had multiple medical [DIAGNOSES REDACTED]. Staff "B" stated the facility did not have a wound care nurse, but the residents who required special care could be sent out to local hospital wound clinic. Director of Nursing, (staff "B") was asked why the staging of both the right buttock wound and the left heel ulcer were documented as suspected deep tissue injury from the onset to current dates, although the wound had changes in characteristics such as having slough or hard necrotic tissue. Director of Nursing "B" had no clear explanation. ( )

Based on observation, interview and record review, the facility failed to provide appropriate catheter care for 1 of 4 residents (#5) with catheters from a total 24 sampled residents, resulting in catheter-related complications including pain, skin erosions, bleeding and urinary tract infections. Findings include: According to the undated face sheet, Resident #5 was a [AGE] year old female first admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. In addition, Resident #5 was listed as having a history of osteo[DIAGNOSES REDACTED], stage 4 ischial decubitus, [MEDICAL CONDITIONS], depression, [MEDICAL CONDITION] and dementia with behaviors. The minimum data set ((MDS) dated [DATE] reflected Resident #5 had a BIMS (brief interview for mental status) score of 3 out of 15, meaning she had a significant cognitive impairment. The CAA (care area assessment) worksheet dated 8/11/13 reflected Resident #5 had a suprapubic catheter (SP) and she was unable to care for the catheter due to her [DIAGNOSES REDACTED]. The nurses notes dated 6/7/13 through 4/26/14 reflected Resident #5 had an on-going catheter-related complications such as bleeding around the catheter, leaking, plugging up, skin irritation around the catheter site and, the development of urinary tract infections. Resident #5 had her catheter changed 28 times (6/14/13, 20, 27, 7/3, 9, 14, 8/6, 12, 26, 9/22, 10/1, 23, 31, 11/5, 11, 16, 25, 30, 12/11/2013, 1/20/14, 3/2, 8, 15, 22, 27, 4/12, 16, 26/2014) due to above mentioned problems during this period. The nurse's note dated 6/8/13 reflected, "...Resident #5 agitated, using swear words when performing dressing change to suprapubic (SP) catheter (indication that she may be experiencing pain), serosanguineous drainage present on old dressing, area (2 cm x 3 cm) around SP catheter red and excoriated, urine orange, white cloudy particles in tubing..." The nurse's note dated 6/14/13 reflected, "...skin check done...bleeding around SP catheter site...unable to irrigate, SP changed..." The nurse's note dated 6/20/13 reflected, "...SP plugged, unable to irrigate...area around SP cath red-open, irritated..." The nurse's note dated 6/27/13 reflected, "...no urine in tubing or bag, SP catheter changed with 18 french with 30 ml water balloon..." The nurse's note dated 7/9/13 reflected, "SP catheter changed with 20 french with 30 ml balloon due to clogging..." The nurse's note dated 7/13/13 reflected, "SP leaking, Resident #5's brief wet with urine...SP catheter changed with 20 french with 30 ml water balloon..." noted to be voiding through urinary meatus..." The nurse's note dated 7/14/13 reflected, "SP catheter leaking...noted white crystallized drainage in tube...unable to flush..." The nurse's note dated 7/19/13 reflected, "...urine cloudy and dark yellow...antibiotic ([MEDICATION NAME] 500 mg three times daily for 7 days) started for urinary tract infection [MEDICAL CONDITION]" The nurse's note dated 8/6/13 reflected, "22 french catheter balloon protruding out of resident #5's vagina...aide stated earlier that Resident #5 had no urine output and catheter was separated from bag, catheter was reinserted into the bag and 15 minutes later aide called this nurse where this nurse observed balloon protruding from vagina...physician paged..." The physician's orders [REDACTED].#5 was to have 1) KUB: kidney, ureter, bladder x-ray 2) ultrasound of kidney and bladder 3) urology consult. The abdomen/KUB radiology report dated 8/6/13 indicated "unremarkable abdomen examination." The renal and pelvic ultrasound report dated 8/6/13 indicated, "normal kidneys, no uterine mass and benign ovarian syst." The reasons for these tests were written as "doctor is trying to figure out why SP catheter have to be changed so frequently." It did not include specific problem (possible fistula formation). The urology consult had never been made, thus the report was not available. The nurse's notes dated 8/12/13 through 4/26/14 reflected Resident #5 continued having catheter-related complications (bleeding, skin irritation, infection; 2/12/14, plugging, leaking) on almost daily basis. On 5/2/14 at 9:30 a.m., Director of Nursing, (staff "B") was asked about urology consult. Staff "B" stated the order was written before he started working as a unit manager (month ago) and had no knowledge why the order was not carried through. On 5/2/14 at 10:40 a.m., the Licensed Practical Nurse, (staff "P") was asked what could have been the causes of Resident #5's catheter complications. Staff "P" could not respond. On 4/30/14 at 9:00 a.m., during a pressure ulcer dressing change in the room, Resident #5's SP catheter dressing was observed lifted off from the site. The catheter site had been eroded, surrounding skin (approximately 2 cm x 5 cm) was red and excoriated with multiple dark brown scabs and moderate amount of serosanguinous drainage. The nurse aide, (staff " Q") stated the resident sometimes pulled on the catheter. Staff "P" simply reattached the old dressing to the site. Despite the on-going complications with SP catheter Resident #5 had no comprehensive care plan developed. The Activities of Daily Living (ADL) care plan dated 8/23/11 included the presence of catheter as a part of focus area, but there was no risk/cause statement addressing the complication or interventions to prevent UTI, how to mange catheter-related pain, skin breakdown or long-term goal or objectives. ( )

This citation has multiple deficient practice statements (DPS A and DPS B) DPS A) Based on observation, interview, and record review, the facility failed to ensure that fall interventions were in place for 3 (Resident #3, #6, #7) of 8 residents reviewed for falls, from a total sample of 24, resulting in Resident #3 sustaining a fall with fracture, an avoidable fall for Resident #6, and the potential for continued falls and injury for Resident #7. Findings include: Resident #3 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 was a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #3 scored 6/15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), did not exhibit any behavioral symptoms, did not reject care, transferred, walked, and used the toilet with limited assistance from one staff member. The MDS revealed Resident #3 was not steady with balance during transitions and walking, was frequently incontinent of urine and bowel and was not on a urinary or bowel toileting program. Review of the MDS Fall Care Area Assessment (CAA), revealed Resident #3 "does not have a noted history of falls but he is at risk due to the confusion, weakness. He also is having trouble with his hemoglobin being too low, this could contribute to a fall. He is also taking blood pressure medications". Review of the Fall Risk Admission Care Plan dated 4/22/14, revealed "All residents are at risk on admission due to change of environment..." Resident #3's interventions included orient to surroundings, PT (physical therapy) referral, OT (occupational therapy) referral, and assist with toilet as needed. On 4/28/14, "gripper socks when up" was added as an intervention. Review of the Elimination Admission Care Plan dated 4/22/14, revealed that urinal at bedside was added as an intervention on 4/28/14. Review of the Nurse's Notes dated 4/4/14, revealed Resident #3 ambulated in his room without assistance. The Nurse's Notes dated 4/7/14, revealed Resident #3 urinated in the trash can. The Nurse's Notes dated 4/8/14, revealed Resident #3 wandered in the hall without his pants on. The Nurse's Notes dated 4/12/14, revealed Resident #3 urinated in his trash can. The Nurse's Notes dated 4/13/14, revealed Resident #3 urinated in his trash can. Review of the Unusual Occurrence form dated 4/25/14 at 9:10 pm, revealed Resident #3 was "lying on his back in the bathroom" and had complaints of pain in his left shoulder. The Unusual Occurrence Form revealed a section for "Items witnessed and in place at time of event. Check all that apply". Footwear in place was not checked and it was noted that his urinal was within reach, but did not specify where. The immediate interventions taken were pain assessment, x-ray, and neuro check. The statement written by Licensed Practical Nurse (LPN) "E" revealed there was urine on the floor in Resident #3's bathroom. Review of the Supervisor/Manager's Investigation dated 4/25/14, revealed "Urine present on the floor that resident (Resident #3) slipped on". Additional corrective actions taken included room/floor checks every 1 hour and as needed, urinal at bedside, and gripper socks. Review of the Review of Indicators of Fall Risk, revealed Resident #3 was "found on the floor...urine present on floor. Lack of appropriate footwear in place" Review of the Radiology Report dated 4/25/14, revealed Resident #3 sustained an "acute humeral neck and greater tuberosity fractures, with mild displacement". In an interview on 4/29/14 at 3:20 pm, LPN "E" reported that she was on duty at the time of Resident #3's fall. LPN "E" stated that Resident #3 was "not alert and oriented times 3" and was "known to urinate on the floor sometimes". When queried what interventions were in place, knowing that Resident #3 urinated on the floor, LPN "E" stated Resident #3 had a urinal. When queried if Resident #3 was a fall risk, LPN "E" stated "No, not that I would know because he had been ambulating in the room". LPN "E" reported that she did not witness Resident #3's fall, but that she heard a noise and that was what prompted her to check on Resident #3. LPN "E" reported that she observed Resident #3 on his bathroom floor and there was urine on the floor. LPN "E" reported the urinal was empty and in the bathroom. LPN "E" reported it was unclear if Resident #3 had placed the urinal in the bathroom or if it was in there prior to his fall. LPN "E" reported Resident #3 was not wearing any shoes or socks at the time of the fall. When queried why he did not have proper footwear in place, LPN "E" stated "Because he won't keep them on when the CNAs (Certified Nursing Assistants) put them on". When queried where Resident #3's socks were at the time of the fall, LPN "E" stated "Um, I don't know for sure. I did not look for the socks at that moment". When queried if Resident #3 got up without assistance often, LPN "E" stated "very, yes". In an interview on 4/29/14 at 3:35 pm, LPN "II" reported that she was orienting with LPN "E" at the time of Resident #3's fall. LPN "II" reported that she observed Resident #3's socks in his bed. In an telephone interview on 5/1/14 at 9:10 am, CNA "DD" reported that she cared for Resident #3 the night of his fall. When queried what interventions were in place, knowing that Resident #3 had a history of [REDACTED]. blue moon". CNA "DD" stated "I tried to check him every 2 hours, but he refused a lot of times". CNA "DD" reported that Resident #3's fall interventions included gripper socks, but that "he would take them off every time I tried to put them on". When queried if a new intervention was put in place, knowing that Resident #3 removed his gripper socks, CNA "DD" stated "Not that I know of". The night of the fall, CNA "DD" reported that she last checked on Resident #3 at approximately 8:30 pm. CNA "DD" reported that at 8:30 pm, she did not see Resident #3's gripper socks on the floor so she assumed he had them on his feet. When queried where Resident #3's urinal was located at 8:30 pm, CNA "DD" stated "I don't really remember". When queried if she checked the placement of his urinal, CNA "DD" stated "I do not" remember. In an interview on 4/30/14 at 1:05 pm, Unit Manager (UM) "D" reported that every resident is a high fall risk for the first 2 weeks after admission, at which time the interdisciplinary team re-evaluates the resident. reported that Resident #3 had a history of [REDACTED]. UM "D" reported that the facility implemented the intervention of a bedside commode, but Resident #3 continued to urinate on the floor. When queried what other interventions were in place to prevent Resident #3 from slipping in urine on the floor, UM "D" reported Resident #3 had a urinal at his bedside, but most of the time he would throw it and not use the urinal. UM "D" reported that she "believed" Resident #3 had gripper socks prior to his fall, but that he did not like to keep the gripper socks on. UM "D" stated "I just think he slipped" when queried about the root cause of Resident #3's fall. UM "D" reported that after the fall, the new interventions included checking his room every hour to make sure there is nothing on the floor, gripper socks, continued resident education, and a urinal at bedside. An observation on 4/29/14 at 11:42 am, revealed a therapy staff member doing range of motion exercises with Resident #3 while he was lying in bed. An observation on 4/29/14, revealed Resident #3 was lying in bed. Resident #3 was unable to recall why his left arm was in a sling. Resident #3's urinal was hanging from the left assistive bar on the bed and his bedside table was on his right side, out of reach. There was a chair positioned between Resident #3's bed and the bedside table. It was the same chair that therapy staff used during the 11:42 am observation. Observations on 4/29/14 at 2:10 pm and 3:05 pm, revealed Resident #3 asleep in bed. His urinal was to his left, in a basin on the nightstand. His left arm was in a sling. An observation on 4/29/14 at 3:55 pm, revealed Resident #3 was awake in bed with gripper socks on his feet. His urinal was to his left, in a basin on the nightstand. His left arm was in a sling. An observation on 4/30/14 at 8:07 am, revealed Resident #3 lying in bed with his gripper socks on. His left arm was in a sling and his urinal was in a basin on the nightstand to his left. ( ) Resident #7 Review of the Face Sheet and MDS dated [DATE], revealed Resident #7 was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #7 scored 5/15 (severe cognitive impairment) on the BIMS, was not steady with balance during transitions and walking, and transferred with extensive assistance of 1 staff member. The MDS revealed Resident #3 had one fall with injury since admission to the facility. Review of the Fall CAA, revealed "according to nurse's note 12/18/13-fall took place in bedroom; at 1235 (12:35 pm); resident returned from lunch in commons to put her stuffed monkey to bed; resident attempted to self-transfer..." Review of Resident #7's Resident Care Guide, revealed accompany resident back from commons (dining room) to room and auto lock wheelchair breaks. Review of Resident #7's Falls Care Plan initiated 12/12/11 and revised on 1/13/14, did not mention to accompany Resident #7 back to her room from the commons and did not mention the auto lock wheelchair breaks. Review of the ADL (Activities of Daily Living) Care Plan initiated 12/12/11 and revised on 12/10/13, revealed Resident #7 transferred with one person assist. The ADL care plan did not mention the auto lock wheelchair breaks or for staff to accompany her back from the commons. Review of the Unusual Occurrences and Supervisor/Manager's Investigations, revealed Resident #7 was wearing non-gripper socks and no shoes and fell in her room on 1/24/14. The Supervisor/Manager's Investigation revealed the corrective actions taken included: new gripper socks and "resident to be brought back to room from commons and assisted to bed". On 1/26/14, Resident #7 fell in her room and that her gripper socks were "worn thin". The Supervisor/Manager's Investigation revealed additional corrective actions taken included auto lock wheelchair breaks. On 2/27/14, Resident #7 fell in her room after attempting to walk to her bathroom to turn the light off. On 4/22/14, Resident #7 fell in her room. In an interview on 4/30/14 at 1:05 pm, UM "D" reported that she previously managed Resident #7's floor. UM "D" reported that auto lock wheelchair breaks were implemented. UM "D" reported that Resident #3 "would go back to her room after lunch and they (staff) wouldn't know she was back in her room and transferring herself" and that was why she implemented for staff to accompany Resident #7 back to her room from the commons. UM "D" reported that laundry staff was responsible for checking the condition of gripper socks. An observation on 4/30/14 at 12:25 pm, revealed Resident #7 self propelling her wheelchair from the commons area towards her room. Resident #7 was then observed on her unit and self propelled past the nurses station, where 3 nurses were looking at charts. At 12:34 pm, Resident #7 entered her room. There was a nurse passing medications and was back and forth from resident rooms to the med cart. At 12:40 pm, Resident #7 was observed self transferring from her wheelchair to her bed. Once sitting on the edge of the bed, Resident #7 pushed her wheelchair out of the way and laid down. At 12:45 pm, a staff member entered Resident #7's room to speak with her roommate. In an interview on 4/330/14 at 1:25 pm, Registered Nurse (RN) "BB" was queried about the lack of the auto lock wheelchair breaks for Resident #7's. RN "BB" stated "This morning I noticed it wasn't working. Maybe a little before lunch". RN "BB" reported that Resident #7's wheelchair should lock when she got up. RN "BB" reported that she insisted that staff follow Resident #7 into her room after meals because Resident #7 was noncompliant and self transfers. RN "BB" then went to the nurse's station and called maintenance to notify them of Resident #7's nonfunctioning auto lock wheelchair breaks. On 4/30/14 at 2:12 pm, RN "BB" reported that she called maintenance twice and she thought she would have to call them again because Resident #7's auto lock wheelchair breaks had not been fixed yet. An observation on 5/1/14 at 12:42 pm, revealed Resident #7 gave permission for this surveyor to enter her room. Resident #7 was observed on the toilet with her bathroom door open. There was no staff member present in the room or bathroom. Resident #7 then stood up, pulled up her brief and transferred into her wheelchair. Resident #7 then pulled her pants up to her thighs, propelled her wheelchair out of her bathroom, reached over and turned the bathroom light off. At 12:47 pm, Resident #7 self transferred herself from her wheelchair to her bed. The auto lock wheelchair breaks had engaged. An observation on 5/1/14 at 2:20 pm, Resident #7 was transported to her room by CNA "CC". Resident #7 requested to lay down. CNA "CC" placed one hand under Resident #7's right arm, held Resident #7's right hand and assisted Resident #7 to bed. CNA "CC" did not use a gait belt. In an interview on 5/1/14 at 2:25 pm, when queried about gait belt use, CNA "CC" stated it "depends on transfer status. If just one person as long as the transfer was so close" then no gait belt was required. In an interview on 5/1/14 at approximately 3:00 pm, Nurse Consultant "Y" reported that if a resident is a one person assist with transfers, a gait belt is expected to be used. Review of the Gait Belt Policy and Procedure dated 7/1/08, revealed "procedure: 2. Residents who require assist with transfers and do not require an electric lift will utilize a gait belt with all transfers". ( ) According to the facility admission record, dated 10/24/13, Resident #6 was an [AGE] year old male admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. According to the Minimum Data Set (resident assessment), dated 4/14/14, Resident #6 had moderate memory loss, exhibited behaviors of yelling out, verbal and physical aggression towards staff and others and was usually understood and understands the spoken word. Resident #6 required assist of a hoyer lift and 2 staff for transfers, assist of 2 staff for bed mobility, dressing and toileting. Resident #6 required the assist of 1 staff to push his wheelchair, eat, provide hygiene and showers. Resident #6 was frequently incontinent of bowel and bladder and had fallen a minimum of 3 times in the facility. On 4/29/14 at 3:20 p.m., Resident #6 was observed in the hall area by the dementia unit nurses station. He was neatly dressed, but stood from his wheelchair and urinated on the floor near other seated residents. Four staff attempted to redirect him, but could not. In response to the coaxing attempts of the staff to stop urinating and redirect him to the bathroom, Resident #6 responded verbally, but made no sense. On 3/30/14 at 9:44 a.m., Certified Nurse Assistant (CNA) "KK" and "LL" were interviewed. When asked, both CNAs stated that Resident #6's behaviors were very difficult to redirect, and was often anxious and restless. According the the facility "Unusual Occurrence" report, dated 2/14/14, Resident #6 was found partially out of bed. On 2/10/14 at 6:45 p.m., Resident #6 was found hanging on to his grab bar with his upper body on the floor and his legs on the bed. When asked, Resident #6 was unable to verbalize what he was trying to do. According to the root cause analysis conclusion on the "Unusual Occurrence" report, 2/14/14, Resident #6 became anxious and restless when he was in bed and not tired, and was put to bed before he was ready by a Certified Nurse Assistant (CNA) who was not familiar with him. The intervention to prevent further falls of this nature was to re-educate the staff to not lay Resident #6 down in bed until he is ready and asks staff to help him to bed. On 5//14 at approximately 10:30 a.m., Clinical Care Coordinator Nurse "U" was interviewed. When asked how CNAs know about each resident's needs, Nurse "U" said that the Resident Care Guide were kept in a 3-ring binder at the nurse's station, and CNA's were to check the binder about information for each resident's care needs. Nurse "U" said that Resident #6, also, had a separate page with a few specifics as follows: -"When resident is awake and restless, offer snacks/drinks and activities. -Check on resident every half hour while in bed. -Keep noise level low when checking on resident while in bed. -Resident is not to be laid down in bed until he is ready and asks staff to help him to bed". The CNA, unfamiliar with Resident #6, neglected to check his Resident Care Guide or forgot, put him in bed shortly after dinner and he rolled/fell out of bed. On 5/2/14, this surveyor was unable to reach CNA "K" by phone to discuss why Resident #6 was placed in bed early. ( ) DPS B) Based on observation and interview, the facility failed to secure all exit doors, ensure a secure grab bar (Room 126), and lock chemicals and sharps in the beauty shop, resulting in the potential for elopement and/or injury of 12 independently mobile/wander risk residents from a total sample of 24 residents. During a tour of the environment on 5/1/14 starting at 12:40 p.m., in the presence of Director of Housekeeping "GG", the following hazards were identified: 1.) A garage door in the laundry area which led to the outside of the facility was found to be unsecured. A door directly next to the garage door was unlocked despite a sign on the door instructing staff to "Keep Door Locked at All Times". The adjacent doorways which lead to the garage door in the laundry area was also not secure, despite a sign on the door telling staff to "Keep Door Closed At All Times", giving access to any resident who was independently mobile (currently 12 residents) the ability to exit the facility unbeknownst to staff. During an interview on 5/1/14 at 4:40 p.m., the Engineering Supervisor (ES) "HH" and the Nursing Home Administrator "A" were shown the signage on the door next to the unsecured garage door as well as signage on the set of double doors leading to the laundry area instructing staff to keep the door shut at all times and NHA "A" said she would educate all staff who have access to that area immediately not to leave those doors open and to always keep the door next to the garage door locked. 2.) A grab bar in the bathroom of room 126 was loose, posing a hazard for falling for anyone who used the grab bar as an assistive device for standing. ( ) On 5/01/2014 at 4;00 p.m., the facility beauty shop (located next to the commons area, which is where resident gather to socialize, watch television etc..) was observed to have the door wide open. The facility beautician was not in the beauty shop. There were 3 cabinets observed , all equipped with locks however none were locked. The 3 cabinets contained 3 shelves each and were noted to be filled with hair dyes, shampoos, cleaning chemicals, a jar full of liquid sanitizer used for combs etc..the jar was clear with the blue colored liquid which potentially could be construed as enticing for someone with dementia. In the drawers, 3 pairs of scissors were discovered. After time had elapsed for approximately 6 minutes, the facility Administrator "A" was asked to come to the beauty shop. Administrator "A" too observed the beautician was not present and was made aware of the multiple chemicals and scissors that were left unsecured in the beauty shop. ( )

This citation pertains to MI 648 and MI 336. Based on interview and record review, the facility failed to provide care that met professional standards by 1) failed to properly assess resident and follow facility policy and manufacturers instructions for transfers in 1 of 4 sampled residents (Resident #101) and 2) failed to follow resident care guide in 1 of 4 sampled residents (Resident #103) reviewed for falls and accidents resulting in Resident #101 suffering acute blood loss secondary to pectoralis (chest) muscle hemorrhage (uncontrollable loss of blood) and Resident #103 falling and fracturing his hip. Findings include: Resident #101 Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 had clear speech, was usually understood, usually understands, had severe cognitive impairment and required extensive assistance of 2 people for transfers. Review of the Admission Record dated [DATE], revealed Resident #101 had [DIAGNOSES REDACTED]. Resident #101 no longer resided at the facility. Review of the physician order [REDACTED]. Review of the Laboratory Report dated [DATE] at 11:00 a.m., revealed Resident #101 had a blood hemoglobin (part of blood that carries oxygen) level of 7.2 grams/deciliters (g/dL; normal is 12XXX,[DATE].0). Review of the Unusual Occurrence Report dated [DATE], revealed Resident #101 was found to have bruises on the left side of the breast, "...believe this may be related to EZ Stand (device used for lifting and moving residents) transfers". Under the Supervisor/Manager's Investigation section the report revealed Resident #101's bruise on the left breast/chest, right side and under breast "...is consistent (with) EZ Stand transfer sling". Review of the Rehab Services Screening Form dated [DATE], revealed, "(Resident) in am is unsafe transfer in EZ Stand. (Resident) does not stand straight and sling and hands only thing holding her up. Legs are not bearing weight..." Review of the Physical Therapy Discharge Summary dated [DATE], revealed the resident's lower extremities will break/relax suddenly. Review of the Mechanical Lift Transfer Policy dated [DATE], revealed, "Mechanical lifts are used to safety (sic) transfer a resident unable to transfer in any other manner...follow manufacturer's instructions". Review of the EZ Way Stand Operator's Instructions revised [DATE], revealed, "The EZ Way Smart Stand was designed to transfer weight bearing patients..." During an interview on [DATE] at 10:45 a.m., Registered Nurse (RN) #11 revealed that on [DATE] two Certified Nursing Assistants (CNAs) #3 and #12 voiced their concerns about using the EZ Stand with Resident #101. RN #11 stated the CNAs reported that Resident #101 was to weak to use the EZ Stand. RN #11 stated she made therapy aware of this situation by using a rehab screening form. During an interview on [DATE] at 11:00 a.m., CNA #3 stated when Resident #101 was being transferred using the EZ Stand, the sling would be the only thing holding up the resident. CNA #3 stated the bruising on the resident's chest and side that was discovered on [DATE] was from the EZ Stand sling. During an interview on [DATE] at 11:10 a.m., CNA #12 stated that on [DATE] she spoke with RN #11 about it being unsafe to use the EZ Stand for Resident #101. CNA #12 stated she did see bruising on the chest and under the breast and stated it looked like it was from the sling on the EZ Stand. CNA #12 stated if Resident #101 was able to hold herself up on the EZ Stand, Resident #101 would probably not suffered the bruising. During a telephone interview on [DATE] at 9:30 a.m., Family Member (FM) #10 stated she was in to visit Resident #101 on [DATE] and staff was using the EZ Stand to transfer Resident #101. FM #10 stated Resident #101 was not able to help with the transfer and was just "hanging there" on the EZ Stand. FM #10 stated she was upset and spoke with Social Worker (SW) #13 and did not want staff to use the EZ Stand when transferring Resident #101. Review of the ADLs (Activities of Daily Living) Care Plan dated [DATE], revealed the EZ Stand was used until [DATE]. The plan revealed that on [DATE] Resident #101's transfer status was changed to using a Hoyer Lift. Review of the hospital Emergency Department Records dated [DATE], revealed, "(Resident) arrived with multiple bruises all over body. Grossly covering chest, abd (abdomen), bilat (both) arms, hands, fingers and (both) legs...Symptomatic [MEDICAL CONDITION] associated with acute blood loss secondary to pectoralis hemorrhaging bilaterally (both left and right) by recent trauma in EZ lift chair". Review of the hospital CT Scan report dated [DATE], revealed, "...abnormal scattered areas of high density within the pectoralis muscles bilaterally...consistent with areas of hemorrhage." Review of the hospital Physician Discharge Summary dated [DATE], revealed Resident #101 was admitted to the hospital on [DATE] with acute [MEDICAL CONDITION] believed secondary to pectoralis muscle hemorrhage. Trauma to chest and underarms was sustained while using EZ chair lift (EZ Stand) at rehab (rehabilitation) facility...On arrival to the hospital, labs revealed (hemoglobin) of 7.2 (g/dL). The summary revealed that Resident #101 deceased on [DATE]. Resident #103 Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #103 had clear speech, was understood, usually understands, had severe cognitive impairment and required extensive assistance of 2 people for transfers Review of the Admission Record dated [DATE], revealed Resident #103 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #103 no longer resided at the facility. Review of the Unusual Occurrence report dated [DATE], revealed Resident #103 was "Observed on the Floor" at 9:00 a.m.. Review of the Admission History and Physical dated [DATE], revealed Resident #103 had a history of [REDACTED]. Review of the SOAP note dated [DATE], revealed, "(Resident #103) was seen in a (follow up) visit. He had a fall, and was sent to (hospital)". Review of the untitled, undated document that was given to this surveyor revealed, "Fall occurred on [DATE]. Resident was assisted to the bathroom by CNA and sitting on the toilet when he attempted to self transfer off the toilet and fell . CNA discovered resident on his side between toilet and wall...complaint of pain on [DATE]...On [DATE] x-ray was ordered...X-ray results...indicated positive [MEDICAL CONDITION]" Review of the Supervisor/Manager's Investigation report dated [DATE], revealed, "Resident was taken to the toilet by CNA who left resident on the toilet to go assist another resident. Resident then attempted to transfer himself off the toilet". Review of Radiology Report dated [DATE] revealed, "acute impacted subcapital fracture ([MEDICAL CONDITION])". Review of the Falls Reduction Program policy dated [DATE] and revised [DATE] revealed, if resident is determined to be a fall risk, "Place a visual identification of fall risk (yellow dot) on the Resident Care Guide". Review of Resident #103's Resident Care Guide undated, revealed a yellow dot, indicating "high risk for falls". The guide revealed Resident #103 required 1 person assist for transfers. Review of untitled, undated document that was given to this surveyor revealed, "The Yellow Sticker...high risk for fall...Not to be left unattended on the toilet". In an interview on [DATE] at 3:30 p.m., CNA #5 stated on [DATE], "put him (resident) on the toilet, while the resident was on the toilet, Nurse (LPN #6) asked me to put someone else on the toilet so I left the resident alone on the toilet. When asked CNA #5 stated, "if resident is a fall risk, no you are not supposed to leave the resident (on the toilet)" In an interview on [DATE] at 3:46 p.m., LPN #6 stated, "CNA was not in the room when the resident was on the toilet..I saw her leave (Resident #103's) room...I knew (Resident #103) was on the toilet. LPN #6 stated, "...wasn't sure if resident was to be left alone on the toilet, would have to be care planned to not be left alone on the toilet". LPN #6 stated that CNA #5 was disciplined for leaving the resident when he was on the toilet. When asked why the CNA should have stayed with the resident while on the toilet, LPN #6 stated, "If resident was restless on the toilet, then the CNA shouldn't have left him on the toilet...he was restless all day". Review of the Employee Disciplinary Warning dated [DATE], revealed CNA #6 was disciplined, "CNA left (Resident #103) unattended on toilet resulting in fall". ( )

This citation pertains to MI 648 and MI 336. Based on interview and record review the facility failed to ensure residents received the necessary care and services to maintain the highest practicable well-being in 2 residents (#101 and #103) from a total sample of 4 residents reviewed for accidents and falls resulting in Resident #101 being improperly assessed for transfers and suffering acute blood loss secondary to pectoralis (chest) muscle hemorrhage (uncontrollable loss of blood) and Resident #103 falling and fracturing his hip. Findings include: Resident #101 Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 had clear speech, was usually understood, usually understands, had severe cognitive impairment and required extensive assistance of 2 people for transfers. Review of the Admission Record dated [DATE], revealed Resident #101 had [DIAGNOSES REDACTED]. Resident #101 no longer resided at the facility. Review of the physician order [REDACTED]. Review of the Laboratory Report dated [DATE] at 11:00 a.m., revealed Resident #101 had a blood hemoglobin (part of blood that carries oxygen) level of 7.2 grams/deciliters (g/dL; normal is 12XXX,[DATE].0). Review of the Unusual Occurrence Report dated [DATE], revealed Resident #101 was found to have bruises on the left side of the breast, "...believe this may be related to EZ Stand (device used for lifting and moving residents) transfers". Under the Supervisor/Manager's Investigation section the report revealed Resident #101's bruise on the left breast/chest, right side and under breast "...is consistent (with) EZ Stand transfer sling". Review of the Rehab Services Screening Form dated [DATE], revealed, "(Resident) in am is unsafe transfer in EZ Stand. (Resident) does not stand straight and sling and hands only thing holding her up. Legs are not bearing weight..." Review of the Physical Therapy Discharge Summary dated [DATE], revealed the resident's lower extremities will break/relax suddenly. Review of the Mechanical Lift Transfer Policy dated [DATE], revealed, "Mechanical lifts are used to safety (sic) transfer a resident unable to transfer in any other manner...follow manufacturer's instructions". Review of the EZ Way Stand Operator's Instructions revised [DATE], revealed, "The EZ Way Smart Stand was designed to transfer weight bearing patients..." During an interview on [DATE] at 10:45 a.m., Registered Nurse (RN) #11 revealed that on [DATE] two Certified Nursing Assistants (CNAs) #3 and #12 voiced their concerns about using the EZ Stand with Resident #101. RN #11 stated the CNAs reported that Resident #101 was to weak to use the EZ Stand. RN #11 stated she made therapy aware of this situation by using a rehab screening form. During an interview on [DATE] at 11:00 a.m., CNA #3 stated when Resident #101 was being transferred using the EZ Stand, the sling would be the only thing holding up the resident. CNA #3 stated the bruising on the resident's chest and side that was discovered on [DATE] was from the EZ Stand sling. During an interview on [DATE] at 11:10 a.m., CNA #12 stated that on [DATE] she spoke with RN #11 about it being unsafe to use the EZ Stand for Resident #101. CNA #12 stated she did see bruising on the chest and under the breast and stated it looked like it was from the sling on the EZ Stand. CNA #12 stated if Resident #101 was able to hold herself up on the EZ Stand, Resident #101 would probably not suffered the bruising. During a telephone interview on [DATE] at 9:30 a.m., Family Member (FM) #10 stated she was in to visit Resident #101 on [DATE] and staff was using the EZ Stand to transfer Resident #101. FM #10 stated Resident #101 was not able to help with the transfer and was just "hanging there" on the EZ Stand. FM #10 stated she was upset and spoke with Social Worker (SW) #13 and did not want staff to use the EZ Stand when transferring Resident #101. Review of the ADLs (Activities of Daily Living) Care Plan dated [DATE], revealed the EZ Stand was used until [DATE]. The plan revealed that on [DATE] Resident #101's transfer status was changed to using a Hoyer Lift. Review of the hospital Emergency Department Records dated [DATE], revealed, "(Resident) arrived with multiple bruises all over body. Grossly covering chest, abd (abdomen), bilat (both) arms, hands, fingers and (both) legs...Symptomatic [MEDICAL CONDITION] associated with acute blood loss secondary to pectoralis hemorrhaging bilaterally (both left and right) by recent trauma in EZ lift chair". Review of the hospital CT Scan report dated [DATE], revealed, "...abnormal scattered areas of high density within the pectoralis muscles bilaterally...consistent with areas of hemorrhage." Review of the hospital Physician Discharge Summary dated [DATE], revealed Resident #101 was admitted to the hospital on [DATE] with acute [MEDICAL CONDITION] believed secondary to pectoralis muscle hemorrhage. Trauma to chest and underarms was sustained while using EZ chair lift (EZ Stand) at rehab (rehabilitation) facility...On arrival to the hospital, labs revealed (hemoglobin) of 7.2 (g/dL). The summary revealed that Resident #101 deceased on [DATE]. Resident #103 Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #103 had clear speech, was understood, usually understands, had severe cognitive impairment and required extensive assistance of 2 people for transfers Review of the Admission Record dated [DATE], revealed Resident #103 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #103 no longer resided at the facility. Review of the Unusual Occurrence report dated [DATE], revealed Resident #103 was "Observed on the Floor" at 9:00 a.m.. Review of the Admission History and Physical dated [DATE], revealed Resident #103 had a history of [REDACTED]. Review of the SOAP note dated [DATE], revealed, "(Resident #103) was seen in a (follow up) visit. He had a fall, and was sent to (hospital)". Review of the untitled, undated document that was given to this surveyor revealed, "Fall occurred on [DATE]. Resident was assisted to the bathroom by CNA and sitting on the toilet when he attempted to self transfer off the toilet and fell . CNA discovered resident on his side between toilet and wall...complaint of pain on [DATE]...On [DATE] x-ray was ordered...X-ray results...indicated positive [MEDICAL CONDITION]" Review of the Supervisor/Manager's Investigation report dated [DATE], revealed, "Resident was taken to the toilet by CNA who left resident on the toilet to go assist another resident. Resident then attempted to transfer himself off the toilet". Review of Radiology Report dated [DATE] revealed, "acute impacted subcapital fracture ([MEDICAL CONDITION])". Review of the Falls Reduction Program policy dated [DATE] and revised [DATE] revealed, if resident is determined to be a fall risk, "Place a visual identification of fall risk (yellow dot) on the Resident Care Guide". Review of Resident #103's Resident Care Guide undated, revealed a yellow dot, indicating "high risk for falls". The guide revealed Resident #103 required 1 person assist for transfers. Review of untitled, undated document that was given to this surveyor revealed, "The Yellow Sticker...high risk for fall...Not to be left unattended on the toilet". In an interview on [DATE] at 3:30 p.m., CNA #5 stated on [DATE], "put him (resident) on the toilet, while the resident was on the toilet, Nurse (LPN #6) asked me to put someone else on the toilet so I left the resident alone on the toilet. When asked CNA #5 stated, "if resident is a fall risk, no you are not supposed to leave the resident (on the toilet)" In an interview on [DATE] at 3:46 p.m., LPN #6 stated, "CNA was not in the room when the resident was on the toilet..I saw her leave (Resident #103's) room...I knew (Resident #103) was on the toilet. LPN #6 stated, "...wasn't sure if resident was to be left alone on the toilet, would have to be care planned to not be left alone on the toilet". LPN #6 stated that CNA #5 was disciplined for leaving the resident when he was on the toilet. When asked why the CNA should have stayed with the resident while on the toilet, LPN #6 stated, "If resident was restless on the toilet, then the CNA shouldn't have left him on the toilet...he was restless all day". Review of the Employee Disciplinary Warning dated [DATE], revealed CNA #6 was disciplined, "CNA left (Resident #103) unattended on toilet resulting in fall". ( )

This citation pertains to MI 648 and MI 336. Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive devices for 2 of 4 residents reviewed for falls and accidents (Residents #101 and #103) from a total of 4 sampled residents, resulting in Resident #101 being improperly assessed for transfers and suffering acute blood loss secondary to pectoralis (chest) muscle hemorrhage (uncontrollable loss of blood) and Resident #103 falling and fracturing his hip. Findings include: Resident #101 Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 had clear speech, was usually understood, usually understands, had severe cognitive impairment and required extensive assistance of 2 people for transfers. Review of the Admission Record dated [DATE], revealed Resident #101 had [DIAGNOSES REDACTED]. Resident #101 no longer resided at the facility. Review of the physician order [REDACTED]. Review of the Laboratory Report dated [DATE] at 11:00 a.m., revealed Resident #101 had a blood hemoglobin (part of blood that carries oxygen) level of 7.2 grams/deciliters (g/dL; normal is 12XXX,[DATE].0). Review of the Unusual Occurrence Report dated [DATE], revealed Resident #101 was found to have bruises on the left side of the breast, "...believe this may be related to EZ Stand (device used for lifting and moving residents) transfers". Under the Supervisor/Manager's Investigation section the report revealed Resident #101's bruise on the left breast/chest, right side and under breast "...is consistent (with) EZ Stand transfer sling". Review of the Rehab Services Screening Form dated [DATE], revealed, "(Resident) in am is unsafe transfer in EZ Stand. (Resident) does not stand straight and sling and hands only thing holding her up. Legs are not bearing weight..." Review of the Physical Therapy Discharge Summary dated [DATE], revealed the resident's lower extremities will break/relax suddenly. Review of the Mechanical Lift Transfer Policy dated [DATE], revealed, "Mechanical lifts are used to safety (sic) transfer a resident unable to transfer in any other manner...follow manufacturer's instructions". Review of the EZ Way Stand Operator's Instructions revised [DATE], revealed, "The EZ Way Smart Stand was designed to transfer weight bearing patients..." During an interview on [DATE] at 10:45 a.m., Registered Nurse (RN) #11 revealed that on [DATE] two Certified Nursing Assistants (CNAs) #3 and #12 voiced their concerns about using the EZ Stand with Resident #101. RN #11 stated the CNAs reported that Resident #101 was to weak to use the EZ Stand. RN #11 stated she made therapy aware of this situation by using a rehab screening form. During an interview on [DATE] at 11:00 a.m., CNA #3 stated when Resident #101 was being transferred using the EZ Stand, the sling would be the only thing holding up the resident. CNA #3 stated the bruising on the resident's chest and side that was discovered on [DATE] was from the EZ Stand sling. During an interview on [DATE] at 11:10 a.m., CNA #12 stated that on [DATE] she spoke with RN #11 about it being unsafe to use the EZ Stand for Resident #101. CNA #12 stated she did see bruising on the chest and under the breast and stated it looked like it was from the sling on the EZ Stand. CNA #12 stated if Resident #101 was able to hold herself up on the EZ Stand, Resident #101 would probably not suffered the bruising. During a telephone interview on [DATE] at 9:30 a.m., Family Member (FM) #10 stated she was in to visit Resident #101 on [DATE] and staff was using the EZ Stand to transfer Resident #101. FM #10 stated Resident #101 was not able to help with the transfer and was just "hanging there" on the EZ Stand. FM #10 stated she was upset and spoke with Social Worker (SW) #13 and did not want staff to use the EZ Stand when transferring Resident #101. Review of the ADLs (Activities of Daily Living) Care Plan dated [DATE], revealed the EZ Stand was used until [DATE]. The plan revealed that on [DATE] Resident #101's transfer status was changed to using a Hoyer Lift. Review of the hospital Emergency Department Records dated [DATE], revealed, "(Resident) arrived with multiple bruises all over body. Grossly covering chest, abd (abdomen), bilat (both) arms, hands, fingers and (both) legs...Symptomatic Anemia associated with acute blood loss secondary to pectoralis hemorrhaging bilaterally (both left and right) by recent trauma in EZ lift chair". Review of the hospital CT Scan report dated [DATE], revealed, "...abnormal scattered areas of high density within the pectoralis muscles bilaterally...consistent with areas of hemorrhage." Review of the hospital Physician Discharge Summary dated [DATE], revealed Resident #101 was admitted to the hospital on [DATE] with acute anemia believed secondary to pectoralis muscle hemorrhage. Trauma to chest and underarms was sustained while using EZ chair lift (EZ Stand) at rehab (rehabilitation) facility...On arrival to the hospital, labs revealed (hemoglobin) of 7.2 (g/dL). The summary revealed that Resident #101 deceased on [DATE]. Resident #103 Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #103 had clear speech, was understood, usually understands, had severe cognitive impairment and required extensive assistance of 2 people for transfers Review of the Admission Record dated [DATE], revealed Resident #103 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #103 no longer resided at the facility. Review of the Unusual Occurrence report dated [DATE], revealed Resident #103 was "Observed on the Floor" at 9:00 a.m.. Review of the Admission History and Physical dated [DATE], revealed Resident #103 had a history of [REDACTED]. Review of the SOAP note dated [DATE], revealed, "(Resident #103) was seen in a (follow up) visit. He had a fall, and was sent to (hospital)". Review of the untitled, undated document that was given to this surveyor revealed, "Fall occurred on [DATE]. Resident was assisted to the bathroom by CNA and sitting on the toilet when he attempted to self transfer off the toilet and fell . CNA discovered resident on his side between toilet and wall...complaint of pain on [DATE]...On [DATE] x-ray was ordered...X-ray results...indicated positive hip fracture..." Review of the Supervisor/Manager's Investigation report dated [DATE], revealed, "Resident was taken to the toilet by CNA who left resident on the toilet to go assist another resident. Resident then attempted to transfer himself off the toilet". Review of Radiology Report dated [DATE] revealed, "acute impacted subcapital fracture (fracture of the hip)". Review of the Falls Reduction Program policy dated [DATE] and revised [DATE] revealed, if resident is determined to be a fall risk, "Place a visual identification of fall risk (yellow dot) on the Resident Care Guide". Review of Resident #103's Resident Care Guide undated, revealed a yellow dot, indicating "high risk for falls". The guide revealed Resident #103 required 1 person assist for transfers. Review of untitled, undated document that was given to this surveyor revealed, "The Yellow Sticker...high risk for fall...Not to be left unattended on the toilet". In an interview on [DATE] at 3:30 p.m., CNA #5 stated on [DATE], "put him (resident) on the toilet, while the resident was on the toilet, Nurse (LPN #6) asked me to put someone else on the toilet so I left the resident alone on the toilet. When asked CNA #5 stated, "if resident is a fall risk, no you are not supposed to leave the resident (on the toilet)" In an interview on [DATE] at 3:46 p.m., LPN #6 stated, "CNA was not in the room when the resident was on the toilet..I saw her leave (Resident #103's) room...I knew (Resident #103) was on the toilet. LPN #6 stated, "...wasn't sure if resident was to be left alone on the toilet, would have to be care planned to not be left alone on the toilet". LPN #6 stated that CNA #5 was disciplined for leaving the resident when he was on the toilet. When asked why the CNA should have stayed with the resident while on the toilet, LPN #6 stated, "If resident was restless on the toilet, then the CNA shouldn't have left him on the toilet...he was restless all day". Review of the Employee Disciplinary Warning dated [DATE], revealed CNA #6 was disciplined, "CNA left (Resident #103) unattended on toilet resulting in fall". ( )

This citation pertains to MI 403. This report contains 2 Deficient Practice Statements (A and B) A. Based on observation, interview, and record review the facility failed to provide adequate supervision and prevent the elopement in 1 of 3 sampled residents (Resident #101) reviewed for elopement, from a total of 6 sampled resident, resulting in an Immediate Jeopardy when Resident #101, who had been assessed at risk for elopement, eloped from the facility on [DATE] at approximately 12:44 PM, unbeknownst to facility staff. This deficient practice placed 29 additional residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: According to the facility Elopement and/or Exit-Seeking Management Policy and Procedure, dated [DATE], "...When a resident leaves a safe or secure area, for an unsafe area without assistance or supervision...If elopement is observed...Initiate the Frequent Visual Checks Log...Document in the medical record the elopement incident...update...current plan of care and update the Resident Care Guide..." According to the facility Unusual Occurrence Policy and Procedure, dated [DATE], "...An unusual occurrence is...Elopement (exiting the building not in accordance with the care plan). A resident that wanders into unsafe areas or into harms way...As soon as possible the Supervisor/Manger completes the investigatory tool and takes additional corrective action. He/she reviews and updates the care plan and the Resident Care Guide. According to an Incident/Accident report, entitled Unusual Occurrence, dated [DATE] at 1:30 PM, "(Resident #101) outside in parking lot...Wander guard left ankle not expired and working. Staff feels that when another resident's family left the unit, resident exited out the door with them." Review of Nurse's Notes from [DATE] revealed the following documentation: "(3:00 PM) Incident took place approx. (approximately) (1:30 -1:45). Spouse and physician notified with no new orders. Resident denies pain." There was no other documentation, or a Frequent Visual Checks Log in Resident #101's medical record regarding the elopement on [DATE]. In an interview, on [DATE] at 2:20 PM, Administrator #1 reported surveillance cameras revealed Medical Records staff #2, "went up the stairwell, pushed the code in and entered the unit. (Resident #101) went behind her, down the stairwell (at 12:43 PM), out the fire exit (on the first floor). The alarm sounded. (Environmental Supervisor #3) looked outside and silenced the alarm; (RN/Registered Nurse #4) saw (Resident #101) outside (at 12:50 PM) and redirected (Resident #101) to the building." According to an Employee Disciplinary Warning, dated [DATE], regarding Medical Records staff member #2, "On [DATE] at approx. (approximately) 12:44 PM, you entered the 2 North Unit through the south stairwell. You failed to assure that the door (2 North stairwell) securely closed and alarm reset before moving away from the door." According to an Employee Disciplinary Warning, dated [DATE], regarding Environmental Supervisor #3, "On [DATE] at approx (approximately) 12:45, you responded to exit alarm code on 1 North/South stairwell. You silenced the alarm and observed the area for any residents, however, you failed to announce a Code Green." According to a witness statement, signed by RN/Registered Nurse #10, dated [DATE] at 9:10 AM, "[DATE] at 12:50 PM, I was checking on a resident who was in the day room on 1 South. A family member casually mentioned there was a man outside looking into the parked cars; she further stated he was at the front door when she came in. I visualized an elderly gentleman walking past the parked cars in the admissions parking lot. After excusing myself with the resident, I requested him to take a walk with me. As we left the building via the back door, I observed an elderly gentleman talking with a resident's family member on the pavement as they returned from a walk..." In an interview, on [DATE] at 2:17 PM, RN #10 reported, "I was sitting at 1 South Nurse's Station. There was a guy outside who went past the butt-hut (smoking area), standing with a family member of another resident. He had on long sleeves, fully clothed, with a baseball cap on. I asked him who he was here to see and he said, 'I'm here to get (Resident #101's male relative's name). I think he's in the woods hunting'. RN #10 reported she asked Resident #101 how he got there and he told her he drove his truck, and she asked him to let her look at his watch and she saw he was wearing a wander guard bracelet. RN #10 stated, "It took me awhile to convince him to come with me, and I held his hand and took him in the building (at 12:55 PM). I brought him to his nurse (#4) (around 1:05 PM-1:10 PM); they (the Dementia Unit staff) were not aware (Resident #101) he had gone through the door even though, from what I can guess, 25 minutes had elapsed from the time he left the building. No one came outside looking for him." In an interview, on [DATE] at 2:40 PM, Medical Records staff #2 reported, "I went upstairs, saw (Resident #101) when I opened the door; (Resident #101 is) usually exit seeking. I did not hear the alarm or any kind of Code called." Medical Records staff #2 reported management did not ask her to write a witness statement. On [DATE] at 2:46 PM, Engineering Director/Maintenance Supervisor #5, reported the stairwell doors on the Dementia Unit where Resident #101 exited on [DATE], "Yes, has a wander guard system on them. (Resident #101) slipped in behind a staff member. When the door code is put in, it disables the alarm until the door is shut and reset. There is a 4 second trailer rest ...I can't give you a complete, full answer on that. I'm not sure if it can be tightened (decrease the delay). It has been set at 3.7 seconds in case the elevator goes down and it is needed to get carts, food, and residents down the stairwell and the alarm won't sound ...Visitors exit those stairwells; more casual in and out. I couldn't deny that our solution (educating staff) is inadequate ...It's an old (alarm) system that needs to be updated. The 2 North stairwells need wander alarms." Accompanied by the facility Engineering Director/Maintenance Supervisor #5, surveyor observed there was no wander guard alarm on the stairwell exits on the Dementia Unit. Supervisor #5 stated, "I can see a need for wander guard alarms on the stairwells." On [DATE] at 3:08 PM, Resident #101 was observed walking casually on the 2 North Dementia Unit; he was well groomed, and wearing a plaid dress shirt, dress pants, and black loafers. On [DATE] at 5:00 PM, surveyor observed ? of facility grounds were surrounded with woods and ? by a divided 55/hour highway at the west side of the property. The out buildings (butt-hut) were against the wooded area at the east side of the property. In an interview, on [DATE] at 11:30 AM, in regards to Resident #101's elopement on [DATE], RN #4 reported she was the acting supervisor on [DATE] and stated, "In the absence of (Unit Manager #27), I had to pick up the pieces". In an interview, on [DATE] at 9:17 AM, Unit Manager/Registered Nurse RN #27 reported she was not sure that visual checks were initiated on Resident #101 after his elopement on [DATE] and was unable to provide documentation that they were done. In an interview, on [DATE] at 3:10 PM, DON/Director of Nursing #17 reported there was no video surveillance of the stairwell emergency exit door to confirm that Resident #101 exited the building via that door. Review of Resident #101 ' s Face Sheet and the Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was admitted to the facility on [DATE] and resided on the Dementia Unit. The MDS indicated Resident #101 had a Brief Interview Mental Status (BIMS) score of 4, which indicates severe cognitive impairment. Review of a History and Physical, dated [DATE], revealed Resident #101 had [DIAGNOSES REDACTED]. A review of Resident #101's medical record revealed an Elopement and/or Exit Seeking Behavior Risk Analysis was conducted on [DATE] that documented Resident #101 had a "history of elopement attempts or actual elopement in previous living situation, that he verbalized the desire to leave facility, stayed near exit door waiting to leave, and had a history of [REDACTED]. Per Resident #101's Cog/Beh (Cognitive/Behavioral) Care Plan, dated [DATE], "I have impaired cognition related to dementia which affects my decision making ability, reasoning, judgment and insight. At times I exit seek and therefore wear a wander guard and reside on the 2 North (Dementia) unit for my own safety ...I will not leave my unit or exit the building without staff or family assisting me ...Redirect me to a safe area when I am exit seeking ..." Review of Resident #101's Care Plan, on [DATE], revealed it was not updated with new interventions to prevent elopement. Review of Resident #101's Elopement Care Plan - Initiated on [DATE], "Follow facility policy related to elopement..." On [DATE] at 4:53 PM, Administrator #1 was notified of Immediate Jeopardy that began on [DATE] at 12:44 PM when Resident #101 eloped from the facility unsupervised and immediacy was removed on [DATE]. The facility initiated the following to remove immediacy: 1. On [DATE] at 1:00 PM, Resident #101 returned to the facility by RN #4 assessed by RN #4 and found no injuries. LPN #11 checked functioning of Resident #101 ' s wander guard and found it was functioning properly. 2. On [DATE] at 1:30 PM, on 10 stairwell doors, 8 entrance doors, 1 laundry room door, 1 break room door, 1 south ramp door, 4 exit doors were checked for functionality of alarms. Adjusted hydraulic closer speed in laundry, so it would latch. 3. On [DATE] Resident #101 care plans were reviewed, and an Elopement care plan was initiated for Resident #101 on [DATE]. 4. On [DATE] at 1:30 PM, Policy and Procedure reviewed #ADM-112 on Elopement/and or Exit Seeking Management, dated [DATE]; An Addendum to Policy # ADM-112 was added entitled: Responding To Exit Alarm/Securing of Doors. Instructed staff on Responding to an Exit Alarm: 1) Staff responding to an exit door alarm should inspect the area; 2) Silence alarm; 3) Announce for Code Green; 4) Follow protocol for Code Green; 5) Ensure accurate head count of residents; 6) Secure area. Instructed staff on Secure Doors: 1) Be certain that all doors closed securely behind you; 2) Do not allow any residents to follow you through doors. 5. On [DATE] at 1:35 PM, education began on Elopement/and or Exits Seeking Management and Responding to Exit Alarm/Securing of Doors. As of [DATE], 212 of 221 staff have been completed; remaining staff will not be allowed to work until education is completed. 6. On [DATE] 7:30 AM, Resident #101, and an additional 28 residents known to be at risk for elopement, had wander guard bracelets checked for functioning and expiration, and all were found to be functioning properly. Ongoing, as of [DATE], the facility continues to assess all patients residing in this facility for risk of elopement and exit seeking. 7. On [DATE] at 3:45 PM, contacted a company to install antennas for wander guard systems and terminate access to 2-N from stairwell. 8. On [DATE], Access code was disabled on the two 2-N stairwells. (Egress to the 1st floor from the 2-N stairwell is accessible when the fire alarm goes off.) Signs were installed on the 1-N stairwell door and at the 2-N stairwell door indicating that there is No Access to 2-N. Although the facility removed the Immediate Jeopardy, the facility remained out of compliance at a scope of pattern and severity of no actual harm but the potential for more than minimal harm that is not Immediate Jeopardy as the State had not been able to verify sustained compliance. ( ) This citation pertains to MI 297, MI 344, and MI 408. B. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent falls on 2 of 6 residents (Resident #103 and Resident #104) reviewed for accidents and supervision, from a total of 6 residents, resulting in falls that resulting in injury for Resident #103 and Resident #104. Findings include: In an interview, on [DATE] at 11:10 AM, nurse aide #20 reported the facility was a "no alarm facility". According to the facility Transfer Techniques Policy and Procedure, dated [DATE], "...Transfer from bed to wheelchair - Resident Unable to Assist: 1. Obtain equipment from designated area and bring to bedside..." Resident #103 Review of Resident #103's medical record revealed Resident #103 fell and sustained a right upper arm fracture on [DATE], and Resident #103's Falls Care Plan, initiated [DATE] and updated [DATE], had not been updated after Resident #103 fell on [DATE]. According to an incident/accident report entitled, "Unusual Occurrence", dated [DATE] at 7:45 AM, "(Resident #103)...was observed lying on right side of bed on floor mat, right side lying. Nurse aide present. Knees flexed (semi fetal position). ..Nurse aide stated she had resident sitting on side of bed. Aide was reaching on left side of bed for shoes and socks (crouched somewhat) when (Resident #103) slipped onto floor..." According to Resident #103's Minimum Data Set, dated dated [DATE], Resident #103 was an [AGE] year old woman who was admitted to the facility on [DATE], scored 7 on the Brief Interview for Mental Status, indicating she had severe cognitive impairment, was not steady - only able to stabilize with staff assistance for moving from seated to standing position and for surface-to-surface transfers (transfer between bed and chair or wheelchair), and had [DIAGNOSES REDACTED]. According to Resident #103's CAA (Care Assessment Area) dated [DATE], the Resident #103 had difficulty maintaining siting balance and impaired balance during transitions, and needed extensive assistance (3 persons) for bed mobility. According to a hospital right upper arm x-ray report regarding Resident #103, dated [DATE], "Patient fell ....Findings: Note is made of a spiral fracture involving the proximal (near the shoulder) to mid shaft of the humerus (middle of the upper arm). No significant displacement (out of alignment) is present. Spiral fracture". "Proximal humeral fractures...Usually after a fall on to an outstretched hand from standing height...A Swedish study in 2006 found most (humerus) fractures are caused by a simple fall..." (http://www.patient.co.uk/doctor/Fractured-Humerus.h..." According to a contracted, mobile radiology company radiology x-ray regarding Resident #103's right upper arm, dated [DATE] at 3:15 PM, "Conclusion: 1. Acute (new) nondisplaced long fracture from the mid to the distal shaft of humerus (towards the elbow)". According to a hospital right upper arm x-ray report regarding Resident #103, dated [DATE] at 6:44 PM, "Right Humerus...There is interim callous formation (new bone tissue) of a spiral fracture at the proximal to mid humerus. There is diffuse osteopenia (weakened bone). No new fracture is seen...since the previous study. No new abnormality is seen." According to an Addendum Radiology Report regarding Resident #103's right upper arm, dated [DATE], Radiologist #18 documented, "Addendum (to above x-ray): The fracture extends obliquely from the lateral proximal humeral metaphysis to the medial mid diaphyseal cortex and then laterally to the diaphyseal cortex. Total length of the fracture is approximately 13 cm." In a telephone interview, on [DATE] at 9:12 am, Radiologist #18 (from the contracted mobile radiology company) reported that the discrepancy between the x-ray done by the mobile radiology company Radiologist #18 read on [DATE] at 3:15 PM, and the hospital x-rays dated [DATE] at 6:44 PM, "could be a component with the second fall - I'd say that is possible." Radiologist #18 reported the fall on [DATE] could have been responsible for increasing the length of the fracture to the new area he described as "beginning 10 cm (centimeters) above the elbow." Radiologist #24 stated, "Without the hospital's x-ray to compare it with, it is impossible for me to be sure." In an interview, on [DATE] at 9:10 AM, nurse aide #21 stated she was present on [DATE] at 7:45 AM, when Resident #103 fell . Nurse aide #21 stated she had cared for Resident #103 "since (Resident #103) first came (to the facility)". Nurse aide #21 reported Resident #103 was a "1 person assist before and after this happened (the fall on [DATE])", and stated, "(Resident #103) had the black brace on (her right upper arm) at the time of the fall. That (the fall) was my fault; she's gotten so much weaker. I was squatting down. She should not be a sit-up on the side of the bed; she's not steady enough." I now put her shoes and socks on while she's laying down. (Resident #103) went to the floor on her knees, and rolled to her right, onto her right arm." Review of Resident #103's Resident Care Guide instructed nurse aides that Resident #103 was a 1 person assist for ambulating, 1 person assist for transfers with a walker, was to wear a right arm sling at all times, was to have floor mats and a body pillow "to right side while in bed". On [DATE] at 10:00 AM, accompanied by nurse aide #21, Resident #103 was observed sitting in a wheel chair in her room; she was wearing a red sweatshirt, blue jeans, white socks and white tennis shoes. Resident #103 was alert but did not respond when spoken to. Nurse aide #21 exposed Resident #103's right upper arm and a black inflatable brace was observed wrapped around the mid section of Resident #103's upper arm. Nurse aide #21 stated, "(Resident #103) used to have a sling for her arm, but she doesn't wear it any more." Nurse aide #22 was standing in Resident #103's room and reported she had just transferred Resident #103 from bed to wheelchair by herself. When asked if Resident #103 was able to assist with the transfer, both nurse aide #21 and nurse aide #22 stated, "No. She doesn't put any weight on her legs." Nurse aide #21 and nurse aide #22 stated they use a gait belt and use all their own strength to transfer Resident #103, stating, "(Resident #103) does nothing." Nurse aide #21 reported Therapist #26 taught her how to transfer Resident #103 after she came back from the hospital in May, 2013 with a broken arm. In an interview, on [DATE] at 12:10 PM, OT/Occupational Therapist #26 reported she was the therapist that taught staff how to transfer Resident #103 in May, 2013 after Resident #103 returned from the hospital with a cast on her right arm. OT #26 stated, "(Resident #103) is a really delicate little lady. I wasn't there to assess her legs." OT #26 reported she recommended a "modified one person pivot transfer", because, "When I asked (Resident #103) to stand up, she popped right up." OT #26 stated, "(Resident #103) had no balance problems before or after May, 2013. OT #26 stated, "We don't do anything (assessments) unless we get a Communication Form". OT #26 reported nurse aides should not perform a 1 person/gait belt transfer with residents that are unable to bear weight and assist with the transfer. In an interview, on [DATE] at 9:10 AM, with PT/Physical Therapist #19, she reported she re-evaluated Resident #103's transfer status and changed Resident #103's transfer status to a two person gait belt transfer. PT #19 stated, "(Resident #103) is full weight bearing, she has bilateral lower extremity weakness (both legs); 75% of weight bearing was by me and 25% by (Resident #103). (Resident #103) has tightness in her hamstrings (leg muscles); her legs are 25% flexed (unable to stand up straight). (Resident #103) was walking a few feet before the broken arm, but can not walk at all now". Resident #104 Review of Resident #104's face sheet revealed he was originally admitted to the facility on [DATE]. Review of Resident #104's Minimum Data Set, dated dated [DATE], revealed Resident #104 scored 2 on the Brief Interview for Mental Status, indicating he had severe cognitive impairment, needed extensive assistance (3 persons) with transfers, was not steady with surface-to-surface transfers, had 2 falls with no injury since his prior assessment, and had [DIAGNOSES REDACTED]. According to a hospital Discharge Summary, dated [DATE], "admitted /Time: [DATE] 0611 (6:11 AM)...(Resident #104) is a [AGE] year-old man who fell from standing height. He sustained rib fractures and a left foot fracture..." Review of Resident #104's chest x-ray, dated [DATE], revealed left lower lobe pneumonia. Review of Resident #104's Medical Record, revealed he had 8 documented falls at the facility in 2013: [DATE] at 9:45 PM - unwitnessed fall in Resident #104's room. [DATE] at 3:50 AM - unwitnessed fall in Resident #104's room. [DATE] at 7:30 PM - unwitnessed fall in room near Resident #104's bathroom/floor wet. [DATE] at 2:30 PM - unwitnessed fall in day room. [DATE] at 4:45 PM - witnessed fall in dining room. [DATE] at 7:30 PM - unwitnessed fall in Resident #104's room near bathroom/left unattended/floor wet/sustained serious injuries (see below). [DATE] at 4:20 PM - unwitnessed fall in room. [DATE] at 2:00 PM - unwitnessed fall in room Review of Resident #104's Falls Care Plan, dated [DATE], revealed, "Falls: I have become more unsteady on my feet and I don't have the best safety awareness anymore. When I was at home with my wife I started falling." On [DATE], Resident #104's Falls Care Plan was updated with, "Please keep educating and reminding me that I need to be asking for help with transferring an ambulating...When I am in my room unattended please come and check on me at least every hour to make sure my pathway remains clear. I am very noncompliant with transfers and ambulations and I don't want to fall". Resident #104's Fall Care Plans revealed the frequency of checks on Resident #104 had not been increased, interventions did not include interventions such as personal alarms, perimeter mattress, fall mats, or bedside commode, and the Fall Care Plans were not updated after Resident #104's fell on [DATE]. Resident #104's Falls Care Plan did not specify where to place his wheelchair when Resident #104 was in bed. Review of facility Incident/Accident reports, entitled Unusual Occurrence, revealed no Unusual Occurrence reports for Resident #104's falls on [DATE], and [DATE]. In an interview, on [DATE] at 9:17 AM, Unit Manager/Registered Nurse RN #27 reported there was no tracking system in place to monitor the number of falls or the interventions put in place to prevent falls. RN #27 reported there had been no increase in the monitoring Resident #104 because, "(Resident #104) is very mobile on his own". RN #27 also reported, "He (Resident #104) has had a lot of falls in his room; he has taken a rapid decline (since [DATE]). (Resident #104's) wife is very concerned." RN #27 reported, "If the front office doesn't have an Occurrence Report, it wasn't done." RN #27 reported that Resident #104 sustained a rib fracture and a toe fracture from one of the above falls." In an interview, on [DATE] at 10:32 AM, regarding Resident #104's 9 falls and lack of care planned interventions, NHA/Nursing Home Administrator #1 stated, "Besides one hour checks and putting him closer to the nurse's station, what are we supposed to do?" Immediately following, surveyor went to Resident #104 room #202 and measured the distance between room #202 and the nurse's station. Resident #104's room was at the end of the hallway, approximately 50 feet from the nurses' station. On [DATE] at 10:32 AM, Resident #104 was observed laying in bed with a hard boot/brace on his left foot; there were no fall mats, perimeter mattress, or alarms, but there was a bedside commode outside of Resident #104's bathroom door. Resident #104 did not reply when spoken to. In an interview, on [DATE] at 11:45 AM, Unit Manager/Registered Nurse RN #27 presented the Daily Hours Rounds form, dated [DATE] for 2 West (the unit that Resident #104 resided); ,[DATE] hourly rounds were not documented as being done. RN #27 stated, "Sometimes they (nurse aides) forget to chart". In a telephone interview, on [DATE] at 11:20 AM, nurse aide #36 reported she was assigned to Resident #104 on [DATE] at 7:30 PM. Nurse aide #36 stated, "I was across the hall putting another resident in bed. I heard (Resident #104) yelling. I went to check on him; he was on the floor. I could tell he was in pain, moaning, grimacing, and breathing heavy; he couldn't take a full, deep breath. Resident #104) was in bed when I last saw him...45 minutes at most. I usually put (Resident #104's wheelchair in the bathroom because he likes to self transfer". When asked if Resident #104's Care Guide instructed staff to place Resident #104's wheelchair in the bathroom, nurse aide #36 stated, "I don't know", and reported no one instructed her to do so. Nurse aide #32 reported, "I think we do need the alarm for him; I do". Nurse aide #32 reported, "Recently, (Resident #104) had been trying to self transfer, more lately, in the past week or so. I try to check on him every time I walk by his room". Nurse aide #3 reported although she tries to check on Resident #104, "at least every 15 minutes now. I don't think that's on (Resident #104's) Care Guide". Review of Resident #104's current Care Guide revealed, "I am sometimes non-compliant with T/F (transfers); Every 1 hr (hour checks to clear pathways for non-compliant T/F...bathroom light on at night"; the use of a bedside commode was not on Resident #104's Care Guide. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS AND MONITOR SKIN BREAKDOWN DURING EARLY PHASES OF ADMISSION FOR 1 OF 2 RESIDENTS (#14) REVIEWED FOR PRESSURE ULCERS FROM A TOTAL 24 SAMPLED RESIDENTS, RESULTING IN A STAGE 3 COCCYX PRESSURE ULCER ASSOCIATED WITH SIGNIFICANT PAIN. FINDINGS INCLUDE: ACCORDING TO THE physician's orders [REDACTED]. COMPREHENSIVE NUTRITIONAL assessment dated [DATE] REFLECTED RESIDENT #14 HAD "...A FALL AT HIS ASSISTED LIVING AND WAS LYING IN BETWEEN FURNITURE FOR 10 HOURS...HAD AN ACUTE CARDIAC EVENT AND SPINAL CORD DAMAGE...HAS "MIAMI" COLLAR IN PLACE...IS ON MECHANICAL SOFT DIET AND IS BEING ASSISTED WITH MEALS FROM STAFF...EATING GREAT SINCE ARRIVAL...HAS SOME EXCORIATED BUTTOCKS BUT NO PRESSURE AREAS...PROTEIN LEVELS ARE LOW..." THE ADMISSION SKIN ASSESSMENT, COMPLETED BY THE LICENSED NURSING STAFF AND DOCUMENTED WEEKLY, DATED 1/18/13 REFLECTED RESIDENT #14 HAD REDDENED , BLANCHABLE AND EXCORIATED AREA OVER COCCYX (TAIL BONE). THE NEXT SKIN ASSESSMENT ENTRY WAS DOCUMENTED ON 1/23/13 (6 DAYS FROM THE IST ONE) REFLECTED RESIDENT #14 STILL HAD BLANCHABLE REDDENDA AREA OVER COCCYX. THE THIRD SKIN ASSESSMENT ENTRY WAS DOCUMENTED ON 2/6/13 (15 DAYS FROM THE 2ND ONE) REFLECTED RESIDENT #14 HAD BLANCHABLE REDDENED RAW AREA OVER COCCYX. THE TOTAL SCORE FOR BRADEN SCALE-FOR PREDICTING PRESSURE SCORE RISK: LOWER THE SCORE, THE HIGHER THE RISK, DATED 1/18/13 THROUGH 4/25/13 WAS 14, INDICATING THE RESIDENT WAS AT MODERATE RISK. THE BRADEN SCORE PERFORMED BY THE WOUND CARE NURSE, (STAFF "E") DATED 4/16/13 WAS 12, INDICATING THE RESIDENT WAS AT HIGH RISK. THE SKIN CARE PLAN INITIATED 1/31/13 REFLECTED RESIDENT #14 WAS AT RISK FOR DEVELOPING A PRESSURE ULCER DUE TO A HISTORY OF PRESSURE ULCERS, NEED FOR EXTENSIVE ASSISTANCE WITH TURNING AND REPOSITIONING, URINARY INCONTINENCE AND USE OF NARCOTIC USE. THE ADDITIONAL CONTRIBUTING FACTORS INCLUDED IMPAIRED SENSORY RECEPTION OF LOWER BODY AS WELL AS [DIAGNOSES REDACTED]. THE INTERVENTIONS INCLUDED 1) ADMINISTER TREATMENT AS ORDERED, 2) ALTERNATING PRESSURE MATTRESS, 3) TURN AND REPOSITION EVERY 2 HOURS IN BED, EVERY HOUR IN CHAIR, 4) AIR BOOTS WHILE IN BED, 5) DAILY SKIN CHECKS BY NURSE AIDES, 5) CHANGE BRIEF WITH PERI-CARE EVERY 2 HOURS, 6) PRAFO BOOT, 6) WEEKLY SKIN ASSESSMENT, 7) FLOAT HEELS IN BED. THE ADDED INTERVENTION DATED 4/12/13 INCLUDED THE RESIDENT TO BE REMINDED OF TURNING BENEFITS. THE NURSE'S NOTES DATED 1/18/13 THROUGH 1/30/13 REFLECTED RESIDENT #14 WORE "MIAMI J" COLLAR AT ALL TIMES, COMPLAINED SEVERE PAIN IN HIS BACK/NECK, RECEIVED SCHEDULED NARCOTIC, AND HE FREQUENTLY ASKED TO RE REPOSITIONED OR GET OUT OF BED. RESIDENT WAS ASSISTED TO BE UP IN A "BRODER" CHAIR PER "HOYER," AND OFTEN ANXIOUS DUE TO NICOTINE DESIRE. RESIDENT #14 WAS SENT TO hospital on [DATE] FOR 8 HOURS FOR COMPLAINT OF CHEST PAIN. THE ONLY PERTINENT SKIN DOCUMENTATION WAS DATED 1/26/13, STATING " CLEAN BUTTOCKS WITH SAF CLENS, APPLY [MEDICATION NAME] SIGNAL TO DENUDED AREA ON BUTTOCKS, USE BARRIER WIPE AROUND EDGES FOR ADHESIVE..." THE NURSES NOTES 2/1/13 THROUGH 2/28/13 REFLECTED RESIDENT #14 HAD RESPIRATORY DISTRESS AS WELL AS URINARY ISSUES, REQUIRING ANTIBIOTIC AND INSERTION OF INDWELLING URINARY CATHETER. THE PERTINENT SKIN DOCUMENTATION WAS DATED 2/9/13, STATING "...CHANGED DRESSING TO BUTTOCK RELATED TO IT WAS FALLING OFF...BUTTOCK STILL EXCORIATED/RED/OPEN..." ANOTHER PERTINENT NURSING NOTE RELATED TO SKIN WAS DATED 2/15/13, STATING "... BUTTOCK DRESSING CHANGED AS PREVIOUS DRESSING NOT STAYING INTACT. THE RESIDENT HAD HIS BRODA CHAIR CHANGED TO HIGH-BACK WITH "ROHO" CUSHION ON 2/27/13 AND HE WAS ALLOWED TO HAVE HIS "MIAMI J" COLLAR OFF WHILE IN BED. THE "WOUND ASSESSMENT DETAILS REPORT," A DOCUMENT CONTAINED WOUND MEASUREMENTS AS WELL AS WOUND CHARACTERISTICS, DATED 2/15/13 REFLECTED RESIDENT #14 DEVELOPED A STAGE 2, FACILITY ACQUIRED PRESSURE ULCER ON HIS COCCYX WITH MEASUREMENT OF 3.90 X 4.80 X 0.2 CM. THE WOUND BED HAD 40 % SLOUGH, 60 % BRIGHT BEEFY RED GRANULATION TISSUE. THE WOUND EDGES WERE RED AND MACERATED. DESPITE THE EVIDENCE THAT THE RESIDENT HAD AN EXCORIATED BUTTOCKS AND THE STAFF WERE CHANGING DRESSINGS THIS WAS THE FIRST WOUND DOCUMENTATION WITH MEASUREMENT RESIDENT #14 HAD. THE PRESSURE ULCER INDICATED A LARGE AREA WITH SIGNIFICANT DEPTH, ALREADY AT STAGE 3. THE SUBSEQUENT WOUND ASSESSMENT DETAILS AS FOLLOWS: 2/20/13 3.8 X 4.8 X .20 CM 50 % SLOUGH 3/7/13 3.7 X 4.8 X .20 50 % SLOUGH 3/27/13 3.2 X 4.0 X .10 50 % SLOUGH 4/4/13 3.2 X 4.2 X .10 75 % SLOUGH 4/17 13 2.9 X 4.5 X .10 85 % SLOUGH 4/24/13 4.9 X 4.7 X .10 60 % SLOUGH 5/8/13 4.3 X 4.0 X .10 80 % SLOUGH 5/22/13 3.8 X 3.8 X .10 80 % SLOUGH 5/30/13 3.6 X 3.7 X .10 60 % SLOUGH 6/6/13 3.5 X 2.0 X .10 50 % SLOUGH 6/19/13 2.9 X 1.5 X .10 40 % SLOUGH ALL OF THESE WOUNDS WERE LABELED AS A STAGE 2 (PARTIAL THICKNESS LOSS OF DERMIS PRESENTING AS A SHALLOW OPEN ULCER WITH A RED OR PINK WOUND BED, WITHOUT SLOUGH) AND AS HAVING LIGHT SEROSANGUINEOUS EXUDATE. ON 6/26/13 AT 2:00 P.M., THE WOUND NURSE, (STAFF "E") WAS ASKED WHY SHE HAD LABELED THESE WOUNDS AS A STAGE 2 RATHER THAN STAGE 3 (FULL THICKNESS TISSUE LOSS, SUBCUTANEUS FAT MAY BE VISIBLE BUT BONE, TENDON OR MUSCLE IS NOT EXPOSED. SLOUGH MAY BE PRESENT BUT DOES NOT OBSCURE THE DEPTH OF TISSUE LOSS/PER MINIMUM DATA SET DEFINITION). STAFF "E" WAS NOT ABLE TO PROVIDE CLEAR DEFINITION OF STAGE 2 PRESSURE ULCER. STAFF "E" WAS ASKED WHAT RISK FACTORS RESIDENT #14 HAD IN DEVELOPING PRESSURE ULCER. STAFF 'E" STATED THE RESIDENT WAS PARALYZED FROM WAIST DOWN, HAD POOR NUTRITION AND HE WAS RESISTANT WITH POSITIONING, FAVORING TO LIE ONLY ON HIS RIGHT SIDE. ON 6/27/13 AT 8:45 A.M., RESIDENT #14'S POSITIONING ISSUE WAS CONFIRMED BY THE NURSE AIDE, (STAFF "H"), STATING THE RESIDENT PREFERRED TO LIE ON HIS RIGHT SIDE EVEN WITH THE LOCATION OF THE BED WAS CHANGED TO FACE EITHER WINDOW OR WALL. STAFF "H" ADDED THAT THE RESIDENT LAID IN BED MORE THAN UP IN A WHEELCHAIR. ON 6/26/13 AT 11:30 A.M., THE DRESSING CHANGE TO RESIDENT #14'S COCCYX WOUND WAS OBSERVED IN HIS ROOM. THERE WERE 3 REGISTERED NURSES (STAFF "E," "F," AND "G") PRESENT. STAFF "E" REMOVED THE BRIEF FROM THE RESIDENT AND ROLLED IN UNDER THE RESIDENT'S BUTTOCK WHILE STAFF "G" HOLDING THE RESIDENT ON HIS SIDE. STAFF "F" WAS TAKING PICTURES OF THE WOUND AFTER STAFF "E" CLEANED THE WOUND AND MEASURED. THE COCCYX PRESSURE ULCER WAS LOCATED SLIGHTLY TOWARD TO LEFT FROM THE CENTER AND HAD OBLONG SHAPE WITH 50 % LOOSE YELLOW SLOUGH AND 50% RED GRANULATED TISSUE. THE WOUND MEASURED 2.2 X 1.0 X UNKNOWN DEPTH. THE SURROUNDING WOUND TISSUE WAS DARK RED WITH EXTENSIVE MACERATION. ALTHOUGH THE DRESSING CHANGE WAS DONE UNDER CLEAN TECHNIQUE RESIDENT #14'S COCCYX WOUND WAS CONTAMINATED WITH INCONTINENCE PAD AND OUTER PART OF BRIEF DURING THE PROCEDURE AFTER CLEANSING THE WOUND AND BEFORE APPLYING WOUND OINTMENT ([MEDICATION NAME]) AND COVERED WITH [MEDICATION NAME] FOAM, BECAUSE STAFF "G" LET THE RESIDENT DOWN TO BED. BOTH STAFF "G" AND THE RESIDENT COULD NOT KEEP LONG PERIOD OF LYING SIDE POSITION. ON 6/27/13 AT 2:15 P.M., THE WOUND NURSE, (STAFF "E") STATED RESIDENT #14 WAS NOT SEEN BY A WOUND CARE PHYSICIAN AND SHE HAD WORKED AS A WOUND NURSE FULL TIME FOR LAST 2 MONTHS, ALTHOUGH SHE HAD AN EXPERIENCE WITH WOUND CARE FOR 2 YEARS PRIOR TO THAT. STAFF "E" STATED SHE WAS NOT YET CERTIFIED AS A WOUND NURSE. ON 6/27/13 AT 2:00 P.M., THE NUTRITIONAL STATUS RELATED TO THE DEVELOPMENT OF PRESSURE ULCER OF RESIDENT #14 WAS DISCUSSED WITH REGISTERED DIETITIAN, (STAFF "X"). STAFF "X' STATED THE RESIDENT WEIGHT HAD SIGNIFICANT DECLINE DURING EARLY PHASE OF HIS ADMISSION (FROM 212.4 POUNDS ON 1/18/13 TO 197.8 POUNDS/NO DATE WRITTEN THEN 194.1 POUND ON 2/11/13) DUE TO SEVERE PAIN ISSUES AND ADJUSTMENT PROBLEMS. HOWEVER, FOR THE PAST 3 MONTHS (FROM MARCH TO JUNE) RESIDENT #14 HAD STABILIZED, MAINTAINING HIS IDEAL BODY WEIGHT (186-188 POUNDS). THE PERTINENT LABORATORY VALUES ([MEDICATION NAME] WAS AT 2.9 G/DL ON 1/18/13, GLUCOSE 97 MG/DL ON 2/6/13) RELATED TO WOUND HEALING WAS SLIGHTLY IMPROVED TO [MEDICATION NAME] LEVEL OF 3.1 G/DL ON 2/6/13. ON 6/24/13 AT 3:00 P.M., RESIDENT #14 WAS OBSERVED LYING ON HIS RIGHT SIDE AWAKE IN HIS ROOM. THE RESIDENT STATED HE WAS NOT VERY COMFORTABLE AND NEEDED HIS TRUNK TO BE SHIFTED MORE TOWARD TO THE LEFT SIDE. RESIDENT #14 WAS ASKED HOW HE ACQUIRED HIS BED SORE. HE STATED, " I MAY HAVE BEEN SITTING TOO LONG IN MY CHAIR." THE RESIDENT WAS THEN ASKED WHETHER HE SHIFTED HIS BUTTOCKS WHILE HE WAS SITTING IN HIS WHEELCHAIR. HE SAID, " I TRIED, BUT THERE WAS SOME KIND OF BUTTON TOUCHING MY BUTTOCK AND HURT SO I COULD NOT SHIFT MY BOTTOM." HE WAS ASKED WHETHER THE STAFF SHIFTED HIS BUTTOCKS AND HE SAID, "NO." ( )

This citation pertains to intake number M 8143 Based on observation, interview, and record review the facility failed to prevent the development of a pressure sore in 1 of 10 sampled resident (#102), from a total sample of 10 residents, resulting in Resident #102 developing a facility acquired pressure ulcer. Findings include: According to the Face Sheet Resident #102 was admitted to the facility on [DATE]. The Minimum Data Set ((MDS) dated [DATE], revealed Resident #102 was a [AGE] year old female with [DIAGNOSES REDACTED]. Review of the "Braden Scale For Predicting Pressure Sore Risk" dated 12/5/12, revealed Resident #102 scored "12". The Braden Scale score key indicated a score of "12" placed Resident #102 at "High Risk for Pressure Sores. This form indicated the "mobility" Resident #102 to be "very limited". Process Guidelines for the Prevention and Management of Pressure Ulcers, dated 2/24/2003, #12 indicated "Staff should initiate pressure reduction measures consistent with basics principles. If staff believe that a resident's ability or unwillingness to cooperate prevents them from consistently achieving or maintaining an effective change in position or pressure reduction, they should try to address these limitations and document related efforts". The Admissions Care Plan dated 12/5/12, indicated Resident #102 was to be repositioned (turned) every 2 hours while in bed and repositioned every 1 hour when up in a chair. There were no further interventions noted. Review of the Process Guidelines for the Prevention and Management of Pressure Ulcers dated 2/24/2003, #11 reads, "Did the staff address factors related to the development or healing of a pressure ulcer?". "Staff should address wound-related factors such as pain, decreased mobility, dependency for eating, continence and pressure reduction. At or near the time that an ulcer developed or was being treated, staff should identify and document factors that they believe affected their ability to prevent or heal a pressure ulcer". Review of the Admission Skin Assessment sheet dated 12/5/12, revealed Resident #102 had no identified skin problem. Review of the Admission Care Plan #20 "Skin Care/ Pressure Ulcer Risk" dated 12/5/12, revealed Resident #102 was to have weekly skin assessments by a nurse. Review of the MDS dated [DATE], under section "M" #210, revealed Resident #102 did not have a pressure ulcer at Stage 1 or higher. Review of the Nurse's Notes dated 12/17/12, at 3:00 AM revealed "See new Sensicare Order". Review of the "Licensed Nurse Weekly Hydration And Skin Assessment" form revealed on 12/22/12, an open area on the coccyx was discovered. The form revealed Resident #102 had an "open red area". Review of the Nurses Notes dated 12/22/12, revealed there was no documentation regarding Resident #102's open area on the coccyx. Review of the facility Wound Management Policy with a revised date of 8/31/10, revealed #6 documented "Report any abnormal findings to the physician and Certified Dietary Manager or Registered Dietician". and, "Initiate treatment according to physician guidance". Review of the Document Checklist: Process Guidelines for the Prevention and Management of Pressure ulcers dated 2/24/2003, #16 reads, "Did the staff adjust interventions based on the wound's evolution, underlying causes, medical complications, the resident's overall conditioned prognosis, and other related factors". Review of the facility Wound Management Policy revised 8/31/10 , #7.1 indicated "Initiate interdisciplinary plan of care". Process #1.2 indicated "Develop an individualized plan of care based on assessment". Review of the Wound Assessment Details Report dated 12/27/12, revealed that Resident #102's wound was discovered on 12/22/12. This form indicated the Dr. was notified of the wound on 12/27/12, at 6:45 PM. Review of the Admission Care Plan dated 12/5/12, for Resident #102, #20 "Skin Care" section did not indicate new interventions were implemented when Sensicare was ordered on [DATE]. No change of interventions were documented when the wound on the coccyx progressed to an open wound on 12/22/12. On 12/28/12 the Care Plan was updated to include an Alternating Pressure Mattress. Director of Nursing (DON) #2 provided a handwritten time line dated 2/7/13, regarding Resident #102. In an interview on 2/7/13 at 3:30 PM, DON #2 stated the physician acknowledgement of notification of the change of skin condition was his signature for the Sensicare order on 12/17/12 and his signature of the Doctor's (Dr. s) Order written 12/22/13, changing treatment to that of an open coccyx wound. Review of the medical record revealed the Dr.s Order for Resident #102 on 12/17/12, was signed by the physician but not dated and the Dr.s Order on 12/22/12, for the change of treatment to that of an open wound was signed by the Dr. 11 days later on 1/2/13. Review of the handwritten time line dated 2/7/13, provided by DON #2 revealed "unavoidable risk factors" for Resident #102 that included "poor positioning choices". The written time line provided by DON #2 indicated Resident #102 was not compliant of turning and repositioning. Review of the Nurses Note Dated 12/17/12, at 6:00 AM states that Resident #102 was "pleasant and cooperative with care". Review of the medical record revealed no documentation to indicate that Resident #102 was non-compliant with care or any documentation indicating Resident #102 was educated regarding potential health outcomes of DON #2's said non-compliant behaviors.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO MONITOR/PREVENT THE DEVELOPMENT FOR 2 OF 3 RESIDENTS REVIEWED WITH PRESSURE ULCERS (#10 AND #11) FROM A TOTAL OF 24 SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF AVOIDABLE UNSTAGEABLE PRESSURE ULCERS AT THE RIGHT HEEL (#10) AND THE DEVELOPMENT OF A STAGE #2 (PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS, DERMIS, OR BOTH) PRESSURE ULCER AT THE COCCYX AND UNSTAGEABLE PRESSURE ULCER TO LEFT HEEL (#11). FINDINGS INCLUDE: ACCORDING TO THE AUGUST 2012 physician's orders [REDACTED]. RECORD REVIEW OF THE NURSE'S NOTES REFLECTED RESIDENT #10 DEVELOPED AN UNSTAGEABLE PRESSURE ULCER ON 4/19/12. THE FACILITY'S BRADEN SCALE (FOR PREDICTING PRESSURE SORE RISK) OBSERVED IN THE CHART DATED 3/19/12 REFLECTED THE RESIDENT HAD A SCORE OF 15 (MILD RISK 15-18). THE FACILITY'S PRESSURE ULCER (PU) CARE PLAN FOR RESIDENT #10 WAS INITIATED ON 9/26/11, REFLECTED THE RESIDENT'S INABILITY TO REPOSITION HERSELF INDEPENDENTLY, AND A HISTORY OF PRESSURE ULCERS LISTED UNDER THE FOCUS OF THE CARE PLAN. ACCOMPANYING INTERVENTIONS FOR THE FOCUS INCLUDED THE FOLLOWING: STAFF WILL CHECK MY SKIN DAILY DURING CARE AND REPORT ANY PROBLEMS TO THE NURSE IMMEDIATELY, THE NURSE WILL CHECK MY SKIN WEEKLY AND DOCUMENT WHERE APPROPRIATE AND TURN EVERY TWO HOURS WHEN IN THE BED AND EVERY ONE HOUR IN THE WHEELCHAIR. THE WEEKLY SKIN ASSESSMENT (REVIEWED, SIGNED AND DATED BY LICENSED PRACTICAL NURSE "CC") AND NURSE'S NOTES DATED 4/15/12 REFLECTED THE RESIDENT HAD NO SKIN CONCERNS LOCATED AT THE RIGHT HEEL AREA. HOWEVER, 4 DAYS LATER THE NEXT NURSING NOTE ENTRY DATED 4/19/12 AT 4:00 AM REFLECTED THE FOLLOWING: "RES (RESIDENT) WAS OBSERVED WITH AN APPROXIMATELY 3 X 2.5 CM (CENTIMETER) ESCHAR-APPEARING WOUND ON R (RIGHT) HEEL (L (LEFT) SIDE), ROUNDED IN SHAPE. NO CURRENT DRAINAGE. AIDE REPORTED SCANT PUS-LIKE STAIN ON BED-SHEET, TENDER TO PALPATION. PERIMETER OF WOUND BED IS MACERATED AND HARD TO PALPATION. THERE IS A THIN VIOLET-COLORED RING AT PERIMETER OF MACERATION. WOUND WAS CLEANED WITH SAF-CLENS AND COVERED WITH VERSUA & WRAPPED IN KERLIX". THE FACILITY'S "WOUND ASSESSMENT DETAILS REPORT" DATED 5/4/12 AT 2:18 PM REFLECTED THE WOUND AS UNSTAGEABLE CLOSED WITH 70% [MEDICATION NAME] TISSUE AND 30% NECROTIC TISSUE, MEASURING 2.00 LENGTH X 1.80 WIDTH CM. THE ESCHAR NOTED ON 4/15/12 PER NURSES NOTES PROGRESSED TO AN UNSTAGEABLE PRESSURE ULCER BY 5/4/12. THE 15 TH EDITION OF TABER'S CYCLOPEDIC MEDICAL DICTIONARY REFLECTED ESCHAR AS A SLOUGH, AND SLOUGH AS DEAD MATTER OR NECROSED TISSUE SEPARATED FROM LIVING TISSUE OR AN ULCERATION. THE 7 TH EDITION PERRY & POTTER'S CLINICAL NURSING SKILLS & TECHNIQUES REFLECTED AN UNSTAGEABLE PRESSURE ULCER AS THE FOLLOWING: FULL-THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE ULCER IS COVERED BY SLOUGH (YELLOW, TAN, GRAY, GREEN, OR BROWN) AND/OR ESCHAR (TAN, BROWN, BLACK) IN THE WOUND BED. UNTIL ENOUGH SLOUGH AND/OR ESCHAR IS REMOVED TO EXPOSE THE BASE OF THE WOUND, THE TRUE DEPTH, AND THEREFORE STAGE, CANNOT BE DETERMINED. THE RIGHT HEEL WAS OBSERVED ON 8/15/12 AT 1:20 PM, AND WAS FOUND TO BE HEALED. ON 8/16/12 AT 3:00 PM RESIDENT #10'S PRIMARY DOCTOR/MEDICAL DIRECTOR AND THE NURSE MANAGER (NURSE "Q") WERE INTERVIEWED. THEY WERE ASKED WHAT OCCURRED DURING THE TIME BETWEEN 4/15/12 AND 4/19/12 THAT CAUSED THE RESIDENT TO DEVELOP AN UNSTAGEABLE PRESSURE ULCER. NURSE "Q" REVEALED SHE WAS NOT EMPLOYED AT THE FACILITY DURING THAT TIME. THE NURSE'S NOTES, AND PRESSURE CARE PLAN WAS PRESENTED TO THE DOCTOR AND NURSE "Q" WHICH REFLECTED DAILY AND WEEKLY SKIN CHECKS. THE PHYSICIAN ENCOURAGED NURSE "Q" TO REVIEW THE RESIDENT'S RECORDS FOR INFORMATION THAT WOULD EXPLAIN WHAT CAUSED THE PRESSURE ULCER. STAFF "Q" STATED SHE WOULD REVIEW THE RECORDS AND FOLLOW UP WITH AN EXPLANATION. ON 8/17/12 AT APPROXIMATELY 10:45 AM NURSE "Q" REVEALED SHE DID NOT HAVE ANY DOCUMENTATION TO JUSTIFY THE CAUSE OF THE PRESSURE ULCER DEVELOPMENT, FROM NO SKIN BREAKDOWN TO ESCHAR WITHIN 4 DAYS. ON 8/17/12 AT 11:52 AM NURSING ASSISTANT (STAFF "P") WAS ASKED IF SHE HAD RECALLED OR VIEWED RESIDENT #10'S HEEL PRESSURE ULCER, AND WHAT STEPS WERE TAKEN DURING A DAILY SKIN CHECK. STAFF "P" REPLIED THAT SHE DID NOT GET TO SEE THE PRESSURE ULCER, AND WITH DAILY SKIN CHECKS SHE LOOKED FOR CHANGES IN THE SKIN AND THAT SHE LOOKS AT FEET TOO. ALSO, THAT DAILY SKIN CHECKS WERE USUALLY DONE IN THE MORNING. LASTLY, ON SKIN ASSESSMENT DAY THE NURSE WOULD COME IN AND ASSESS THE SKIN HEAD TO TOE WITH SHOWER. ON 8/17/12 AT 11:52 AM NURSING ASSISTANT (STAFF "AA") WAS ASKED WHAT STEPS WERE TAKEN DURING A DAILY SKIN CHECK. STAFF "AA" REPLIED THAT SHE LOOKED AT FEET, HEELS, BOTTOM, ELBOWS, SHOULDERS, ALL OVER AND IF ANYTHING IS ABNORMAL WE WOULD GO GET THE NURSE TO LOOK AT IT RIGHT AWAY. ON 8/17/12 AT 11:52 AM NURSING ASSISTANT (STAFF "O") WAS ASKED WHAT STEPS WERE TAKEN DURING A DAILY SKIN CHECK. STAFF "O" REPLIED THAT SHE WOULD LOOK TO SEE IF THE RESIDENT HAD ANYTHING NEW ON THEIR BODY. ALSO, THAT SHE LOOKED EVERYWHERE WHEN SHE GOT THE RESIDENT DRESSED, IF ANYTHING JUMPED OUT AT HER, AND LOOK AT ARMS, LEGS, FACE, EVERYWHERE. LASTLY, SHE WOULD LOOK AT THE RESIDENT'S FEET WHEN SHE WOULD PLACE SOCKS ON. ON 8/17/12 AT APPROXIMATELY 10:45 AM NURSE "Q" REVEALED SHE HAD NO DOCUMENTATION TO JUSTIFY THE DEVELOPMENT OF THE UNSTAGEABLE PRESSURE ULCER FOR RESIDENT #10. ( ) ACCORDING TO THE 7/10/12 FACE SHEET RESIDENT #11 WAS A [AGE] year OLD MALE admitted TO THE FACILITY 7/6/12 WITH [DIAGNOSES REDACTED]. ACCORDING TO THE ADMISSION MDS (MINIMUM DATA SET, AN ASSESSMENT TOOL) DATED 7/20/12, RESIDENT #11 HAD DIFFICULTY BEING UNDERSTOOD AND WAS DIFFICULT TO UNDERSTAND. RESIDENT #11 WAS ALSO SEVERELY COGNITIVELY IMPAIRED WITH A BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF -0- OF A POSSIBLE OF 15. ACCORDING TO AN "UNUSUAL OCCURRENCE" INCIDENT REPORT DATED 7/20/12 AT 11:00 PM, RESIDENT #11 WAS OBSERVED ON THE FLOOR NEXT TO HIS BED, IN HIS ROOM. THE "SUPERVISOR / MANAGER'S INVESTIGATION", DATED 7/23/12, UNDER THE QUALITY IMPROVEMENT ROOT CAUSE ANALYSIS CONCLUSION, REFLECTED THAT RESIDENT #11 WAS "LETHARGIC AND RESTLESS" AFTER BEING AWAKENED TO CHECK FOR INCONTINENCE AND TURNED AT 10:40 PM. THE INTERVENTIONS IMPLEMENTED INCLUDED: NOT TO AWAKEN FOR CHECKING AND CHANGING BETWEEN 12 MIDNIGHT AND 6 AM. ONLY HOURLY CHECKS (TO OBSERVE FOR RESTLESSNESS, INDICATING A NEED FOR CHANGING OR ASSISTANCE). A REVIEW OF THE CARE PLANS DATED 8/14/12 REFLECTED THE SAME INTERVENTIONS / APPROACHES. A REVIEW OF THE ADMISSION CARE PLANS DATED 7/6/12 REFLECTED NO OPEN AREAS. INTERVENTIONS INCLUDED: TO TURN AND REPOSITION EVERY 2 HOURS WHILE IN BED, TO CHANGE POTION EVERY 1 HOUR WHILE UP IN A WHEELCHAIR, AND TO FLOAT THE HEELS WHEN IN BED (AS CAN TOLERATE). BOTH CARE PLANS INCLUDED: CNA'S TO CHECK SKIN DAILY, NURSE TO DO A THOROUGH WEEKLY SKIN ASSESSMENT, AND ROHO (SPECIALIZED) CUSHION TO RESIDENT #11'S WHEELCHAIR. AT APPROXIMATELY 9:43 AM, NURSE "S" STATED THAT RESIDENT #11'S NOW PINPOINT PRESSURE ULCER ON HIS COCCYX WAS FACILITY ACQUIRED AND WAS NOT admitted WITH IT. ON 8/16/12 AT APPROXIMATELY 10:20 AM, OBSERVATION OF RESIDENT #11'S STAGE 2 PRESSURE ULCER LOCATED ON HIS COCCYX WAS OBSERVED WITH (CNAs) CERTIFIED NURSING ASSISTANTS "T" AND "V". AND THEN TREATMENT / APPLICATION OF "SENSICARE" CREAM BY REGISTERED NURSE "S". RESIDENT #11 WAS OBSERVED TO HAVE EXCORIATION OF HIS SCROTUM AND THE UNDERNEATH SIDE OF HIS PENIS. NURSE "S" WAS OBSERVED AT APPROXIMATELY 10:30 AM, TO APPLY SENSICARE TO RESIDENT #11'S, STAGE 2 PRESSURE ULCER ON HIS COCCYX AND ALSO TO THE EXCORIATED AREAS ON HIS SCROTUM AND PENIS. NURSE "S" WAS ASKED HOW RESIDENT #11 HAD DEVELOPED THE PRESSURE TO HIS COCCYX. NURSE "S" STATED SHE BELIEVED IT WAS FROM ALL THE LOOSE STOOLS RESIDENT #11 HAD. A REVIEW OF RESIDENT #11'S NURSE'S NOTES DATED 7/6/12 AT 5:30 PM REFLECTED RESIDENT #11'S SKIN WAS INTACT UPON ADMISSION. DURING THE FOLLOWING DATES AND TIMES RESIDENT #11 WAS OBSERVED LYING ON HIS BACK, WITH HIS FEET FLAT ON TOP OF THE MATTRESS AND NOT FLOATED: ON 8/16/12 AT APPROXIMATELY 9:35 AM, RESIDENT #11 WAS OBSERVED WITH HIS EYES CLOSED AND NOT RESPONDING TO HIS NAME BEING CALLED OR KNOCKING ON THE DOOR. RESIDENT #11'S FEET WERE FLAT ON THE MATTRESS AND FLUSH AGAINST THE FOOT BOARD. ON 8/16/12 AT APPROXIMATELY 10:20 AM, RESIDENT #11 WAS OBSERVED AWAKE NOW, STILL ON HIS BACK. THE CNAS ENTERED TO PERFORM PERINEAL CARE. AFTER CARE WAS PERFORMED (APPROXIMATELY 10:35 AM) NO ATTEMPT WAS MADE TO REPOSITION RESIDENT #11 OFF HIS BACK OR TO ELEVATE HIS HEELS. ON 8/16/12 AT APPROXIMATELY 2:30 PM AN INTERVIEW WITH REGISTERED DIETITIAN, (RD) "X" WAS CONDUCTED. RD "X" STATED THAT FIBERSTAT HAD JUST BEEN STARTED TO HELP BULK UP HIS STOOLS. ACCORDING TO THE PHYSICIAN'S TELEPHONE ORDERS DATED 7/10/12, RESIDENT #11 WAS PRESCRIBED [MEDICATION NAME] 100 MILLIGRAMS (MG), IN 10 MILLILITERS (ML), THROUGH HIS GASTRIC FEEDING PEG TUBE, ONCE DAILY, FOR CONSTIPATION. ON 8/3/12 THE [MEDICATION NAME] WAS DISCONTINUED, BECAUSE OF LOOSE STOOLS. ON 8/17/12 AT APPROXIMATELY 9:30 AM, AT THE SOUTH NURSE'S STATION, REGISTERED NURSE, AND UNIT MANAGER "W" REVEALED WHILE DISCUSSING RESIDENT #11'S PRESSURE ULCER, THAT THE [MEDICATION NAME] HAD BEEN ORDERED AS PART OF THE STANDING physician's orders [REDACTED].#11 HAD RECEIVED MILK OF MAGNESIA, 30 ML'S PER HIS PEG TUBE, FOR CONSTIPATION, THE DAY BEFORE THE [MEDICATION NAME] WAS STARTED FOR NO BOWEL MOVEMENT. ALSO AS PART OF THE STANDING physician's orders [REDACTED]. THE MAR indicated LOOSE STOOLS". HOWEVER, IT WAS NOTED THAT ON 7/15/12 THE [MEDICATION NAME] WAS HELD AT 6 AM, DUE TO LOOSE STOOLS, BUT THE BOWEL MOVEMENT (BM) RECORD FAILED TO DOCUMENT WHAT CONSISTENCY THE TWO RECORDED MEDIUM MOVEMENTS WERE ON 7/14/12 AND THE MEDIUM MOVEMENT RECORDED ON 7/15/12. FURTHER DISCREPENTENCYIN DOCUMENTATION INCLUDED: ON THE AFTERNOON SHIFTS OF BOTH 7/15/12 AND 7/16/12, THE BM RECORD DOCUMENTED LOOSE STOOL/S, YET THE MAR indicated [REDACTED]. RESIDENT #11 ALSO HAD LOOSE STOOL/S RECORDED ON THE DAY AND AFTERNOON SHIFTS OF 7/17/12. ACCORDING TO THE BOWEL ELIMINATION RECORD FOR JULY, 2012 AND AUGUST, 2012 THE FOLLOWING DAYS AND SHIFTS RECORDED LOOSE STOOL/S: ON 7/15, 7/16, 7/17, 7/19, 7/22, 7/23, AND 7/26/12, ALL ON THE AFTERNOON SHIFT. ON 7/31/12 ON THE MIDNIGHT SHIFT. ON 7/17, 7/18, 7/26 AND 7/30/12 ON THE DAY SHIFT. ON 8/2, 8/3, 8/4, 8/5, 8/6, 8/7, 8/8, 14 AND 8/15/12 ALL ON THE MIDNIGHT SHIFT. ON 8/3, 8/4, 8/5, 8/7, 8/9, 8/11, 8/14, 8/15, AND 8/16/12 ON THE AFTERNOON SHIFT. ON 8/4, 8/5, 8/10, 8/14 AND 8/16/12 ON THE DAY SHIFT. ON THE AFTERNOON SHIFT OF 8/15/12 THE RECORD RECORDED 3 LARGE STOOLS, BUT THERE WAS NO MARKING TO KNOW IF THAT MEANT ALL WERE LOOSE OR JUST 1 OR 2 OF THEM WERE. ON 8/16/12 AT APPROXIMATELY 9:43 AM, AT THE EAST NURSE'S STATION, NURSE "S", STATED RESIDENT #11'S PRESSURE ULCER DEVELOPED IN HOUSE. THE DATE RECORDED IN THE NURSE'S NOTES DATED 7/15/12 AT 8:15 PM REFLECTED A STAGE 2 ON THE COCCYX. ON 8/17/12 AT APPROXIMATELY 8:50 AM, AT THE EAST NURSE'S STATION, CNA "T" WAS ASKED ABOUT WHY NO PILLOWS WERE OBSERVED UTILIZED FOR POSITIONING RESIDENT #11 ON HIS SIDE OR FOR FLOATING THE HEELS. CNA "T" STATED THAT RESIDENT #11 WOULD NOT STAY OVER ON HIS SIDE, THAT HE WOULD ROLL ONTO HIS BACK AND KICK THE PILLOWS OUT FROM UNDER HIS FEET. ACCORDING TO THE BEHAVIOR TRACKING LOG RESIDENT #11 HAD NO RECORDED REFUSALS OF BEING TURNED. THE ONLY TARGETED BEHAVIORS FOR RESIDENT #11 WERE ATTEMPTING TO GET OUT OF BED AND INCREASED CONFUSION. ACCORDING TO THE NURSE'S NOTES, THERE WERE ONLY THREE ENTRIES RECORDED THAT ADDRESSED RESIDENT #11 BEING TURNED OR REPOSITIONED, THEY INCLUDE: ON 7/10/12 AT 4:20 AM, "RES. (RESIDENT) STIFF AND RESISTANT AGAINST TURNING SIDE TO SIDE." ON 7/15/12 AT 8:15 AM, "...RES. REFUSED TO STAY REPOSITIONED OFF BUTTOCKS..." ON 8/6/12 AT 10:40 AM, "RES. CONT. (CONTINUES) TO BE 2 PA (PHYSICAL ASSIST) FOR TRANSFERS AND BED MOBILITY CONT. R/T (RELATED TO) STIFFNESS AND NON COOPERATIVE WITH TURNING R/T PRESSURE ULCER AND EXCORIATION ON BUTTOCKS AND GROIN AREA." ON 8/17/12 AT APPROXIMATELY 8:40 AM, AT THE EAST NURSE'S STATION, CNA "T" STATED RESIDENT #11 DID NOT VERBALLY OR PHYSICALLY REFUSE TO BE POSITIONED ON HIS SIDE, BUT THAT HE (RESIDENT #11) WOULD PULL THE PILLOW OUT FROM BEHIND HIM OR MOVE IN BED SO THAT THE PILLOW WOULD NOT KEEP HIM OVER. CNA "T" ALSO STATED RESIDENT #11 WOULD KICK A WEDGE OR PILLOW OUT FROM UNDER HIS FEET. ON 8/17/12 AT APPROXIMATELY 11:20 AM, RESIDENT #11'S HEELS WERE VIEWED WITH CNA "T" WHILE RESIDENT #11 WAS LYING IN HIS BED. A SMALL ESCHAR SURROUNDED BY DRY PEELING SKIN WAS OBSERVED ABOVE RESIDENT #11'S LEFT HEEL, ACHILLES TENDON AREA. CNA "T" STATED BEING SURPRISED TO SEE THE ESCHAR ABOVE THE HEEL. ON 8/17/12 AT APPROXIMATELY 11 AM RESIDENT #11 WAS OBSERVED LYING AWAKE IN HIS BED, WITH THE HEAD OF HIS BED UP, THE KNEES OF THE BED WERE SLIGHTLY RAISED, BUT RESIDENT #11'S FEET WERE AT THE FOOT OF THE BED. CNA "T" WAS ASKED ABOUT WHY RESIDENT #11 DID NOT HAVE HIS HEELS ELEVATED. CNA "T" STATED THAT THE PILLOWS USED TO ELEVATE RESIDENT #11'S HEELS WERE SOILED AND BEEN SENT TO LAUNDRY. CNA "T" ALSO STATED THAT RESIDENT #11 SLIDES DOWN IN THE BED AND WILL PUSH THE PILLOW OUT FROM UNDER HIS FEET, HE DOES NOT UNDERSTAND THE NEED FOR KEEPING THEM UP. ON 8/17/12 AT APPROXIMATELY 11:30 AM, AT THE SOUTH NURSE'S STATION, RD "X" AND NURSE "W" STATED THEY WERE UNAWARE OF RESIDENT #11'S ESCHAR ON THE LEFT HEEL. ALTHOUGH THE INTERVENTION OF ALLOWING RESIDENT #11 TO SLEEP FOR 6 HOURS WITHOUT WAKING HIM TO BE CHANGED WAS THOUGHT TO BE FOR HIS SAFETY FROM FALLING, NO CONSIDERATION HAD BEEN GIVEN TO RESIDENT #11'S NEED FOR TURNING, REPOSITIONING AND FLOATING OF THE HEELS, OR THE PRESSURE ULCER, AND NOW DEVELOPMENT OF A NEW UNSTAGEABLE PRESSURE ULCER. A REVIEW OF THE WEEKLY SKIN SHEETS REFLECTED NO SKIN ISSUES IDENTIFIED EXCEPT THE PRESSURE ULCER ON THE COCCYX, NO NOTE OF RESIDENT #11'S LEFT HEEL BREAKDOWN AND SUBSEQUENT LEFT HEEL ESCHAR WAS LOCATED. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROMOTE HEALING OF AN UNSTAGABLE (WOUND BED IS NOT VISIBLE TO ALLOW ASSESSMENT OF THE DEPTH OF THE WOUND) LEFT HEEL PRESSURE WOUND AND COORDINATE WITH [MEDICAL TREATMENT] SERVICES TO PREVENT THE DEVELOPMENT OF AN UNSTAGABLE RIGHT LATERAL FOOT PRESSURE WOUND FOR 1 OF 4 RESIDENTS REVIEWED FOR PRESSURE WOUNDS (#35) FROM A TOTAL OF 14 SAMPLED RESIDENTS RESULTING IN THE POTENTIAL FOR A DELAY IN HEALING OF THE LEFT HEEL WOUND AND THE DEVELOPMENT OF A RIGHT LATERAL FOOT WOUND. FINDINGS INCLUDE: BASED ON THE "INITIAL ADMISSION ASSESSMENT", DATED 8/14/12, AND THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 9/18/12, RESIDENT #35 WAS A [AGE] year OLD ALERT AND ORIENTED FEMALE WHOSE [DIAGNOSES REDACTED]. THE BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE FROM THE 9/18/12 MDS REFLECTED A SCORE OF 14 OUT 15 MEANING RESIDENT #35 WAS COGNITIVELY INTACT. THE MDS, dated [DATE] AND 9/18/12, REFLECTED RESIDENT #35 REQUIRED 1-2 STAFF ASSISTANCE FOR TRANSFERS, AMBULATION, EATING AND TOILETING. THE 9/20/12 AND 10/2012 MEDICATION ADMINISTRATION RECORDS REFLECTED RESIDENT #35'S BLOOD SUGAR LEVELS WERE CHECKED 4 TIMES DAILY. THE BLOOD SUGARS RANGED FROM 156 MG/DL-502 MG/DL (NORMAL RANGE FROM 80-120 MG/DL) WHICH WERE HIGHER THAN NORMAL. THE "TRACKING MY NUMBERS" FORM FROM THE [MEDICAL TREATMENT] PROVIDER REFLECTED RESIDENT #35'S [MEDICATION NAME] LEVEL IN THE BLOOD HAD DECREASED EACH MONTH FROM 3.7 IN 7/2012 TO 3.3 IN 10/2012. THE IDENTIFIED GOAL WAS TO MAINTAIN AN [MEDICATION NAME] LEVEL OF 4.0 OR HIGHER. BASED ON THE PHYSICIAN ORDERS, 8/2012-10/2012, THE RESIDENT WAS RECEIVING A PROTEIN SUPPLEMENT TWICE DAILY. [MEDICATION NAME] IS A MEASURE OF THE PROTEIN STORES NEEDED FOR MAINTENANCE AND/OR HEALING OF SKIN. THE NURSING NOTES, DATED 9/22/12 AT 10:00 PM, REFLECTED "3 X (BY) 2 CM BLACKENED SKIN ON LEFT HEEL, NOT NOTED ON PREVIOUS SKIN CHECKS...". ON 9/24/12 AT 5:00 PM THE NURSING NOTES REFLECTED THE LEFT HEEL WOUND WAS RELATED TO RESIDENT #35 STORING A KEY RING IN HER SOCK. PHOTO DOCUMENTATION AND MEASUREMENT OF THE WOUND ON THE "WOUND ASSESSMENT DETAILS REPORT", DATED 9/27/12, REFLECTED A FACILITY ACQUIRED 2.4 CM BY 2.9 CM SUSPECTED DEEP TISSUE INJURY WOUND ON THE BACK OF THE LEFT HEAL. THE WOUND WAS 100% COVERED WITH HARD BLACK (DEAD) TISSUE. THE PUSH SCORE (GRAPHIC REPRESENTATION OF THE SEVERITY OF A WOUND WITH THE HIGHER THE NUMBER THE WORSE THE WOUND CONDITION) WAS 11. THE NARRATIVE NOTE ON THE SAME FORM BY UNIT MANAGER REGISTERED NURSE (RN) "A" REFLECTED "RESIDENT FOUND ON 2 SEPARATE OCCASIONS STORING MONEY AND A KEY ON A KEY RING IN HER SOCKS. RESIDENT WAS PROVIDED A LANYARD FOR THE KEY TO HER LOCKBOX AND NSG (NURSING) STAFF IS CHECKING HER SOCKS Q (EVERY) SHIFT FOR FOREIGN OBJECTS. RESIDENT EDUCATED ABOUT KEEPING HER PERSONAL BELONGINGS IN HER LOCK BOX..." THE MEASUREMENT AND PUSH SCORE WERE THE SAME ON THE 10/3/12 "WOUND ASSESSMENT DETAILS REPORT". THE "WEEKLY HYDRATION AND SKIN ASSESSMENT" FORM, DATED 9/2012, REFLECTED RESIDENT #35 HAD NO SKIN ISSUES ON 9/5/12 AND 9/12/12 AND HAD REFUSED HER SKIN ASSESSMENT ON 9/19/12 BEFORE THE LEFT HEEL WOUND WAS IDENTIFIED ON 9/22/12. THE CARE PLAN RELATED TO "PRESSURE" REFLECTED RESIDENT #35 WAS AT RISK FOR DEVELOPING A PRESSURE WOUND RELATED TO HER LIMITED MOBILITY, DEPENDENCE FOR REPOSITIONING, KIDNEY DISEASE AND DIABETES. THE "ORANGE BUTTERFLY SKIN CARE STANDARDS" INITIATED ON ADMISSION (8/14/12) BASED ON A BRADEN PRESSURE WOUND RISK ASSESSMENT SCORE OF 14 REFLECTED INTERVENTIONS OF BRIDGING HEELS OFF THE BED, BARRIER CREAM TO REDDENED AREAS AND REPOSITIONING. BASED ON THE "TREATMENT RECORD", DATED 8/2012 AND 9/2012, BARRIER CREAM WAS PROVIDED TO BOTH HEELS 3 TIMES A DAY FROM 8/14/12-8/20/12 THEN ONCE DAILY FROM 8/31/12-9/30/12. ON 10/10/12 AT 9:40 AM LEFT HEEL WOUND CARE FOR RESIDENT #35 WAS OBSERVED IN HER ROOM. THE RESIDENT WAS SEATED IN A WHEELCHAIR AND HAD LACE-UP STYLE SHOES ON WITH ANKLET STYLE SOCKS. UNIT MANAGER RN "A" PERFORMED THE TREATMENT AND UNIT MANAGER RN "B" PERFORMED THE PHOTO/WRITTEN DOCUMENTATION. THE HEEL WOUND WAS MEASURED AT 4 CM BY 3.3 CM AND WAS COMPLETELY COVERED WITH BLACK ESCHAR. THE PUSH SCORE ON THE "WOUND ASSESSMENT DETAILS REPORT" OF THE SAME DATE WAS 13 INDICATING A WORSENING OF THE WOUND SINCE 10/3/12. THE TOTAL AREA OF THE WOUND HAD INCREASED FROM 6.96 CM SQUARED TO 13.2 CM SQUARED. DURING THE OBSERVATION RESIDENT #35 STATED THAT DURING [MEDICAL TREATMENT] (MONDAY, WEDNESDAY, FRIDAY) SHE WAS POSITIONED IN A RECLINING CHAIR WITH HER FEET UP ON THE FOOTREST. RESIDENT #35 STATED HER SHOES REMAINED ON AND RESTED ON THE FOOTREST. NURSING NOTES, DATED 9/24/12-10/11/12 AT 6:30 AM, REFLECTED NO COMMUNICATION WITH THE [MEDICAL TREATMENT] PROVIDER RELATED TO THE RESIDENT'S ADVANCEMENT FROM "AT RISK" OF SKIN BREAKDOWN TO ACTUAL SKIN BREAKDOWN OF THE LEFT HEEL. THE FIRST [MEDICAL TREATMENT] TREATMENT AFTER THE IDENTIFICATION OF THE LEFT HEEL WOUND BY THE FACILITY WOULD HAVE BEEN ON 9/24/12. THE "[MEDICAL TREATMENT] CENTER COMMUNICATION RECORD(S)", DATED 9/26/12, 9/28/12, 10/5/12, 10/8/12 AND 10/10/12 REFLECTED NO INFORMATION FROM THE FACILITY TO THE [MEDICAL TREATMENT] PROVIDER THAT RESIDENT #35 HAD DEVELOPED A LEFT HEEL PRESSURE ULCER. THERE WAS NO DOCUMENTATION THE [MEDICAL TREATMENT] PROVIDER HAD IDENTIFIED THE WOUND BASED ON THE INFORMATION PROVIDED IN THE "[MEDICAL TREATMENT] NURSE" SECTION OF THE "[MEDICAL TREATMENT] CENTER COMMUNICATION RECORD(S)" OF THE SAME DATES. ON 10/11/12 AT 10:20 AM RESIDENT #35 WAS OBSERVED IN HER ROOM SEATED IN A WHEELCHAIR WITH AIR FILLED PROTECTIVE BOOTS ON BOTH FEET. RESIDENT #35 STATED SHE GOT THE BOOTS ON 10/10/12 AFTER RETURNING FROM [MEDICAL TREATMENT]. SHE AGAIN STATED HER FEET WERE IN HER SHOES ON THE FOOTREST OF THE RECLINING CHAIR DURING [MEDICAL TREATMENT]. RESIDENT #35 STATED SHE HAD SOME NUMBNESS IN BOTH FEET BUT WAS AWARE OF PAIN AT THE WOUND SITE. ON THE SAME DAY AT 11:50 AM UNIT LICENSED PRACTICAL NURSE (LPN) "C" STATED SHE HAD CARED FOR RESIDENT #35 SINCE ADMISSION ON 8/14/12. LPN "C" STATED SHE HAD TALKED WITH THE [MEDICAL TREATMENT] PROVIDER DURING THE WEEK OF SURVEY "IN THE LAST DAY OR TWO" ABOUT ELEVATING HER HEELS AND THE FACILITY WOULD BE SENDING A PILLOW AND BLANKET WITH THE RESIDENT TO [MEDICAL TREATMENT] IN THE FUTURE. ON 10/12/12 AT 12:30 PM LPN "C" STATED SHE HAD CALLED THE [MEDICAL TREATMENT] PROVIDER ON 10/10/12 AND LEFT A MESSAGE. THE [MEDICAL TREATMENT] PROVIDER CALLED BACK ON 10/11/12 AND THE PRESENCE OF A NEW WOUND ON THE OUTSIDE OF THE RESIDENT'S RIGHT FOOT WAS DISCUSSED ALONG WITH POSITIONING OF THE RESIDENT'S FEET TO MAINTAIN PRESSURE RELIEF. LPN "C" CONFIRMED SHE HAD NOT TALKED WITH THE [MEDICAL TREATMENT] PROVIDER PRIOR TO 10/11/12 RELATED TO THE LEFT HEEL. LPN "C" STATED SHE DID NOT KNOW IF ANY OTHER NURSE HAD. ON 10/12/12 AT 2:30 PM IN HER OFFICE COMMON AREA UNIT MANAGER "A" STATED THE [MEDICAL TREATMENT] PROVIDER WAS NOT NOTIFIED OF THE LEFT HEEL WOUND BECAUSE THE KEY IN THE RESIDENT'S SOCK WAS THE ROOT CAUSE OF THE WOUND. THE [MEDICAL TREATMENT] PROVIDER WAS NOTIFIED OF THE SECOND WOUND ON THE RIGHT FOOT AS PRESSURE WAS PROBABLY THE ROOT CAUSE. UNIT MANAGER "A" STATED RESIDENT #35 HAD TOLD UNIT MANAGER "A" ON 10/10/12 THAT SHE WAS NEVER MOVED WHILE IN THE RECLINING CHAIR AT [MEDICAL TREATMENT]. UNIT MANAGER "A" STATED THERE WAS PROBABLY NO DOCUMENTATION RELATED TO EDUCATION PROVIDED TO RESIDENT #35 TO KEEP HER FEET OFF THE PRESSURE OF THE FOOTREST WHILE AT [MEDICAL TREATMENT]. NO ADDITIONAL [MEDICAL TREATMENT] CENTER COMMUNICATION RECORDS INFORMATION FROM THE [MEDICAL TREATMENT] PROVIDER TO THE FACILITY WAS AVAILABLE DURING THE SURVEY. THE ELEVATED BLOOD SUGAR LEVELS, LACK OF MOBILITY, ALTERED SENSATION IN THE FEET AND PRESENCE OF THE LEFT HEEL WOUND PUT THE RESIDENT AT RISK FOR THE DEVELOPMENT OF ADDITIONAL PRESSURE WOUNDS. COMMUNICATION BETWEEN THE FACILITY AND THE [MEDICAL TREATMENT] PROVIDER RELATED TO THE INCREASED NEED FOR PRESSURE PREVENTION/RELIEF DID NOT OCCUR UNTIL 10/11/12 AFTER AN UNSTAGABLE PRESSURE WOUND ON THE RIGHT LATERAL FOOT WAS IDENTIFIED. ( )

This citation pertains to MI 027. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices for 2 of 2 Sampled residents that needed the assistance of two staff for bed mobility (Resident #101 and Resident #103), from a total of 3 Sampled residents, resulting in an avoidable fall from bed with the potential for serious injury for Resident #101, and a potentially avoidable fall from bed with the potential for serious injury for Resident #103. Findings include: Resident #101 Per the "Facility Investigation Report - 5 Working Days", on 3/20/12 at 6:15 PM, "(Resident #101) was being turned in bed and rolled out the other side, resulting in contusion to scalp and face. (Resident #101) struck the night stand. Resident was assessed, sent to hospital for follow up. Staff member was given next progressive discipline for actions. Family and doctor aware of incident ..." On 4/05/12 at 10:02 AM, Resident #101 was observed lying in her bed that was in a low position; there were grab bars at the head of the bed. Resident #101's hand were bent inward at her wrists, and although her eyes were open they did not follow voices, and she did not speak when Surveyors spoke to her. Per the "MDS/Minimum Data Set", dated 9/05/11, Resident #101 was totally dependent on staff, needed two + persons physical assist for bed mobility, and had [DIAGNOSES REDACTED]. Per "Physician Telephone Orders", regarding Resident #101, dated 3/20/12 at 6:30 PM, "Send to ER (emergency room )for evaluation. Bruise to head". Per the "Emergency Physician Record - Fall", regarding Resident #101, dated 3/20/12 at 8:35 PM, Resident #101 had "Injuries" on her head, right shoulder, and both knees. Per Resident #101's plan of care, "Falls: I have not had a fall in a while but at risk because I am totally dependent on staff for all care. I have immobility..." There was no intervention for the need for two + staff persons assist for bed mobility. However, per Resident #101's "Resident Care Guide", dated 3/21/12, "Reposition in bed ...2 PA (person assist)". In an interview, on 4/05/12 at 2:40 PM, RN/Registered Nurse #8 stated she was the charge nurse on 3/20/12 at 6:15 PM, and that she remembered nurse aide #2 came to her and told her that Resident #101 was on the floor, and she went to Resident #101's room, observed Resident #101 lying naked on the floor. RN #8 said that she found a bruise forming on Resident #101's forehead during the assessment she performed on Resident #101, told the (unnamed) nurse aides move Resident #101 from the floor to bed and then called the facility physician, at which time the physician ordered that Resident #101 be sent to the hospital for evaluation. RN #8 told the Surveyors she thought, "There is no difference with or without an injury, as far a moving the resident back to bed". In an interview, on 4/09/12 at 1:10 PM, Surveyor # asked RN #16/Clinical Care Coordinator if Resident #101's fall from bed on 3/20/12 was avoidable or unavoidable and RN #16 replied, "In my opinion, it was avoidable", and further explained that she formed that opinion because Resident #101 was a two person assist and nurse aide #15 was performing cares without the assistance of another staff person. Per an "Employee Disciplinary Warning", dated 3/20/12, "Termination ...On 3/20/12 (nurse aide #15) attempted to care for (Resident #101) independently while she was a 2 person assist. (Resident #101) was injured and sent to hospital ... " Resident #103 Review of Resident #103's "Individual Record of Accident/Incident" document revealed he had falls on 11/17/11, 12/15/11, 1/23/12 and 2/05/12. On 4/09/12 at 11:05 AM, DON/Director of Nursing #3 stated she could not find an incident report for Resident #103, dated 1/23/12. Per the "MDS/Minimum Data Set", dated 8/02/11, Resident #103 needed "Extensive assistance (two persons physical assist)" with bed mobility. Per "Nurse's Notes", dated 1/23/12 at 3:25 AM, "(Resident #103) attempting to get out of chair frequently...increased restlessness and standing up frequently...encouraged (Resident #101) to stay in bed and stayed with (Resident #101) until his eyes were closed and resting..." Per "Nurse's Notes", dated 1/23/12 at 7:30 AM, "Observed (Resident #103) laying across his bed with head under roommate's bed ...(Resident #103) opened his eyes and was looking forward. (Physician #20) ordered to transfer to (hospital) for eval and tx (evaluation and treatment) ..." Per Resident #101's plan of care, "Falls: I have a history ...of a fall with a fracture, schizophrenia, depression, [DIAGNOSES REDACTED] (disease of the brain), mental retardation that puts me at risk for falls...I have a perimeter (elevated sides) mattress..." However, per Resident #103's "Resident Care Guide", currently in use on 4/05/12 and 4/09/12, "Safety Interventions" included "Perimeter mattress". In a telephone interview, on 4/09/12 at 2:25 PM, nurse aide #22 said, "(Resident #103) is unpredictable...needs one on one (supervision) at times". On 4/05/12 at 10:11 AM, the Surveyors observed Resident #103 lying in bed; Resident #103's bed was in a low position, and there mats on the floor on both sides of the bed; there was no perimeter (raised edge) mattress on Resident #103's bed. On 4/09/12 at 10:11 AM, the Surveyors observed Resident #103 lying in bed; Resident #103's bed was in a low position, and there mats on the floor on both sides of the bed; there was no perimeter (raised edge) mattress on Resident #103's bed. Per "Physician Telephone Orders", dated 1/23/12 at 6:30 AM, "Send to ER (hospital) for evaluation. Post (after) fall. Increased Agitation. Increased heart rate". Per the Emergency Department's "Physician Clinical Report", dated 1/23/12 at 7:52 AM, "... Course of Care: (8:23 AM). (Report from facility:) He's just not behaving his regular self, I'm not his regular nurse so I don't know, he is just very anxious. I don't know what we give him, I don't know him well so I just sent him in...(8:45 AM) (Report from Facility Physician #18:)...the two concerns are trauma and seizure..." According to the report, Resident #103 was "discharged home (to the facility) in good and improved condition." ( and )