Every finding on record at Durand Senior Care and Rehab Center

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for two (R5 and R21) of 24 reviewed. Findings include: R21: Review of the medical record reflected R21 admitted to the facility on [DATE], with diagnoses that included anemia, congestive heart failure, anxiety disorder and major depressive disorder. The Quarterly MDS, with an Assessment Reference Date (ARD) of 3/5/26, reflected R21 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 06/09/2026 at 11:06 AM, R21 was observed in bed. R21 reported gaining weight since admission to the facility, despite decreasing their intake at meals. R21 reported being weighed daily. The Quarterly MDS, with an ARD of 3/5/26, was coded as no or unknown for question K0310, pertaining to weight gain of 5 percent (%) or more in the last month or gain of 10% or more in last 6 months. According to the medical record, on 02/05/2026, R21 weighed 251.4 pounds. On 03/05/2026, R21 weighed 264.6 pounds, which was a 5.25% gain. In an interview on 06/10/2026 at 1:28 PM, Registered Dietitian (RD) E reported R21's Quarterly MDS, with an ARD of 3/5/26, should have been coded for a 5% weight gain in one month. Resident #5(R5) Review of the medical record revealed R5 was admitted to the facility 02/26/2025 with diagnoses that included type 2 diabetes, dementia, obstructive and reflux uropathy (blockage in the urinary tract), hypertension, venous insufficiency, tachycardia, anemia (low amount of red blood cells), hypothyroidism (low thyroid hormone), atrial fibrillation, gastro-esophageal reflux, spinal stenosis (narrowing of spaces in spine), ischemic (lack of blood flow) heart disease, constipation, lymphedema (buildup of fluid in the lymphatic system that causes swelling), and dysphagia (difficulty swallowing). Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/10/2026, revealed R5 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. During observation and attempted interview on 06/09/2026 at 10:14 a.m. R5 was observed lying down in bed. R5 did not respond to verbal stimuli. Review of R5's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/10/2026, revealed Section K- Swallowing/Nutritional Status; subsection K0300-Weight (loss of 5% or more in the last month or loss of 10% or more in the last 6 months was documented yes. Review of R5's medical record revealed a weight of 194.8 lbs. (pounds) on 09/05/2025, 184.0 lbs. on 02/05/2026, and 178.8 lbs. on 03/10/2026. Review of the weights for 30 days revealed a change of -2.93%. Review of the weights for 6 months revealed a change of 9.1%. During an interview on 06/10/2026 at 09:37 a.m. Registered Dietician (RD) E explained that she had completed Section K-Swallowing/Nutritional Status of R5's Minimum Data Set (MDS), with an Assessment Reference Date of 03/10/2026. RD E was asked to verify that R5 had a weight loss of 5% or greater in 30 days or had a weight loss of 10% or greater in 6 months, as marked yes on his MDS. RD E confirmed from R5's medical record that he had a weight of 194.8 lbs. (pounds) on 09/05/2025, 184.0 lbs. on 02/05/2026, and 178.8 lbs. on 03/10/2026. RD E further confirmed that R5's weights for 30 days revealed a change of -2.93%. RD E also confirmed that R5's weights for 6 months revealed a change of 9.1%. RD E explained that R5's MDS, section K, had not been completed accurately as R5 had not lost 5% of his weight in one month or 10% of his weight in 6 months. RD E could not explain why she had coded R5's MDS, Section K, inaccurately.

Based on interviews and record review the facility failed to conduct the required Monthly Medication Regimen Review on one resident (R11) of the five residents reviewed for Monthly Medication Regimen Review completion. Findings Include:Review of the medical record reflected R11 was an initial admission to the facility on [DATE]. Diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, Osteoarthritis, low back pain and ankylosing spondylitis lumbar region.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/16/2026 revealed R11 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Based on record reviews, R11 had Monthly Medication Regimen (MMR) for 06/03/26- with no recommendations at this time. Date of 05/05/26- with no recommendations at this time. Date of 04/02/26 with no recommendations at this time. Date of 03/04/26 with no recommendations at this time. Date of 02/03/26 with no recommendations at this time. Date of 01/19/26 with no recommendations at this time. Date of 01/06/26 with no recommendations at this time. Date of 12/03/26 with no recommendations at this time. Date of 11/07/25 with no recommendations at this time. Date of 10/14/25 with no recommendations at this time.Date of 10/03/25 recommendations made were parameter and dosage added to order for Voltaren 1% Gel. No documentation to support that the medical director or any other provider responded to the recommendation is agreement or disagreement. Date of 09/30/25 recommendations were made Voltaren Gel is not approved for or effective for treatment of shoulder pain; as such, a recommended dose is not available to complete the above order. Suggest D/C Voltaren Gel by pharmacist. No documentation to support that the medical director or any other provider responded to the recommendation as agreement or disagreement. Date of 08/17/25 with no recommendations at this time. Date of 07/17/25 with no recommendations at this time. Date of 06/28/25 with no recommendations at this time.On 06/10/2026 at 11:18 AM, writer requested of LNHA A any documentation by the provider validating review (agreeing or disagreeing) with the pharmacy recommendations for the dates of 09/30/25 and 10/03/25. During an interview on 06/10/2026 at 4:06 PM, DON B stated there was nothing in writing showing the providers were aware of these recommendations or any response from providers showing they approved or disapproved. Regional Director of Clinical O stated she was going to reach out to the pharmacy as those recommendations were out of the normal request. Regional Director of Clinical O stated they wrote a new order to reflect the recommendations by pharmacy. Writer asked her if they consulted with the provider. Regional Director of Clinical O stated no.During an interview on 06/11/2026 at 9:05 AM, Nurse Practitioner (NP) N stated the pharmacy sends them a list of residents, and they look at the recommendations. NP N stated MD (name of Dr.) typically looked at the recommendations and determined if he agreed or disagreed, and documents response. NP N stated the DON B gave them to the MD. NP N stated if nursing wrote an order in response to recommendation, they call the provider for permission to do so, before writing it. DON B was able to provide the printed off blank recommendation made by pharmacy but not any documentation showing they responded. Record review did not reveal any documentation to show communication between nursing and the providers before writing those orders.

Based on observation, interview, and record review the facility failed to provide one out of one residents (Resident #32) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds, facility acquired stage 3 pressure wound (full thickness skin loss ), osteomyelitis, and hospitalization . Findings Include: Resident #32(R32) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R32 was a [AGE] year-old female admitted to the facility on [DATE], with most recent re-admission 3/10/25 related to osteomyelitis (wound infection) with other diagnoses that included stage 4 pressure ulcer(full thickness skin and tissue loss, exposing muscle, tendon or bone), diabetes Mellitus, irregular heart rhythm, anxiety and depression. The MDS reflected R32 required substantial/maximal assistance with repositioning in bed. During an observation and record review on 4/28/25 at 9:46 AM, R32 was observed laying in bed, flat on back, with eyes closed on specialty air mattress that appeared slightly deflated. Observed air mattress pump located at foot of the bed with no lights or sound noted with electrical cord laying on the floor and unplugged from wall outlet, revealing no power to pump. Review of the MDS Indicators reflected R32 had a major wound infection and several hospitalization s. During an observation on 4/28/25 at 3:57 p.m., R32 was laying in bed, flat on back and air mattress pump continued to be non-functioning with no light and unplugged from wall outlet. R32 bed continued to appear deflated with sheets corners off of the mattress. During an observation and interview on 4/29/25 at 8:40 AM, R32 was laying in bed with air mattress now plugged into wall outlet. R32 reported had a wound on buttock area that caused her a lot of pain. When asked if staff provided her with medication for pain control, she reported they offer her Tylenol that does not help. R32 reported unable to independently reposition self in bed and staff do not assist or offer every two hours but instead about two times per shift. R32 reported did not get out of bed yesterday and bed seems more comfortable today than yesterday. Review of R32 Physician Progress Note, dated 4/11/25, reflected, [named R32] is a [AGE] year-old female who is recently in the hospital for UTI [urinary tract infection] and osteomyelitis. She had been on IV Zosyn which she developed an allergy to. She's being monitored for improvement of her rash before starting her next dose of antibiotics. The rash appears to be improving. [named R32] also has a wound on her sacrum area that does not appear to be improving. Referral to [named wound clinic] clinic has been placed Review of R32 Wound Evaluation, dated 12/5/24, reflected R32 had a new stage 3 pressure wound to right gluteus that measured 2.93cm length x 2.74cm width x 0.2 cm depth described as 80% epithelial and 20% granulation and no slough. The note reflected, Resident readmitted from hospital with pressure injury . The picture appeared to be a small shallow wound that appeared to look like stage 2 pressure injury (partial thickness loss of dermis presenting as shallow open ulcer with a red or pink wound bed, without slough). Review of R32 Wound Evaluation, dated 1/27/25, reflected R32 now had two pressure wounds including one new facility acquired pressure wound. --#3-Stage 3 pressure wound to Sacrum(Prior #2) measured 2.95cm x 1.1cm x 0.1cm described as 90% epithelial and 10% granulation tissue with PUSH(pressure ulcer scale for healing, with 0-17 with 0 as healed) of 9. --#4-NEW facility acquired unstageable pressure wound right gluteus measured 2.81cm x 1.1cm with no depth described as 60% slough(dead skin), 40% granulation tissue with PUSH score of 11. The assessment reflected, Previous pressure injury re-opened . Review of the Wound Evaluation, dated 2/24/25, reflected worsening of two wounds and suspected wound infection. --#3-unstageable pressure wound Sacrum-12.93cm x 17.16cm with no depth and PUSH score of 15. --#4-Facility Acquired Stage 3 Pressure wound Right Gluteus-1.73cm x 1.04cm x 0.1cm with PUSH score of 7. Review of R32 Nurse Progress Note, dated 2/23/25, reflected, PRN[as needed] standing order for Tylenol 325mg. Resident is observed lying in bed yelling out in pain and discomfort from sacrum wound. Staff have attempted to reposition resident several time but resident has no relief. Review of R32 Progress Note, dated 2/25/25, reflected, Tx[treatment] to sacrum completed as the resident would not allow it to be done earlier. The resident c/o[complain of] pain to the area and saying Oh it hurts it hurts. The resident was given Tylenol but spit it out. The resident (sp) continues to assist the resident and reassure her. Review of R32 Active Discharge Planning Progress note, dated 2/26/25, reflected, .History Of Present Illness: [named R32] was seen today as she hasn't been eating and has been refusing all meds. Due to her refusal and inability to take oral meds, was started on IM [intramuscular] Rocephin as wound appears infected . Review of R32 Nurse Progress Note, dated 3/4/25, reflected, The resident was readmitted to [named facility]. Transferred to her room per EMT's[emergency medical staff] from [named] Hospital .Skin assessment completed at admit. Debrided wound to the sacral/coccyx. Bandage intact changed and wounds assessed. Wound is beefy red with small amount of bloody drainage on the drsg[dressing]. The resident is c/o severe pain to the area. Tylenol given p.o[by mouth] .Assisted with HS[night] care and repositioning in the bed x 1PA[one person assist] . Review of R32 Wound Evaluation, dated 3/4/25, reflected R32 had three pressure wounds: --#5-unstageable pressure wound Sacrum(Prior #3)-6.51cm x 7.79cm with no depth and 3cm undermining and PUSH score of 17. --#6-New unstageable pressure Sacrum superior-3.95cm x 1.31cm and no depth with 10% slough, 20% granulation and 70% epithelial tissue with PUSH score of 12. --#7-Facility acquired unstageable Right Gluteus(Prior #4)-3.86cm x 3.07cm with no depth with 20% slough, 10% granulation and 70% epithelial tissue with PUSH score of 13. Review of R32 Physician Progress Note, dated 3/5/25, reflected, [named R32] is a[AGE] year-old female who is a long-term resident of [named facility] who was sent to [named hospital] on 2/26/25 for worsening mental status, low grade temp and worsening sacral decubiti. She had recently completed rx[medication] for a UTI. In the ER she met septic protocol with leukocytosis, tachycardia, lactic acidosis and tachypnea. She was started on sepsis protocol and started on IV Vanco and Rocephin. She was admitted for urosepsis and an infected decubiti, which appeared necrotic. She underwent debridement of her wound. Infectious disease was consulted and she continued on Vanco and Rocephin. [named R32] was stabilized and transferred back to [named facility] on Augmentin. Wound culture done at [named facility] prior to being sent out resulted ESBL E.coli/ Providencia stuarti and Enterococci/the later of which was treated based on sensitivities. Placed on Bactrim/Levaquin in place of Augmentin on return to facility . Review of R32 Nurse Progress Note, dated 3/7/25, reflected, resident still unable to keep medications down she is now reporting intermittent chest pain with new irregular tachycardic pulse . new orders for resident to be transferred to hospital. Resident is aware and agreeable she states she feels overall terrible. Review of R32 Nurse Progress Notes, dated 3/10/25 at 3:36 p.m., reflected, Resident arrived back to the facility from [named hospital] at approximately 1411[2:11 p.m.] .Resident has a picc[peripheral inserted central catheter] line in her right arm and appears to be clean . Review of R32 Physician History and Physical, dated 3/13/25, reflected, [named R32] was sent back out to [named hospital] on 3/7/25 after c/o[complaints of] nausea and being unable to keep fluids down since returning from hospital. Was hospitalized from 2/26/25 through 3/3/25 for Enterococci UTI [urinary tract infection] and stage 4 sacral decubiti that was debrided .CT of abdomen pelvis showed left product decubitus ulcer with abscess and possible osteomyelitis of the coccyx .She was seen by ID[infectious disease] and felt to have osteomyelitis of sacrum. She had PICC [peripheral inserted central catheter] placed in her right upper arm and started on IV Zosyn. Transferred back to [named facility] to complete 6 weeks IV Zosyn for osteo[osteomyelitis] . Review of R32 Wound Evaluation, dated 3/11/25, reflected R32 had pressure wounds as follows: --#8-Facility Acquired unstageable pressure wound right gluteus(Prior#7)-2.49cm x 1.74 with no depth with PUSH score of 12. --#9-unstageable pressure wound Sacrum (Prior #5) - 4.98cm x 5.99 with no depth with PUSH score of 17. Continued review of the Wound Evaluation reflected, Resident readmitted with wound. Resident on course of IV antibiotics for osteomyelitis related to wound. Surrounding tissue is non-blanchable & fragile & is at high risk for breakdown. Further tissue damage is probable . APM[air mattress] & Roho cushion in place & properly functioning . Review of R32 Wound Evaluation, dated 4/29/25, reflected wounds as follows: --#8 - Facility Acquired Stage 3 pressure wound right gluteus - 0.54cm x 1.8 cm x 0.1 cm with PUSH score of 6. The Evaluation note reflected, Surrounding tissue is non-blanchable & is at high risk for breakdown . --#9 - Unstageable Pressure wound Sacrum - 4.63cm x 3.59cm with no depth with 10% slough, 10% escar and 80% granulation tissue and PUSH score of 14. Wound Evaluation note reflected, Resident currently receiving course of Zyvox for osteomyelitis r/t[related] to wound. Surrounding tissue is non-blanchable & fragile & is at risk for breakdown. Further tissue damage is possible . Review of R32 SKIN MANAGEMENT Care Plan, revised 3/1025, reflected interventions that included, Encourage me to make small, frequent shifts in my position . I have pressure reducing device on bed- APM[alternating pressure mattress] mattress set to my comfort. LN[licensed nurse] to ensure it is functioning q shift . Review of the Wound Clinic Consult, dated 4/30/25, reflected R32 was seen for infection of stage 4 Pressure Ulcer to Coccyx and right ischium open area. The consultation reflected orders to change dressing to coccyx wound two times daily and as needed and to reposition R32 every two hours while lying and every 15 to 20 minutes while sitting. During an interview on 4/30/25 at 9:48 AM, Registered Nurse Wound Nurse (WN) M reported had been wound nurse for about three years at the facility. WN M verified R32 admitted to the facility 1/5/24 with no wounds and developed wounds post hospital admissions and did not have any facility acquired pressure ulcers. WN M verified wound #2 was present on admission post hospital on 12/5/24 as stage 3 that was later wound #3 then #5 and currently #9 unstageable pressure sacrum wound. WN M reported wound #9 had depth but because it had area of escar depth was not able to be measured. WN M verified wound worsened and was currently being treated for osteomyelitis. WN M reported R32 had new open wound (#4) on 1/27/25 to right gluteus that had history of prior pressure wound. WN M verified New wound #4 was later #7 then #8 current stage 3 pressure wound to right gluteus. WN M verified R32 wound #8 had worsened between onset of 1/27/25. WN M reported would expect staff to follow care plans and Kardex interventions including turning and repositioning R32 every two hours and making sure air mattress was functioning. WN M reported staff expected to complete change of condition for new wounds and verified no change of condition completed on 1/27/25 because new wound had a history. WN M reported wound #4 that developed on 1/27/25 was not facility acquired because of prior history of wound and would provide evidence to support. During an interview and record review on 4/30/25 at 10:43 AM, Clinical Care Coordinator RN N verified occasionally covered for wound nurse and when reviewing wounds uses PUSH scores to document wound progress. RN N reported would expect staff to follow care plans and Kardex and nurse to monitor R32 functioning of air mattress every shift and document. RN N verified R32 required assistance with bed mobility for repositioning and staff expected to assist related to standard of practice and not required to document as completed task. During a second interview on 4/30/25 at 12:25 p.m., WN M verified R32 wound #4 was identified incorrectly and should have been identified as facility acquired pressure ulcer on 1/27/25 that was currently wound #8 stage 3 pressure wound to right gluteus. During an interview on 4/30/25 at 12:32 p.m., Director of Nursing (DON) B reported would expect staff to follow Care Plan and Kardex interventions.

Based on observation, interview, and record review, the facility failed to label medication in accordance with accepted professional principles, dating of open medication for three out of six medication carts reviewed and failed to ensure proper medication storage of medications for one Resident (#72) out of 112 current residents residing at the facility. Findings Included: During observation of the 200-hall medication cart on 04/29/2025 at 02:06 p.m. it was observed that the following medications did not have a date present when the medication was opened and placed on the container of medications: two inhalers of Symbicort 160/4.5mcg(micrograms), one inhaler of Spiriva 2.5mcg, and one inhaler of Trelegy Ellipta 200mcg/62.5mcg/25mcg. Licensed Practical Nurse (LPN) C explained that it was facility policy that all multidose medication was to be dated at the time that it was opened. LPN C explained she would discard the multidose medication list above and would re-order those medications. During observation of the 100-hall medication cart on 04/29/2025 at 02:26 p.m. it was observed that the following medication did not have a date present when the medication was opened and placed on the container of medication: one eye drop container of timolol maleate 0.5%. Registered Nurse (RN) G explained that it was facility policy that all multidose medication was to be dated at the time that the medication was opened. RN G could not explain what to do with the undated medications and did not have a date present when the medication was opened and placed on the container of medications: During observation of the 300-hall medication cart on 04/29/2026 at 02:31 p.m. it was observed that the following medication did not have a date present when the medication was opened and placed on the container of medication: one inhaler of albuterol sulfate 90mcg (micrograms). Registered Nurse (RN) H explained that is was facility policy to date all multidose medication was to be dated at the time that the medication was opened. RN H explained that he would discard the open multidose medication and re-order that medication. During an interview on 04/29/2025 at 03:01 p.m. Director of Nursing (DON) B explained that it was professional practice and facility policy that all multidose medication containers must be dated with the date that they are opened. DON B explained that if multidose medication containers did not have dates on them when opened then those medications would be discarded and new multidose medications would be ordered. 27306 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident 72 (R72) was admitted to the facility on [DATE] with multiple medical diagnoses. R72 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 04/30/25 at 09:14 AM, during a bedside interview with R72, the overbed table was observed to have R72's breakfast tray (which had been consumed) and a medication cup that contained 8 pills, some white, some round in shape, some red in color. R72 was queried what the medication was and he reported a water pill and a statin maybe, I am not really sure. R72 also counted 8 pills and reported the normal routine was to leave them at bedside. R72 did not have any assessment in the clinical record indicating he could self administer medication's. On 4/30/25 at 9:37 am, during an interview with the Director of Nursing (DON) B she reported she had no residents that self administered medications and reported the nurse was to observe residents consume medications upon administration of the medication and not be left at bedside.

Based on interview and record review the facility failed to ensure a Preadmission/Annual Resident Review (PAS/ARR) was completed after the 30 day exemption period and failed to notify the State Agency Health Authority for 1 Resident( #98) of 1 reviewed for PAS/ARR from a total sample of 19. Findings include: Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] revealed Resident 98 (R98) was admitted to the facility on [DATE] with multiple medical diagnoses including but not limited to adult personality disorder with behaviors, alcohol abuse with a history of alcohol induced psychotic disorder with hallucinations, anxiety and major depression and had a physician order for a psychotropic medication since admission. Review of the MDS revealed R98 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review R98's clinical record revealed a 3877 level one screen dated 10/22/24 reflected R98 was prescribed an anti-anxiety order on an as needed basis. The 3878 screen reflected R98 was under a 30 day exemption and was expected to be discharged to the community within that time frame. There was no further level one screen/3877 after R98's 30 day exemption. On 4/29/25 at 11:10 am, during an interview with Social Worker (SW) K she reported she completed 3877 after R98's 30 day exemption but was unable to locate it. When queried if there was any record or documentation that the state agency community mental health (CMH) was aware of R98's admission SW K stated she would follow up. At 3:50 PM SW K provided a level one screen /3877 dated 4/29/25 and offered no explanation as to why CMH had not been notified prior to today.

Based on observation, interview, and record review the facility failed to implement comprehensive resident-centered care plans for one out of 19 residents (R32), resulting in worsening of and facility acquired pressure wounds. Findings include: Resident #32(R32) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R32 was a [AGE] year-old female admitted to the facility on [DATE], with most recent re-admission 3/10/25 related to osteomyelitis (wound infection) with other diagnoses that included stage 4 pressure ulcer (full thickness skin and tissue loss, exposing muscle, tendon or bone), diabetes Mellitus, irregular heart rhythm, anxiety and depression. The MDS reflected R32 required substantial/maximal assistance with repositioning in bed. During an observation and record review on 4/28/25 at 9:46 AM, R32 was observed laying in bed, flat on back, with eyes closed on specialty air mattress that appeared slightly deflated. Observed air mattress pump located at foot of the bed with no lights or sound noted with electrical cord laying on the floor and unplugged from the wall, revealing no power to pump. Review of the MDS Indicators reflected R32 had a major wound infection and several hospitalization s. During an observation on 4/28/25 at 3:57 p.m., R32 was laying in bed, flat on back and air mattress pump continued to be non-functioning with no light and unplugged from wall outlet. R32 bed continued to appear deflated with sheets corners off of the mattress. During an observation and interview on 4/29/25 at 8:40 AM, R32 was laying in bed with air mattress now plugged into wall outlet and with lights on the bed. R32 reported had a wound on buttock area that caused her a lot of pain. When asked if staff provided her with medication for pain control, she reported they offer her Tylenol that does not help. R32 reported unable to independently reposition self in bed and staff do not assist or offer every two hours but instead about two times per shift. R32 reported did not get out of bed yesterday and bed seems more comfortable today than yesterday. Review of R32 Physician Progress Note, dated 4/11/25, reflected, [named R32] is a [AGE] year-old female who is recently in the hospital for UTI [urinary tract infection] and osteomyelitis. She had been on IV Zosyn which she developed an allergy to. She's being monitored for improvement of her rash before starting her next dose of antibiotics. The rash appears to be improving. [named R32] also has a wound on her sacrum area that does not appear to be improving. Referral to [named wound clinic] clinic has been placed. Review of R32 Wound Evaluation, dated 4/29/25, reflected wounds as follows: --#8 - Facility Acquired Stage 3 pressure wound right gluteus - 0.54cm x 1.8 cm x 0.1 cm with PUSH score of 6. The Evaluation note reflected, Surrounding tissue is non-blanchable & is at high risk for breakdown . --#9 - Unstageable Pressure wound Sacrum - 4.63cm x 3.59cm with no depth with 10% slough, 10% escar and 80% granulation tissue and PUSH score of 14. Wound Evaluation note reflected, Resident currently receiving course of Zyvox for osteomyelitis r/t[related] to wound. Surrounding tissue is non-blanchable & fragile & is at risk for breakdown. Further tissue damage is possible . Review of R32 SKIN MANAGEMENT Care Plan, revised 3/1025, reflected interventions that included, Encourage me to make small, frequent shifts in my position . I have pressure reducing device on bed- APM[alternating pressure mattress] mattress set to my comfort. LN[licensed nurse] to ensure it is functioning q[every] shift . Review of the Wound Clinic Consult, dated 4/30/25, reflected R32 was seen for infection of stage 4 Pressure Ulcer to Coccyx and right ischium open area. The consultation reflected orders to change dressing to coccyx wound two times daily and as needed and to reposition R32 every two hours while lying and every 15 to 20 minutes while sitting. During an interview on 4/30/25 at 9:48 AM, Registered Nurse Wound Nurse (WN) M reported had been wound nurse for about three years at the facility. WN M verified R32 admitted to the facility 1/5/24 with no wounds and developed wounds post hospital admissions and did not have any facility acquired pressure ulcers. WN M verified wound #2 was present on admission post hospital on 12/5/24 as stage 3 that was later wound #3 then #5 and currently #9 unstageable pressure sacrum wound. WN M verified wound worsened and was currently being treated for osteomyelitis. WN M reported R32 had new open wound (#4) on 1/27/25 to right gluteus that had history of prior pressure wound. WN M verified New wound #4 was later #7 then #8 current stage 3 pressure wound to right gluteus. WN M verified R32 wound #8 had worsened between onset of 1/27/25. WN M reported would expect staff to follow care plans and Kardex interventions including turning and repositioning R32 every two hours and making sure air mattress was functioning. WN M reported staff expected to complete change of condition for new wounds and verified no change of condition completed on 1/27/25 because new wound had a history. WN M reported wound #4 that developed on 1/27/25 was not facility acquired because of prior history of wound and would provide evidence to support. During an interview and record review on 4/30/25 at 10:43 AM, Clinical Care Coordinator RN N verified occasionally covered for wound nurse and when reviewing wounds uses PUSH scores to document wound progress. RN N reported would expect staff to follow care plans and Kardex and nurse to monitor R32 functioning of air mattress every shift and document. RN N verified R32 required assistance with bed mobility for repositioning and staff expected to assist related to standard of practice and not required to document as completed task. During a second interview on 4/30/25 at 12:25 p.m., WN M verified R32 wound #4 was identified incorrectly and should have been identified as facility acquired pressure ulcer on 1/27/25 that was currently wound #8 stage 3 pressure wound to right gluteus. During an interview on 4/30/25 at 12:32 p.m., Director of Nursing (DON) B reported would expect staff to follow Care Plan and Kardex interventions.

Based on observation, interview, and record review the facility failed to maintain infection control practices for one resident (#111) out of one resident sampled during observation of blood glucose level testing, with a glucometer. Findings Included: Resident #111 (R111) Review of the medical revealed R111 was admitted to the facility 04/10/2025 with diagnoses that included fracture right femur, type 2 diabetes, hypothyroidism (low thyroid hormone), depression, anxiety, hyperlipidemia (high fat content in blood), hypertension, and pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/16/2025, revealed R111 had a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. During observation and interview on 04/29/2025 at 08:57 a.m. R111 was observed lying down in bed. R111 could not remember if she had received her insulin yet this morning. Review of R111's medical record revealed a physician order for Insulin Degludec subcutaneous solution pen-injector 100 unit/ml (milliliters) inject 50 unit subcutaneously in the morning. During interview on 04/29/2025 at 09:08 a.m. Licensed Practical Nurse (LPN) C explained that she had not administered R111's insulin injection to her yet this morning because R111's blood sugar was lower, and she wanted to obtain another glucose reading after she consumed her breakfast. On 04/29/2025 at 09:15 a.m. Licensed Practical Nurse (LPN) C was observed to collect a glucometer and R111's Insulin pen. LPN C was observed to proceed to R111's room and was observed to collect R111's blood and placed it on the glucometer stick, which was placed into the glucometer. R111's glucometer reading was observed to be 123mg (milligrams)/dl (deciliter). LPN C was then observed to provide R111 with the ordered insulin injection of Degludec subcutaneous solution100units/ml (milliliter) 50 units. LPN C was then observed to leave the room and place the glucometer in the top drawer of the 200-hall medication cart, which also contained other residents' insulin pens. In an interview on 04/29/2025 at 09:31 a.m. Director of Nursing (DON) B explained that it was her expectation that glucometers were to be cleaned after each use in accordance with the manufacture's recommendations. DON B explained that the cleaning should be completed prior to placing the glucometer back in the medication carts and prior to use of another resident. Review of the manufactures instructions for cleaning and disinfection of the Assure Prism Mulit Blood Glucose Monitoring System (BGMS) revealed The meter should be cleaned and disinfected after use on each patient.

This deficiency pertains to Intake MI00150515 Based on interview and record review, the facility failed to provide timely notification to the physician for one Resident (#106) of three residents reviewed for a change in condition. This deficient practice resulted in a delay in medical treatment for a significant change in condition with diabetic ketoacidosis. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R106 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included multiple pelvic fracture post fall 2/4/25, hypertension(high blood pressure), insulin dependant diabetes mellitus (elevated blood sugar), and mild dementia. R106 was readmitted to the hospital 2/17/25 for diabetic ketoacidosis. The MDS reflected R106 had a BIM (assessment tool) score of 12 which indicated her ability to make daily decisions was moderately impaired. During a telephone interview on 3/10/25 at 9:24 a.m., complainant H reported R106 was admitted to the facility on [DATE] for rehab after falling at home and breaking pelvis. The complainant H reported when the resident was at the hospital recovering from fall, the doctor changed R106's long-acting insulin to a short acting insulin with meals as needed. Complainant H reported R106 had been on 25 units long acting insulin prior to fall for diabetes with recent A1C(test that measures average blood sugar levels over past two to three months) of 7.8% (normal below 5.7%). Complainant H reported R106 had order for insulin from the hospital but was unsure if facility was giving R106 insulin. Complainant H reported on 2/14/2025 that R106 became very sick, including, nausea, vomiting and diarrhea and unable to keep anything down for three days and blood sugar was elevated. Complainant H reported Physician had discussed possibly related to Ozempic and Complainant H reported R106 had been on Ozempic for over three years. Complainant H reported requested R106 to be taken to the hospital because she was continuing to decline on 2/17/25. Complainant states the resident was taken to the hospital and R106's blood sugar level was over 650 and was told R106 was in diabetic ketoacidosis and later passed away 2/19/2025 after several life saving efforts. Complainant H reported the R106's medication list that the hospital doctors pulled from the facility didn't have insulin listed as a prescribed medication and facility Physician was aware R106 had been on long-acting insulin prior to admission. Review of R106 facility Progress Notes, dated 2/7/25 at 4:00 p.m., reflected, Res. is a [AGE] year old female, married. She is coming to the facility from [named] hospital after a fall at home. She has a dx[diagnosis] and hx[history] of non-displaced fx[fracture] L[left] acetabulum, fx L pubis, falls, DM2[diabetes mellitus type 2], GERD[gastroesophageal reflux disease], OA[osteoarthritis], HTN[hypertension], hyperlipidemia, Dementia, diverticulosis, osteoporosis, OA, depression. She is A&Ox3[alert and oriented x 3] to person, place, time. She is able to answer questions appropriately. She is able to make needs and wants known. She scored 12/15 on BIMS. She can be forgetful at times and may need reminders. Her mood appears stable, very social with writer and reminisced about daughter. She denied concerns with mood. She is on Lexapro. She declined psych services. No trauma indicated. Her speech is clear and understandable, can hear a normal conversation, no glasses present. She is a full code. She is here for short term rehab. Plan to return home with husband. Also has support of son and and granddaughter as needed. She was independent prior . Review of R106 Nurse Progress Note, dated 2/7/25 at 6:48 p.m., reflected, Resident admitted from [named] Hospital . Able to speak in full sentences .Wishes to be full code at this time. Denies any pain/ discomfort. Appears to be resting comfortably in bed with call light in reach. Family at bedside. Review of R106 Hospital Discharge Instructions, dated 2/7/25, reflected medication list that included, Continue Medications (10) These are your current medications to keep taking at home. The list included, Insulin Detemir(long acting insulin) U-100 100 units/ml pen, 10-15 units subcutaneous daily (hand written DC ok per provider next to order); metformin 1000 mg twice daily; Ozempic 0.5mg weekly. Continued review of hospital documents reflected R106 had received last dose of Insulin Detemir 10 units on 2/7/25 at 9:49 a.m. along with Lispro Insulin (fast acting insulin) per sliding scale of 3 units. Review of the Physician orders dated 2/7/25 through 2/15/25, reflected no orders for insulin for R106 with known insulin dependent diabetes mellitus. Continued review of R106 physician orders reflected, Accu-check two times a day related to TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS .Notify provider of blood sugar <70 or >400 Review of R106 Electronic Medical Record(EMR), dated 2/7/25 through 2/17/25, reflected R106 and 12 readings greater than 250 including 9 blood sugars over 300. Review of R106 Physician Note, dated 2/10/25 at 5:01 p.m., reflected, Chief Complaint / Nature of Presenting Problem: Fall with non-displaced left acetabular fracture with inferior left pubic rami fracture and left sacral ala fracture. History Of Present Illness: Available records reviewed. Patient was seen and examined 2/10/2025 .hospitalized at [named hospital] from 2/4/25 - 2/7/25. [named R106] is a 93 y.o w/f[year old white female], who fell backwards at home and landed on her buttocks. She had severe pain with movement and was taken to [named] Hospital where pelvic/hip x-ray revealed non-displaced left acetabular fracture with inferior left pubic rami fracture and left sacral ala fracture. Seen by ortho and recommended 4-6 weeks of non-weight bearing with PT/OT .Transferred to [named facility] for SAR[sub acute rehab] services. Seen with granddaughter and husband present with patient consent .Plan .Type 2 diabetes mellitus without complications: continue metformin, Ozempic, monitor bs, check hgba1c, appeared to be on insulin at home. Will monitor accu-checks and adjust meds///add Jardiance 10mg/d, hgba1c pending//accuchecks on high side . Review of R106 Nutritional Note, dated 2/11/25, reflected, BS reviewed, ranging from 131-374mg/dL . Diet: regular texture/thin liquids, consuming 50-100% of meals per FARs. Agreeable to DM diet modifications. NKFA[no known food allergies]. Food preferences honored/updated. Tolerating current PO[oral] diet, no issues c/s food or fluids- wears dentures, fit well. Able to feed self and make wants and needs known. Review of R106 Rehab Services Screening Form, dated 2/12/25, reflected, BIMS 5/15. Kitchen staff reported to SLP [speech-language-pathologist] that pt[patient] was having difficulty swallowing; pt denies difficulties but further ST [speech therapy] assessment warranted. Pt stated she was (I) with IADLs[independent activities of daily living] at baseline, so further cognitive communication assessment warranted. Review of the Food Acceptance Record, dated 2/7/25 through 2/17/25, reflected R106 had decrease in food intake starting 2/14/25 including two consecutive refused meals. Continued review of the document reflected continued poor intake including 0-25% intake for three consecutive meals on 2/16/25. Review of R106 Nutritional Note, dated 2/15/25 at 11:05 a.m., reflected, Diet downgraded to mechanical soft texture 2/12 per SLP recommendations. Record review reflected R106 blood sugars were between 313 and 468 on 2/15/25 through 2/17/25 with limited food intake. Review of the Electronic Medical Record(EMR), dated 2/7/25 through 2/17/25, reflected no evidence Physician was notified of change in R106 condition on 2/14/25 or 2/15/25. Continued review of R106 EMR reflected Provider was contacted on 2/16/25 at 8:00 p.m. related to elevated blood sugar of 468 with no mention of poor intake for past 3 days. Review of R106 Nurse Progress Note, dated 2/17/25 at 2:26 p.m., reflected, Resident family expressed increased concern with residents lack of appetite and decreased fluid intake. Would like resident to be Sent to [named hospital] for further evaluation. MD[medical doctor] notified and management aware. Review of R106 Hospital History and Physical, dated 2/17/25, reflected, Problem/Assessment Plan 1-10: Problem 1: Diabetic ketoacidosis Plan 1: Insulin drip, ICU[intensive care unit] consult, secondary to discontinuation of medications and commendation of stress of illness. Problem 2: AKI (acute kidney injury) Plan 2: Secondary to intravascular depletion, IV hydration, dose meds Problem 3: Diarrhea Plan 3: Secondary to recent viral infection . Problem 4: Pelvic fracture Plan 4: Continue to monitor supportive care . CHIEF COMPLAINT .Nausea vomiting diarrhea .History of Present Illness .Is a [AGE] year-old female with history of diabetes type 2 who recently sustained a pelvic fracture 2 weeks ago. the patient was sent to subacute rehab. The patient presented with 3 days nausea vomiting diarrhea .The patient while hospitalized had her long-acting insulin discontinued and she was placed on short acting insulin. This was discontinued in the facility per family report. The patient was found to be in DKA[Diabetic Ketoacidosis]. She was started on a heparin drip. She was hospitalized in the ICU . Review of R106 Hospital Endocrinology Consult, dated 2/18/25, reflected, Problem 1: Diabetic ketoacidosis Plan 1: With a CO2 of 17 high anion gap high lactic acid high troponin and creatinine of 2 patient now going to tachycardia and possible cardiogenic shock .She states after her discharge from the hospital, patinet's insulin regimen was changed. Patients family states she was on Tresiba but it go discontinued at discharge. They state at the facility patient had been receiving metformin and Ozempic. They state about 3 days ago patient started having episodes of diarrhea .She states after 34 hours patient continued to have abdominal pain. They state that diarrhea hot less but patient started having episodes of nausea/vomiting. They also endorse patient was having increased thirst and urination. Family states since patient was not improving it prompted them to bring her to the ED[emergency department] .Upon arrival to ED .glucose 547 .Hemoglobin A1c 8.5 . Review of R106 Discharge Summary Physician, dated 2/19/25, reflected, Discharge .Time of death: 19-Feb-2025 02:55[2:55 a.m.]. Preliminary cause of death Asystole . During a telephone interview on 3/12/25 at 10:35 a.m. Licensed Practical Nurse (LPN) I reported was R106 nurse on 2/16/25 evening shift. LPN I reported completed Change of Condition document for R106 related to high blood sugar of 468 around 8:00 p.m. LPN I reported R106 did not have orders for insulin at that time. LPN I reported R106 had also been complaining of nausea and vomiting on 2/16/25 and reported was unsure if she reported to provider but should be documented on Change of Condition document.(Verified not mentioned). LPN I reported received order from provider to repeat R106 blood sugar check and administer 10 units Humalog (fast acting insulin) on 2/16/25 around 9:00 p.m. LPN I reported to day shift nurse on 2/17/25 around 7:00 a.m. During an interview on 3/13/25 at 11:32 a.m. Clinical Care Coordinator (CCC) C reported facility process for new admissions included three step check. CCC C reported CCC often assist with new admissions and enter medications from hospital discharge documents into EMR queue and before saving call placed to Medical Director to verify orders. CCC C reported if he makes changes staff hand write DC and initial next to medication on hospital discharge document. CCC C reported verify medications with two nurses then reported corporate Nurse Practitioner reviews for third check and reported was unsure who that might be. CCC C reported Medical Director(MD) G was present at facility every Monday, Wednesday, and Friday. CCC C reported MD G routinely adjusted resident diabetic medications on admission including insulin and facility did not use sliding scales. CCC G reported would expect staff to complete Change of Condition form for blood sugar greater than 400 per physician parameters. CCC C reported according to R106 food acceptance on 2/14/25 staff should have completed a Change of Condition form that would include notifying provider and responsible party related to two consecutive meals less than 25% eaten. Request was made for evidence that MD had been notified. Did not receive evidence Provider had been notified of Change of condition between 2/14/25 and 2/15/25 prior to survey exit on 3/13/25. During a telephone interview on 3/13/25 at 1:30 p.m. Medical Director(MD) G reported was familiar with R106. MD G reported staff contact him for new admissions and verify medications orders. MD G reported when R106 admitted to facility he recalled R106 being on a range scale for long acting insulin that was not typical. MD G reported continued R106 oral diabetic medication metformin and weekly Ozempic orders to monitor blood sugar. MD G reported after R106 admission visit on 2/10/25 added additional oral medication Jardiance because of added benefits and stated, low blood sugar is far more emergent than high as it takes years to show damage. MD G reported family was unsure how insulin was used at home and often takes caution related to insulin dosing. MD G reported would expect staff to notify provider of blood sugar greater than 400 as well as change in appetite, change in food acceptance, nausea, vomiting, or diarrhea. MD G reported did recall Nurse Practitioner visit and would plan to follow up with this surveyor. During a telephone interview on 3/13/25 at 2:11 p.m., MD G verified R106 was seen by provider on 2/17/25 and several medication were adjusted including adding insulin same day R106 was transferred to the hospital. MD G reported recalled discussing possible reasons for nausea included Ozempic. MD G verified was not notified of R106 change in intake, nausea, vomiting or elevated blood sugars between 2/14/25 through 2/16/25 at 8:00 p.m. and would expect staff to notify provider.

This citation refers to intake MI00150353, MI00149992 Based on observation, interview, and record review, the facility failed to provide adequate supervision, conduct timely root cause analysis of fall incidents, implement appropriate interventions to prevent future falls and re-evaluate the effectiveness of interventions for 3 residents (R103, R104, and R105) out of 3 residents reviewed for falls, resulting in R105 falling and re-fracturing recently repaired hip and R103 fall with laceration requiring emergency room treatment and R104 fall with fracture and subdural hematoma and overall decline. Findings included: Resident #105(R105) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R105 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included aftercare of left bipolar hemiarthroplasty(surgical repair of left ball of hip) post fall at home, peripheral vascular disease, orthostatic hypotension(drop in blood pressure with change in position), need for assistance with person care, heart disease, hypertension (high blood pressure), and diabetes mellitus. The MDS reflected R105 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. Continued review of the MDS reflected dated 11/12/24 through 12/3/24 reflected three unplanned discharges to acute care. An anonymous complaint received by the State Agency alleged the facility failed to prevent avoidable fall for R105 that resulted in re-fracture of the left femur on 12/3/24. Review of R105 Nursing Progress notes, dated 11/12/24, reflected, Resident arrived via stretcher from [named] Hospital. He is alert and oriented times 4 .Lt(left) hip surgical site with derma bond dressing . Pain present at surgical site with movement . Review of R105 Social Service Note, dated 11/13/2024 at 11:55 a.m., reflected, [named R105] was admitted here yesterday afternoon from [named] Hospital. Resident was admitted to hospital after fall at home. Resident has fx[fracture] of left femur. Resident is a [AGE] year WMM[year old white male]. Resident has been living fairly independent in own home with wife. He was independent with own ADL [activities of daily living] .Resident is planning on returning home after short term rehab . Review of R105 Nurse Progress Note, dated 11/19/2024 at 1:00 p.m., reflected, called and spoke with ortho office as resident has not returned since 10:45 appointment. Resident was sent to [named emergency department] from ortho office due to bleeding from left hip incision as well as poor mental status and lethargy . Review of the Nurse Progress Notes, dated 11/20/2024 at 5:02 p.m., reflected R105 returned from the hospital. Review of R105 Physician Progress Note, dated 11/21/2024, reflected, .Chief Complaint / Nature of Presenting Problem: Lethargy, confusion .Patient seen and examined with note entered. [named R105] was initially admitted to [named facility] on 11/12/24 after suffering a fall and suffering a displaced left femoral neck fracture. He was admitted to [named hospital] for such and underwent left bipolar hemiarthroplasty on 11/7/24 .On 11/19/24 he went for follow-up orthopedics appointment but became unresponsive at the appointment and was sent back to [named hospital]. Labs revealed initial blood sugar by accu check of 56 . pt did have bout of hypoglycemia in facility and likely d/t hypoglycemia . Review of R105 Nurse Progress Note, dated 11/24/25 at 10:23 p.m., reflected, LN[licensed nurse] was called into resident room, resident was sitting in chair, shivering. Upon assessment, BP[blood pressure] 112/89, pulse 89, temp 99.1, O279% on room air, BS[blood sugar] 459. Physician was contacted, started on 3L[liter] of O2[oxygen]. Resident to be sent to [named hospital] for further evaluation. Review of the Hospital History and Physical, dated 11/24/25, reflected, Chief Complaint: fever, altered mental status .Code Status Discussed with?: Spouse (patient is not of sound mind to make this decision currently, no advanced directive on chart) .[named R105] is a [AGE] year old male with history of diabetes, hypertension, abdominal aortic aneurysm, claudication, emphysema and chronic kidney disease. Patient is currently residing at [named facility] for rehabilitation. This is his third admission this month since fracturing his left hip approximately 3 weeks ago. Prior to that spouse and son report that he was independent and functional. EMS[emergency medical services] was contacted by SNF[skilled nursing facility] staff due to altered mental status .At moderate risk for fall .Active Problems .Acute metabolic encephalopathy .Exam .Neuro: General: oriented to person and confusion (reports he is at church when asked) . Review of R105 Hospital Progress Note, dated 11/25/24, reflected, Patient admitted for sepsis secondary to UTI[urinary tract infection], there was also concern of possible surgical site infection of the left hip. The patient was started on broad-spectrum antibiotics .Patient seen and examined at bedside. He is alert and oriented to self only .Patient is exhibiting some confusion . Review of R105 Hospital Rehabilitation Service Note, dated 11/15/24, reflected, Acute Care OT(Occupational Therapy) Assessment .Transfers Sit to stand: Contact Guard .Toilet Transfer: Contact Guard Comments:: PT CURRENTLY REQUIRES US OF FWW[4 wheel walker] AND 1 PERSON ASSIST FOR TRANSFERS AND MOBILITY. Cognition Orientation: Minimally impaired .Judgement: Minimally impaired .Short Term Memory: Moderately Impaired .Follows Commands: Minimally Impaired .Comments .BED ALARM ON FOR SAFETY .Assessment: .UPON OT EVALUATION, PT IS PHYSICALLY FUNCTIONING SLIGHTLY BELOW HIS BASELINE STATUS OF MOBILITY AND INDEPENDENCE. HE FATIGUES QUICKLY. HE CONTINUES TO REQUIRE USE OF FWW TO ENSURE BALANCE AND SAFETY DURING MOBILITY AND TRANSFERS. HE REQUIRES 1 PERSON ASSIST FOR ADL ROUTINE. HE WILL BENEFIT FROM RETURNING TO REHAB IN ORDER TO MAXIMIZE INDEPENDENCE AND FUNCTIONING PRIOR TO RETURNING HOME WITH HIS WIFE . Review of the Fall Incident/Accident report, dated 12/3/24 at 4:30 p.m., reflected R105 had an unwitnessed fall in bathroom after self-transfer with left thigh fracture. The document reflected, Immediate Action taken: Neuro assessment completed prior to transferring resident from floor to wheelchair. Resident's ROM in left leg decreased .Resident rated pain in left hip 4/10. Resident transferred from floor to wheelchair with 2PA[two person assist], NWB[non weight bearing] to LLE[left lower extremity] maintained during transfer. VS[vital signs] obtained, BP[blood pressure] slightly low without s/sx[signs and symptoms] of hypotension. Skin tears present on left elbow & left forearm. Both areas cleansed & treatment with Xeroform completed. All appropriate parties notified. Provider ordered a STAT[immediately] left hip X-ray to R/O fx[rule out fracture]. Resident educated regarding use of call light for safe transfers & ambulation. Continued review of the document reflected, Predisposing Situation Factors, including the following marked; call light not used, admitted within last 72 hours, Ambulating without assistance. The document reflected R105 wife was present in room at time of fall and no witness statements found. Continued review reflected R105 wife was notified at 4:30 p.m. and the Provider at 4:40 p.m. and the form was completed by CCC D.(Not R105's nurse at the time.) Review of Electronic Medical Record (EMR) Census, dated 12/3/24, reflected R105 readmitted to the facility on [DATE] at 4:08 p.m.(Just prior to R105 unwitnessed fall with fracture on 12/3/24). Review of the Progress Notes, dated 12/3/24, reflected no mention of R105 fall. Review of R105 Nursing Progress Note, created 12/3/24 at 6:36 p.m., reflected, Resident arrived to facility via private transportation. Resident has had full skin assessment performed with no skin breakdown noted on bony prominences. Residents lungs cta[clear to auscultation],heart rate regular. No cough or sob[short of breath] noted. Residents' radial and pedal pulses present and palpable bilaterally. Resident has swelling noted to left lower extremity from hip to toes. Resident has left hip incision with large scab noted and swelling with no heat redness or drainage noted. Resident has been re-oriented to facility, resident able to use call light unassisted. Resident aware that he is not to get up unassisted. Resident wife here at bedside. (No mention of R105 fall that occurred about two hours prior to note created.) Review of R105 fall assessment, dated 11/20/24, reflected, Fall risk assessment completed upon admission. Resident is at high risk for fall secondary to hx[history] of falls .Additional fall risks include; medical hx, recent hospitalization , & medications .Staff to follow current POC [plan of care]. Review of R105 Fall Assessment, dated 12/3/24 at 4:30 p.m., reflected, Root Cause: Resident is at high risk for falls r/t to recent hospitalization s, medical history & medications. Resident has multiple cormorbidities that attribute to fall risk including; recent left hip replacement, active infections (UTI & bacteremia), fatigue & weakness, hx of falls, pain, intermittent claudication of B/L Les[bilateral lower extremities], & PVD[peripheral vascular disease]. Resident assisted to bathroom prior to fall. CENA[competency evaluated nursing assistant] instructed resident to pull call light when he was ready to exit bathroom (resident a&o x4 with a bims of 15). Resident did not comply with CENA instructions and attempted to self-transfer/ambulate. Resident stated he thought he could get out of the bathroom without help. Immediate Safety Intervention: Resident educated regarding use of call light for safe transfers & ambulation [Not effective intervention as was already attempted and failed resulting in fall]. IDT review day #1 12-4-24: IDT agrees with root cause and intervention. Care plan reviewed and updated. Will continue to monitor. X-Ray obtained post fall. Femur fracture noted. Resident sent out to hospital. Review of R105 Brief interview of Mental Status (BIMS), dated 12/3/24 at 6:57 a.m.(over eight hours prior to R105 return to the facility), reflected BIMS score of 15. Review of R105 Rehab Services Screening Form, dated 12/3/24 at 6:38 p.m., reflected, Per discussion with nurse, patient sustained a fall while he was in the bathroom and attempted to self-transfer shortly after he was admitted . Awaiting x ray to r/o[rule out] fracture. OTR[Occupational Therapist, Registered] spoke with family and educated about not bearing weight into lower extremities until x ray is completed and imaging report is received. Will hold therapy evaluation until clearance is provided on weight bearing status. Review of the eINTERACT Transfer Form, dated 12/3/24 at 8:30 p.m., reflected, R105's most recent admission was 12/3/24 at 4:08 p.m. with diagnosis that included, sepsis, urinary tract infection, fracture of unspecified part of neck of left femur. Review of R105 Nurse Progress Note, dated 12/3/24 at 8:30 p.m., reflected, Resident transferred to hospital after X-ray results came in. Dr. G ordered. Nurse notified resident's wife [named] and on call manager of send out. Resident a&ox3 and states pain is 8/10. Review of R105 Radiology Report, dated 12/3/24 at 7:32, reflected the left hip and pelvis indicated, Acute nondisplaced mid femoral fracture extending away from the distal tip of the femoral THA[total hip arthroplasty] stem. During an interview on 3/11/25 at 2:45 p.m., Interim Director of Nursing (IDON) B reported had soft file on R105's fall on 12/3/24 and facility had completed Past Non-Compliance related to falls with alleged compliance date 1/31/25 after recognizing several falls including falls with major injury. IDON B provided complete investigation for R105, R104 and R103 falls along with past noncompliance binder. Review of the facility Staffing Assignment Sheet, dated 12/3/24 2nd shift, reflected R105 nurse was Clinical Care Coordinator Registered Nurse (CCC) C and two Certified Nurse Aids(CNA) were assigned to R105 hall(CNA J and CNA E) with a facility census of 93. Review of R105 Fall investigation Interview Statement, dated 12/4/24, reflected CNA J completed witness statement. The document reflected, To whom it may concern on the day in question. [named CNA E] and I were told to go assist with getting [named R105] out of the car. He had just arrived at our facility. We brought him into the building and immediately took him to get weighted. On the way to his room, he stated he had to go to the restroom. [named CNA E] and I assisted him with gait belt from his wheelchair to the toilet. He stated he needed a few minutes so we educated him on pulling the red string on the call light so it would let us know he was finished. [named CNA E] and I left him on the toilet . Review of R105 fall investigation witness statement, undated and unsigned, reflected, Resident was placed on toilet by CNAs, CNAs gave resident call light and was told to call when ready, CNAs left resident for privacy, CNA asked if he was ready, but needed more time, CNA went to answer call light going off and upon returning resident was on the floor. Review of R105 Fall investigation Interview Statement, undated, signed by CCCRN C reflected R105 had fall on 12/3/25. The statement reflected, Resident readmitted to the facility apx[approximately] 18:15 p.m.[6:15 p.m.]. Resident arrived via private transportation with wife present. Resident had initial skin assessment vital signs and education performed at apx 1820[6:20 p.m.] Resident was recently a resident in this same room and hallway, during education resident remembered the names of staff assisting him. He was aware of where he was, date, moth and also remembered room, bathroom and how to use call light. Resident was toileted per his request at apx 18:25[6:25 p.m], he was transferred to toilet with 2 CNAs . (Interview statement does not appear to reflect correct time according to all other documents and evidence). During a telephone interview on 3/12/25 at 1:57 p.m., Certified Nurse Assistant (CNA) K reported knows how to care for residents by reviewing Kardex and verified received recent fall training from facility at end of January. CNA K reported residents with high risk for falls should never be left alone in bathroom especially with history of post hip surgery related to fall. During an interview on 3/12/25 at 3:30 p.m., CNA J reported was working on 12/3/24 when R105 fell in bathroom. CNA J reported her, and CNA E were told to assist R105 from personal car, driven by wife, into the facility. CNA J reported obtained R105 weight and then R105 reported had to use restroom and the two CNAs assisted R105 from the wheelchair onto the toilet and instructed to use call light when done and left R105 in bathroom alone. CNA J reported had returned to check on R105 who was not ready and upon returning again had fallen in the bathroom after attempting to self-transfer. CNA J reported assisted R105 off the floor with two to three staff by picking up under R105 arms and transferring to the wheelchair then from wheelchair to bed with pivot transfer and at least two assist. CNA J reported nurse took over from there. CNA J reported completed witness statement after fall but not same day as R105 fall and received education from facility to not leave residents alone especially if high risk for fall. During a telephone interview 3/13/25 at 10:49 a.m., R105's Family Member F reported R105 was doing well enough at the hospital, and she transported him in a personal car from the hospital to the facility on [DATE]. FM F reported two staff met her at the car and they wheeled R105 in the facility. FM E reported R105 had to use the bathroom right away so two staff took R105 in his bathroom and before nurse staff could even complete body check. FM F reported stepped out of room for moment to make call and returned and asked roommate, is he still in there?' and roommate reported yes. FM F reported waited outside the door for maybe five minutes and figured staff were in the bathroom with him and then heard a big crash. FM F reported opened the door and R105 was on the floor with no staff present. FM F reported it concerned her R105 had been left alone because he was such a high fall risk they had not been back in facility for more than 15 minutes. FM F reported went and found the nurse and reported R105 was on the floor, who responded, can he get up? FM F reported they got him in bed did body check, they didn't see anything significant but R105 was complaining of pain to left hip area. FM F reported they ordered X-ray right away, but it was a few hours before they got there and it was around 8:00 p.m., when they received call R105 left leg was broken and facility planned to send R105 to local hospital. FM F reported local hospital transferred R105 to a trauma center who performed eight-hour surgery to repair R105 re-fractured, shattered left leg. FM F reported R105 was currently on hospice and stated, it shouldn't have happened .To leave him unassisted and I don't know the circumstances, I know they were busy and understaffed, that's not a reason to leave him unattended. FM F reported R105's second fall with fracture on 12/3/24 extended the first one and shattered left leg and hardware had to be removed and replaced and continued to decline. FM F reported staff did not mention using call light after the fall and was chaotic scene. FM F reported the roommate thought the staff was in bathroom with R105 but staff must have exited shared room door because the roommate said they never saw the staff leave the bathroom. FM F was queried of R105 would have used call light when done? FM F stated, I would not have trusted him to do that even if he was well enough. During a telephone interview on 3/13/25 at 12:35 p.m., CNA E reported was working on 12/3/24 when R105 had a unwitnessed fall in the bathroom. CNA E reported CCCRN C requested CNA E and CNA J assist transfer R105 from personal car to room. CNA E reported transported R105 in wheelchair from parking lot with CNA J to room and R105 requested to use the bathroom, and both CNAs assisted R105 from wheelchair to toilet. CNA E reported was not told R105 could not be left alone and both CNAs left R105 on toilet alone and left to answer call lights on the hall. CNA E reported returned in about five minutes and R105 was on the bathroom floor, called for Registered Nurse (RN) L, FIT team paged overhead (fall team). CNA E reported Occupational Therapy Staff (OT) M was present and R105 was transferred from floor to wheelchair but unable to recall how and reported R105 was then transferred from wheelchair to bed with two-person pivot assist with OT M. CNA E reported resident acuity was high that day for only two CNA staff on hall. CNA E verified he wrote witness statement several days after R105 fall that was not dated or signed. CNA E reported was not aware R105 was high fall risk or even know transfer status when told to assist R105 from personal car on 12/3/24, prior to readmission. During an interview on 3/13/25 at 1:13 p.m., OT M reported was called down to 100 hall on 12/3/24 after R105 had fallen in bathroom by CNA E. OT M reported R105 was sitting on bathroom floor with definite signs of pain including facial grimacing. OT M reported was familiar with R105 because worked with R105 after original admission post hip repair within prior month. OT M reported RN L was present after fall and R105 was transferred from the floor to the wheelchair with 2-person assist with gait belt. OT M reported did not complete witness statement because she did not witness fall. OT M reported staff are expected to follow hospital transfer status until therapy evaluation completed at facility. During an interview on 3/13/25 at 1:50 p.m., CCC C reported was R105 nurse on 12/3/24 at the time of R105's unwitnessed fall in the bathroom that resulted in re-fracture of left hip and later transfer to hospital. CCC C reported completed R105 admission assessment shortly after arrival and then R105 requested to use the bathroom and was transferred by two CNA staff. When asked if the resident had fallen before or after admission assessment CCC C reported I am sure R105 had fallen after but do not recall and stated, what does my documentation say? CCC C was unable to say why witness statement did not match EMR documents related to R105 fall. Resident #103 (R103) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R103 was an [AGE] year old female admitted to the facility on [DATE], and most recently re-admission post fall with facial hematoma and contusion with other diagnoses that included dementia, heart disease, atrial fibrillation with use of blood thinners, hypertension (high blood pressure), depression and anxiety. The MDS reflected R103 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired. During a telephone interview on 3/10/25 at 11:29 p.m. R103 Family Member (FM) N reported R103 had an unwitnessed fall on 1/23/25 with facial injuries that required transfer to hospital. FM N reported facility was not able to answer how R103 fall occurred or how long R103 was on the floor before staff found R103. FM N reported R103 had significant facial bruising over entire face with open area to area above left eye several days after alleged fall. During an observation on 3/10/25 at 1:47 p.m., R103 was observed sitting in Main Dining Room during group activity with nickel size scabbed area located above left eyebrow. Review of R103 Nurse Progress Note, dated 1/23/2025 at 11:11 p.m., reflected, LN[licensed nurse] was alerted resident was on the floor of residents room. resident was laying on her stomach next to bed. resident stated she slipped out of her chair. Helped resident back into her chair. contacted on call doctor on call manager and residents daughter. [NAME] checks were started at 1920[7:20 p.m.]. resident sent to hospital for CT[computed tomography] scan as resident is on a blood thinner. Review of R103 Nurse Progress Note, dated 1/24/2025 at 6:07 a.m., reflected, resident returned from the hospital via ambulance after a fall. assessment completed. all bony prominences checked and intact. Review of R103 Fall Incident/Accident Report, dated 1/23/25 at 8:42 p.m., reflected R103 had an unwitnessed fall in room and was found lying on stomach next to the bed with abrasion noted on face. The report reflected, Resident states that she slipped off her chair . The report reflected R103 had impaired memory and no witness statements were found and Physician was contacted at 7:30 p.m.(Report had discrepancy in times, no mention of interventions that were in place on not in place including footwear, dysem or grip strips on floor). Review of R103 Hospital Radiology Report, dated 1/23/25, reflected CT scan of the brain revealed, LEFT frontal scalp soft tissue contusion and/or organized hematoma . Review of R103 Physical Therapy Assessment, dated 1/24/25, reflected, Reason for Referral/Current Illness: Patient is a [AGE] year old female with history of dementia who is a LTC[long term care] resident of the facility. She has a history of falls and has had 5 falls in the last year. She has been referred to skilled PT services following patient having a recent fall on 1/23. She sustained a bump with bruising to her forehead. She was transferred to the hospital for further evaluation and then returned to this facility. Per nursing notes, patient reported she slipped out of her w.c[wheelchair]. Patient told PT this date that she was walking without AD[assistive device] and only had socks on and slipped on the floor. Educated patient on having assistance, wearing shoes/grippy socks and using walker for safety . Review of R103 Physician Progress Note, dated 1/29/25, reflected, [named R103] had a fall the other day and was sent to ED[emergency department] as she has been on eliquis for hx of paroxysmal atrial fib . quarter size hematoma on left frontal area/diffuse echymosis both cheeks, infraorbital with subconjunctival hemorrhages bilateral . s/p fall with facial bruising d/t eliquis/ASA[aspirin] hx[history] paroxysmal atrial fib, currently in NSR[normal sinus rhythm] by exam//feel risk of continuing eliquis at this time outweighs the benefit and will stop and continue to assess as needed . Review of R103 Fall Care Plan, dated 10/28/2019, reflected, FALLS: At risk for falls due to Dementia, weakness, medications, Major Neuro cognitive Disorder, insomnia, bowel and bladder urgency .Interventions .I have gripper strips in front of my bed to prevent slipping .I will wear non-slip footwear for all transfers and walking . Review of R103 Fall Risk assessment, dated 11/23/25, reflected, The resident continues to be at risk for falls due to poor cognition and poor safety awareness. She continues at risk for further falls. Resident stood up unassisted and fell back when she missed her chair. Intervention: Upon standing, remind me to reach back for wheel chair before sitting . During an interview on 3/12/25 at 3:15 p.m., Certified Nurse Aid (CNA) O reported had found R103 on 1/23/25 in room on the floor after fall. CNA O reported was unsure if R103 had grip socks or shoes on or if wheelchair breaks were on or if gripper strips were in place on the floor by bed. CNA O reported did not complete witness statement because she did not witness fall. CNA O reported was unsure how long resident had been no floor prior to finding and reported facility had recently provided fall training at end of January. CNA O reported training included more frequent supervision of all residents especially residents with increased risk for falls to be able to encourage assistance and make sure interventions were in place. During an observation and interview on 3/13/25 at 9:30 a.m., R103 was sitting in Main Dining Room in wheelchair watching television with regular socks with no grip on them. R103 had nickel size abrasion noted to area above left eyebrow and was very hard of hearing. R103 reported fell out of bed and laid on floor until staff arrived and then was sent to hospital for several hours. R103 reported she is careful now and was told she had to wear shoes. Resident #104 (R104) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was an [AGE] year-old male admitted to the facility on [DATE], and most recently re-admission post fall at facility with left displaced hip fracture requiring surgical repair, compression fracture T-12(spinal fracture, and traumatic subdural hematoma. R104 had other diagnoses that included dementia, hypertension (high blood pressure), depression and anxiety. The MDS reflected R104 had a BIM (assessment tool) score of 3 which indicated his ability to make daily decisions was significantly impaired. The MDS reflected R104 did not have behaviors including wandering or rejection of care. An anonymous complaint received by the State Agency alleged the facility failed to prevent fall for R104 that resulted in hip fracture and passed away. Review of R104 Nursing Note, dated 2/4/25 at 1:52 p.m., reflected, Resident agitated. Hitting staff. Staff is unable to redirect resident. Resident throwing LN[licensed nurse] equipment off of medication cart. LN was eventually able to get resident to sit in his recliner in his room LN sat with him for a few minutes. Resident then got back out of his chair and starting yelling again. Review of R104 Social Service Note, dated, 1/5/2025 at 9:11 a.m., reflected, IDT[interdisciplinary team] reviewed alert for res.[resident] agitated, hitting staff, yelling out, throwing things. Staff reapproach, assist to calmer environment. Did yell out again. The review reflected no mention of staffing or adjustments. Review of R104 Unusual Occurrence Note, dated 1/6/2025 at 3:46 p.m., reflected, LN was alerted by a family member (visitor) that resident was laying on the floor at the end of the hallway. When LN arrived at residents side he was laying on his left side, head up against the wall feet outstretched into the hallway, by room [ROOM NUMBER] at the end of 500 long hall. Resident was noted picking up his hat when he fell over. Resident did not ask for assistance with his hat. Resident is noted wearing hipsters and non-slip footwear. Resident was noted ambulating in the hallway 15 minutes prior and offered a chair to rest. LN asked resident what he was attempting to do when he fell over? resident stated, just give me my damn hat LN did a full head to toe assessment on resident has full range of motion of both upper extremities without pain or difficulty. Resident has full range of motion in right hip. LN noted external rotation of left hip upon assessment. C/O[complained of] pain with minimal movement. no other injuries noted. Staff members were unable to assistance resident off the floor with a gait belt, resident was assisted off the floor by a hoyer lift with a sling and assisted to his bed. A staff member sat with resident until EMTS[emergency medical technicians] arrived . Review of R104 Social Service Note, dated 1/12/25 at 10:10 a.m., reflected, [Named R104] was readmitted yesterday evening from Hospital. Resident was readmitted with Dx of HX[history] of interchanteric FX[fracture] of left femur. Unspecified part neck Left Femur. Traumatic subdural hemorrhage without loss of consciousness. Occlusion and stenosis of unspecified cardio artery. Falls. CKD[chronic kidney disease] stage 3. Gastro reflux. Anxiety disorder. Insomnia, Alzheimer's disease. Vascular dementia. Hyperlipidemia. HTN[hypertention]. Major depression. Resident remains alert and oriented to person or name. No significant change in cognition. Staff anticipate and assist with support care and redirection . Review of R104 Hospital Discharge Summary, dated 1/11/25, reflected, .Hospital Course-80 y M[year male] with history of .dementia as a transfer from [named] after being found down at his facility. Patient sustained Parietal subdural hematoma, Left displaced comminuted intertrochanteric femur fracture and acute compression fracture of T12. Patient underwent Left intertrochanteric InterNail repair on 1/7/25. The parietal SDH[subdural hematoma] and T12 compression fracture was managed non-op[non-operative]. Hospital course was significant for agitation that was managed with Zyprexa. Otherwise, patient progressed will during hospital course. Patient is weight-bear as tolerated to the left lower extremity with a walker and is to be on TLSO[thoracolumbar sacral othosis] brace when out of bed . Review of R104 Fall Incident/Accident Report, dated 1/6/25 at 2:15 p.m., reflected R104 had a fall in the hall, unwitnessed by staff, with 10/10 left pain hip with hipster in place. The Incident accident report indicated left leg had external rotation and staff were unable to stand with gait belt(with assessment of external rotation and Range of Motion not tolerated to left hip). The report reflected R104 was transferred from the floor in hall to bed with hoyer lift then sent by ambulance to hospital. The report had section for predisposing physiological factors that had the following marked; confused, impaired memory and gait imbalance. Continued review of the report reflected section for predisposing situational factors that had the following marked; call light not used, wandering, and ambulating without assistance. Review of R104 Change in Condition assessment, dated 1/6/25, reflected had fall in hall and R104 not cognitively able to rate pain and showed the following signs of pain; short periods of hyperventilation, repe [TRUNCATED]

This citation pertains to intakes: MI00149397, MI00150353, Based on observation, interview and record review, the facility failed to ensure sufficient levels of nursing staff to meet resident needs and supervision for three residents (Resident #103, #104, #105) and per resident council with the potential for unmet care needs and facility residents to not attain or maintain the highest practicable physical, mental, and psychosocial well-being. Finding include: An anonymous complaint received by the State Agency alleged the facility failed to maitain sufficient staff levels to meet resident needs including supervision. During an interview on 3/10/25 at 10:45 a.m., Nursing Home Administrator(NHA) A reported facility census was 106. Resident #105(R105) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R105 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included aftercare of left bipolar hemiarthroplasty(surgical repair of left ball of hip) post fall at home, peripheral vascular disease, orthostatic hypotension(drop in blood pressure with change in position), need for assistance with person care, heart disease, hypertension (high blood pressure), and diabetes mellitus. The MDS reflected R105 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. Continued review of the MDS reflected dated 11/12/24 through 12/3/24 reflected three unplanned discharges to acute care. An anonymous complaint received by the State Agency alleged the facility failed to prevent avoidable fall for R105 that resulted in re-fracture of the left femur on 12/3/24. Review of the Fall Incident/Accident report, dated 12/3/24 at 4:30 p.m., reflected R105 had an unwitnessed fall in bathroom after self-transfer with left thigh fracture. The document reflected, Immediate Action taken: Neuro assessment completed prior to transferring resident from floor to wheelchair. Resident's ROM in left leg decreased .Resident rated pain in left hip 4/10. Resident transferred from floor to wheelchair with 2PA[two person assist], NWB[non weight bearing] to LLE[left lower extremity] maintained during transfer. VS[vital signs] obtained, BP[blood pressure] slightly low without s/sx[signs and symptoms] of hypotension. Skin tears present on left elbow & left forearm. Both areas cleansed & treatment with Xeroform completed. All appropriate parties notified. Provider ordered a STAT[immediately] left hip X-ray to R/O fx[rule out fracture]. Resident educated regarding use of call light for safe transfers & ambulation. Continued review of the document reflected, Predisposing Situation Factors, including the following marked; call light not used, admitted within last 72 hours, Ambulating without assistance. The document reflected R105 wife was present in room at time of fall and no witness statements found. Continued review reflected R105 wife was notified at 4:30 p.m. and the Provider at 4:40 p.m. and the form was completed by CCC D.(Not R105's nurse at the time.) Review of Electronic Medical Record (EMR) Census, dated 12/3/24, reflected R105 readmitted to the facility on [DATE] at 4:08 p.m.(Just prior to R105 unwitnessed fall with fracture on 12/3/24). During an interview on 3/11/25 at 2:45 p.m., Interim Director of Nursing (IDON) B reported had soft file on R105's fall on 12/3/24 and facility had completed Past Non-Compliance related to falls with alleged compliance date 1/31/25 after recognizing several falls including falls with major injury. IDON B provided complete investigation for R105, R104 and R103 falls along with past noncompliance binder. Review of the facility Staffing Assignment Sheet, dated 12/3/24 2nd shift, reflected R105 nurse was Clinical Care Coordinator Registered Nurse (CCC) C and two Certified Nurse Aids(CNA) were assigned to R105 hall(CNA J and CNA E) with a facility census of 93. During an interview on 3/12/25 at 3:30 p.m., CNA J reported was working on 12/3/24 when R105 fell in bathroom. CNA J reported her, and CNA E were told to assist R105 from personal car, driven by wife, into the facility. CNA J reported obtained R105 weight and then R105 reported had to use restroom and the two CNAs assisted R105 from the wheelchair onto the toilet and instructed to use call light when done and left R105 in bathroom alone. CNA J reported had returned to check on R105 who was not ready and upon returning again had fallen in the bathroom after attempting to self-transfer. CNA J reported assisted R105 off the floor with two to three staff by picking up under R105 arms and transferring to the wheelchair then from wheelchair to bed with pivot transfer and at least two assist. CNA J reported nurse took over from there. CNA J reported completed witness statement after fall but not same day as R105 fall and received education from facility to not leave residents alone especially if high risk for fall. During a telephone interview 3/13/25 at 10:49 a.m., R105's Family Member F reported R105 was doing well enough at the hospital, and she transported him in a personal car from the hospital to the facility on [DATE]. FM F reported two staff met her at the car and they wheeled R105 in the facility. FM E reported R105 had to use the bathroom right away so two staff took R105 in his bathroom and before nurse staff could even complete body check. FM F reported stepped out of room for moment to make call and returned and asked roommate, is he still in there?' and roommate reported yes. FM F reported waited outside the door for maybe five minutes and figured staff were in the bathroom with him and then heard a big crash. FM F reported opened the door and R105 was on the floor with no staff present. FM F reported it concerned her R105 had been left alone because he was such a high fall risk they had not been back in facility for more than 15 minutes. FM F reported went and found the nurse and reported R105 was on the floor, who responded, can he get up? FM F reported they got him in bed did body check, they didn't see anything significant but R105 was complaining of pain to left hip area. FM F reported they ordered X-ray right away, but it was a few hours before they got there and it was around 8:00 p.m., when they received call R105 left leg was broken and facility planned to send R105 to local hospital. FM F reported local hospital transferred R105 to a trauma center who performed eight-hour surgery to repair R105 re-fractured, shattered left leg. FM F reported R105 was currently on hospice and stated, it shouldn't have happened .To leave him unassisted and I don't know the circumstances, I know they were busy and understaffed, that's not a reason to leave him unattended. FM F reported R105's second fall with fracture on 12/3/24 extended the first one and shattered left leg and hardware had to be removed and replaced and continued to decline. FM F reported staff did not mention using call light after the fall and was chaotic scene. FM F reported the roommate thought the staff was in bathroom with R105 but staff must have exited shared room door because the roommate said they never saw the staff leave the bathroom. FM F was queried of R105 would have used call light when done? FM F stated, I would not have trusted him to do that even if he was well enough. During a telephone interview on 3/13/25 at 12:35 p.m., CNA E reported was working on 12/3/24 when R105 had a unwitnessed fall in the bathroom. CNA E reported CCCRN C requested CNA E and CNA J assist transfer R105 from personal car to room. CNA E reported transported R105 in wheelchair from parking lot with CNA J to room and R105 requested to use the bathroom, and both CNAs assisted R105 from wheelchair to toilet. CNA E reported was not told R105 could not be left alone and both CNAs left R105 on toilet alone and left to answer call lights on the hall. CNA E reported returned in about five minutes and R105 was on the bathroom floor, called for Registered Nurse (RN) L, FIT team paged overhead (fall team). CNA E reported Occupational Therapy Staff (OT) M was present and R105 was transferred from floor to wheelchair but unable to recall how and reported R105 was then transferred from wheelchair to bed with two-person pivot assist with OT M. CNA E reported resident acuity was high that day for only two CNA staff on hall. CNA E verified he wrote witness statement several days after R105 fall that was not dated or signed. CNA E reported was not aware R105 was high fall risk or even know transfer status when told to assist R105 from personal car on 12/3/24, prior to readmission. Resident #103 (R103) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R103 was an [AGE] year old female admitted to the facility on [DATE], and most recently re-admission post fall with facial hematoma and contusion with other diagnoses that included dementia, heart disease, atrial fibrillation with use of blood thinners, hypertension (high blood pressure), depression and anxiety. The MDS reflected R103 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired. During a telephone interview on 3/10/25 at 11:29 p.m. R103 Family Member (FM) N reported R103 had an unwitnessed fall on 1/23/25 with facial injuries that required transfer to hospital. FM N reported facility was not able to answer how R103 fall occurred or how long R103 was on the floor before staff found R103. FM N reported R103 had significant facial bruising over entire face with open area to area above left eye several days after alleged fall. Review of R103 Fall Incident/Accident Report, dated 1/23/25 at 8:42 p.m., reflected R103 had an unwitnessed fall in room and was found lying on stomach next to the bed with abrasion noted on face. The report reflected, Resident states that she slipped off her chair . The report reflected R103 had impaired memory and no witness statements were found and Physician was contacted at 7:30 p.m.(Report had discrepancy in times, no mention of interventions that were in place on not in place including footwear, dysem or grip strips on floor). Review of R103 Hospital Radiology Report, dated 1/23/25, reflected CT scan of the brain revealed, LEFT frontal scalp soft tissue contusion and/or organized hematoma . Review of R103 Physical Therapy Assessment, dated 1/24/25, reflected, Reason for Referral/Current Illness: Patient is a [AGE] year old female with history of dementia who is a LTC[long term care] resident of the facility. She has a history of falls and has had 5 falls in the last year. She has been referred to skilled PT services following patient having a recent fall on 1/23. She sustained a bump with bruising to her forehead. She was transferred to the hospital for further evaluation and then returned to this facility. Per nursing notes, patient reported she slipped out of her w.c[wheelchair]. Patient told PT this date that she was walking without AD[assistive device] and only had socks on and slipped on the floor. Educated patient on having assistance, wearing shoes/grippy socks and using walker for safety . During an observation and interview on 3/13/25 at 9:30 a.m., R103 was sitting in Main Dining Room in wheelchair watching television with regular socks with no grip on them. R103 had nickel size abrasion noted to area above left eyebrow and was very hard of hearing. R103 reported fell out of bed and laid on floor until staff arrived and then was sent to hospital for several hours. R103 reported she is careful now and was told she had to wear shoes. Resident #104 (R104) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was an [AGE] year-old male admitted to the facility on [DATE], and most recently re-admission post fall at facility with left displaced hip fracture requiring surgical repair, compression fracture T-12(spinal fracture, and traumatic subdural hematoma. R104 had other diagnoses that included dementia, hypertension (high blood pressure), depression and anxiety. The MDS reflected R104 had a BIM (assessment tool) score of 3 which indicated his ability to make daily decisions was significantly impaired. The MDS reflected R104 did not have behaviors including wandering or rejection of care. An anonymous complaint received by the State Agency alleged the facility failed to prevent fall for R104 that resulted in hip fracture and passed away. Review of R104 Unusual Occurrence Note, dated 1/6/2025 at 3:46 p.m., reflected, LN was alerted by a family member (visitor) that resident was laying on the floor at the end of the hallway. When LN arrived at residents side he was laying on his left side, head up against the wall feet outstretched into the hallway, by room [ROOM NUMBER] at the end of 500 long hall. Resident was noted picking up his hat when he fell over. Resident did not ask for assistance with his hat. Resident is noted wearing hipsters and non-slip footwear. Resident was noted ambulating in the hallway 15 minutes prior and offered a chair to rest. LN asked resident what he was attempting to do when he fell over? resident stated, just give me my damn hat LN did a full head to toe assessment on resident has full range of motion of both upper extremities without pain or difficulty. Resident has full range of motion in right hip. LN noted external rotation of left hip upon assessment. C/O[complained of] pain with minimal movement. no other injuries noted. Staff members were unable to assistance resident off the floor with a gait belt, resident was assisted off the floor by a hoyer lift with a sling and assisted to his bed. A staff member sat with resident until EMTS[emergency medical technicians] arrived . Review of R104 Social Service Note, dated 1/12/25 at 10:10 a.m., reflected, [Named R104] was readmitted yesterday evening from Hospital. Resident was readmitted with Dx of HX[history] of interchanteric FX[fracture] of left femur. Unspecified part neck Left Femur. Traumatic subdural hemorrhage without loss of consciousness. Occlusion and stenosis of unspecified cardio artery. Falls. CKD[chronic kidney disease] stage 3. Gastro reflux. Anxiety disorder. Insomnia, Alzheimer's disease. Vascular dementia. Hyperlipidemia. HTN[hypertention]. Major depression. Resident remains alert and oriented to person or name. No significant change in cognition. Staff anticipate and assist with support care and redirection . Review of R104 Hospital Discharge Summary, dated 1/11/25, reflected, .Hospital Course-80 y M[year male] with history of .dementia as a transfer from [named] after being found down at his facility. Patient sustained Parietal subdural hematoma, Left displaced comminuted intertrochanteric femur fracture and acute compression fracture of T12. Patient underwent Left intertrochanteric InterNail repair on 1/7/25. The parietal SDH[subdural hematoma] and T12 compression fracture was managed non-op[non-operative]. Hospital course was significant for agitation that was managed with Zyprexa. Otherwise, patient progressed will during hospital course. Patient is weight-bear as tolerated to the left lower extremity with a walker and is to be on TLSO[thoracolumbar sacral othosis] brace when out of bed . Review of R104 Fall Incident/Accident Report, dated 1/6/25 at 2:15 p.m., reflected R104 had a fall in the hall, unwitnessed by staff, with 10/10 left pain hip with hipster in place. The Incident accident report indicated left leg had external rotation and staff were unable to stand with gait belt(with assessment of external rotation and Range of Motion not tolerated to left hip). The report reflected R104 was transferred from the floor in hall to bed with hoyer lift then sent by ambulance to hospital. The report had section for predisposing physiological factors that had the following marked; confused, impaired memory and gait imbalance. Continued review of the report reflected section for predisposing situational factors that had the following marked; call light not used, wandering, and ambulating without assistance. Review of R104 Change in Condition assessment, dated 1/6/25, reflected had fall in hall and R104 not cognitively able to rate pain and showed the following signs of pain; short periods of hyperventilation, repeated troubled calling out, loud moaning or groaning, crying, facial grimacing, fists clenched, knees pulled up, [NAME] or pushing away, striking out and unable to console. The assessment reflected, Since the change of condition occurred have the symptoms or signs gotten: Stayed the same[marked] .Things that make the condition or symptoms worse are: movement and touch .Things that make the condition or symptoms better: laying still medication .This condition, symptom or sign has occurred before: No[marked]. Review of R104 Physical Therapy Evaluation, dated 10/22/25, reflected, Patient is a [AGE] year old male with history of dementia who is a LTC[long term care] resident of this facility. He has had 7 falls since he was admitted here. He usually chooses to transfer and ambulate on his own without assistance despite therapy recommendation for 1 person assist. He has been referred to skilled PT[physical therapy] services by nursing following his most recent fall on 10/20. Per nursing documentation, it was a witness fall by the nurses station and parient's only comments were that he was tired. Patient is demonstrating decreased BLE[bilateral lower extremity] strength, impaired standing balance, impaired safety awareness, impaired ability to follow direction and reduced functional activity tolerance . Review of R104's requested Fall Incident reports, 10/1/24 through 3/10/25, reflected R104 had the following falls; 1/20/24 at about 2:44 p.m. fell while wandering/actively exit seeking, 11/28/24 at about 2:04 a.m. fell while wandering, ambulating without assistance. 12/12/24 at about 4:02 a.m. fell during attempted self-transfer, ambulating without assistance. 1/6/25 at about 2:15 p.m. fell while wandering, ambulating without assistance. (Resulting in left hip fracture, compression fracture of T12, and acute subdural hematoma) 1/12/25 at about 7:02 a.m. fell in room resulting in skin tear. During an observation on 3/10/25 at 1:50 p.m. resident in room [ROOM NUMBER] called this surveyor into room from hall and reported needed assistance. Call light was observed to be illuminated in room and resident reported was waiting for staff for over 30 minutes to use bathroom. Verified at nurse station call light had been on since 1:14pm (35 minutes) according to call light electronic system at the Nurse station. Continued review of the call light system reflected room [ROOM NUMBER]b call light on since 1:30 p.m. (20 minutes), and room [ROOM NUMBER]a on since 1:46 p.m. (6 minutes). Continued observation reflected staff turned room [ROOM NUMBER] call light off at 1:53 p.m. and turned it back on and exited the room. Staff entered returned to room [ROOM NUMBER] at 2:01 p.m. (47 minutes after resident used call light) During an observation on 3/11/25 at 9:00 a.m., 300 hall call light system reflected room [ROOM NUMBER]b call light had been on since 8:40 a.m.(20 minutes). During a telephone call on 3/12/25 at 11:08 a.m., CNA S returned was on break when R104 fell on [DATE] and R104 was in bed. CNA S reported four CNA staff on 500 hall and two go on break at a time. CNA S reported assisted R104 change cloths and brief and clean R104 after bowel movement. CNA S reported R104 was agitated, in pain with verbal outburst screaming and yelling with movement. (R104 had been transferred with hoyer lift, provided incontinence care and clothing changed prior to EMS arrival with displaced left hip fracture. During a telephone interview on 3/12/25 at 11:18 a.m., RN T reported was on break when R104 fell on [DATE] and when returned R104 was in bed and appeared scared, in pain and repeat attempts to get out of bed and was told may have broke hip. RN T reported R104 often walked the halls independently. RN U reported sat with R104 until EMS arrived and repeatedly saying, help me, with repeat attempts to get out of bed. RN S reported R104 returned to facility after left hip surgery and was very anxious, no longer ambulatory and was admitted to hospice and passed away. During an interview on 3/12/25 at 1:50 p.m., CNA V reported did not witness R104 fall on 1/6/25 but was R104 CNA at the time. CNA V reported was assisting another resident at time of fall. During an interview and observation on 3/13/25 at 3:50 a.m., Confidential Resident(CR) X was sitting in bed and appeared able to answer questions without difficulty. CR X had family at bedside who verified resident was own responsible person. CR X reported call light response times are often over 1 hour long mostly on night shift and told not allowed to go to bathroom on without assist. CR X reported often waits for long time then gets up on own and goes and staff get upset with him and stated, I don't want to poop myself. Review of the facility Resident Council Minutes, September 2024 through February 2025, reflected three of past six months had reported concerns with call light response times with follow up that indicated discussed at staff meeting.

Based on observation, interview and record review the facility failed to maintain dignity for 4 residents (Resident #'s 393, R24, and R13 and one unknown resident) the during the initial dining observation in the 500 hall dining room, using the reasonable person standard this deficient practice resulted in decreased self worth and loss of dignity. Findings include: Resident 393 (R393) According to the clinical record, Including the Minimum Data Set (MDS) dated [DATE] Resident # 393 (R393) was a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included Parkinson's disease, anxiety and respiratory failure. Resident # 393 scored 8 out 15 on the Brief Interview for Mental Status (BIMS) , the MDS further reflected R393 had adequate hearing and clear speech. Resident 24 (R24) According to the clinical record, including the MDS dated [DATE], reflected R24 was an [AGE] year old female admitted with a diagnosis of dementia on 12/31/14. R24 scored 00 on the BIMS (severe cognitive impairment) on the MDS dated [DATE]. Resident 13 (Resident 13) Review of the clinical record, including the MDS dated [DATE]. Resident 13 (R13) was admitted on [DATE] scored 00 (severe impairment) on the BIMS from the 04/03/24 MDS. On 05/07/24 at 12:27 PM during the 500 hall dining observation, Registered Nurse/ Clinical Care Coordinator (RN/CCC) E , Life Enrichment Director (LED) U were observed feeding residents #13 and R#24, R393 was sitting in-between them, an unknown staff person from the therapy department was initially assisting the unknown resident at the table. RN/CCC E and LED U carried on personal conversations while mechanically feeding the perspective residents, there was no attempt to engage any of the residents in conversation, there was no addressing the residents, i.e.: how are you today? or are you hungry? Would you like a drink? What would you like a bite of next? etc . instead there was a 21 minute observation of RN/CCC E and LED U discussing RN/CCC 's upcoming trip to Colorado, the number of their remaining balance of their vacation time, the fact that RN/CCC E was a vegetarian in college, what kind of macaroni and cheese they liked powder versus liquid cheese packet, how good the local fast food restaurants Jamocha shakes were, what they fed there kids for breakfast, of note it was cinnamon toast and RN/CCC E had scooby fruit snacks, what was planted in their gardens, floating down the Ausable river, their camper, their kayak and on and on. After 19 minutes of constant conversation between the two staff persons there was not one attempt made to include any of the residents at the table. With the exclusion of one interaction when RN/CCC E asked R13 if she wanted desert. After 21 minutes LED U announced to RN/CCC E that she had paper work to attend to and would get someone to cover to finish feeding R24. During this same observation Minimum Data Set Nurse (MDS Nurse) Q was assisting passing trays, she stood in the middle of the 500 hall dining room and yelling out to staff Ok, which one is [name redacted] Which one is [name redacted]. 05/10/24 08:39 AM during an interview with Nursing Home Administrator A was made aware of the direct observations that were made.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 2 (Resident #7 and Resident #10) of 20 residents reviewed resulting in the potential for unmet care needs. Findings include: Resident #7 (R7) Review of the medical record revealed that Resident #7 (R7) was admitted to facility 4/7/22 with diagnoses including chronic kidney disease stage 3, hypertension, bilateral carotid artery stenosis, and polyneuropathy. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/1/24 revealed that R7 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 13 (cognitively intact). Review of an Annual MDS dated [DATE] revealed that R7 required set up assist with dressing including placing/removing TED hose (thromboembolic deterrent hose-specially designed stockings to help prevent blood clots and swelling in legs). In an observation and interview on 5/07/24 at 10:35 AM, R7 was observed lying in bed, on back, with head of bed positioned at an approximate 90-degree angle. R7's legs and feet were observed to be bare with mild swelling noted to both ankles and feet. R7 stated that she had issues with circulation in her legs, off and on swelling in her feet, and that she had special elastic stocking that she was supposed to wear that helped with both but stated, I couldn't really tell you the last time I've worn those. R7 stated that she was unable to put the stocking on herself, struggled to take them off, and that the staff never really offered to help her put them on. Two pair of white, knee-high TED hose observed to be hanging on the bar of R7's front wheeled walker which was positioned against the wall between her dresser and closet. In an observation and interview on 5/07/24 at 12:05 PM, R7 was observed to be self-propelling wheelchair out of her room with nonskid slippers noted on bare feet. R7 denied that staff had approached her to offer or assist with placement of TED hose yet that day. Two pair of white, knee-high TED hose observed to remain hanging on R7's front wheeled walker positioned in the same location in her room. In an observation and interview on 05/08/24 at 1:44 PM, R7 was observed sitting in wheelchair, in room, watching television. R7 was observed to have non-skid slippers on bare feet. R7 stated that she didn't have her elastic stockings on as reiterated that she was unable to put them on herself and that staff had not offered or assisted with placement yet that date. Two pair of white, knee-high TED hose observed to remain hanging on R7's walker positioned in the same location in her room as on 5/07/24. R7's Physician Order dated 12/1/23 stated, Bilateral knee high ted hose to be place [sic] on in the AM (morning) and removed at HS (bedtime). R7's corresponding Treatment Administration Record (TAR) dated 5/1/24-5/31/24 was noted to reflect same order with order signed out as administered on both 5/7/24 and 5/8/24 although not observed to be in place on either date. R7's Cardiac Care Plan Focus included an intervention which stated, Bilateral knee high ted hose to be placed on in the AM and removed at HS with a 7/11/22 date of initiation. R7's Kardex section titled Individual Instructions/Preferences stated, Bilateral knee high ted hose to be placed on in the AM and removed at HS. Review of R7's Progress Notes and Resident/Family Education Records for 5/7/24 and 5/8/24 was not noted to include any indication of TED hose refusal. In an interview on 5/08/24 at 2:26 PM, Certified Nurse Aide (CNA) C confirmed familiarity with R7 and was her assigned aide that date. CNA C stated that R7 was fairly independent with transfers, toileting, and dressing and used a wheelchair as her main mode of mobility. CNA C further stated that he believed R7 wore TED hose, didn't know how much help she needed to put them on as denied ever having helped her place them before, but believed that she had them on that date. Per CNA C, the assigned nurse tracked the residents that wore TED hose, would alert him of need to place, and assumed she had them on as the nurse had not told him otherwise. CNA C stated that he did not believe TED hose were reflected on the resident Kardex (tool used by the CNA to guide them as to the care needs of a specific resident) as the assigned nurse just informed him of those residents that needed to have them placed. In an interview on 5/08/24 at 2:23 PM, Registered Nurse (RN) D stated that each resident with TED hose had a specific physician order, the assigned nurse was responsible for placement, and that the TAR would be signed out to reflect placement as well as any refusal. RN D confirmed familiarity with R7 and was her assigned nurse that date. Per RN D, R7 was alert, oriented, and able to make all needs known, wore TED hose due to circulatory issues, and although was independent with most dressing required assistance with TED hose placement as was not able to physically get them on herself. RN D further stated that R7's TED hose had been placed that morning, she believed by Registered Nurse/Clinical Care Coordinator (RN/CCC) E, and therefore she had signed out the treatment as completed although had not verified that R7 actually had the TED hose in place. Upon observing R7 in the dining room participating in an activity, RN D stated that R7 did not actually have TED hose in place as she had thought and that she would be assisting her with placement upon completion of the activity. In an interview on 5/08/24 at 2:39 PM, RN/CCC E stated that TED hose was generally a physician order, applied by the assigned nurse, and signed out on the treatment sheet. RN/CCC E confirmed familiarity with R7, stated that she tended to transfer, toilet, and dress herself independently although assist of one was recommended for safety and upon referencing R7's medical record confirmed that she had an order for TED hose placement in the morning with removal at bedtime. RN/CCC E denied that she had ever assisted R7 with the placement of her TED hose, denied that she had interacted with R7's assigned nurse that date regarding her TED hose placement, and that she would be following up for there placement. In a follow-up interview on 5/9/24 at 8:53 AM, RN/CCC E stated that as confusion was present amongst staff over whose responsibility it was for the placement of physician ordered TED hose, facility wide education had been initiated as stated it was the primary responsibility of the CNA to place, per Kardex indication, and for the nurse to verify placement through order signed out on the TAR. 38383 Resident #10 (R10): Review of the medical record reflected R10 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included diabetes, end stage renal disease and dependence on renal dialysis. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/28/24, reflected R10 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 05/10/24 at 08:38 AM, R10 was observed lying on his left side, in bed. R10 reported he went to dialysis on Monday's, Wednesday's and Friday's. He stated he returned from dialysis with a bandage to his access site, which he reported was in his left upper arm. On 05/09/24 at 01:30 PM, review of R10's medical record, including Physician's Orders and Care Plans, did not reflect care restrictions for his left arm. According to the University of Michigan, Vascular Access for Hemodialysis: What You Need to Know .What are hemodialysis and vascular access? Hemodialysis uses a dialysis machine to remove poison and extra fluid from your blood when your kidneys cannot do it (kidney failure). In order to access your blood for hemodialysis, you must have surgery to reach your blood. Vascular access is a surgical procedure that connects your artery directly to your own vein (fistula) or your artery to your vein with an artificial tube (graft). Vascular access makes lifesaving hemodialysis treatments possible .Do I have any restrictions on my access arm? . Do not let anyone take your blood pressure, start an intravenous line (IV) or draw blood from your access arm . (https://www.med.umich.edu/1libr/Surgery/VascularSurgery/HemodialysisAccess.pdf) During an interview on 05/10/24 at 09:21 AM, Certified Nurse Aide (CNA) T stated she believed R10's dialysis access port was in his left arm, so staff would not obtain blood pressures from that arm. If she was unsure, she would check the Kardex (CNA care guide) and ask the nurse. CNA T reviewed R10's Kardex and confirmed that she did not see documentation pertaining to not obtaining blood pressure on his left arm. During an interview on 05/10/24 at 09:26 AM, CNA L reported staff did not do vital signs or obtain blood pressures on the side (arm) that had a (dialysis) port. CNA L was unsure which side/arm R10's dialysis access site was on. He stated the nurse usually obtained R10's vital signs. On 05/10/24 at 09:35 AM, Registered Nurse (RN) I reported R10's dialysis port was located in his left arm, so staff would not obtain blood pressures on his left arm.

Based on observation, interview and record review, the facility failed to ensure antibiotic treatment for Methicillin-resistant Staphylococcus aureus (MRSA/type of bacterial infection that is resistant to many antibiotics) was started timely for one (Resident #6) of one reviewed. Findings include: Review of the medical record reflected Resident #6 (R6) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included schizophrenia and MRSA (as of 4/29/24). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/15/24, reflected R6 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 05/09/24 at 10:18 AM, R6 was observed lying on his right side, in bed, as two Certified Nurse Aides (CNAs) prepared to enter his room. On 05/09/24 at 10:23 AM, R6 was observed seated in a high-back wheelchair, with a mechanical lift sling beneath him. He was observed to self-propel his wheelchair in the hallway. A Nurse Practitioner Progress Note for 4/23/24 reflected R6 had a large abscess on his left inner thigh. According to the Note, a wound culture (test to identify type of bacteria in a wound) was collected and sent to the laboratory. R6's medical record reflected an aerobic wound culture was collected on 4/23/24 and was received by the laboratory the same day. The laboratory report reflected the final results were reported on 4/27/24 and were timestamped for 2:36 PM. The culture results revealed heavy growth of MRSA and included sensitivity results (test that identifies antibiotic treatment options). R6's Physician Orders reflected Doxycycline Hyclate (antibiotic) 100 milligrams by mouth every 12 hours, for MRSA, for 14 days, was prescribed with a start date of 4/29/24 and a stop date of 5/13/24. R6's May 2024 Medication Administration Record (MAR) reflected Doxycycline administration times were scheduled for 9:00 AM and 9:00 PM. The first dose was signed out as being administered for a 9:00 PM scheduled dose on 4/29/24, which was two days after the final wound culture and sensitivity results were reported. During an interview on 05/09/24 at 10:32 AM, Registered Nurse (RN) G reported laboratory reports were entered into the electronic medical record (EMR) by the laboratory and were provided to the physician. Nurses did not receive an alert that results were available for review but were made aware through nurse shift report if laboratory test results were pending. Laboratory reports were printed out and placed in the physician's book, according to RN G. In an interview on 05/09/24 at 10:38 AM, RN/Infection Preventionist (IP) M reported laboratory results were received through the Results tab of the EMR. She stated nurses did not receive an alert that results were available for review but were good at reporting off (nurse shift report) when results were pending. IP M acknowledged that R6's wound culture was collected on 4/23/24, and results were received/reported on 4/27/24. She stated R6 started antibiotic treatment for MRSA on 4/29/24. IP M reported there were not any Nursing or Provider Progress Notes referencing why antibiotic treatment was not started on 4/27/24. She reported her expectation was that the on-call provider would have at least been notified of the results. She stated many facility providers preferred to be called personally.

Based on observation, interview and record review facility failed to: 1) accurately assess, monitor, treat and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for three Residents (R103, R107 and R109) of four reviewed for pressure ulcers, resulting in R109 facility acquired stage 2 pressure ulcer, and the increased likelihood for delayed wound healing and or worsening of wounds and overall deterioration in health status, and worsening of pressure ulcer wounds with sepsis. Findings include: Resident #103(R103) Review of the Face Sheet and Minimum Data Set (MDS) with ARD date [DATE], reflected R103 was a [AGE] year old female admitted to the facility on [DATE] related to cerebral infarct with dysphasia, diabetes mellitus, dementia, metabolic encephalopathy, hypertension (high blood pressure), renal failure, The MDS reflected R103 had a BIM (assessment tool) of 13 which reflected R103 was cognitively intact. The MDS assessment reflected R103 had no behaviors including no rejection of care. According to the National Pressure Ulcer/Injury Advisory Panel (NPUAP); Unstageable Pressure Ulcer/Injury is full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (necrotic dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bonemuscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Review of the facility, Wound Management Program, revised [DATE], reflected, Policy: To assure that residents who are admitted with, or acquire, wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing .forms or documentation applicable to this policy .care plan/kardex, weekly hydration and skin assessment .point of care(POC) .Unless otherwise specified, the Charge Nurse is responsible for the following .Monitor skin changes during routine daily care(CNA) .Report concerns/observations to the Charge Nurse(Nurse) via POC alert .Report any abnormal findings to the physician and Certified Dietary Manager(CDM) or Registered Dietician(RD) via Alert in PCC .Initiate treatment according to physician guidance .Assess protein and calorie needs, hydration status and overall nutritional status admission and as needed .Initiate interdisciplinary plan of care .Monitor any acute illness or change in condition .Process (Management of Pressure Ulcers/Non Pressure Wounds) .Complete the following steps if pressure ulcer identified: 1.1.Refer to the [named facility corporation] health System Managed Community Wound Protocol and Support Surface Product Formulary for treatment and intervention options .Complete the following daily (Charge Nurse): 3.1.Verify that resident-specific Care Plan interventions are in place (pressure relieving devices, turning schedules, etc.). 3.2. Inspect dressing to assure it is intact. 3.3. Inspect skin surrounding pressure ulcer. 3.4.Inspect any pressure ulcer that does not require a dressing . Review of the facility Matrix(802), dated [DATE], reflected no residents with pressure ulcers not present on admission. During a telephone interview on [DATE] at 12:22 p.m. Complainant G reported R103 admitted to the facility [DATE] after short hospital stay related to stroke for rehabilitaiton. Complainant G reported R103 had poor oral intake, was sedated, and small wound to coccyx area that significantly worsened including odor and increase in size and fever. Complainant G reported R103 was transferred to the hospital on [DATE] and admitted and treated for septic shock and later died related to complications related to coccyx wound. Review of the Hospital Records, dated [DATE] through [DATE], reflected Occupational Therapy Assessment that included, Bed Mobility: sit to supine: Moderate Assistance of 2, Supine to Sit: moderate assistance of 2 .upon OT evaluation, pt is physically and cognitively functioning significantly below her baseline status of independence. She is currently alert to self. She is requires max pa x 1 for all aspects of badl routine and mobility at this time . Review of the Hospital Lab Results, dated [DATE], reflected R103 GFR result was 42. (GFR is indicator for chronic kidney disease. GFR healthy adult 90 or greater. Stage 3b = moderate to severe loss of kidney function ,d+[DATE], Stage 4=severe loss of kidney function ,d+[DATE]. The Labs reflected R103 BUN was elevated at 27(indicator of kidney function but also may be elevated if dehydrated). Review of the Lab Results, dated [DATE], reflected R103 GFR was 38 (worsened) and BUN was 33 (worsened). Review of the Skin Care Plan, dated [DATE], reflected R103 had interventions that included, Please help me turn and reposition while in bed or in my wheelchair as needed .Bed mobility with 1 assist as needed . Review of the Physician Orders, dated [DATE], reflected, Cleanse coccyx with soap & water, pat dry, apply zinc oxide twice daily for skin protection for 30 Days -Start Date-[DATE] 0700-D/C Date- [DATE]. Review of the Physician Orders, dated [DATE], reflected, Cleanse coccyx with wound cleanser, pat dry, an Aquacel foam dressing. every day shift every 3 day(s) for pressure injury wound care -Start Date-[DATE] During an interview on [DATE] at 10:05 a.m., Wound Nurse(WN) RN I reported had been facility wound nurse for one year and reported had not completed certified wound training. WN I reported completed weekly wound rounds including pictures and documented in Electronic Medical Record(EMR) Skin and Wound Evaluations and Progress Notes. WN I reported new admission residents are assessed next business day then every seven days. WN I verified R103 admitted on Monday [DATE] with pressure ulcer documented on admission assessment with no description including measurement. WN I reported admitting nurses inform her or Clinical Care Coordinator (CCC)RN C of wounds and seen by next business day. WN I verified R103 was assessed by RN C on [DATE] and reported she (WN I) had been on vacation at that time and was unsure why delay in treatment. WN I reported facility had standing physician orders for wound care treatments and physicians not contacted unless need for change in treatment or new or worsening wounds noted. WN I reported R103's coccyx wound was documented on [DATE] as deep tissue injury pressure ulcer, present on admission, staged by in-house nursing that measured 3.9cm by 2.2 cm by 0.2cm depth with 100% of wound covered with epithelial and surface intact, serous drainage(however documented as intact skin) and no odor. WN I reported R103 intervention included roho cushion for wheelchair, low air loss mattress, daily multivitamin, repositioning devices, aquacel foam dressing every three days and an needed. Review of R103, Skin & Wound Evaluation V7.0, dated [DATE] and edited [DATE], reflected R103 had deep tissue injury pressure wound to coccyx present on admission. The document reflected notes, Resident admitted with pressure injury. Segments of wound are maroon in color & persistently non-blanchable. Treatment order in place: Cleanse coccyx with wound cleanser, pat dry, an Aquacel foam dressing q3 days & prn soiled or dislodged dressing. Roho cushion placed on wheelchair. Low air loss mattress ordered. Multivitamin ordered daily to promote wound healing .Resident educated regarding;*Weekly wound rounding program*Importance of frequent repositioning while in bed, wheelchair, and chair to promote wound healing and hinder any further tissue damage. *Use of APM mattress, roho cushion, and daily multivitamin to promote wound healing. *Treatment order in place . Review of the attached picture dated [DATE] reflected evidence of deep tissue injury with open area. Review of R103, Skin & Wound Evaluation V7.0, dated [DATE], reflected R103 had deep tissue injury pressure wound to coccyx that measured 2.7cm by 1.8cm by 0.1cm depth. The document reflected 70% epithelial and 30% granulation with notes that reflected, PUSH score indicates wound progress is stable. Segments of wound remain maroon in color & persistently non-blanchable. Tx order in place: Cleanse coccyx with wound cleanser, pat dry, an Aquacel foam dressing q3 days & prn soiled or dislodged dressing. Document did not reflect physician notified. Review of the attached picture, dated [DATE], reflected large open area with non viable skin, continued deep tissue injury, discolored peri area with overall worsening in wound. Review of R103 EMR, dated [DATE] through [DATE], reflected R103 admission weight was 132 pounds on [DATE] and 127 pounds on [DATE](5 pound weight loss in 14 days). Review of the food acceptance reflected food acceptance that included R103 had eight entries of ,d+[DATE]% eaten and 16 entries of ,d+[DATE]% eaten documented in 14 days prior to transfer to hospital. Review of R103 vitals with slowly elevated blood pressure and heart rate over 14 days. Review of the EMR reflected no mention of urine output or fluid input. Continued review of EMR reflected R103 was transferred to the hospital on [DATE] related to altered mental status, abnormal vitals, fever, increased assistance with ADLS, decline in mobility and eating, tachycardia. Review of the facility POC Task charting(Certified Nurse Aid documentation), dated [DATE] through [DATE], reflected no evidence of frequent repositioning, repositioning devices, hydration, toileting or skin observations. During an interview on [DATE] at 11:30 a.m. Director of Nursing (DON) B was asked how CNA staff know what resident needs are DON B reported they follow the care plan and kardex and reported turning and reposition residents was a standard of care every two hours and just know to do and they do not document task as completed. When asked why, DON B repeated because standard of care. DON B reported does not no a lot about wound care but has a wound team at facility that included wound care nurse WN I who he trusts with wounds. During an interview on [DATE] at 1:36 p.m., CNA J reported know how to care for residents by following kardex. CNA J reported assist with Activities of Daily Living(ADL) including repositioning or input or output as needed but unable to document ADL tasks performed. CNA J reported if resident did not have output for shift or change in condition would verbally report to nurse. During an interview on [DATE] at 1:40 p.m., CNA K reported CNA charting changed about one year ago and no longer document several ADL tasks as completed because they are standard of care. CNA K reported if CNA staff notice change in resident verbally report to nurse but not able to document in EMR. During an interview on [DATE] at 2:15 p.m., CNA L reported know how to care for residents by reviewing kardex. CNA L reported about one year ago documentation changes with no need to document ADL tasks as completed including turn and reposition, toileting/check and change, input/output, grooming, and oral care. CNA L reported if cna staff notice change for resident verbally report to nurse or can enter new alert in charting for including change in wound, new skin breakdown, or change in input or output. During an interview on [DATE] at 2:47 p.m., CNA M reported had worked at the facility for more than a year and had changed resident dressings occasionally after nurse provided dressing supplies and asked CNA M to change dressings. CNA M reported had not been asked to perform dressing changed in several weeks and reported aware nurse tasks and reported would help when asked. During an interview on [DATE] at 2:57 p.m., CNA N reported occasional changed resident dressings if asked to complete by nurse and reported knows was not ok because he does not have skills to assess or recognize change in wound. During an interview on [DATE] at 3:18 p.m., CNA O reported had worked at the facility for about one year reported knows what resident needs are by reviewing the care plan and speaking to residents and staff. CNA O reported only able to document limited ADL tasks in EMR including amount eaten, showers, ambulation if ordered and weights. CNA O reported not able to document change in input or output or change in skin and can verbally report to nurse. CNA O reported was not aware of alert charting until recently. During a telephone interview on [DATE] at 4:50 p.m., Confidential Staff(CS) P reported had worked at facility for several years. CS P reported had changed resident dressings several times, at least one to two times weekly as asked by the nurse staff. CS P reported was not part of job duties because not trained as nurse to assess for changes in wounds including infections and reported management staff was aware. CS P reported about one year about POC charting changed and now only document limited ADL tasks and if change for resident verbally report to nurse and or can complete new alert. CS P reported R109 has had open wound on right hip for several weeks that has worsened with R109 showing signs of increased pain and nurses have been informed. CS P reported observed dressing had been changed from foam dressing to bandaid after after worsening of wound bed from pencil tip size to nickel size open area currently on right hip. Review of the Hospital Records, dated [DATE] at 5:15 p.m., reflected Emergency Department Note that reflected R103 vitals were Temperature 103, heart rate 95, respirations 27, blood pressure ,d+[DATE](abnormal). Continued review of the records reflected, Skin: There is a stage II decubitus ulcer with surrounding erythema, warmth and foul odor. Continued review of the records reflected wound assessment completed on [DATE] that included measurements 3.2cm by 2.5cm pressure injury with yellow/gray/eschar with skin note,bright red ring of skin around open area then darker red/purple skin-nonblanchable measuring 8x7 . Review of the History and Physical(H&P), dated [DATE], reflected reason for visit was septic shock. The H&P reflected, Septic Shock .Patient was positive SIRS criteria with temperature of 103, heart rate of 95 white blood count of 21.5 initial lactic acid 3.2. blood pressure is ,d+[DATE] despite receiving 30cc/kg of normal saline .fluid bolus .Was likely source of infection is UTI and sacral decubitus ulcer with surrounding cellulitis in the presence of urinary and fecal incontinence Review of the Hospital wound consult, dated [DATE], reflected,Pt has 3cm x 3cm sacral pressure ulceration present. Wound bed is covered with a thin layer of slough/escar making staging difficult, however she has [NAME] little fatty tissue under this ulcer, thus this is most likely a stage 4 . Review of the Discharge Summary, dated [DATE], reflected R103 had admitting diagnosis of generalized weakness, decubitus ulcer of sacral region(unstageable), urinary tract infection, encephalopathy, cellulitis, chronic kidney disease 3b. The summary included, Moderate parenchymal atrophy. Patient was given IV fluids and broad-spectrum antibiotics in ED. Initially during her stay the patient had hypotension requiring Levophed which was discontinued following fluid resuscitation. Patient completed 7 days of antibiotics for her cellulitis which appears to have improved. Patient underwent chemical debridement and wound care of her chronic sacral pressure ulcer . Review of the Hospital Discharge Summary, dated [DATE], reflected R103 was admitted to the hospital on [DATE]. The record reflected, Patient admitted with large sacral decubitus ulcer with osteomyelitis status post debridement on [DATE], with wound cultures growing Proteus, staph and Vanco resistant Enterococcus with Candida .) Review of the Death Certificate, dated [DATE], reflected R103's cause of death was sepsis, osteomyelitis, and protein calorie malnutrition. During a telephone interview on [DATE] at 3:00 p.m. Medical Director (MD) Q reported would expect staff to notify physician of change in wound or new wounds. MD Q reported was not aware of R103 coccyx wound and verified review of physician visit with no mention of pressure wound and reported wound have mentioned if made aware by staff. Resident #107(R107) Review of the Face Sheet and Minimum Data Set (MDS) with ARD date [DATE], reflected R107 was a [AGE] year old male admitted to the facility on [DATE] related to pneumonia, diabetes mellitus, heart disease, hip replacement, hypertension (high blood pressure), The MDS reflected R103 had a BIM (assessment tool) of 14 which reflected R107 was cognitively intact. The MDS assessment reflected R103 had no behaviors including no rejection of care. During an observation and interview on [DATE] at 330 pm. R107 was lying in bed and reported had open area on bottom with very painful to sit on. R107 appeared to be able to answer questions without difficulty. During an interview and record review on [DATE] at 10:05 am WN I reported R107 was readmitted to facility on [DATE] had was seen by RN C for wound assessment and determined to be moisture associated dermatitis related to irregular borders on both sides of buttock cheeks. WN I reported she stages wounds and follows standing orders for treatments until communication with provider. RN I verified R107 had picture taken of wound on [DATE] that was described with escar present.(no eschar present on moisture associated wounds). WN I reported difficult to change staging after initial identification. Resident #109(R109) Review of the Face Sheet and Minimum Data Set (MDS) with ARD date [DATE] , reflected R109 was a [AGE] year old male admitted to the facility on [DATE] related to bipolar disorder, seizure disorder, hypertension (high blood pressure). The MDS reflected R103 had a BIM (assessment tool) which reflected R107 was severely impaired. During an observation on [DATE] at 8:30 a.m. R109 was laying in bed directly on right hip. During an interview on [DATE] at 835 am, RN R reported R109 had a facility acquired pressure ulcer on the right hip with treatments in place. Review of the EMR dated [DATE] to current reflected no mention of pressure ulcer including weekly skin notes or MDS records. Continued review of R109 EMR reflected nurse progress notes that included,[DATE] 09:08 Nurses Note DOCUMENT RELEVANT INFORMATION ABOUT THE RESIDENT:: Right hip area assessed. Skin is light red in color & blanchable. Area of excoriation has increased, measuring approximately 0.4cm x 0.5cm. Skin is dry & flaky. No s/sx of pain noted. New treatment order placed: Cleanse R hip with wound cleanser, pat dry.Apply wound gel and cover with Aquacel foam dressing BID. During an interview on [DATE] at 10:14 am, DON B escorted CNA N to this surveyor, DON B reported CNA N wanted to clarify statement made yesterday. CNA N reported he meant he assisted nurse with dressing changes. DON remained present during interview. During an interview on [DATE] at 1115am RN T reported R109 would not allow dressing change at this time and might after lunch. During an observation on [DATE] at 12:20 p.m., CNA U entered R109 room with full Personal Protective Gear(PPE) related to current contact isolation with MRSA, in attempt to get R109 out of bed. Observed dressing in place on right hip dated [DATE]. CNA U reported plan to get nurse for dressing change prior to getting R109 out of bed. This surveyor remained in room. R109 continued to lay directly on right hip with facial grimacing observe with position changes with staff assistance. At 12:40 p.m. RN C and WN I entered room to performed wound care. Foam border dressing was removed from R109 right hip with dime size open area that appeared to be stage 2 pressure ulcer with possible fatty tissue observed. Peri wound was bright red non-blanchable about baseball size. RN C changed dressing and cleaned area with wound cleanser, used lounge depressor to apply get directly to open area on R109 right hip and covered with aquacel foam dressing. During an interview on [DATE] at 1:09 p.m. WN I and RN C entered conference room. When asked what type of wound R109 had on right hip RN C responded stage 2 pressure ulcer that was identified today. WN I reported observed R109 skin on [DATE] and completed progress note. When asked WN I what type of would it was at that time RN C could not stay and stated, what the note said it was. WN I verified was area of excoriation and explained as red, raised streaks but not open. WN I reported saw R109 right hip skin on [DATE] and changed treatment to zinc oxide and reported no discussion with physician. WN I reported saw R109 on [DATE] and continued worsening of excoriation to right hip and treatment changed to wound gel and and cover with dressing twice daily. WN I reported area improved and saw again on [DATE] and changed treatment to A & D ointment. WN I reported right hip skin area worsened and seen on [DATE] (not above). RN C reported today R109 hip was open stage 2 with blanchable peri wound. When asked if RN C would explain, blanchable, RN C could not say what blanchable was and stated, Do you want me to Google blanchable? This surveyor ask for RN C professional judgement. RN C reported when pressure applied to red area turns white. RN C and WN I verified R109 was not followed weekly for wound because was not pressure ulcer until today and did not report to physician because they followed standing orders. During a telephone interview on [DATE] at 2:30 p.m. Medical Director (MD) Q reported was not aware R109 had skin breakdown on right hip. MD Q reporter would expect staff to contact physician with new or change in skin breakdown.

This Citation Pertains To Intake # MI00143774 and MI00143825 Based on observation, interview and record review, the facility failed to respond, assess and render immediate aid in a timely manner for one resident (resident #105) of three reviewed for falls. Findings Include: Review of the clinical record reflected R105 was a [AGE] year-old male admitted to the facility on [DATE]. R105 transferred to another facility on 4/5/24. Review of the Minimum Data Set (MDS) dated [DATE] reflected R105 had a diagnosis of Multiple Sclerosis (MS) and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS reflected assistance was required for all transfers. Review of R105's Social Work progress notes dated 2/7/24 reflected R105 had periods of confusion related to a famous Hollywood actress coming to pick him up and threatening self-harm if she doesn't. On 05/01/24 at approximately 10:25 am during an interview with Receptionist V she reported she was aware of R105 falling while shopping next door but stated she was not on duty at that time and referred writer to Receptionist E who was on duty at the time of R105's fall. On 05/01/24 at 1:15pm during a phone interview with complainant/ random stranger R she reported that she frequents the apartment complex next door to the facility and behind [name redacted] store. Random Stranger R stated she had repeatedly observed the same man in a wheelchair at local store lying on the pavement. Random Stranger R stated she did not know the man's name but assumed he was a resident of the facility since the buildings were right next door to one another - separated by a side street. Random Stranger R stated April 4th of 2024 was the last straw, stating this time she observed R#105 fall out of his wheelchair onto the pavement behind the store and in front of the apartment complex with blood coming from the [NAME] forehead. Random Stranger R stated the same resident was always alone and due to the 4/4/2024 fall she was so concerned for his wellbeing thought it was best to file a complaint with the State Agency. On 05/01/2024 at 1:40 pm, during a phone interview with a separate Complainant/ Random Stranger S she reported on 4/4/24 she was in her car and observed a man on the ground behind the store next to the facility and in front of the apartment complex. Random Stranger S stated that on way back into the apartment complex noticed the man was still on the ground, she reported she could not get him up by herself and called a neighbor and they together helped the man off the cement and back into his wheelchair. Random Stranger S stated she does not know who the man is but has watched him struggle on more than one occasion at the local nearby stores, when asked to clarify struggle she elaborated that man was always alone and the area was very hilly and he struggles to get up and down the hills in his wheelchair, and on another occasion Random Stranger S stated she had observed the same man lying in the road in front of the facility and on that occasion a passerby stopped his car and assisted him back into his wheelchair. Random Stranger S stated she then personally went next door into the facility and told the receptionist an unknown man, that appeared to be a resident of the facility, fell out of his wheelchair next door and was bleeding from his head. Random Stranger S stated she was dismissed by the receptionist and when leaving the facility she was a staff member (name unknown) in the parking lot and tried to explain to the facility staff her concern to that person, that man appeared to be resident of the facility as well but was again dismissed by facility staff. Random Stranger S stated she waited 10 to 15 minutes with the man but nobody from next door (the facility) came to check on him, to see if he lived at the facility. Random Stranger S then called her neighbor and the two of them picked the man up off the ground and placed him back in his wheelchair and helped him back. Random Stranger S stated she was concerned about the man's safety and given her prior observations of him falling in the road, parking lots and being dismissed by the facility staff , she thought a formal complaint was warranted after learning that the man did live in the facility. On 05/01/2024 at approximately 2:00pm during a phone interview with Receptionist E she reported she worked on 4/4/24 and recalled a random stranger came into the facility and reported she thought one of our residents fell out of his wheelchair, was bleeding from the head lying on the cement/parking lot next door. Receptionist E stated she automatically assumed it was R105 because he would often sign himself out and go alone to local stores. Receptionist E stated she called the nurses station where R105 resided and relayed the message (Receptionist E could not recall whom at the nurses stated she spoke with) from the unknown woman. On 5/1/24 at 11:21am during a phone interview with Licensed Practical Nurse (LPN) D she reported she was assigned to R105 on 4/4. LPN D stated on 4/4/24 she received a call from the front desk that R105 fell while shopping next door. When queried if she was notified, that a resident was lying on the pavement and had a head wound LPN D stated she could not recall the exact conversation with the receptionist. When queried if she looked out of any facility window to check to see if one of her residents was lying on the pavement, LPN D stated no R105 was on an LOA. Of note, R105 was not documented as being on an LOA on 4/4/24. LPN D further stated she went on break and did not assess the resident upon his return until her return from break. LPN D stated R105 was alert and oriented but did have periods of confusion. Review of an Incident and Accident report dated 4/04/2024 reflected R105 fell while on a Leave of Absence (LOA) LN (licensed Nurse) alerted that while resident was out of center going to [name redacted] (store next to facility) he was going down the hill by the apartment complex causing him to go at an unsafe speed. Resident then placed feet down on the ground trying to slow him self-down causing him to come forward out of his wheelchair causing abrasion to right forehead 10-millimeter (mm) x 10 mm, right knee (5 mm x 5 mm) and right pinky knuckle (3 mm x 3 mm). Resident stated he then placed himself back in his wheelchair and continued to [name of store redacted] for shopping. When resident returned to center he was assessed. R.O.M. (Range of Motion) and pain assessed as well. {sic} neuro's started and resident alert and verbal. Resident states he has pain 5 out of 10. Resident speech is appropriate for resident pupils plus two active to light. extremities strength and length are equal with no issues noted. education complete for LOA safety. On 05/02/24 at 8:22 am during an interview with Unit Manager/Registered Nurse (UM/RN) C the scenario of the fall was given, and it was queried what the expectation of the staff was, UM/RN C stated the scenario was so weird and ridiculous she could not answer the question. UM/RN C was then queried if facility staff should have responded to the concern that a facility resident was lying on the ground, for example by walking next door to see if it was a facility resident or calling 911 opposed to random strangers picking up facility resident R105 off the cement, UM/RN C reported she was not in charge of the staff at [store name redacted]. When queried if she expected staff to look out of the facility window to verify the report of the man was a resident of the facility, as the safety of the facility resident was a concern, UM/RN C stated if they are on LOA there was nothing to be done. Review of the LOA book did not reflect R105 was ever signed out on 4/4/24 when queried how the facility would know it was R105 as he never signed out, would that not prompt someone to look out the window to ensure a facility resident did not elope? UM/RN C had no response to the question. On 05/02/24 at 11:45 am during an interview with Director of Nursing (DON) B stated Resident #105 had periods of confusion and believed movie stars and famous wrestlers were coming to see him. DON B further stated R105 was on an approved LOA on 4/4/2024 when DON B was informed the sign out log reflected R105 never left the faciity on [DATE] DON B replied not technically signed out. When asked for clarification of not technically DON B stated he thinks R105 just wrote the wrong date on the sign out sheet. When queried about the incident DON B stated he did not expect his staff to walk next door or look out the window to verify if the person was on the ground was a resident of the facility, citing the fact it didn't matter because it would have been a LOA and he was not responsible. When queried even after being notified of a facility resident with an alleged head injury, alone, and unable to get up that could be visualized from the end of the 400 hall, 100 hall and lobby window? DON B stated LOA meant he and the facility were completely not responsible for the facility resident and it was up to the staff at [name redacted] store to call 911. When queried if the facility had a LOA policy, DON B stated no.

Based on observation, interview, and record review, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold for five (Resident #11, #50, #57, #72, and #82) of six residents reviewed for hospitalization resulting in the potential of residents and/or representatives to be uninformed of the bed hold policy. Findings include: Resident #82 Resident # 82 (R82) initially admitted to facility 1/13/23 with subsequent rehospitalization and facility readmission on 2/14/23 with diagnoses including urinary tract infection, encephalopathy, delirium due to known physiological condition, gastrostomy status, pharyngeal phase dysphagia, hemiplegia and hemiparesis following cerebral infarction, seizure, heart failure, dementia, and schizoaffective disorder. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/2023 reflected Brief Interview for Mental Status (BIMS) score of 13. Section G of MDS revealed that R82 required two-person total dependence for bed mobility and transfer, one-person total dependence with toilet use, and supervision with eating after set up. Review of the Discharge MDS dated [DATE], revealed that R82 had an unplanned discharge to an acute care hospital with return to the facility anticipated. In an observation and interview on 2/21/23 at 2:08 PM, R82 was observed to by lying on left side, in bed, with foley catheter tubing noted to extend from under blanket toward foot of bed on left side. R82 stated that he had been hospitalized recently for an urinary infection that required surgery but was unable to provide additional details nor did he recall or seem to understand what a bed hold policy was or whether one was reviewed with him prior to hospitalization . Review of R82's medical record completed with the following findings noted: Physician's Order dated 2/1/2023 at 5:04 PM stated, Send to (name of hospital). Nurses Note dated 2/1/2023 at 5:22 PM stated, Sending to ER (emergency room ), Notified (name of nurse), ER [NAME]. Family notified. (Name of Physician) notified. Nurses Note dated 2/1/2023 at 5:40 PM stated, EMS (Emergency Medical Services) arrived to transport resident to (name of hospital), Step-daughter (name) notified of departure per her request. Hospital Discharge Summary reflected hospital admitted [DATE] and hospital discharge date of [DATE]. In an interview on 2/27/23 at 10:36 AM, Social Worker (SW) C stated that there were individual packets, at each nurse's station, that contained the facilities bed hold policy/procedure, involuntary transfer/discharge paperwork, and the Ombudsman contact information. Per SW C, the assigned nurse reviewed the information within the packet, which included the bed hold policy, with the resident/responsible party at the time of the hospital transfer and that the packet was then sent with the resident to the hospital. SW C stated that the nurse would then document either within the nurses notes or in the section titled Additional relevant information within the Nursing Home to Hospital Transfer Form that this informational packet was sent. Upon review of R82's nurses notes and Nursing Home to Hospital Transfer Form, SW C stated that there was no documentation noted that the required information, including bed hold notification, was reviewed, or provided to the resident or responsible party at the time of or after the 2/1/23 hospital transfer. In an interview on 2/27/23 at 1:40 PM, Nursing Home Administrator (NHA) A confirmed that upon the review of R82's record that no documentation regarding bed hold notification could be found within the medical record that indicated that the bed hold policy was reviewed with R82 or the responsible party at the time of or following R82's 2/1/23 hospital transfer. Facility policy titled Discharge or Transfer of Resident with an 8/5/21 revision dated stated, .PURPOSE: To provide safe departure from the Center, and provide sufficient information for after care of the resident .PROCEDURE .Emergency Transfer/Discharges .8. Provide a notice of the resident's/guest bed hold policy to the resident and representative at the time of transfer, as possible but no later than 24-hours of transfer . 45135 Resident #11 (R11) Review of the medical record reflected R11 was admitted to the facility on [DATE] with diagnoses of cerebrovascular accident (CVA-stroke), falls and back pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2023, revealed R11 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Section G, functional status reveals R11 is independent of care and uses a walker to ambulate. During an interview and observation on 02/22/23 at 08:40 AM, R11 stated he was in the hospital in 01/23 due to respiratory infection. When asked if he received information on bed hold policy, he stated no, had never heard of anything about that. R11 was given a verbal explanation of these forms and stated, he had not been given one or had one explained to him. During an interview on 02/27/23 at 09:18 AM, Social Worker (SW) C stated a bed hold policy with transfer/discharge sheet is sent with residents when they go out to the hospital. Also handing surveyor the transfer packet that is sent to the hospital. SW C observed looking through electronic medical records (EMR), could not locate any documentation to support R11 received this information or understood the bed hold policy at the time of his departure from the facility to the hospital. During an interview on 02/27/23 at 12:22 PM, Director of Nursing (DON) B stated he did not know who provided this information to the residents when they transferred out of the facility. Resident #50 (R50) Review of the medical record reflected R50 was admitted to the facility on [DATE] with diagnoses of dementia, cognitive communication deficit, compression fracture of the first and third lumbar vertebra and decreased functional mobility. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/2022, revealed R50 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Section G, functional status reveals R50 needed limited assistance of all care and could verbalize her needs. During an interview and observation on 02/22/23 at 07:36 AM, R50 stated she had been hospitalized for urinary tract infection and sepsis (infection throughout her body) on 02/06/23 through 02/11/23. Also stated she is still on antibiotics for the infection. Inquired if R50 had received a bed hold policy when she went to the hospital. R50 stated, she had no idea what this was and has never seen these forms before. During a record review of nursing progress notes and hospital discharge notes revealed R50 was hospitalized for abdominal pain, sepsis and urinary tract infection from 02/06/23 through 02/11/23. During an interview on 02/27/23 at 09:18 AM, Social Worker (SW) C stated a bed hold policy with transfer/discharge sheet is sent with residents when they go out to the hospital. Also handing surveyor the transfer packet that is sent to the hospital. SW C observed looking through electronic medical records (EMR), could not locate any documentation to support R50 received this information or understood the bed hold policy with transfer/discharge information at the time of her departure from the facility to the hospital. During an interview on 02/27/23 at 12:22 PM, Director of Nursing (DON) B stated he did not know who provided this information to the residents when they transferred out of the facility. Resident #57 (R57) Review of the medical record reflected R57 was admitted to the facility on [DATE] with diagnoses of progressive neurological condition, paraplegic with multiple sclerosis and was bedbound. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/2023, revealed R57 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Section G, functional status reveals R57 to dependent of all care, and can verbalize his needs. During an interview and observation on 02/21/23 at 12:42 PM, R57 stated he went to hospital for pneumonia and kidney stones. When asked if he received a bed hold policy, R57 stated, I have no idea what that is. During record review of nursing notes and hospital discharge orders, revealed R57 went to the hospital for sepsis, urinary tract infection, chronic suprapubic catheter, nausea and vomiting, muscular sclerosis (MS) and chronic indwelling catheter on 11/01/22 (10/28/22-11/01/22), 09/08/22 (09/03/22-09/08/22), and 02/18/23 (02/14/23-02/18/23). Record review of nursing note dated 02/14/23, reveals R57 had been sent out to the emergency department twice before sent to a different hospital that hospitalized him from 02/14/23 through 02/18/23. During an interview on 02/27/23 at 09:18 AM, Social Worker (SW) C stated a bed hold policy with transfer/discharge sheet is sent with residents when they go out to the hospital. Also handing surveyor the transfer packet that is sent to the hospital. SW C observed looking through electronic medical records (EMR), could not locate any documentation to support R57 received this information or understood the bed hold policy at his departure from the facility to the hospital on the three listed hospitalization s. During an interview on 02/27/23 at 12:22 PM, Director of Nursing (DON) B stated he did not know who provided this information to the residents when they transferred out of the facility. Resident #72 (R72) Review of the medical record reflected R72 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, cerebrovascular accident (CVA-stroke) and dementia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/03/2023, revealed R72 had a Brief Interview of Mental Status (BIMS) of 10 (moderately impaired) out of 15. Section G, functional status reveals R57 required extensive assistance of all care, is unable to make needs known and uses a wheelchair. During an interview and observation on 02/21/23 at 01:01 PM, R72 stated he had a bad fall and had to go to the hospital. R72 was sitting in his wheelchair at the dining room table following lunch. During a record review of admission notes and nursing progress notes, revealed R72 fell backwards while ambulating independently, was sent to the hospital for posterior head laceration evaluation. R72 wsa hospitalized on [DATE] through 11/04/22 for frequent falls and hallucinations. During an interview on 02/27/23 at 09:18 AM, Social Worker (SW) C stated a bed hold policy with transfer/discharge sheet is sent with residents when they go out to the hospital. Also handing surveyor the transfer packet that is sent to the hospital. SW C observed looking through electronic medical records (EMR), could not locate any documentation to support R57 received this information or understood the bed hold policy at his departure from the facility to the hospital. During an interview on 2/27/23 at 11:51 AM, DON B stated after every fall we updated his plan of care, he was a tricky guy, we would try to sit him in a high traffic area to keep an eye on him. DON B stated that he also made rounds on him, and a lot of his falls were in the dining room. Staff had caught him from literally falling to the floor. He hasn't had any falls with those interventions in place. DON B also stated he did not know who provided information on bed hold, transfer/discharges to the residents when they transferred out of the facility. According to a document titled DISCHARGE OR TRANFER OF RESIDENT dated 08/01/2008, revision date of 08/05/2021, Attachment G, specifies Bed Hold's and Readmissions. When a resident is discharged to the hospital for further care and evaluation, [NAME] Senior Care and Rehab Center are required by Michigan law to offer the resident, resident representative, and/or Guarantor the opportunity to pay privately to hold a bed for at least 10 days. Procedure: 1) Within 24 hours of discharge from the facility, the resident will be contacted by a representative of the facility via phone and/or letter to determine if a bed hold is desired. This notification and the decision will be documented in the medical record. 2) If bed hold is desired, a bed hold agreement will need to be signed and an initial seven-day deposit will be required within 48 hours. MEDICAID Bed Hold Rules are stated as follows. Medicaid reimburses a nursing home facility to hold a bed for up to ten days during a beneficiary's temporary absent from the facility only when there is a 98% occupancy. Facility would follow same procedure as private pay.

Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for four (Resident #1, #3, #40, and #87) of 21 reviewed, resulting in care planned interventions that were not in place and the potential for unmet care needs. Findings include: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, dementia with behavioral disturbance, delusional disorder, history of falls, diabetes, major depressive disorder, and anxiety. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/23 revealed R1 scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS), had a significant weight loss, and needed supervision for transfers and walking in the room. Review of R1's fall care plan revealed interventions that included call light accessible (initiated 12/16/19) and gripper strips on the floor next to the bed (initiated 4/7/22). On 2/21/23 at 12:26 PM, R1 was observed in bed with her door closed. The bed was positioned at an angle. One gripper strip was observed under the bed and the other was approximately two feet away from the bed. R1's call light was on the floor. At 12:27 PM, a staff member delivered R1's lunch and placed the tray on the overbed table. The staff member rearranged R1's oxygen tubing so that it was not wrapped around her feet. The call light was not placed within R1's reach. On 2/27/23 at 08:27 AM, R1 was observed asleep in bed. The bed was positioned at an angle. New gripper strips were observed to each side of the bed along with the previously observed gripper strips. In an interview on 2/27/23 at 10:19 AM, Registered Nurse (RN) I reported R1's bed had been at an angled position for approximately a year. In an interview on 2/27/23 at 10:43 AM, Unit Manager (UM) J reported R1 was care planned to have gripper strips to both sides of the bed. R1 reported maintenance placed new gripper strips to both sides of R1's bed on 2/22/23. Review of R1's nutritional risk care plan revealed an intervention of provide nutrition supplement as ordered, record % consumed (initiated 1/13/23). Review of the Physician's Order dated 1/13/23 revealed R1 had an order for vanilla Glucerna (nutrition shake) every day at bedtime. Review of the medical record revealed the percentage consumed was not documented. In an interview on 2/28/23 at 10:32 AM, Registered Dietitian (RD) H reported the percentage consumed was previously documented under the tasks section, but there was no longer an option to document there. RD H reported she thought the nurses documented the percentage on the Medication Administration Record (MAR), but reported she did not have access to those documents to review. RD H reported she was never shown how to access the MARs. RD H reported the percentage consumed of R1's Glucerna should be documented. Resident #3 (R3) Review of the medical record revealed R3 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, morbid obesity, diabetes, epilepsy, bilateral above the knee amputations, and pressure ulcer sacral region stage 4. The MDS with an ARD of 12/16/22 revealed R3 scored 13 out of 15 (cognitively intact) on the BIMS and had a stage 4 pressure ulcer present on admission. On 2/21/23 at 10:55 AM, R3 was observed lying in bed. R3 reported she had a pressure ulcer that gets better then worse. R3 reported her wheelchair cushion did not hold enough air. When a hand was placed on R3's roho cushion, the wheelchair seat could be felt as the cushion deflated. R3 stated I can feel my butt bone hitting the seat. In an interview on 2/27/23 at 9:42 AM, UM J reported R3 often got up in her wheelchair and pressure ulcer interventions included a roho cushion to R3's wheelchair. When asked about any issues with the roho cushion, UM J reported a new cushion was ordered for R1 approximately one month ago because the previous cushion was uncomfortable. Upon observation of R3's roho cushion with UM J, UM J reported the roho cushion was definitely losing air. R3 stated It's always lost air. R3 reported the new cushion was still in the box in her closet because it was the incorrect size. UM J reported therapy was in charge of roho cushions. On 2/27/23 at 10:02 AM, Certified Nursing Assistant (CNA) N entered R3's room with a pump. CNA N was able to pump over forty times, but the cushion still lost air. On 2/27/23 at 11:38 AM, UM J reported she had not been back into R3's room to notice that the roho cushion was once again deflated. UM J reported she was going to check with therapy to see if they had the correct size roho cushion. On 2/27/23 at 11:40 AM, R3 was observed sitting in her wheelchair. R3 reported the cushion was still the same and was deflated. A box was observed in R3's closet that contained a new 18-inch roho cushion. R3 reported she needed a 16-inch roho cushion. On 2/27/23 at 11:53 AM, Director of Nursing (DON) B reported he was not aware of R3's wheelchair cushion issues prior to today. Review of R3's pressure ulcer care plan revealed R3 had a stage 4 pressure ulcer. Interventions included a roho cushion to R3's wheelchair. Resident #40 (R40) Review of the medical record revealed R40 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included left femur fracture (12/5/22), anxiety, retention of urine, and Alzheimer's Disease. The significant change MDS with an ARD of 12/11/22 revealed R40 scored 3 out of 15 (severe cognitive impairment) on the BIMS, required extensive assist of two for transfers, did not walk, total dependence of two for toileting, and had one fall without injury. On 2/21/23 at 11:52 AM, R40 was observed in the dining room. At 12:59 PM. R40 stood up from her wheelchair, and took a couple shuffled steps before staff redirected her back to the wheelchair. R40 stated she had to go to the bathroom. A staff member then transported R40 out into the hallway without the use of footrests for the wheelchair. The footrests were observed in a bag on the back of the wheelchair. Once in the hallway, another staff member was observed pulling R40 in her wheelchair by holding on to the left armrest. R40's left foot was dragging on the floor. The staff member then asked R40 if she wanted to walk, assisted R40 to a standing position by holding onto R40's left hand. R40 was then ambulated to her room without the use of a walker or gait belt. Review of R40's care plans revealed R40 was a one person assist with a rolling walker for ambulation. In an interview on 2/27/23 at 09:42 AM, UM J reported R40 should have wheelchair footrests in place when being transported in her wheelchair. In an interview on 2/27/23 at 12:25 PM, DON B reported he was not sure on the facility's policy for wheelchair footrest and gait belt use. 27446 Resident #87 (R87): Per R87's face sheet in an electronic medical record (EMR) R87 was admitted to the facility on [DATE], with 2/13/2023 being the most recent admission. The face sheet also revealed R87 had diagnoses of gastroesophageal reflux disease (GERD-stomach acid that flows back up into the esophagus toward the mouth causing a burning sensation), and dysphasia (difficultly in swallowing). In an observation and interview on 2/21/2023 at 1:13 PM, Clinical Care Coordinator (CCC) D, who was the Unit Manager, was observed attempting to assist R87 to eat orally solid food. Also observed was a bottle of tube feeding on a pole infusing at 70 milliliters (ML) per hour with water in a separate bag infusing at 50 ML per hour. CCC D stated that both the tube feeding and the water infuse for 20 hours a day. During the same observation and interview, R87 was observed lying on her left side while bed. The head of the bed was elevated up to approximately 30 degrees, however R87 was observed to have slid down from the head of the bed, with her head resting at the bottom of the raised portion in the area where the bed bent when the head of he bed was elevated. CCC D was observed to exit R87's room, however did not re-adjust R87 in her bed so that she was sitting up at about 30 degrees to prevent aspiration. On 2/21/2023 at 2:46 PM, Resident #87 was observed with the head of the bed up at approximately 30 degrees, however R87 remained with her head in the bend area of the bed, and lying on her left side. R87's tube feeding and water was observed to be infusing into her feeding tube in her stomach, with no change in the rates of infusion. Record review of Physician's orders dated 1/5/2023, revealed and order to, Ensure HOB (head of bed) is elevated 30-45 degrees while tube feed being administered and for at least 30 minutes after tube feeding is completed. Record review of Physician's orders dated 2/5/2023, revealed and order to, Ensure HOB (head of bed) is elevated 30-45 degrees while tube feed being administered and for at least 30 minutes after tube feeding is completed. Record review of R87's care plan that was created on 10/19/2022, with a Focus of NUTRITIONAL PREFERENCES/HYDRATION. revealed for the Focus R87's list of diagnoses that included gastrostomy status, dysphasia, and GERD, and pertaining to R87's tube feeding, Gastrostomy status, monitor toleration of feeds ., Swallowing difficulty r/t (related to) dysphasia, PEG (percutaneous endoscopic gastrostomy), tube placed, mechanically altered diet texture . The care plan revealed the latest revision dated was 2/5/2023. Under Interventions R87's care plan revealed, Feeding tube, gastrostomy status. Provide enteral nutrition as ordered, adjust PRN (as needed) ., date initiated was 2/5/2023, and Keep HOB elevated, not less that 30 degrees during and 1 hour after tube feeding ., date initiated was 2/5/2023. Therefore, R87's plan of care did include the interventions to keep her head of bed elevated during and after completion of her daily tube feeding infusion until 2/25/2023. Record review of a Treatment Administration Record (TAR) for the month of February revealed that on 2/5/2023 the order to assure R87's HOB was up at 30 degrees while infusing and for 30 minutes after tube feeding was completed, was documented to have been assured for the day shift, however per the observation on 2/21/2023 at 1:13 PM, the order was not followed, but was documented to have been completed, including R87's order to remain up at 30 degrees for 30 minutes due to her GERD diagnosis. In an interview on 2/27/2023 at 1:14 PM, Registered Dietician (RD) H stated that R87's tube feeding was to infuse 70 ML per hour with a water flush at 50 ML per hours for 20 hours a day. RD H stated that Director of Nursing (DON) B put in an order for R87's head of the bed to be a 30 degrees while tube feeding and water infusing, and for 30 minutes afterwards. RD H said she updated R87's care plan based the order. RD H stated that her expectation was R87's head of the bed be at 30-45 degrees while receiving her tubing infusions. In an interview on 2/28/2023 at 10:39 AM, DON B was asked what his expectation was regarding R87's tube feeding and head of the bed up 30 degrees while infusing and for 30 minutes after the feeding was completed. DON B stated that he expected staff to do their job. Review of the facility's policy and procedure titled, Enteral Nutritional Feeding dated 7/1/2008 with the last revision dated of 9/23/2019, revealed on page #2 under, MONITORING THE RESIDENTS ON ENTERAL FEEDINGS: .#3 Head of bed must be elevated 30-45 degrees at all times during feeding and for at least 30 minutes after the feeding unless otherwise indicated per order/plan or care.

Based on observation, interview, and record review, the facility failed to revise care plans for four (Resident #21, #26, #28, and #75) of 21 reviewed, resulting in the potential for unmet care needs. Findings include: Resident #26 (R26) Review of the medical record revealed R26 admitted [DATE] with diagnoses that included dementia, diabetes, and major depressive disorder. The significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/23 revealed R26 scored 3 out of 15 (severe cognitive impairment on the Brief Interview for Mental Status (BIMS) and required extensive assist of one to two people for activities of daily living. R26 was admitted to hospice services on 1/12/23. Review of the Physician's Order dated 2/3/23 revealed carrot to left hand on at all times as tolerated. Review of R26's care plans revealed the hand carrot was not added to R26's care plans. On 2/21/23 at 10:37 AM, R26 was observed lying in bed awake. Two hand carrots were observed on R26's overbed table. A hand carrot was not in place in R26's left hand. On 2/21/23 at 12:36 PM, R26's hand carrot was still not in place. Two hand carrots were observed on the overbed table. On 2/21/23 at 01:09 PM, staff had finished feeding R26 lunch. The hand carrot was not in place. Two hand carrots were observed on the overbed table. Review of the Treatment Administration Record (TAR) revealed R26 was marked as using the hand carrot on 2/21/23. No refusals were documented. In an interview on 2/27/23 at 12:18 PM, Director of Nursing (DON) B reported he was not able to locate the care plan update to include R26's hand carrot. 27446 Resident #21 (R21): Per the facility face sheet R21 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure. Record review of the Physician's orders dated 12/20/2022, revealed R21 was to have oxygen (02) two liters of oxygen placed on during the night shift and check SP02 (oxygen levels) every night. The order also revealed that a licensed nurse was to change the 02 tubing and date the tubing every Thursday. The order also dated 12/20/2022 revealed that R21 was to have trial periods of being on room air (no 02 on) and check 02 level on the 15 of every month. Record review of R21's care plans that were active revealed that there was no care plan in place regarding R21's 02 use, nor were there any interventions related to the room air 02 trials. and none of the ordered specifics were placed as an intervention on any of R21's care plans. Review of a care plan dated 12/16/2022, that was in place for respiratory issues related to complications of COPD, did not have any interventions in place pertain to R21's 02 use, and the perform trial room air 02 checks. The last added interventions that were on the care plan were dated 12/16/2022. Review of another care plan dated 12/16/2022, revealed R21 was at risk for cardiac complications. The care plan did not have any interventions in place regarding R21's use of 02, nor to perform trials of room air 02 checks. The care plan had no new or revised interventions since 12/16/2022. Resident #75 (R75): Per the facility face sheet R75 was admitted to the facility on [DATE], and had a diagnosis of heart failure. In an interview on 2/21/2023 at 11:02 AM, R75 stated he never had received an invitation, attended, nor was notified of a care plan conference since his admission, and therefore had not ever had a care conference. In an interview on 2/27/2023 at 10:21 AM, Social Worker (SW) C stated that she did not find in R75's electronic medical record (EMR) that he had ever had a care conference (CC), and confirmed that a CC should have been conducted seven days after R75's admission and Minimum Data Set (MDS) assessment was completed. Record review of the facility's policy and procedure titled, CARE PLAN CONFERENCES: SCHEDULING AND RESIDENTIAL/FAMILY INVITATION dated 7/1/2008 with no revision dates, revealed under, Policy: the facility should involved the resident, resident's family or representative in the care planning, Their attendance and participation in the care plan conference must be encouraged trough timely invitation. Under Protocol: #2a. The Care Plan Conference for long term care residents must be scheduled at least seven (7) days after the ARD (Assessment Reference Date) of scheduled MDS., and b. The Care Plan Conference for newly admitted resident/s must be schedules within the first 21 days from admission. Under 3. The facility designee shall generate the following: a, Care Plan Conference letters addressed to the following recipients (as appropriate): i. Family Member/Responsible Party, ii. Guardian, b. invitation addressed to the resident. The policy further stated under #4. The Care Plan Conference letters shall be sent two (2) weeks prior to the month of the scheduled meeting. In cases of new admissions, re-admissions ., letters shall be sent simultaneous to scheduling of the meeting. In another interview on 2/21/2023 at 10:47 AM, R75 stated that a nurse (could not recall nurses' name) about three days prior checked his 02 level which was 85% and one like 89/90%. R75 said the nurse put me on 02 at about 2 liters. During the interview an 02 concentrator was observed in R75's room with a nasal cannula (tubing goes in the nose to deliver 02) on the floor. R75 stated he turned his 02 on and off himself. Record review a care plan in place for R75's cardiac issues dated 1/19/2023, revealed no intervention in place addressing R75's oxygen use or 02 room air trials. No other care plan was found in R75's EMR that addressed R75's 02 use or trial 02 room checks. In an interview on 2/28/2023 at 10:33 AM, Director of Nursing (DON) B stated his expectations were that when a nurse wrote a new Physician's order that nurse would add or revise the residents care plan at that time also. 46955 Resident # 28 Resident # 28 (R28) admitted to facility 10/29/2021 with diagnoses including essential hypertension, unspecified intellectual disabilities, and fracture of upper and lower end of right fibula. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/23 revealed that R28 had a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairment). Section G of MDS revealed that R28 required extensive two-person assist with bed mobility, two-person total dependence with transfer and toilet use and was independent with eating after set up. Section O of same MDS indicated that R28 utilized oxygen while a resident at the facility. In an observation on 2/21/23 at 10:35 AM, Resident # 28 (R28) was observed to be lying in bed, on back, with head of bed at an approximate 60-degree angle. R28 was noted to have nasal cannula oxygen tubing positioned just to the left of her nares with tubing connected to oxygen concentrator, at bedside, set at 2 liters/minute (liters per minutes). The oxygen tubing was labeled with a handwritten date of 2/9/23. R28 shook head to acknowledge name but verbal response was garbled and unclear. Review of R28's medical record completed with the following findings noted: Nurses Note dated 1/6/23 at 11:21 AM stated, While assessing residents vital signs residents O2 (oxygen) level was 87 percent on room air. Supplemental O2 was placed at 2 L (liters) via NC (nasal cannula). Residents O2 rose to 94 percent with the O2 in place. Doctor was informed and auscultated resident lung sounds . Physician's Note dated 1/7/23 at 5:54 AM stated, Seen d/t (due to) nursing notification of O2 sats (saturations) of 87% (percent). Improved to 96% with low dose O2 .a/p) (action/plan) acute hypoxic respiratory failure possibly d/t atelectasis .p) (plan) supplemental O2 as needed . Order dated 1/6/23 at 11:58 AM stated, O2 at 2L (liters) continuously via nasal cannula every shift for Hypoxia. Order dated 1/6/23 at 11:58 AM stated, Room air trial every shift starting on the 15th and ending on the 15th every month for evaluation of O2 use; LN (licensed nurse) to remove O2 for 15 minutes & document SPO2 (oxygen saturation) on room air. Treatment Administration Records (TARs) dated 1/1/2023 to 1/31/2023 and 2/1/2023 to 2/28/2023 reflected order for Room air trial starting on the 15th and ending on the 15th every month with corresponding documentation on January TAR for 1/15/23 under O2 Sats (saturation) noted to reflect 81 for day shift, 85 for evening shift and 88 for night shift and on February TAR for 2/15/23 under O2 Sats noted to reflect 84 for day shift, NA (not applicable) for evening shift, and 89 for night shift. TARs dated 1/1/2023 to 1/31/2023 and 2/1/2023 to 2/28/2023 also reflected order for O2 at 2L continuously via nasal cannula with all corresponding day, evening, and night shift administration boxes noted to be signed out starting evening shift of 1/6/2023 and continuing to present date. Review of all care plans contained within Care Plan tab completed with no respiratory or oxygen related care plan noted to indicate R28's oxygen needs and related orders. Cardiac Care Plan was noted although was not noted to include oxygen needs. In an interview on 2/27/23 at 11:05 AM, Resident Assessment Instrument Coordinator/Registered Nurse (RN) E confirmed familiarity with R28 and upon review of orders, confirmed that R28 had oxygen initiated on January 6, 2023. RN E also confirmed that 1/23/2023 quarterly MDS (Minimum Data Set) assessment included coding for oxygen usage. Upon review of the comprehensive care plans, RN E confirmed that no care plan had been developed to reflect initiation of oxygen therapy and that there was still no care plan in place to reflect R28's ongoing oxygen needs. RN E stated that since R28 received oxygen therapy, that a corresponding care plan should have been formulated at the time of oxygen initiation by the assigned nurse or within 24 to 48 hours by the Clinical Care Coordinator or MDS nurse. On 2/27/23 at 11:30 AM, Nursing Home Administrator (NHA) A was requested to provide the facility care planning policy with a facility policy titled Baseline Care Plans received from NHA A. On 2/27/23 at 11:45 AM, NHA A was requested to provide the facility policy for care plan updates/revisions or any other policy regarding the facilities care planning process at which time NHA A confirmed that the facility did not have a specific care plan policy that addressed the initiation of a new care plan or the revision of an existing care plan.

Based on observation, interview and record review, the facility failed to ensure accuracy of advance directives for two (Resident #1 and #57) of two reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility. Findings include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised 3-25-14), revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir. (3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence. Further review of this Act revealed, Sec. 4. A do-not-resuscitate order executed under section 3 or 3a shall include, but is not limited to, the following language, and shall be in substantially the following form: DO-NOT-RESUSCITATE ORDER This do-not-resuscitate order is issued by _______________________________________, attending physician for _________________________________________. (Type or print declarant's or ward's name) Use the appropriate consent section below: A. DECLARANT CONSENT I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. _______________________________________ _______________ (Declarant's signature) (Date) _______________________________________ _______________ (Signature of person who signed for (Date) declarant, if applicable) _______________________________________ (Type or print full name) B. PATIENT ADVOCATE CONSENT I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Patient advocate's signature) (Date) _______________________________________ (Type or print patient advocate's name) C. GUARDIAN CONSENT I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Guardian's signature) (Date) _______________________________________ (Type or print guardian's name) _______________________________________ _______________ (Physician's signature) (Date) _______________________________________ (Type or print physician's full name) ATTESTATION OF WITNESSES The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the declarant has (has not) received an identification bracelet. ______________________________ ______________________________ (Witness signature) (Date) (Witness signature) (Date) ______________________________ ______________________________ (Type or print witness's name) (Type or print witness's name) THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT. Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, dementia with behavioral disturance, delusional disorder, diabetes, major depressive disorder, and anxiety. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/23 revealed R1 scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 2/27/23 at 8:27 AM R1 was observed asleep in bed. Review of R1's Code Status Form revealed R1's Guardian chose Do Not Resuscitate and signed the form on 5/18/20. Two witnesses signed the form on 5/26/20, which was same date the physician signed the form. In an interview on 2/27/23 at 11:29 AM, Social Worker (SW) C could not explain why the two witnesses signed eight days after R1's Guardian. SW C reported the witnesses should have signed the same time/date as the Guardian. 45135 Resident 57 (R57) Review of the medical record reflected R57 was admitted to the facility on [DATE] with diagnoses of progressive neurological condition, paraplegic from multiple sclerosis and was bedbound. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/2023, revealed R57 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Section G, functional status reveals R57 to dependent of all care, and can verbalize his needs. During a record review of code status on 02/21/23, revealed R57 had signed his name and dated under the code status of full code. Witnesses and physician signed and dated under do not resuscitate section. During an interview with Social Worker (SW) C, stated the Do Not Resuscitate (DNR) was signed and dated by witnesses and the physician under DNR. When noting R57 signed higher on the form under full code. Also stated, this is not right, I will have him complete a new form today. During an interview on 02/28/23 with SW C, presented an updated, clear copy of R57 code status revealing all parties signed under the DNR section and dated.

This citation pertains to MI00130722 Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #17) was free from abuse of one reviewed, resulting in Resident #17 being abused by a staff member. Findings include: Review of the medical record revealed Resident #17 (R17) was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included anemia, dysphagia, vascular dementia with other behavioral disturbances, major depressive disorder, and anxiety. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/22 revealed R17 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 02/21/23 11:04 AM, R17 was observed lying in bed. R17 was unable to recall the incident with Registered Nurse (RN) K. R17 reported she had one or two occasions where a staff member had yelled at her and stated, they just got mad at me for some reason. Review of the facility reported incident and investigation revealed Based upon the investigation and witness statements, the allegations of mistreatment has been substantiated. Nurse K's employment with the facility has been terminated and her license has been reported. According to the Investigation Report, on 6/30/22 the RN assigned to care for R17 was heard having an exchange with R17 in an elevated tone. The RN was suspended, all notifications were completed, and a full investigation into the occurrence is in process. According to the Investigation Report, R17 was interviewed by Former Director of Nursing (DON) M. R17 reported she was rude to me when she was taking care of me. I got mad and threw a cup at her. Then she said f*ck. I have a problem with my stomach. I told her to get out of my room. She gave me two pills. She told me I needed to give the pills time to make me feel better. I'm not scared or anything, I just want her fired. RN K was interviewed by former DON, M. RN K reported I was trying to give R17 simethicone tablet (a medication that aids in alleviating discomfort caused by bloating and gas). I said here (R17) this well help. Then she started arguing with me. I have been trying to keep the residents medicated and I had enough. According to the same Investigation Report, Certified Nursing Assistant (CNA) 'L reported she observed R17 come out of her room to tell RN K that she can't take this (the pill) like that. RN K said what do you mean? R17 said I can't take this pill whole. RN K offered to crush the pill but stated you always take this pill whole. R17 disagreed and said she always gets it crushed. CNA L then reported she heard RN K say what do you want me to do, chew it up and spit it in your mouth for you? CNA L said they began yelling at each other and heard RN K tell R17 to just shut the f*ck up. R17 become more upset and stated she wanted another nurse and told RN K she was going to report her to a person in charge. R17 was quite upset and threw her can of pop at RN K. In an interview on 02/27/23 at 01:39 PM, CNA L reported she was nearby when she heard the verbal argument, R17 was telling RN K that she gets her pills crushed up, and RN K told R17 that she does not get her pills crushed up. R17 and RN K proceeded to get into a verbal argument. CNA L reported she heard RN K say to R17, what do you want me to do, chew them up and spit them into your mouth. CNA L witnessed R17 throw a can of soda at RN K. In a telephone interview on 02/28/23 at 08:31 AM, former DON M reported R17 had asked that her medication be crushed and a CNA overheard RN K tell R17 to shut the f*ck up. Former DON M asked RN K what was going on and RN K reported to her that R17 was arguing with her. Former DON M told RN K you cannot tell a resident to shut the f*ck up, RN K responded with I know, I should not have said that. In a telephone interview on 02/28/23 at 11:59 AM, RN K reported [R17] was already worked up about her stomach hurting . she was complaining about bloating, so I medicated her first and told her that should help. I continued with medication pass . [R17] got louder and was screaming, and if she's not addressed she will get up and try to walk, so I kept going back and forth . [R17] had gotten upset after so many times of trying to explain to her that it is gas, I gave her chewable simethicone .she insisted it was not gas and started screaming again . I went back in there a final time and let her know they were chewable . that's when [R17] threw an open can of soda at me. It was a knee jerk reaction when I said what the eff . enough! I realized afterwards that it was an accident, and it should not have happened, but it was heard down the hall and reported that I said shut the eff up, which I would never do that in front of residents. I took a break to go change clothes . when I came back, [management] didn't let me go to the floor . I was suspended and went home . 5 or 6 days went by, I called and requested to speak with the [Nursing Home Administrator]. I asked for an explanation [at the meeting] . they told me about the cussing and something about chewing up and a baby bird, I'm unsure about that part, that was the first time I heard about that I regret cussing in front of her, it was response to a can being thrown at me. The following Past Non-Compliance was reviewed and accepted at the time of the survey: ELEMENT 1: On 6/30/22, upon identification of potential abuse, RN K was immediately suspended pending investigation. She was ultimately terminated, and her license was reported. R17 was assessed and monitored by nursing and social work for seven consecutive days following the occurrence, no psychosocial changes noted. ELEMENT 2: All 500 hall residents were interviewed for abuse, no further concerns identified. ELEMENT 3: All staff were re-educated on the abuse policy and questioned regarding allegations of abuse. The Plan of Correction contained proof of staff reeducation in the form of in-services and Abuse and Neglect Quizzes. ELEMENT 4: The facility Administrator or designate will interview 10 residents weekly regarding abuse for 12 weeks to ensure the facility continues to address allegations according to facility policy and reporting guidelines and to ensure employees allegedly involved have been suspended pending completion of investigation and further disciplinary actions have been taken if indicated. Audits were performed from 7/7/22 until 2/24/2023. Any non-adherence will result in 1:1 education. All audits will be taken to QA committee for review. The facility alleges substantial compliance on 8/15/2022.

This Citation has two deficient practices: Deficient Practice #1 Based on observation, interview and record review the facility failed to ensure fall prevention safety for one (R57) out of six residents reviewed for accidents resulting in R57 falling, sustaining a fracture of the right femoral neck (hip) that required surgery and a hospital stay. Finding include: On 3/14/22 at approximately 8:34AM, R57 was observed sleeping in bed. A second observation was made on 3/15/22 at 12:34 PM, again the resident was sleeping and not able to answer questions asked. A review a R57's clinical record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Fracture of unspecified part of neck of right femur, history of falling, Alzheimer's disease, [CONDITION(S)] disease and chronic kidney disease, stage 3. Review of the resident's Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status Score (BIMS) of 3/15 (severely cognitively impaired) and required extensive one person assist for transfers and bed mobility. The MDS also indicated that the resident balance was not steady, only able to stabilize with staff assistance. A progress noted dated 1/20/22 (authored by Nurse O) documented, in part: Resident was found on floor of his room Prior to fall he had been sleeping when supper arrived was woke up to eat. Staff offered to put him in his wheelchair, but resident refused to get up. He was sitting on side of bed eating upon rounding the aid found resident on the floor in a supine position with his r (right) arm under him legs were curled up. footboard of the bed was ripped off and laying at bed foot. He was able to straighten out his legs with complaint of pain in r hip area. large hematoma noted on outer aspect of right knee and a skin tear on right antecubital area.ROM (range of motion) with pain to r side. Resident had had a BM (bowel movement) so was cleaned up on a sheet on the floor then Picked up with a sheet and put back into bed. All involved parties notified, and res (resident) sent to (name of hospital) per son request. A review of R57's Hospital records documented, in part: .Progress Notes: . Of interest this .male patient .was brought to the hospital after a fall. He was admitted under orthopedic surgery after being found a right femur fracture. He went under a right hemiarthroplasty. After PT (Physical Therapay) and OT (Occupational Therapy) evaluation he was found appropriate for discharge. Unfortunately, he was found to have Covid infection . A review of R57's care plan documented, in part, the following: Focus: Falls: R is at risk for falls . (date initiated 1/20/2020) .Interventions .If I am noted to change my mind about getting up in my wheelchair, offer to assist me back to bed . Focus: ADLs: Resident needs assist for daily care (date initiated 1/20/2020) .Interventions .Assist with meals (date initiated 1/21/2020) . Focus: Nutritional Risk (date initiated 1/20/20-Revision 2/8/22) .Interventions: 1:1 feed assist with meals with resident compliance (date initiated 11/20/2020) . Focus: Mood/Behavior: Readmit for (name redacted) hospital .Dx (diagnosis) of personality disorder (dated initiated 2/2/2020) . Interventions: Observe for Verbal/Rejection of Care/Other. Report and document observations (Date initiated 2/3/2020) . A Functional Abilities and Goals form (10/30/21) documented, in part .Sit to lying. The ability to move from sitting on side of bed to lying flat on the bed .4. Supervision or touching assistance .Sit to stand: The ability to come to a standing position from sitting .on the side of the bed .3. Partial/moderate assist . An I/A (Investigation/Accident Report) dated 1/20/2022 was reviewed and documented, in part: Date: 1/20/2022 (6:05 PM) .Resident: R57. Incident Location: Resident's Room: Person Preparing Report: Nurse O Incident Description: Observed resident lying on floor in supine position with Right arm under him. Foot of bed had been torn off the bed. It appears that resident may have been using foot board to stabilize himself and foot board had broken during fall. Resident stated he was getting up to walk home. Resident had been sleeping prior to dinner coming per his request to lie down before dinner. Staff had offered to get him up in his wheelchair for supper witch <sic> he refused. He was sitting at the bed side eating. He stated, I got up to walk home and fell . Nonslip footwear on at the time. Resident did not use call light or call for assistance . A request was made for any further investigation into the incident that occurred on 1/20/22. The Director of Nursing (DON) reported that all further investigations would be found in a Fall Assessment document located in the resident's electronic record. The Fall Assessment form dated (1/20/22), was reviewed with the DON and documented, in part: Resident: R57. Date: 1/20/2022 (10:27 PM) Does the resident have any of the following physical performance limitations? (check mark) b. Difficulty maintaining standing position. c. Gait problem, such as unsteady gait d. musculearskelatory problem .f. impaired balance during transitions .Does the resident take any of the following types of medications? (check mark) a. Antipsychotics b. Antidepressants .Does the resident have any of the following internal risk factors? (check mark) .b. Orthopedic. c. Psychiatric or cognitive .Provide impute from the resident .I got up to walk home .Summarize the impact of this problem .Root cause: Resident is at risk for further falls due to [CONDITION(S)] with behaviors, Alzheimer's disease .Resident's BIM 3 .Resident stated he got up to walk home and fell . Resident had requested to lie down prior to dinner. When tray was brought in, staff asked resident if he wanted to get up in his chair, but he told staff that he would prefer to sit on the side of the bed to eat. Resident was wearing anti-slip footwear at the time. It appears as though resident used footboard of bed to stabilize himself, but the footboard had broken off the bed at the time of the fall . After reviewing the 1/20/22 fall assessment the DON was asked to provide the name of the person noted as staff. The DON stated that it referred to Certified Nursing Assistant (CNA) R and again noted that there were no further documents included in the investigation. On 3/15/22 at approximately 3:15 PM, an interview and observation were conducted with Maintenance Assistant (MA) P in R57's room. The resident was present, lying-in bed, alert, but not able to provide any information related to the fall, including what caused his footboard to break. MP P demonstrated how a footboard could be removed and stated that he did not believe R57 lifted the footboard but reported that that R57 may have utilized it to prevent a fall. MP P noted the morning after the fall he recalled that a piece that connects the footboard to the bed was broken, and the footboard was replaced. MP P was asked if the facility does routine checks of resident's beds, including the footboards. MP P stated that they did not but replaced beds and bed parts when needed. At 3/15/22 at approximately 4:52PM, Maintenance Supervisor (MS) Q was interviewed about R57's broken foot-board. MS Q reported that they did not witness the incident and recalled that it had broken off the resident's bed but was not certain as to what happened. MS Q also noted that they did not keep a record of routine bed maintenance. On 3/15/22 at approximately 5:18 PM, CNA R was interviewed regarding the R57's fall with injury on 1/20/22. CNA R reported that he did not witness the fall but remembered that prior to dinner he transferred R57 from their wheelchair to their bed, placed them in the middle of their bed on their back with the bed lifted. CNA R stated they then placed the dinner tray on the overbed tray table so the resident could eat dinner. CNA R then noted that they were told by a Nurse that the resident had fallen and was on the floor. He then entered the room and noted that the resident's footboard was broken and helped to put the resident in bed. When asked about fall assessment that noted Staff had placed the resident on the side of the bed to eat dinner, CNA R changed his original statement and indicated that they did put the resident on the side of the bed at the resident's request and placed the tray table in front of the resident and then left the room. Again, CNA R stated they were told the resident was on the floor and entered the room, noted the footboard was broken and assisted the resident back to bed. When asked if they knew R57 had a past fall history, dementia and was noted for 1:1 feeding assist if compliant, CNA R reported that they made sure the bed was in a low position when they put him on the side of the bed. CNA R was asked if R57 could use a call light for assistance back to bed, CNA R reported that they did not believe so. On 3/16/22 at approximately 8:55 AM a phone interview was conducted with Nurse O regarding the fall on 1/20/22. Nurse O reported that CNA R had placed the resident on the side of the bed to eat and then found him on the floor and called her for assistance. Nurse O then did an assessment and called the doctor and the resident's family. When asked if the resident should have been left alone on the side of the bed given his mobility status, Nurse O reported the resident is stubborn and believed the resident tried to get up on his own, grabbed the footboard and it came off and he fell . On 3/16/22 at approximately 9:31AM, a follow-up interview was conducted with the DON. The DON reported that R57 did have a history of falls, was often stubborn and tried to do things on his own. When asked about the resident's care plan that noted 1:1 assist with feeding when compliant, again the DON noted the resident often did things on his own. It was noted that there was no documentation noted on 1/20/22 that the resident was having behavior issues and acting non-compliant. The DON indicated that she believed the resident was trying to get up and go home as noted and used the footboard for assistance and fell . A review of the facility policy titled, Falls Reduction Program (revision date 9/25/16) documented, in part: PURPOSE: To provide a safe environment for residents, modify risk factors, and reduce risk of fall related injury .Identify/analyze resident risk for fall .Observation of resident's mobility and/or behavior . Deficient Practice #2 Based on observation, interview and record review the facility failed to ensure a safe environment to prevent accidents for three residents (R15. R50 and R71) of six residents reviewed for accidents. Findings include: R#50 On 3/14/22 at approximately 10:49 AM, R50 was observed lying in bed. The resident had gauze wrapped on what appeared to be an injection site on their right arm/elbow. R50 was alert and able to answer most questions. R50 lifted what appeared to be a pink closed sharp/syringe (a medical device used to draw blood) from their stomach and asked, what is this thing? At approximately 10:55 AM, the observation was reported to Nurse H who then entered R50's room and stated that the resident had just had his blood drawn, noted that the item most likely was left by the lab company and should have removed from the resident's room and destroyed. A review of R50's clinical record revealed R50 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Dysphasia and Gastroesophageal reflux disease. A review of the resident's Minimum Data Set (MDS) indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12/15 (moderate cognitive impairment) and required extensive one to two person assist for most Activities of Daily Living (ADLs). Continued review of the R50's record noted the resident had a Complete Blood Count (CBC) drawn on 3/14/22 with results noted at 12:00 PM. On 03/15/22 at approximately 3:40 PM an interview was conducted with the Director of Nursing (DON). When asked if any staff and/or outside services should leave a medical sharp in a resident's room, the DON responded that it should have been removed following the blood draw. The facility policy titled, Syringe and Needle Disposal documented, in part: Used syringes and needles are disposed of safely and in accordance with applicable laws and safety regulations .2. Immediately after use, syringes and needles are place into puncture resistant, one-way container specifically designed for that purpose . Resident #15: Review of the clinical record revealed R15 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Alzheimer's disease, paranoid [CONDITION(S)], pseudobulbar affect, delusional disorders, hallucinations, and unspecified dementia with behavioral disturbance. According to the Minimum Data Set (MDS) assessment dated [DATE], R15 had severely impaired cognition, was independent without help from staff for walking in the room and corridor, required supervision of one person for locomotion on unit, and received a mechanically altered diet that required change in texture of food. Review of R15's physician orders included: Regular diet, Pureed texture, Thin consistency ordered 1/19/21. Review of the care plans included: A nutritional care plan included interventions which read: 1:1 feed assist with all meals. Initiated 11/14/20, revised on 7/6/21. Puree diet with thin liquids. Initiated 6/13/14, revised on 1/19/21. A cognition/behavior/mood care plan read: .I am A&O (alert and oriented) to person .I do have poor safety awareness .May try to hit out at others if feel like they are interfering with what I am trying to do. Due to confusion I may not understand my surroundings or others intent i.e. if you bump into me I may think you did it on purpose . Interventions included: Monitor my body language. Reapproach and redirect, move to a quiet environment if agitated. Initiated 6/11/14. Resident will be redirected to common area when propelling around unit. Initiated 8/29/19. Resident is at risk for wandering or elopement due to poor cognition. Resident up walking at times. May not realize she is by exit door. Initiated 5/4/20. Allow for safe wandering within safe areas. initiated 5/4/20 On 3/14/22 at 4:13 PM, R15 was observed walking in the hallway across from their room. There were no staff observed in the hallway, but there were several staff standing and seated at the nursing desk (which did not have direct view of the hallway when seated behind the desk). R15 was then observed to enter the room occupied by R6 and R66 who were both laying in their beds. R15 walked over to R6 who was resting with their eyes closed. R15 bent down close to R15's face and R6 opened their eyes and yelled out repeatedly, What do you want?. R15 moved away from R6 and proceeded to walk over to R66's bed. R15 was observed to take an unopened small bag of potato chips that was on the top of R66's overbed table, exit the room, open the bag of chips in the hallway and begin to eat the chips. At that time, R6 was yelling out repeatedly, Come back with that!. R15 proceeded to walk in the hallway and behind the nursing desk where the nursing staff were observed. One of the nursing staff was heard talking to another staff Oh she's eating her potato chips. None of the staff that were present (including R15's assigned nurse) identified a concern that R15 had taken and was eating a bag chips, despite having a physician ordered diet for only pureed food or that R15 had been in another room occupied by R6 and R66 without supervision. Resident #71: Review of the clinical record revealed R71 was admitted into the facility on [DATE] with diagnoses that included: unspecified dementia with behavioral disturbance, type 2 diabetes mellitus without complications, COVID-19 (1/9/22). According to the MDS assessment dated [DATE], R71 had severe cognitive impairment, was independent with no setup or physical help from staff with walking in the room and required supervision with no physical help from staff for walking in corridor and locomotion on unit. Review of the physician's orders included: Change wanderguard every 90 days and as needed for wanderguard use - active since 12/30/21 Wanderguard placement Check for placement every shift and functioning. active since 7/1/21. Review of the elopement care plans read: .I may go to the front door, verbalize I want to go home. I have a wanderguard in place for safety. Interventions included: Allow for safe wandering within safe areas. Initiated 6/25/21. Reassure if the resident feels lost, abandoned or disoriented. Initiated 6/25/21. A mood/behavior care plan read: .I have a hx (history of) urinating on floor, taking others or nurses belongings and placing them elsewhere, resisting care, running into nurse with my walker. I may hit out with care or push staff away or yell at staff to get away from me,. Initiated 11/11/18, revision on 2/15/22. Interventions included: Redirect me from taking others belongings. Return others belongings to them. Please offer me/show me where my room and belongings are. initiated 10/11/18. On 3/14/22 at 10:27 AM, R71 was observed exiting their room and walking into the hallway without any assistive device. The resident had bare feet and a gray bracelet (wanderguard) was observed secured around their right ankle. R71 was then observed to walk into the room occupied by R8 and R31, rummaging through a package of disposable briefs and pulling several from the package. There were no staff present in the hallway or surrounding area to redirect the resident from this room. On 3/15/22 at 3:55 PM, an interview was conducted with the Director of Nursing (DON). When asked about the supervision provided for residents that required increased supervision due to wandering behaviors, the DON reported that there was increased staffing when possible, during peak hours which was usually 3:00 PM - 7:00 PM and that staff were informed of the need for providing constant redirection on the unit R15 and R71 resided on. The DON was informed of the observations from 3/15/22 with R15 and R71 and concerns regarding the lack of adequate supervision and access to potentially unsafe environments and they acknowledged similar concerns. The DON reported the staff on that area should be able to provide increased supervision and redirection. On 3/16/22 at 9:37 AM, the Administrator reported there was no policy for supervision of residents and reported, We provide a homelike environment and the least restrictive supervision we can based on the resident's individual needs. The facility does this while also ensuring the resident's safety, dignity and independence.

This citation pertains to Intake MI 332 Based on observation, interview and record review, the facility failed to, 1) comprehensively assess, monitor and treat skin alterations for one resident (#102), resulting in delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the, Wound Management Program policy, dated [DATE], reflected, Policy: To assure that residents who are admitted with, or acquire, wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing .Place initial interventions for residents at risk for development of skin breakdown on Care Plans/Kardex .Monitor skin changes during routine daily care (CNA) .Complete Weekly Hydration and Skin Assessments according to schedule .Report any abnormal findings to physician .initiate treatment according to physician guidance . Resident #102 (R102) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R102 was a [AGE] year old male admitted to the facility on [DATE] with recent readmission [DATE] from hospital related to new onset necrotic left foot diabetic ulcer with [CONDITION(S)], [CONDITION(S)] post amputation and [CONDITION(S)], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R102 had a BIM (assessment tool) score of 14 which indicated his ability to make daily decisions was cognitively intact, and he required one person physical assist with bed mobility, transfers, locomotion on unit, dressing, toileting, hygiene, bathing and set up only with eating. Review of the complaint intake, dated [DATE] via hotline [DATE], reflected, Complainant states the resident(R102) was at the hospital for treatment and with his family decided he no longer wanted prolonged measures such as a feeding tube and wanted to be discharged back to the facility under hospice care. Complainant states the facility refused to take the resident back and stated this was because the resident did not have a guardian. Complainant states the resident has lived at the facility for the past 4 years and that is his home . During a telephone interview on [DATE] at 8:15 a.m., Complainant G reported facility initially refused to readmit R102 when ready for discharge from hospital on [DATE] and R102 was own person and wanted hospice services with [named] Hospice but facility would not allow. Complainant G reported R102's next of kin H had communicated R102 wanted to return the the facility with hospice service. Complainant G reported called facility and left message for Administrator ADM A with no return call on [DATE] and later spoke with Social Worker (SW) I who requested one time [named]Hospice contract. Complainant G reported was then informed by (Name of corporate) Central Intake J facility can not take R102 because he did not have a guardian and (Name of cooperate) Central Intake J reported R102 could return to facility with Do Not Resuscitate(DNR) order but facility would send R102 back to the hospital if not eating. Complainant G reported R102 and family did not want Peg tube placed and R102 was DNR prior to hospital admission and planned to return to facility as DNR. Complainant G reported after several calls facility agreed to readmit R102 at 4:00 p.m. on [DATE] with Hospice services. Complainant G reported received call from R102 [named] Hospice Services who reported facility would not allow Hospice Services to enter the facility to see R102 and stated, [named R102] just wanted to go home to die. During an telephone interview on [DATE] at 11:43 a.m. R102 family H reported R102 was own responsible party and R102 family H mother (R102's sister) was R102's Durable Medical Power of Attorney(DMPOA) but passed away in [DATE]. R102 family H reported received call from hospital related to R102 decline after surgical debridement of left foot and change in mental status and was told R102 also had acute and chronic sub-[NAME] hematoma (brain bleed). R102 family H reported hospital spoke with her as next of kin about Hospice care and R102 was planned to discharge to the facility the [NAME] of [DATE] with [named] Hospice services. R102 family H reported hospital had informed family readmission was all set until R102 arrived at facility on [DATE] around 4:00 p.m. and RN L told R102 family H was not allowed to make decision for R102 and R102 not allowed to have Hospice because of no contract. R102 family H reported was upset when RN L told her there was nothing that Hospice can do that they could not do. R102 family H reported situation was very upsetting and stunned at how difficult it was to get R102 extra services who needed them. During a telephone interview on [DATE] at 2:08 p.m., R102 significant other M reported was first informed of wound to R102's left foot on [DATE] when she was contacted by facility that R102 had change of condition on [DATE] related to increased confusion. R102 significant other M reported visited R102 on [DATE] when doctor entered room during visit and removed dressing to R102's left foot and said he needed to go to the hospital for the wound and may need amputation. R102 significant other M reported R102's wound was open with dark area and had very foul smell in room on [DATE]. R102 significant other M reported R102 was sent to hospital for left foot infection and declined and sent back to facility [DATE] with plan for Hospice services but facility would not allow Hospice services until late [DATE]. R102 significant other M reported R102's DMPOA was R102's sister that passed away [DATE]. Review of the Care Conference, dated [DATE], reflected R102 was own person with no updates to DPOA and reflected documents had been reviewed. Review of the Nurse Progress Note, dated [DATE] at 11:51 a.m., for R102, reflected Resident had four falls in the last quarter. All safety interventions remain appropriate for resident at this time. Resident is a 1 assist for transfers and ambulation with fww, however he frequently chooses to be independent with transfers and ambulation . Review of the Nurse Progress Note, dated [DATE], reflected R102 was found on floor in room after fall from bed. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Re-evaluated [DATE] with note foul smell and exam of lateral aspect left foot with black/necrotic area that is soft/moist. Pt lethargic but appropriate and states will go to hospital if absolutely needs to. His foot is necrotic with wet gangrene and he will likely need amputation of part of foot. He is agreeable to hospitalization . Sent to [named hospital]. Review of the Nurse Progress Note, dated [DATE] at 4:45 p.m., for R102, reflected, Resident arrived back to facility via ambulance stretcher. He is non verbal at this time Resident Vs were 145?103 P 115 R 22 Temp 99.2 O2 on via nasal cannula at 2 LPM. Bony prominences were all clear and intact Body assessment done and findings noted. Pt does not appear to be in pain. Head of bed elevated to ease breathing Foot of bed elevated to keep feet off bed. Hands and stomach swollen. Supra pubic foley in place draining to gravity. L foot dressing dry and intact. resident made as comfortable as possible. Review of the Social Service Note, dated [DATE] at 11:02 a.m., for R102 reflected, Res. readmitted from [named] hospital yesterday evening. He has a dx and hx of [CONDITION(S)], heart failure, [CONDITION(S)], CKD, [CONDITION(S)], anxiety, cardiomegaly, [CONDITION(S)], a-fib, DM2, depression, [CONDITION(S)]. He does appear comfortable. He was nonverbal during visit. He did open eyes when name was said. Attempted yes/no questions but did not shake head .He is only on [MEDICATION(S)] for comfort and is resting comfortably at this time. He appears to hear a normal conversation and opens eyes to name. He continues to be a DNR. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Note entered [DATE]. [named R102] was sent to [named] Hospital [DATE] for necrotic ulceration lateral aspect left foot. Underwent metatarselectomy/removal 4th-5th digits left foot. Subsequently refused BKA per significant other who was present. [named R102] subsequently made comfort measures and returned to [named facility]. [named R102] was lethargic and confused when seen and comfort measures have been instituted. HPI: 71 y.o. white male with known [CONDITION(S)] with ef 15%, s/p aicd/pacer, has been in facility since ,d+[DATE], now long term as was living alone and has extreme difficulty with ADL. Recently sent out for chf/AKI and most recently for necrotic foot as above .lethargic//not appropriate//unable to answer questions .Comfort measures//Hospice to be consulted. Review of the Nurse Progress Notes, dated [DATE] at 4:00 a.m., for R102, reflected, The resident was pronounced deceased at 0235 . Review of the Treatment Administration Record(TAR), dated [DATE] through [DATE], reflected R102 had weekly skin assessments ordered every Tuesday that had been documented as completed by evidence of staff initials for [DATE], [DATE] and [DATE]. Review of R102 Skin & Wound-Total Body Skin Assessments, dated [DATE] through [DATE], reflected no evidence of weekly skin assessments for [DATE], [DATE] or [DATE](the three weeks prior to documented necrotic left foot gangrene wound). Review of the R102 Physician Orders, dated [DATE] to [DATE], reflected no orders for Hospice Evaluation and Treat. During a telephone interview on [DATE] at 9:24 a.m., RN N reported Clinical Care Coordinators(CCC) are new name for unit managers. Reported nurses perform weekly skin assessments for residents and document on TAR and complete Form Skin & Wound-Total Body Skin Assessments and reported ideally complete form first then mark off on TAR. RN N reported CCC staff are facility wound nurses that perform more detailed weekly skin assessments. Requested all Incident and Accident reports for R102 for six months as well as Hospice contract on [DATE] at 9:50 a.m. During an interview on [DATE] at 11:55 a.m., Administrator(ADM) A and SW I reported request to clarify requested Hospice information. Second request for Hospice contracts for R102, R106 and R107. ADM A and SW I reported all Hospice visits notes were located in the Electronic Medical Record (EMR) under the miscellaneous tab. ADM A reported R102 hospital records are located in the EMR. Request for R102 Hospital Medical Records to be sent to facility via fax provided by ADM A on [DATE] at 12:09 p.m. During an interview on [DATE] at 12:10 p.m., this surveyor informed ADM A waiting for fax from hospital. ADM A provided requested Hospice contracts for R102. During an interview on [DATE] at 12:40 p.m., DON B reported fax from hospital had started to come through and provided this surveyor 18 of 190 pages. During an interview on [DATE] at 3:14 p.m., CCC O reported had been working in that role for one year and reported weekly skin assessments documented under Forms tab of EMR called, Skin & Wound-Total Body Skin Assessment and staff document on TAR when assessments completed. CCC O reported between her and another CCC they perform weekly wound assessments with pictures. CCC O reported did not take any pictures of R102 wounds prior to [DATE]. CCC O reported R102 was sent to the hospital for left foot wound on [DATE] and was unsure why R102 did not have skin assessments between ,d+[DATE] and [DATE]. CCC O reported maybe R102 had wound orders and was unsure when R102 left foot wound developed. Review of the TAR, dated [DATE] through [DATE], reflected R102 received order for A & D ointment to both feet every Monday, Wednesday and Friday for dry skin up to [DATE]. Continued review of the TAR reflected R102 received treatment that included: Cleanse left lateral foot with normal Saline, pat dry, apply [MEDICATION(S)] AG, gauze and adhere with tape BID and prn soiled or dislodged dressing. two times a day for [CONDITION(S)] with start date [DATE] to [DATE](with no mention open necrotic wound to left foot). Continued review of TAR reflected no additional wound care for left foot wound with exception of left lower extremity to be cleaned BID with wound cleanser and apply petroleum to open area and wrap with rolled gauze for [CONDITION(S)] weeping with start date [DATE] to [DATE]. During an interview on [DATE] at 3:58 p.m. Social Worker (SW) I reported R102 was his own responsible party prior to transfer to the hospital on [DATE] and was DNR. SW I reported R102 did not want to go to the hospital at first but agreed after Physician recommended. SW I reported had spoke with hospital case worker who reported R102 wanted to return to the facility with hospice services and was told R102 had signed up for hospice services at the hospital. SW I reported was told R102 was not responsive and questioned how he signed up for Hospice services. SW I reported anyone can sign up for Hospice and stated, Question was, who was going to sign for Hospice? ADM A joined interview and reported R102 did not have delay in services but required to have signed contract in place prior to start of Hospice services and was a Holiday. SW I and ADM A reported R102 was own responsible party and did not have a Medical Durable Power of Attorney appointed. SW I reported R102 sister was involved in care but but R102 was responsible party and reported Advanced Directives offered quarterly per Care Plan interventions. Review of the Advanced Directive Care Plan, dated [DATE], for R102, reflected, Advance Directives have been discussed & the following has been decided: I am DNR per my decision. My sister is involved and supportive and listed as my POA if needed .INTERVENTIONS .I was provided MI ombudsman advance directive packet & was given opportunity for Q & A. I have advance directives in place and have my sister as MPOA in future needs .Refer to hospice upon my request or wishes. Offer education, information & options as needed, requested .Review Advance Directives/DNR with myself/family if needed or requested. Review of Care Plan Goals, dated [DATE], included, I want to be active in my advance care planning decisions and want others to honor my decisions through next review date . Review of the Actual Infection Care Plan, dated [DATE] with created date [DATE] and resolved dated [DATE], reflected R102 had [CONDITION(S)] of Left Lower extremity. The Care Plan problem, goal and interventions were created by Infection Control Nurse L. Review of the R102 Care Plans, created [DATE], reflected, I have a terminal prognosis r/t . Resident was admitted to [named] Hospice care for [CONDITION(S)]. The Care Plan included Goals, initiated date of [DATE], that reflected, The residents comfort will be maintained through the review date .The residents dignity and autonomy will be maintained at highest level through the review date .Interventions .Collaborate with [named] Hospice ,d+[DATE] for change in condition, medical needs. Contact # ,d+[DATE]-[last 4 digits of number] .Consult with physician and Social Services to have Hospice care for resident in the facility .Hospice CENA visits on (specify days of the week)[not completed]. Will provide ROM during visits .Hospice nurse visits on (days of the week)[not completed] Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met . All Hospice Care Plan created [DATE] (4 days after re-admission from hospital to facility with Hospice orders). Review of the facility Electronic Medical Record (EMR), dated [DATE] through [DATE], reflected no record of Hospice visits notes or scheduled services. During a telephone interview on [DATE] at 10:25 a.m., Hospice Staff K reported facility staff requested Hospice documentation for R102 including visit notes and contract on [DATE]. During an interview and record review on [DATE] at 10:58 a.m., DON B reported just received Hospice documentation by fax for R102 and verified were not part of R102 prior to that day. Review of the [named]Hospice Physician Orders, dated [DATE], reflected R102 terminal Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [named]Hospice Physician Note, dated [DATE], for R102, reflected, [AGE] year old man with DM, PAD with gangrene of LLE, [CONDITION(S)], [CONDITION(S)], CKD, CHF, AF, CAD, s/p MI, [CONDITION(S)] with luminary obstruction requiring suprapubic catheter, anxiety, depression, GERD, [CONDITION(S)], and acute on chronic subdural hematoma who has been admitted with [CONDITION(S)] from [CONDITION(S)] of the LLE due to diabetic foot abscess. [named R102] was hospitalized in [DATE] for left foot abscess and [CONDITION(S)] arising from left foot diabetic ulcer. Underwent left 5th MT amputation. Hospital course was complicated by [CONDITION(S)],[CONDITION(S)], ARF due to tubular necrosis superimposed on CKD, and metabolic [CONDITION(S)]. Despite aggressive therapy , [named R102] did not improve and his family elected to have him return to the nursing facility with hospice enrollment. Now actively dying. No po intake .Given [named R102] [CONDITION(S)], [CONDITION(S)], ARF, and actively dying state, he has a life expectancy <6 months. He is appropriate for hospice services. Review of the Hospital Record, dated [DATE] through [DATE], R102 was seen by Geriatric Nurse Specialist dated [DATE] at 11:53 a.m., with notes that reflected, Patient's niece [named] is next of kin and very involved in his care her and at ECF. [named niece] and patient's other niece feel the best option for him now is hospice acre and no aggressive treatments or surgeries. They would like him to go back to [named facility] with hospice services but not having a MDPOA or legal guardian could be barrier. [named facility] is looking into this and will call me back. Continued review of Geriatric Nurse Specialist Notes, dated [DATE] at 3:41 p.m., reflected, Called [named facility] again, the DON is not in today, Transferred to charge nurse and the phone rang for at least 2 minutes, called back several more times with same response. Spoke with niece and she stated that she spoke with social worker at the ECF and the social worker said she had to have POA or guardian. [named hospital] social worker will call the administrator in the am. Review of Hospital Hospice Referral, dated [DATE] at 10:22 a.m., reflected R102 had Hospice referral for [CONDITION(S)] with [CONDITION(S)] and altered mental state with start of care date [DATE]. Review of the Hospital record, dated [DATE] at 10:41 a.m., reflected R102 was seen by Geriatric Nurse Specialist with note that reflected, Referral and patient information sent to [named Hospice], they will set up one time contract with facility. Review of the Hospital Social Work notes, dated [DATE] at 10:49 a.m., for R102, reflected, Spoke with [named SW I] over at [named facility] at ten am. She spoke to [named ADM A] and they have agreed to take the pt on hospice with [named] hospice to sign a one time contract. [named corporate central intake J] and she states they can not take the pt. Because he does not have a guardian. Pt is a long term there. Pt does not want a Peg tube and family does not either. [named SW I] call back to say [named corporate central intake J] does not feel comfortable in doing hospice they can take the pt back as a DNR but they would send him back if he is not eating. Family does not want him to go back and forth . Review of Hospital Social Work Notes, dated [DATE] at 2:48 p.m., reflected R102 would be returning to the facility with hospice services at 4:00 p.m. Review of the Hospital Nursing Discharge Note, dated [DATE] at 4:50 p.m., reflected R102 was discharged from hospital via EMS with Hospice to Medical Facility and report given to LPN T. During a telephone interview on [DATE] at 12:40 p.m., RN R reported nurses complete skin assessments, located under forms tab in EMR every 7 days then document on TAR as completed. RN R reported R102 had a girlfriend that visited facility and reported they often spoke on the telephone. During an interview on [DATE] at 1:16 p.m., Infection Control Registered Nurse L reported was supervisor on duty at facility on [DATE] when R102 arrived from hospital to re-admit to facility between 4:30 p.m. and 5:00 p.m. RN L reported assisted floor nurse with R102 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN L reported R102 niece H informed her R102 had not eaten for three days and was non-responsive. RN L verified and reported to physician who gave orders for NPO(nothing by mouth). RN L reported R102 did not have an order from the Hospital for Hospice services. Of note, RN L denied conversation with R102 niece H about Hospice and denied conversation with Hospice Staff K on [DATE]. During a second interview and record review on [DATE] at 2:15 p.m., RN L provided this surveyor the Hospital, After Visit Summary and reported that was the documentation that was received from the hospital at the time of R102 re-admission on [DATE]. The document reflected R102 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 4:15 p.m., LPN T reported was R102's nurse on [DATE] when he readmitted from hospital. LPN T reported RN L was the supervisor that assisted with admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN I reported R102 niece H demanded Hospice visit to start that night in conversation with RN L and RN L informed R102 niece H was not allowed. LPN T reported RN L spoke with Hospice staff by phone and informed R102 was not allowed to have Hospice visit until contract was signed next day. LPN T reported did not observe R102 left foot wound as dressing was clean dry and intact at time of admission and reported signed TAR because dressing was clean, dry and intact. LPN T reported several days prior to R102 transfer from facility to hospital on [DATE] R102 had foul odor from left foot wound.

Based on observation, interview, and record review, the facility failed to reduce the risk for falls based on an individualized incontinence assessment and plan, in two of four residents reviewed for falls (Resident #49 & 82), resulting in falls with fractures (Resident #49 & #82), pain (Resident #49 & #82), hospitalization (Resident #82) and surgery (Resident #82). Findings include: Resident #49 (R49) R49's admission and 5-day Minimum Data Set (MDS), with assessment reference date of 8/21/19, triggered a Fall Risk Care Area Assessment (CAA) that revealed he was admitted to the facility on [DATE], from a hospital where he was treated for [REDACTED]. R49's same CAA indicated his other [DIAGNOSES REDACTED]. The same CAA revealed R49 sustained a fall 2 days prior to his hospitalization , had a history of [REDACTED]. R49's same MDS assessment introduced a Brief Interview for Mental Status (BIMS) assessment, a brief cognitive screener, score was 06 (scale 00-07 severe impairment). The same MDS assessment indicated R49 was frequently incontinent of bowel (2 or more episodes of bowel incontinence, but at least one continent bowel movement) and frequently incontinent of bladder (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) and a trial toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted. R49's same MDS assessment revealed he had a history of [REDACTED]. According to Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.16, (MONTH) (YEAR); urinary incontinence increased the risk of falls and injuries resulting from attempts to reach a toilet unassisted. The same reference revealed incontinence could be resolved or minimized by bladder retraining, prompted voiding, or scheduled toileting. The same source revealed a previous fall, especially a recent fall, recurrent falls, and falls with significant injury were the most import predictors of risk for future falls and injurious falls. 8/22/19 at 6:10 PM R49's Nurses Note indicated resident is up in w/c (wheelchair) eating dinner. he is alert and verbal. no c/o pain at this time. he continues to self-transfer out of his chair and try's (sic) to go to the bathroom with out (sic) using his call light. staff has stopped him and helped him to the bathroom each time. his call light is with in (sic) reach. R49's Physicians progress note dated 8/22/19 12:00 AM revealed Fall risk assessed, pt (patient) gait is weak and compromised due to hospital stay and comorbidities. PT (physical therapy)/ OT (occupational therapy) working with patient at this time. Patient currently utilizes wheelchair for mobility. Continued prompting and reminders on use of call light with all transfers; safety measures remain in place. The was no update to R49's fall risk care plan interventions related to his increased risk for falls due to not using his call light, self-transfers and taking himself to the bathroom. Director of Nursing (DON) B was interviewed on 10/15/19 at 3:52 PM and confirmed no additional interventions were implemented based on R49's 8/22/19 nurses note related to observations of R49 self transferring, not using his call light, and using the bathroom without assistance. R49's Fall Care Plan, date initiated 8/14/19, revealed Resident has a history of falls and continues to be at risk for further falls due to [MEDICAL CONDITION], dementia, bilateral hearing loss, arthritis, chronic knee pain, weakness, medications, and decreased functional mobility. R49's Bladder Care Plan, initiated 8/14/19, revealed Resident is frequently incontinent of his bladder and is at risk for further bladder incontinence as well as UTI's (urinary tract infections) and [MEDICAL CONDITION] due to [MEDICAL CONDITION], dementia, bilateral hearing loss, arthritis, chronic knee pain, weakness, medications, responding to bladder urgency, and decreased functional mobility. Physical Therapy (PT) Progress Report signed 8/26/19 at 2:04 PM, revealed R49's goal was Patient requires skilled PT services to increase independence with gait, facilitate (I) (independence) with all functional mobility, promote safety awareness, improve dynamic balance (maintaining balance while moving), increase functional activity tolerance (ability to tolerate completing activities of daily living), increase LE (lower extremity) ROM (range of motion) and strength, minimize falls and facilitate anticipatory reactions in order to enhance patient's quality of life by improving ability to perform gait and transfers w/ (with) increased safety, respond to cues from trained caregivers, perform steady gait, perform functional mobility w/less risk for falls, decrease level of assistance from caregivers and facilitate increased (I) with functional mobility throughout facility. The same document, as of 8/26/19 at 2:04 PM, indicated R49 required contact guard assistance (one or two hands on body to help steady/balance) using a front wheeled walker with cues for proper hand placement for safe transfers. R49's Fall report dated 8/26/19 at 5:30 PM indicated he fell in his room, Resident was found by CNA (certified nurse assistant) sitting on the floor. Resident states he was trying to go to the bathroom and denies hitting his head. Resident assessed, vitals obtained, neuro (neurological) checks initiated, resident assisted back into bed. Small red mark noted to right side of back, resident complaining of right sided pain . The same report indicated R49 had fractures to the right eighth and ninth ribs. The same report for R49 indicated the interdisciplinary team (IDT) team met on 8/27/19 and resident was attempting to get to the bathroom without assist. Call light had not been activated. Care plan will be updated with need for staff to offer resident assistance to the bathroom every day prior to evening meal. DON B was interviewed on 10/15/19 at 3:52 PM and stated prior to R49's fall on 8/26/19, staff provided frequent reminders to use his call light. DON B stated in the same interview that R49's daughter had reported he fell a lot when he was at home. DON B revealed in the same interview R49 did not have an individualized bowel or bladder toileting program. DON B stated during the same interview staff check and toilet R49 every 2 hours. DON B stated in the same interview the facility did not have a policy for bowel and bladder incontinence programs. CNA J was interviewed on 10/16/19 at 11:45 AM and stated on 8/26/19 at 5:30 PM she found R49 after his fall, he was dry, not incontinent of bowel or bladder, and she toileted him right after. R49's Bladder Continence (MONTH) 2019 documentation revealed he was continent at 4:35 PM and at 6:53 PM he was incontinent of bladder. CNA J was interviewed on 10/16/19 at 11:45 AM and stated she was not sure if her documentation of R49's bladder continence on 8/26/19 at 4:35 PM was after his fall on 5:30 PM. CNA J stated in the same interview, she did not remember toileting R49 before dinner, she indicated she asked him if he needed to use the restroom and he replied no. Resident #82 (R82) On 10/14/19 at 11:45 AM R82 was observed sitting in a wheelchair in the assisted dining room, wearing a protective hat. R82's Minimum Data Set (MDS) assessment dated [DATE], indicated he was admitted to the facility on [DATE], had a BIMS score of 03 (00-07 Severe Cognitive Impairment), was frequently incontinent of bowel and bladder, and a trial toileting program had not been attempted on admission or since urinary incontinence was noted in the facility. The same MDS assessment indicated R82 required extensive assistance (resident involved in activity, staff provided weight-bearing support) of one person for walking. R 82's Fall Report titled Observed On 4/26/19 at 9:28 AM indicated the nurse was alerted by the CNA that R82 was on the floor in his room and observed him sitting between the chair and the bed, garbage can was tipped over, his water cup was spilled on the chair on the floor near him. R82 was assisted off the floor, taken to the bathroom and was continent of bowel and bladder. R49's Fall Assessment Report dated 4/26/19 indicated he was responding to bowel and bladder urgency and his risk factors for falls included bowel and bladder incontinence. The same Fall Assessment Report indicated R82 may have been looking for a bathroom and slipped and fell . According to Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.16, (MONTH) (YEAR), a fall should stimulate an evaluation of the resident's need for rehabilitation, ambulation aids, modification of the physical environment, or additional monitoring (e.g., toileting, to avoid incontinence). R82's MDS dated [DATE], indicated he transferred with supervision of one-person physical assist, and required extensive assistance for toilet use. The same MDS assessment revealed R82 was frequently incontinent of bowel and bladder and no toileting program had been attempted. R82's Fall report dated 8/12/19 at 4:30 AM indicated he was found on the floor by the CNA, had urinated by his closet in his room, walked into the urine and fell . The same report indicated R82 sustained a skin tear to his elbow. physician progress notes [REDACTED]. Patient reported no head trauma however is complaining of some left hip pain at this time . The same note indicated a stat x-ray of R82's left hip was pending. R82's Radiology Report dated 8/12/19 and signed at 3:25 PM revealed an acute left [MEDICAL CONDITION]. Nurses Note dated 8/19/19 at 5:51 PM indicated R82 was readmitted to the facility at 5:00 PM, was alert and orientated to person, had a dressing on left hip over a surgical incision. physician progress notes [REDACTED]. The same note indicated R82 had hip surgery on 8/13/19. The DON was interviewed on 10/15/19 at 3:47 PM and indicated R82 usually took himself to the bathroom and had a history of [REDACTED].

Based on observation, interview and record review, the facility failed to supervise 1 (Resident #2) of 4 residents reviewed for falls from a total of 4 sampled residents, who had impaired fluctuating cognitive status, confusion, decreased safety awareness, memory loss, a history of falls and who fell at the facility, resulting in bruises on face and bi-lateral shoulders, a fractured nose, injured right wrist, hematoma over right eye, hospitalization and pain. Finding Include: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 1/27/16, nurses' notes dated 10/1/15 through 4/20/16, physician orders [REDACTED].#2 was a [AGE] year-old female, admitted to the facility on [DATE], with decreased cognition, confusion, decreased safety awareness with a wander/elopement electrical device due to being an elopement risk and with a history of falls. The resident's [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of the Social Service note, dated 4/21/16, revealed the resident had a history of [REDACTED]. Observations of Resident #2 were made on 4/20/16 at 11:00 a.m., in the main dining room, sleeping with her head down and on 4/21/16 at 11:25 a.m., in an activity in the main dining room sitting in her wheelchair. The resident was observed on both occasions to have bruises under both eyes, yellow/green in color. When this surveyor attempted to interview the resident on 4/21/16, she gave no responses to questions asked. Review of physician orders [REDACTED]. (taken for insomnia, side effects of sleepiness and dizziness), Pravastatin (taken for cholesterol, side effects of muscle weakness and dizziness), Tramadol (Ultram, taken for pain, side effects of dizziness and drowsiness, was discontinued on 4/11/16 after her 6 th fall due to side effects of lethargy) and Prednisolone (taken for anti-inflammatory or immunosuppressant, taken for a skin disorder, side effects of agitation, anxiety, blurred vision and dizziness). The above listed medications side effects have the potential to increase the risk for falls. (Drug Information Handbook, American Pharmacists Association, Lexicomp - ) Review of the facility Pharmacists Clinical Consult dated 4/7/16 (after her 6 th fall), stated Having reviewed this resident's current medication list, I have found several possible medications or combinations of medications that may contribute to falls. In this consult, the medications that were listed were, Pravastatin, Dapsone, Gabapentin, Tramadol (Ultram), Furosemide and Metoprolol, with recommendations. Review of Resident #2's cognitive Care Plan, dated 5/21/12 and revised on 1/27/16, revealed she was alert to self and place only at times, had fluctuating cognition and had an electronic wander guard (alarmed if the resident went out of the facility door) on due to confusion. During an interview done on 4/21/16 at 9:43 a.m., staff member O (Social Service) stated she (the resident) usually scores a 9 (cognitively impaired, from a 0 to 15 scale) on her BIMS (cognitive test). Review of the Social Service notes dated 1/27/16, stated Resident can make simple decisions and needs known, resident continues to need 24 hr. supervision. Review of Resident #2's Fall Care Plan, dated 5/22/12 and revised on 2/5/16, and her care guide (Nursing Assistant guide to care), revealed she was at risk for falls due to having a history of falls, stroke with left sided weakness, hard of hearing and having poor safety awareness. She was a 2-person assist with transfers, had perimeter mattress, required extra assistance with transfers and ambulation on her left side and sometimes attempted to self transfer, so needed to be reminded to use her call light and be monitored by staff. Review of Resident #2's incident report, nurse's notes and physician orders [REDACTED].4/6/16, and 4/7/16. Review of the residents falls are as follows: On 10/23/15: Review of the facility incident report dated 10/23/15 at 23:30 (11:30 p.m.), revealed the resident had fallen in her room with no injuries and stated CNA (Nursing Assistant) called this nurse to residents room, resident was laying on floor far side of bed. Head was toward closet and feet were slightly under bed. No socks in place, gown and brief were wet. Alarm (bed alarm) was not sounding. Pad alarm on bed assessed and replaced for proper function. Review of the nurse's notes dated 10/23/15 at 11:30 p.m., stated Resident reeducated in importance of using call light. Review of the IDT notes (Interdisciplinary Team meeting) dated 10/26/15, revealed the residents alarm was replaced due to not being in working condition and staff were provided with education. On 11/19/15: Review of the facility incident report dated 11/19/15 at 5:30 a.m., stated CNA came to this nurse stating that resident had been lowered to the floor during a transfer. Review of the nurses notes dated 11/19/15 at 10:25 a.m., stated No new bruise noted at this time from being lowered to the floor. No other note dated 11/19/15 was found in the nurses notes regarding the residents fall on 11/19/15. Review of the IDT notes dated 11/20/15, stated incident that occurred on 11/19/15, when CNA came to the nurse stating that resident had been lowered to the floor during a transfer. On 11/20/15: Review of the facility incident report dated 11/20/15 at 7:11 a.m., stated tech (CNA) was assisting resident and while resident was standing to get off the toilet, resident's legs became weak, and was slowly lowered to the floor on her knees. Mental Status, poor safety awareness. Review of the nurse's notes dated 11/20/15 at 2:32 p.m., stated During transfer the resident leg became weak and tech (CNA) lower resident to the floor no injury. Review of the IDT notes dated 11/20/15, had documented that the residents toe re-opened during the incident on 11/20/15. Review of the physician order [REDACTED]. Review of the facility IDT notes dated 11/20/15, stated Resident's legs became weak, and resident was slowly lowered to the floor onto knees. Resident had a prior area to toe that re-opened during incident. Resident was previously a one assist for transfers and ambulation, and is now a two assist transfer. On 1/5/16: Review of the facility incident report dated 1/5/16 at 3:30 p.m., stated CNA had to lower resident to the floor, resident sitting on floor with her back to her wheelchair and legs to the wall, she had gait belt on but only one nurse aide in room, resident had been incontinent of stool knees gave out and was not able to hold herself up. Mental Status, Poor safety awareness. Review of the IDT notes dated 1/7/16, stated resident was observed to be sitting on floor with her back to her wheelchair and legs to the wall. Per CNA, resident was assisted to up following shower to get dressed, which caused resident to stand for a prolonged period of time. Resident is a two-person assist for all transfers, and was stood without the assistance of two staff members. Skin assessment showed small abrasion to mid back. Facility failed to follow residents care plan and lift resident with 2 assist due to residents assessed weakness and being a high risk for falls. Review of the Progress note dated 3/11/16, stated Spoke with resident's guardian (Family Member #1) regarding the use of bilateral assist bars, and sensor alarm. Sensor alarms are to be discontinued as they are no longer indicated at this time. During a phone interview done on 4/21/16 at 9:55 a.m., Family Member #1 revealed that the facility had contacted him (on 3/11/16) regarding removing her wheelchair and bed alarms. Family member #1 stated I told them it was ok to take the alarm off her wheelchair but I asked them to leave the alarm on her bed and they said they would discuss it and never informed me that they took it off the bed. I was concerned because there was a pattern (of repeated falls). On 4/6/16: Review of the facility incident report dated 4/6/16 at 12:23 a.m., stated resident was observed on the floor laying in a prone position on the floor to the right of the resident's bed. There was blood on the floor under the residents face. She was trying to get out of bed to answer a phone call and fell on the floor and hit her head (the resident had a head injury). Injury Type: Face, hematoma, left hand, left lower leg, left knee. Level of Pain: 5 Predisposing Physiological factors, confused, incontinent. Review of the nurses notes dated 4/6/16 at 5:08 a.m., stated this nurse (staff member L Charge Nurse, RN) went into the resident room to do the 0400 (4:00 a.m.) neuro assessment (the resident had been put to bed after a head injury involving a large hematoma and bleeding from her nose) and noted that the resident left eye was swollen shut and tender to touch. The on call doctor was called and notified in the change and ordered to send her to the hospital to get checked out. Resident left the facility with (Ambulance) at 0500 (5:00 a.m.). Review of the nurses notes dated 4/6/16 at 10:58 a.m., stated Resident arrived back the facility at about 0800 (8:00 a.m.) via (Ambulance) from the hospital. The resident came diagnosed with [REDACTED]. Review of the IDT notes dated 4/7/16, stated This resident attempted to transfer without assistance. She did not use her call light. Her care plan interventions remain effective. This incident was caused by the resident transferring without assistance. She is encouraged to use her call light. The facility concluded the residents fall was her fault because she failed to use her call light, not taking in to account her fall history, confusion and without assessment of underlining medical causes. An interview was done on 4/20/16 at 3:43 p.m. with staff member A (Administrator) and staff member B (Director of Nursing/DON). Staff member B (DON) stated our intervention was to educate her on using her call light and staff member A (Administrator) stated we educated the resident on using the call light. During an interview done on 4/21/16 at 9:15 a.m., staff member G (Nurse Manager, RN) stated she (the resident) had fluctuating levels of cognition, she was not educateable, we could not educate her on asking for assistance. During an interview done on 4/21/16 at 8:00 a.m., staff member L (Charge Nurse, RN) stated I came in at 3:00 a.m. (on 4/6/16) to do neuro checks, she (the resident) fell a little after midnight. She was in bed asleep when I went in, it was 4:00 a.m., I woke her up, I asked her to open her eyes, she could not open her left eye and that wasn't her norm and it was swollen. I was uncomfortable not seeing her left eye pupil so I called the on-call physician. (Staff Member K, Charge Nurse, LPN) did give me report on her. She said she had a hematoma on her head, she had sat up with an ice pack and they put her to back to bed. She was very confused. I do not think she was teachable, I do not feel the alarm should have been taken off. I called (Family Member #1) and he was up-set that she had fallen and that it was the 5 th time. He wanted to know why the alarm was not going off and I told him they had taken the alarm off and he wanted to know why. We do have a couple of people (residents) with alarms still. I personally would not have put her back to bed (after her fall with a head injury). Following a head injury the patient should be assessed by medical personnel, the physician should be contacted or the person should be taken to the hospital for evaluation. The patient should not be allowed to go to sleep until they are evaluated at a hospital or by a physician because they may have a concussion. A patient with dementia, cognitive impairment and confusion is difficult to evaluate and should be transferred to the hospital for evaluation (x-rays and CT's). (Lippincott Manual of Nursing Practice, Ninth Edition, Wolters Kluwer Health, Lippincott Williams & Wilkins, 2010) Review of the hospital record dated 4/6/16, stated According to (Ambulance), extended care facility staff told them the patient fell at 0000 (midnight) of 4/6/16. Pt (patient) arrived in emergency department via (Ambulance) at 0535 (5:35 a.m.). Injuries that were seen was a broken nose, she did bruise the front of both shoulders when she fell , for her broken nose and black eye ice and Tylenol may be helpful. Review of the hospital History of Present Illness dated 4/6/16, stated Patient lives in (the facility) nursing home and got out of bed last night and fell and landed right on her face. Evidently she got back in the bed and went to sleep and then when the staff realized that happen they sent her here by ambulance this morning. She complains of pain in both shoulders and the left side of her face. She did have a craniotomy surgery years ago. Review of the hospital CT (image of facial area for diagnosis) of the Facial Bones dated 4/6/16, stated Soft tissue swelling and small hematoma over the left frontal bone, fractured nasal bone. Review of the hospital CT of the head dated 4/6/16, stated indication: Injury, left frontal hematoma is seen. Review of the physician orders [REDACTED]. During an interview done on 4/21/16 at 10:15 a.m., staff member Q (CNA) stated she has on-off confusion, if that were my family, I would of wanted an alarm on her. I think if she would have had an alarm on, when she scooted, it would of gone off. When this surveyor asked staff member Q if she felt the residents fall (on 4/6/16) could have been prevented, she stated yes, yes I do. During an interview done on 4/21/16 at 7:00 a.m., staff member J (CNA) stated we checked her every 2 hours, we don't document it, it's hard with 2 aides (CNA's), we can't just be in her room. She's been more confused, one day she just sat up in her bed and said help, help, this was in March, she normally doesn't do that, I did tell my nurse. When this surveyor asked staff member J what she felt the facility could have done to prevent the resident from falling she stated we can increase more checks. During an interview done on 4/21/16 at 7:10 a.m., staff member I (CNA) stated we haven't been told to check on her more often than every 2 hours. She doesn't use a call light, we have told her, I don't think she knows how, she doesn't remember, she's always confused. I think she should have had an alarm, at least we could hear her alarm. During an interview done on 4/20/16 at 3:43 p.m., staff member B (Director of Nursing/DON) stated we increase staff awareness of checking (on the resident more often). During an interview done on 4/20/16 at 1:50 p.m., staff member C (Charge Nurse, RN) stated I think the last 2 falls (on 4/6/16 and 4/7/16) could have been prevented. During an interview done on 4/20/16 at 2:06 p.m., staff member D (CNA) stated we go up and down the hall and watch her, just visual checks. We had a CNA meeting last week (week of 4/11 th through 4/15 th), the DON told me her (the resident) falls are increased. On 4/7/16: Review of the incident report dated 4/7/16 at 00:30 (12:30 a.m.), stated resident observed on the floor (for the 6 th time) while the nurse was doing a treatment on another resident, resident lying on the floor with head toward the door on her left side. There was stools smeared on the edge of her bed. Confused, recent change in condition (fall with a fracture), gait imbalance, incontinent, ambulating without assistance. Review of the nurse's note's dated 4/7/16 at 3:59 a.m., stated resident was found on the floor, resident lying on the floor with head toward the door on her left side. There were stools smeared on the edge of her bed. Resident had a temp of 100.5 (signs/symptom of UTI). Review of nurse's note's dated 4/7/16 at 2:23 p.m., stated New order for UA (Urine Analysis) sample to be obtained. Review of nurse's note's dated 4/11/16 at 6:31 p.m., stated Order obtained to repeat UA. Review of the nurse's notes and physician orders [REDACTED]. A UTI can contribute to increased confusion and increase the risk of falls. Review of the IDT notes dated 4/7/16, stated resident attempted to self toilet, she does not remember to use her call light. IDT discussed this incident, it was recommended to change mattress to the perimeter mattress. Review of the residents At Risk for UTI ' s Care Plan dated 5/22/12, revision on 2/5/16, stated Monitor for s/sx (signs & symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp., urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. If noted notify physician. During an interview done on 4/21/16 at 8:35 a.m., staff member M (MDS Nurse, RN, developed the UTI care plan for the resident) stated I wanted them (nursing staff) to monitor for UTI. During an interview done on 4/21/16 at 7:25 a.m., staff member K (Charge Nurse, LPN) revealed on 4/6/16, a CNA came and got her because the resident was found on the floor in her room and stated the resident was laying on her side and her face on the floor. There was blood under her head, the blood was coming from her nose, she had a knot (hematoma) above her left eye, she said her fingers on her right hand hurt. Her blood pressure was high. She said she was getting up to answer the phone, she was confused. When this surveyor asked staff member K if she monitored the resident for a UTI (urinary tract infection), she stated I didn't know was supposed to be monitored for a UTI, I have never checked a care plan, I honestly didn't know her history. Review of the nurses notes dated 10/2/15 through 10/26/15, 11/2/15 through 12/25/15, 1/3/16 through 2/13/16 and 2/29/16 through 4/7/16 (last documented fall), revealed no documentation of monitoring the resident for signs & symptoms of UTI. An interview was done on 4/20/16 at 3:43 p.m. with staff member A (Administrator) and staff member B (Director of Nursing/DON). Staff member B (DON) stated that the facility only documents if there is an issue and staff member A (Administrator) stated they (nurses) document by exception only. Review of the nurses notes (dated 10/2/15 to 10/26/15, 11/2/15 to 12/25/15, 1/3/16 to 2/13/16 and 2/29/16 to 4/7/16), revealed throughout the charting documentation of no complaints of pain or discomfort, no signs or symptoms of [DIAGNOSES REDACTED] or hyperglycemia and no adverse side effects from medications (documentation not by exception). When this surveyor asked staff member B (DON) for the facility policy, procedure (guidelines) and staff education for charting by exception, she stated it's a standard of care and no policy, procedure, guidelines or staff education was produced. When a facility uses Charting by exception, there should be very explicit protocols and definitions regarding a baseline findings when assessing a patient. When a healthcare provider charts by exception, it means that only exceptions to these baseline findings would be charted. If interventions (following to reflect predefined norms and variances were not charted in detail (monitoring for signs & symptoms of a UTI) then it wasn't done. (Charting By Exception .A Trap for Poor Documentation? [DATE], Med League) A lack of detail could compromise patient safety as well. A patient's medical record is expected to accurately reflect his current condition, and a chart that's missing pertinent information could fail to alert other clinicians to potential problems or complications. (NSO, Nurses Service Organization, www.NSO.com, 2016) Review of the facility Falls Reduction Program dated 7/1/08, revised on 10/29/14, stated Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury. No further documentation was presented or made available by facility prior to exit on 4/21/16. ( )

This citation pertains to MI 740 Based on interview and record review the facility failed to provide professional standards of care during care of a supra pubic care catheter procedure for 1 sampled resident (#101) of 2 reviewed for supra pubic care procedures from a total of 7 residents, resulting in a surgical intervention for Resident #101. Findings include: According to the Minimum Data Set (MDS) dated , 10/20/13 Resident #101 was a [AGE] year old male with [DIAGNOSES REDACTED]. According to monthly physician orders [REDACTED].#101 had a supra pubic catheter. Review of Resident #101's monthly September 2013 Treatment Record reveled separate entries that included 1) change bag and tubing monthly on the 20 th dated 12/29/11, 2) 16 FR foley catheter with 10 ML balloon (foley and 10 ML was crossed out with "Supra pubic" and "to protocol"written in dated 12/29/11 and 3) change catheter as needed with "per CDC guidelines" written in" dated 12/29/11. Review of Resident #101's monthly October 2013 Treatment Record reveled separate entries that included 1) change bag and tubing monthly on the 20 th dated 12/29/11, 2) 16 FR foley catheter with 10 ML balloon dated 12 29/11 and 3) change catheter as needed dated 12/29/11. Review of Resident #101's monthly November 2013 Treatment Record revealed separate entries that included 1) change bag and tubing monthly on the 20 th dated 12/29/11, 2) 16 FR foley catheter with 10 ML balloon dated 12 29/11 and 3) change catheter as needed dated 12/29/11 with the information "Supra pubic" hand written in on each entry. Review of Resident #101's monthly November 2013 physician orders, signed with no date, revealed "change bag and tubing monthly on the 20 th may use leg bag or back (sp) to drainage bag for catheter urine collection and at night time 16 FR catheter with 10 ML balloon change catheter as needed." Review of the Facility's 24 hour Incident report dated 11/21/13 revealed Resident of concern's supra pubic catheter was removed and a new one was re-inserted causing some bruising. Resident #101 was reported to have been sent to the hospital for revision of the supra pubic site. Review of the Facility's Investigative Report 5 days was dated 11/25/13. On 12/11/13 at 9:30 am, Licensed Practical Nurse LPN "C" reported he was responsible for Resident #101 on 11/20/13. LPN "C" reported Resident #101's treatment record was reviewed and stated he saw 14 french foley catheter, gathered supplies and went to Resident's #101's room. Resident #101 was reported to have not been exactly cooperative, was standing up, agreed to have his supra pubic catheter removed while he was standing. LPN "C" reported Resident #101's shirt was covering his stomach, the catheter balloon was deflated and the supra pubic catheter was removed. LPN "C" reported Resident #101 was then positioned on the bed and the supra pubic catheter was not reinserted into the supra pubic catheter insertion site, but rather the foley catheter was re-inserted into the resident's penis. LPN stated "I replaced it in the penis. I thought it was it the penis." LPN "C" noted a small amount of blood was observed when the catheter was placed in the penis and reported the catheter had not been draining urine at approximately 1:30 PM, and requested Registered Nurse (RN) "D" to assess Resident #101. LPN "C" reported he was then informed by RN "D" that the catheter was a supra pubic catheter and was not in the correct site. On 12/11/13 at 12:30 pm, attending physician "N" reported he was in the building starting at approximately 10:30 am to start Resident rounds. Physician "N" stated, and had been requested to look at Resident #101's catheter by LPN "C" as the tubing had blood present and the catheter had not been draining urine. Attending physician "N" reported he had instructed LPN "C" to monitor Resident #101 and encourage fluids, and reported he had looked at the tubing but not the actual suprapubic site. Physician "N" reported he had not realized at the time the suprapubic catheter was in the wrong site. Attending physician "N" reported he was informed of the location of the "site" of the placement of the catheter in the penis not the supra pubic insertion site at approximately 6:00 pm and indicated there was at minimum a 6 hour time gap from removal to attempt of reinsertion. On 12/11/13 at 11:40 am, Registered Nurse "D" was interviewed and reported LPN "C" had approached her and inquired if Resident #101 normally had blood in his urine. RN "D" reported she had informed LPN "C" that the attending physician "N" was in the facility doing rounds and had encouraged him (LPN "C") to request attending physician "N" to have a look at Resident #101 during his rounds. RN "D" reported following rounds LPN "C" again approached her (RN "D") regarding Resident #101. RN "D" reported she then went to the resident's room and upon assessment informed LPN "C" the catheter tubing was placed in the wrong site and reported she notified the unit manager. Review of Resident #101's nurse notes dated 11/20/13 at 1:30 pm revealed, "During shift TX (treatment) indicated to change tubing and bag of supra pubic catheter de-flated and catheter removed. While attempting to reinsert unable to receive return or inflate bulb with 10 cc. Several attempts made to reinsert, all unsuccessful. Physician notified and made aware and stated to send res(resident to (hospital) for reinsertion of suprapubic catheter." According to the nurses progress notes dated 11/20/13 Resident #101 was transported to the hospital at 16:30 pm. Review of Hospital records for Resident #101 dated 11/20/13, revealed "Operation: Reinsertion of suprapubic tube." Upon Resident #101's return to the facility following the hospitalization , Resident #101's Telephone physician order [REDACTED]. Review of Resident #101's Telephone order dated 12/11/13 revealed " Change supra pubic catheter under physician supervision only." Review of the Facility's Catheter Care Care (Indwelling Catheter and Suprapubic) Policy," dated 7/1/2008, revealed no instructions on the insertion or removal of the supra pubic catheter. According to Mosby's Medical, Nursing & Allied Health Dictionary, Sixth Edition, A supra pubic catheter is placed in through the skin about an inch above the symphysis pubis (stomach) and is inserted under general or local anesthetic. According to Fundamentals of Nursing Seventh Edition, the "foley catheter" is placed in a male through the urethral opening in the penis. The Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (2009) current guidelines for supra pubic catheter care refelct, "Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training regarding techniques and procedures for urinary catheter insertion, maintenance, and removal." A review of LPN "C"s' clinical job responsibilities description for RN/LPN Charge nurses, signed and dated 8/16/13 was reviewed and included the key duties and responsibilities of the following "Provides nursing care to resident by performing a variety of treatments, including , but not limited to changing dressings, cleansing and /or irrigating wounds and incisions, performing foley catheterizations..." LPN "C's" failure to perform his job responsibility to provide appropriate nursing care meeting professional standards of quality which resulted in Resident #101 having to endure several attempts of a foley catheter placement into his penis and an unnecessary surgical intervention for re-insertion of a suprapubic catheter into the correct insertion site. ( )

Based on interview and record review, the facility failed to provide professional standards of care and follow physician's orders for care of an indwelling catheter procedure for 1 (Resident #120) of 3 residents reviewed for indwelling catheters from a total sample of 4, resulting in Resident #120 having the incorrect size of an indwelling catheter inserted. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #120 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order dated 12/3/13, revealed an order from the urologist that stated "...change 22 french Foley catheter, tubing, and bag monthly and PRN (as needed)..." Review of the Treatment Administration Record (TAR) dated 12/1/13 to 12/31/13, revealed "LN (licensed nurse) to change 22 french urethra indwelling catheter, tubing and bag monthly and PRN per CDC guidelines..." The treatment record was initialed on 12/21/13. Review of the Nurse's Notes dated 12/21/13, revealed "Foley catheter changed...new #18 Foley inserted, balloon filled..." In a telephone interview on 2/4/14 at 2:04 pm, Registered Nurse (RN) "D" reported that she changed Resident #120's Foley catheter on 12/21/13. This surveyor read the nurse's note to RN "D". RN "D" reported that #18 was the size of the Foley that she inserted into Resident #120. When queried how she knew what size catheter Resident #120 needed, RN "D" stated "I looked at the catheter she had. That was the size of the old catheter. I checked that before I went and got the new one". When queried if she was aware that Resident #120's order was for a 22 french catheter, RN "D" stated "uh, actually no". RN "D" reported that she received education for the recent plan of correction where it was discussed that catheters have to be used according to the physician's order. When queried if she reviewed the physician's order prior to inserting the Foley catheter into Resident #120, RN "D" stated "I checked the TAR (treatment administration record)". When queried if she saw 18 french listed on the TAR, RN "D" stated "No. She had 18 so that's what I replaced". Review of the facility's "Catheter-Insertion-Indwelling and Intermittent/Straight" policy and procedure dated 7/1/08, revealed "Procedure: Indwelling catheter-female resident 1. Check physician's order for catheterization..." Review of the facility's plan of correction, revealed that Resident #120 was audited on multiple dates, including 12/19/13 and 12/24/13. The name of the audit sheet was "Catheter Secure Audit". In an interview on 2/4/14 at 3:00 pm, Unit Manager (UM) "H" reported that she did audits to visualize that the catheter secure was in place as ordered. UM "H" reported that she was not aware that Resident #120 had the incorrect indwelling catheter size inserted. UM "H" reported she did not audit nurse's notes to ensure that the correct catheter size was inserted according to the physician's order. UM "H" reported she did not visualize the catheter size printed on the the catheter.. ( )

This citation pertains to MI 740 Based on interview and record review the facility failed to provide appropriate care and assessment during care of a supra pubic care catheter procedure for 1 sampled resident (#101) of 2 reviewed for supra pubic care procedures from a total of 7 residents, resulting in a surgical intervention for Resident #101. Findings include: According to the Minimum Data Set (MDS) dated , 10/20/13 Resident #101 was a [AGE] year old male with [DIAGNOSES REDACTED]. According to monthly physician orders [REDACTED].#101 had a supra pubic catheter. Review of Resident #101's monthly September 2013 Treatment Record reveled separate entries that included 1) change bag and tubing monthly on the 20 th dated 12/29/11, 2) 16 FR foley catheter with 10 ML balloon (foley and 10 ML was crossed out with "Supra pubic" and "to protocol"written in dated 12/29/11 and 3) change catheter as needed with "per CDC guidelines" written in" dated 12/29/11. Review of Resident #101's monthly October 2013 Treatment Record reveled separate entries that included 1) change bag and tubing monthly on the 20 th dated 12/29/11, 2) 16 FR foley catheter with 10 ML balloon dated 12 29/11 and 3) change catheter as needed dated 12/29/11. Review of Resident #101's monthly November 2013 Treatment Record revealed separate entries that included 1) change bag and tubing monthly on the 20 th dated 12/29/11, 2) 16 FR foley catheter with 10 ML balloon dated 12 29/11 and 3) change catheter as needed dated 12/29/11 with the information "Supra pubic" hand written in on each entry. Review of Resident #101's monthly November 2013 physician orders, signed with no date, revealed "change bag and tubing monthly on the 20 th may use leg bag or back (sp) to drainage bag for catheter urine collection and at night time 16 FR catheter with 10 ML balloon change catheter as needed." Review of the Facility's 24 hour Incident report dated 11/21/13 revealed Resident of concern's supra pubic catheter was removed and a new one was re-inserted causing some bruising. Resident #101 was reported to have been sent to the hospital for revision of the supra pubic site. Review of the Facility's Investigative Report 5 days was dated 11/25/13. On 12/11/13 at 9:30 am, Licensed Practical Nurse LPN "C" reported he was responsible for Resident #101 on 11/20/13. LPN "C" reported Resident #101's treatment record was reviewed and stated he saw 14 french foley catheter, gathered supplies and went to Resident's #101's room. Resident #101 was reported to have not been exactly cooperative, was standing up, agreed to have his supra pubic catheter removed while he was standing. LPN "C" reported Resident #101's shirt was covering his stomach, the catheter balloon was deflated and the supra pubic catheter was removed. LPN "C" reported Resident #101 was then positioned on the bed and the supra pubic catheter was not reinserted into the supra pubic catheter insertion site, but rather the foley catheter was re-inserted into the resident's penis. LPN stated "I replaced it in the penis. I thought it was it the penis." LPN "C" noted a small amount of blood was observed when the catheter was placed in the penis and reported the catheter had not been draining urine at approximately 1:30 PM, and requested Registered Nurse (RN) "D" to assess Resident #101. LPN "C" reported he was then informed by RN "D" that the catheter was a supra pubic catheter and was not in the correct site. On 12/11/13 at 12:30 pm, attending physician "N" reported he was in the building starting at approximately 10:30 am to start Resident rounds. Physician "N" stated, and had been requested to look at Resident #101's catheter by LPN "C" as the tubing had blood present and the catheter had not been draining urine. Attending physician "N" reported he had instructed LPN "C" to monitor Resident #101 and encourage fluids, and reported he had looked at the tubing but not the actual suprapubic site. Physician "N" reported he had not realized at the time the suprapubic catheter was in the wrong site. Attending physician "N" reported he was informed of the location of the "site" of the placement of the catheter in the penis not the supra pubic insertion site at approximately 6:00 pm and indicated there was at minimum a 6 hour time gap from removal to attempt of reinsertion. On 12/11/13 at 11:40 am, Registered Nurse "D" was interviewed and reported LPN "C" had approached her and inquired if Resident #101 normally had blood in his urine. RN "D" reported she had informed LPN "C" that the attending physician "N" was in the facility doing rounds and had encouraged him (LPN "C") to request attending physician "N" to have a look at Resident #101 during his rounds. RN "D" reported following rounds LPN "C" again approached her (RN "D") regarding Resident #101. RN "D" reported she then went to the resident's room and upon assessment informed LPN "C" the catheter tubing was placed in the wrong site and reported she notified the unit manager. Review of Resident #101's nurse notes dated 11/20/13 at 1:30 pm revealed, "During shift TX (treatment) indicated to change tubing and bag of supra pubic catheter de-flated and catheter removed. While attempting to reinsert unable to receive return or inflate bulb with 10 cc. Several attempts made to reinsert, all unsuccessful. Physician notified and made aware and stated to send res(resident to (hospital) for reinsertion of suprapubic catheter." According to the nurses progress notes dated 11/20/13 Resident #101 was transported to the hospital at 16:30 pm. Review of Hospital records for Resident #101 dated 11/20/13, revealed "Operation: Reinsertion of suprapubic tube." Upon Resident #101's return to the facility following the hospitalization , Resident #101's Telephone physician order [REDACTED]. Review of Resident #101's Telephone order dated 12/11/13 revealed " Change supra pubic catheter under physician supervision only." Review of the Facility's Catheter Care Care (Indwelling Catheter and Suprapubic) Policy," dated 7/1/2008, revealed no instructions on the insertion or removal of the supra pubic catheter. According to Mosby's Medical, Nursing & Allied Health Dictionary, Sixth Edition, A supra pubic catheter is placed in through the skin about an inch above the symphysis pubis (stomach) and is inserted under general or local anesthetic. According to Fundamentals of Nursing Seventh Edition, the "foley catheter" is placed in a male through the urethral opening in the penis. The Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (2009) current guidelines for supra pubic catheter care refelct, "Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training regarding techniques and procedures for urinary catheter insertion, maintenance, and removal." A review of LPN "C"s' clinical job responsibilities description for RN/LPN Charge nurses, signed and dated 8/16/13 was reviewed and included the key duties and responsibilities of the following "Provides nursing care to resident by performing a variety of treatments, including , but not limited to changing dressings, cleansing and /or irrigating wounds and incisions, performing foley catheterizations..." LPN "C's" failure to perform his job responsibility to provide appropriate nursing care which resulted in Resident #101 having to endure an unnecessary surgical intervention for re-insertion of a suprapubic catheter. ( )

Based on interview and record review, the facility failed to provide appropriate care and follow physician's orders for care of an indwelling catheter procedure for 1 (Resident #120) of 3 residents reviewed for indwelling catheters from a total sample of 4, resulting in Resident #120 having the incorrect size of an indwelling catheter inserted. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #120 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order dated 12/3/13, revealed an order from the urologist that stated "...change 22 french Foley catheter, tubing, and bag monthly and PRN (as needed)..." Review of the Treatment Administration Record (TAR) dated 12/1/13 to 12/31/13, revealed "LN (licensed nurse) to change 22 french urethra indwelling catheter, tubing and bag monthly and PRN per CDC guidelines..." The treatment record was initialed on 12/21/13. Review of the Nurse's Notes dated 12/21/14, revealed "Foley catheter changed...new #18 Foley inserted, balloon filled..." In a telephone interview on 2/4/14 at 2:04 pm, Registered Nurse (RN) "D" reported that she changed Resident #120's Foley catheter on 12/21/13. This surveyor read the nurse's note to RN "D". RN "D" reported that #18 was the size of the Foley that she inserted into Resident #120. When queried how she knew what size catheter Resident #120 needed, RN "D" stated "I looked at the catheter she had. That was the size of the old catheter. I checked that before I went and got the new one". When queried if she was aware that Resident #120's order was for a 22 french catheter, RN "D" stated "uh, actually no". RN "D" reported that she received education for the recent plan of correction where it was discussed that catheters have to be used according to the physician's order. When queried if she reviewed the physician's order prior to inserting the Foley catheter into Resident #120, RN "D" stated "I checked the TAR (treatment administration record)". When queried if she saw 18 french listed on the TAR, RN "D" stated "No. She had 18 so that's what I replaced". Review of the facility's "Catheter-Insertion-Indwelling and Intermittent/Straight" policy and procedure dated 7/1/08, revealed "Procedure: Indwelling catheter-female resident 1. Check physician's order for catheterization..." Review of the facility's plan of correction, revealed that Resident #120 was audited on multiple dates, including 12/19/13 and 12/24/13. The name of the audit sheet was "Catheter Secure Audit". In an interview on 2/4/14 at 3:00 pm, Unit Manager (UM) "H" reported that she did audits to visualize that the catheter secure was in place as ordered. UM "H" reported that she was not aware that Resident #120 had the incorrect indwelling catheter size inserted. UM "H" reported she did not audit nurse's notes to ensure that the correct catheter size was inserted according to the physician's order. UM "H" reported she did not visualize the catheter size printed on the the catheter. ( )

Based on observation, interview and record review, the facility failed to assess, identify causes of development of pressure ulcer and implement preventive interventions consistently for 2 of 3 residents (#17, #2) with pressure ulcers from a total sample of 24 residents, resulting in the development of recurrent avoidable stage 2 left heel pressure ulcers for resident #17 and left heel deep tissue injury for resident #2. Findings include: According to the admission [DIAGNOSES REDACTED].#17 was a [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care area assessment (CAA) worksheet dated 4/19/13 reflected resident #17 was alert and oriented to time, place and person, able to answer questions and follow directive as she chose. Resident #17 had a history of [REDACTED]. Resident #17 had tone issues to her left leg that prevented her from being steady when she walked and transfer with a quad cane. Resident #17 was continent of bowel and had one incontinence of bladder. Resident #17 was extensive assist and could not put on her own shoes and socks. She was also extensive assist for moving up in bed. Under pressure ulcer CAA dated 4/19/13 Resident #17 was identified as a risk for developing pressure ulcer and other skin integrity problems. Resident #17 was an extensive assist for completing her repositioning in bed and in chair. Resident #17 had [MEDICAL CONDITION] and diabetic [MEDICAL CONDITION] and may not feel the pain or pressure until she had skin damage. Resident #17 had narcotic pain medications that she used frequently for shoulder, arm, coccyx and back pain. Resident #17 had redness to her coccyx the day she was admitted but there was no need for a treatment per the record. Resident #17 had some contractions to her left arm, hand and "excessive tone " to her left leg. She had an increased risk for breakdown to these areas. Resident #17 was coded as having impairment on one side of both upper and lower extremities for the functional limitation in range of motion and her occupational therapy was discontinued on 6/28/13 per nurse's notes. The list of nursing interventions dated 4/23/13 included 1) administer medications as ordered, 2) cleanse skin with soap and water and apply moisture barrier cream, 3) facility policy for prevention/treatment of [REDACTED]. with staff, 13) assess skin while in the tub. The added interventions to maintain skin integrity included 1) heels elevated on 5/9/13, 2) bilateral prafo boots while in bed on 6/23/13, 3) left elbow extension splint at night on 6/26/13, 4) diabetic shoes as allows on 9/18/13. On 11/1/13 at 2:15 p.m., the unit managers (staff G; registered nurse, staff H; registered nurse, staff W; registered nurse) stated these added measures were unsuccessful to prevent resident #17's left heel pressure ulcer. Staff G, H, W stated resident #17 was extremely non-compliant, did not take off her old pair of shoes, wore the shoes 24 hours a day, always lies on her right side except for the bathroom trip and never went out of her room. Staff G stated the resident could put her shoes back on if the staff attempted to take them off. The wound assessment details report with the description of wound characteristics including measurements dated 5/8/13 reflected Resident #17 developed suspected deep tissue injury on her left heel, measuring 3.0 x 1.2 x 0.0 (length x width x depth in centimeters). This wound was healed on 7/26/13, taking over 2 months. Resident #17 developed recurrent stage 2 (partial thickness skin loss) pressure ulcer on the same location (left heel) on 10/25/13 and it measured 1.8 x 1.9 x 0.1. centimeters. The wound assessment details report dated 10/31/13 reflected the wound had 25 % intact skin, 75 % bright beefy red granulation tissue with measurement of 1.6 x 1.8 x 0.1. However, resident #17 had another recurrence on 8/16/13. The nurses notes dated 8/16/13 reflected resident #17's " ...left heel is broke open, triple antibiotic and barrdaid placed over until evaluated in the morning by unit manager for proper treatment. Resident shoes are too tight and rubbing per CNA. Put on 24 hour report and will report to first shift nurse in morning. " It was not clear whether this new open area was ever communicated to the manager or not, since there were no wound assessment detail report available on that day or the day forward. The nurse's note dated 9/10/13 reflected, "heel treatment to left heel done to open areas noted," indicating the left heel wound was still present on 9/10/13. The last wound assessment report for the resident 's left heel was documented as healed on 7/26/13. On 11/1/13 at 1:00 p.m., resident #17's left heel pressure ulcer wound was observed with the licensed practical nurse, (staff DD). The wound was irregularly shaped circle with pale grey blister like skin at one edge and the center of wound was filled with beefy red granulating tissue. The opposite edge was covered with dark black scab. The dressing change was performed by a licensed practical nurse (staff "DD") in the resident's room. Resident #17 was curled up in a fetal position, wearing a white pair of white tennis shoes, lying on her right side with her head placed against the board at the foot of the bed. The left leg had been doubled up on top of her right leg. Staff "DD" removed the resident's left shoe which looked clean, snuggly fitted (did not appear tight). Staff "DD" cleansed the left heel wound with safe cleanse, applied "alkare" barrier wipes to around wound and covered with tagaderm foam adhesive dressing. When staff "DD " asked the resident whether she had pain or not, the resident stated, "no." On 11/1/13 at 1:30 p.m., after the dressing change staff "DD" was asked what may have been the cause of resident #17's pressure ulcer. Staff "DD" stated he was not certain, but he thought that the new pair of shoes resident #17's family brought in about 2 weeks ago may have caused the blister. Staff "DD" stated the new shoes were bigger size than the old ones, but they could cause irritation by rubbing into the skin. Staff "DD" added the new pair of shoes were removed and the resident was now wearing the old pair of shoes. Staff "DD" stated the resident prefer to lie on her right side, thus her left leg including her left foot never touched the surface of the mattress. Despite the fact that resident #17's right leg and foot were in constant contact with the mattress she had no pressure ulcers on her right lower extremities. Staff "DD" stated the nurse aides were to check skin 2-3 times a week during showers and licensed nurses were to perform weekly skin assessments. The electronic skin report (question and response format) documented every shift since the system was available for the nurses aides from 7/11/13 through 11/1/13 reflected resident #17 had documented only " no" responses to the question, " did you notice a new skin issue on this shift? " The weekly skin assessment form completed by the licensed nurses from 4/23/13 through 10/29/13 reflected resident #17 had a red scab on his left heel on 6/4/13, mushy, boggy right heel on 6/18/13, red/dry left heel on 7/2/13 through 7/10/13, abrasion on her right and left head as well as right toe area on 9/18/13, reddened left toe and left heel on 10/8/13. Dry and reddened area was again marked for left toe and heel on 10/15/13 and 10/22/13. The assessment forms were designed to make check marks from 15 numbered categories and identify on body figures for applicable numbers. Resident #17 had 28 possible weekly skin checks between 4/23/13 and 10/29/13, but only 21 weekly skin checks were documented as being done. The study written by Tina Meyer "Preventing heel pressure ulcers and plantar flexion contractures in high-risk sedated patients" from the Journal of Wound, Ostomy and Continence Nurses Society, July 2010, states contracture of the plantar flexion tendons is caused by shortening of the soft tissue sufficient to impair movement. A plantar flexion contracture results in a loss of range of motion due to unopposed plantar flexion, Animal studies have shown that contractures begin at the onset of immobility and they tend to progress over time. The study concluded the use of heel protectors and passive range of motion exercises prevented heel pressure ulcers caused by plantar flexion contractures. The physician's progress notes dated 7/3/13 through 10/25/13 reflected resident #17 was assessed to have [MEDICAL CONDITION] and [MEDICAL CONDITION], thus was to prescribed [MEDICATION NAME]. Also physician progress notes [REDACTED]. However there was no detailed discussion about the possible etiology other than resident's refusal to take off shoes. ( ) According to the physician's orders [REDACTED].#2 was an [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The local hospital's records for Resident #2 reflected she had fell at home and acquired a left femur and intertrochanteric fracture. The admission "SKIN ASSESSMENT" dated 10/8/13 reflected Resident #2 had (3) areas at the left hip with staples/sutures, and a bruises at her right and left lower legs. No areas of concern were identified on Resident #2's left foot or heel. The admission minimum data (MDS) completed on 10/25/13 for resident #2 reflected she had a brief interview of mental status (BIMS) score of 7 out of 15 (severely impaired), required extensive assistance of 2 people for transfers, not observed to walk in room or corridors, required extensive assistance of 1 person for locomotion on/off unit, range of motion impaired on one side, and did not have any pressure ulcers. On 10/29/13 at approximately 4:00 PM Resident #2 was observed sitting up in her wheelchair cleanly clothed. The call light was on her lap in reach, and a cushion was noted in her wheelchair seat. Bilateral ted hose were noted on her lower legs/feet, and her heels were covered with light blue cloth pressure reducing boots. The Admission Care Plans developed for Resident #2 on 10/8/13 consisted of: #2 Adl/Rehab: Checks were noted marked in the boxes for the following interventions: consult PT,OT, ST, Range of motion, Bathing/hygiene assist, grooming assist, transfer assist x 2 assist with RN, toileting assist for tlfs (sic). No amb (ambulation), and other TTWB (toe touch weight bearing) LLE (left lower extremity). #4 Cardiac: Some of the checks marked had the following interventions: monitor for [MEDICAL CONDITION], and ted hose on in AM off at night. #20 Skin Care: Pressure Ulcer Risk; Actual Breakdown. Checks were noted marked in the boxes for the following interventions: Braden per policy, CNA daily skin assessment, Nurse weekly skin assessment, Turn and reposition minimum of q (every)2 hrs. in bed and q 1 hr. in chair, float heel, protective skin barrier per protocol, moisturize PRN, and other DTI (deep tissue injury). On 10/23/13 the intervention "wedge pillow" was added to the care plan. The DTI box did not have a date by it, to identify its onset. Nurse's Notes (NN) dated 10/16/13 at 4:00 PM reflected Resident #2 had [MEDICAL CONDITION] left lower extremity. NN On 10/2/13 (time not documented) reflected to apply [MEDICATION NAME] wipe to left heel q shift for blister. Then on 10/23/13 NN dated 10/23/13 at 1:19 PM reflected a nurse assessed Resident #2's left heel and found a DTI. The "WOUND ASSESSMENT DETAILS REPORT" sheet dated 10/23/13 at 1:33 PM reflected Resident #2 had a closed pressure blister facility acquired on 10/22/13. The Clinical stage documented was suspected deep tissue injury, and measured at 4.50 x 3.50 x unknown (L x W x D). The Weekly Hydration and Skin assessment dated [DATE] were negative for areas of concern of the left foot or heel. On 11/1/13 at 11:20 AM a interview took place with the Clinical Care Coordinator (CCC staff "W") for Resident #2. The following was revealed by staff W: At the beginning of Resident #2"s admission her heels were elevated with a pillow but her heels were in contact with the bed and that was how the pressure area developed. The pillows were under her legs at first and not her heels. We did do a past non-compliance and skin sweeps throughout the facility. Later on 11/1/13 at 12:47 PM a meeting took place with the Director of Nursing (DON "B") and staff W in staff B's office. Staff "B" stated Resident #2 did develop a DTI, and they put measures in place to prevent it from worsening, did skin sweep of the entire building, and a past non-compliance plan of correction. Staff B asked if she could provide the packet and was informed it could be provided and would be taken back to office to management. Staff B continued: the facility did float Resident #2's heels on a regular pillow before, but it was not enough support and her heel made contact with bed. The facility then replaced pillow with foot foam heelz up pillow, air bed mattress, received a consult for bilateral foam boots. When staff B was asked what she considered a DTI to be she replied, it could be caused by bony prominence pushed on hard surface. Also, that Resident #2 was reluctant to get out of bed and refused to get out of bet. Yet NN dated 10/8/13 to 10/23/13 did not reflect the previous statement, nor did the admission skin care care plan reflect the previous statement. Staff W stated that Resident #2's heels could be fine and night depending on her mobility, and that she was reluctant to keep her heels up. When he boots were removed she would slide her legs, and when pillows were under her legs she had complete mobility. Again, the admission skin care plan did not reflect the previous statement. Nor, was any documentation related to eduction of foot placement risk factors to the resident and/or family was provided or available. ( )

Based on observation, interview and record review, the facility failed to demonstrate the use of catheters for 2 of 2 residents (#7, #8) reviewed with catheter from a total of 24 sampled residents, resulting in the development of frequent symptomatic urinary tract infection as well as catheter-related pain and urethral dilation for resident #7 and avoidable dislodging of catheter during a transfer for resident #8. Findings include: According to the monthly physician orders dated 10/1/13 through 10/31/13 resident #7 was an [AGE] year old female admitted to 3/20/13 with [DIAGNOSES REDACTED]. The admission face sheet revealed resident #7 was originally admitted to the facility on [DATE] and was also readmitted on [DATE]. The most recent CAA (care area assessment) dated, over one year ago, 9/17/12 reflected resident #7 " ...is frequently incontinent of her bowels and was occasionally incontinent of her bladder until her catheter had to be reinserted due to bladder retention on 9//13/13 ... " Under the urinary incontinence and indwelling catheter CAA reflected, " ...has a indwelling catheter due to [MEDICAL CONDITION] and resolving UTI (urinary tract infection) in past 30 days and need of extensive assistance for toilet use ... " The social service progress notes dated 11/6/12 through 8/14/13 reflected resident #7 's BIMS (brief interview for mental status) scores fluctuated between 11-15 from possible 15 points, meaning she was alert and oriented and able to make her needs known. She did have an intermittent confusion and fluctuating mood and behaviors. The nursing notes dated 12/2/12 reflected resident #7 "c/o burning sensation at foley cath entrance site with leaking. Tubing had large amount of sediment and cloudy. Also c/o bladder fullness. Bladder was distended upon palpation. Foley cath removed and resident was able to empty bladder. The nursing notes dated 12/2/12 resident #7 was transferred to the hospital due to respiratory difficulties and she was returned on 12/6/12 with [DIAGNOSES REDACTED]. The nursing notes dated 12/7/12 reflected resident #7 was cathed with 1400 cc and the catheter was left in. She was again treated with antibiotic for UTI. The nursing notes dated 12/26/12 resident #7 had her foley out and voided without problems until 1/7 13 the foley was reinserted due to distention. She was again treated with antibiotic ([MEDICATION NAME]) during this time. On 1/28/13 resident #7 was seen by a urologist. The urologist consultation notes dated 1/28/13 reflected " ..XXX[AGE] year old female without prior history of urinary voiding problems before fracture of left leg. Foley cath was inserted because of mobility issues. However attempts to get patient off cath were unsuccessful. Will trial off cath again. If still unable to void will arrange for urodynamic evaluation. The recommendation included 1) discontinue foley, if pt voids on her own, then straight cath for residual > 150 cc, leave cath in and make appointment with my office for urodynamic evaluation. " There was no evidence the urodynamic evaluation was performed. On 10/30/13 at 2:00 p.m., the unit manager (staff G; registerd nurse) was asked how the [MEDICAL CONDITION] could be assessed and how much of post void urine (PVR) residual volume could be considered as a [MEDICAL CONDITION]. Staff G stated there should not be any urine left in the bladder after a person voided. Staff G added she would consider it would be abnormal if there was more than 30 ml urine left in the bladder immediately after a person voided. The article, "urinary catheter policies for long-term bladder drainage" written by Niel-Weise BS, The cochrane database of systemic reviews 2005, [MEDICAL CONDITION] is characterized by documented PVR in a range over 200 ml. The care plan related to catheter use dated 10/1/12 and updated on 8/23/13 reflected resident #7 was at risk due to history of UTI 's and [MEDICAL CONDITION]. The interventions included 1) change catheter according to CDC (center for disease control) guidelines, 2) check urine for signs and symptoms of infection, 3) do not pull on catheter or tubing, 4) antibiotic therapy if UTI develops, 5) place catheter in a privacy bag, 6) catheter care according to policy and procedure. The nurse's notes dated 10/1/12 through 10/29/13 reflected resident #7 had multiple episodes of UTI's ( 12/6/12, 1/6/13, 4/26/13, 7/16/13, 10/17/13) related to the catheter usage. Her symptoms of UTI such as hematuria (blood in urine) or [MEDICAL CONDITION] were often complicated or unclear due to the use of anticoagulants ([MEDICATION NAME] and aspirin) as well as prolonged narcotic use ([MEDICATION NAME] and [MEDICATION NAME]). In addition, interventions to prevent further infection may have been retarded due to the fluid restriction (2000 ml/day) ordered on [DATE]. However, careful monitoring of sufficient fluid intake was not evident in any clinical records even during a period of UTI's. The medication administration records (MAR) dated March 2013 through October 2013 included resident #7 was to have fluid restriction (1320 ml from dietary and 680 ml from nursing) with nurse ' s initials twice daily. No measurement of any fluid intake could be found in the clinical notes either in the dietary notes or nursing notes. On 11/1/13 at 9:30 a.m., the catheter care was observed in the resident's room. Both nurse aides, (staff "BB" CC" ) brought in approximately ? basin full of water with stack of washcloths and placed them across on top of over-bed table. Both wore gloves but it was not clear whether they had washed their hands or not prior to donning them. The privacy curtain had been pulled but the room door was opened and remained open throughput the procedure. Staff "BB " standing next the resident 's right side began cleaning the resident's front part of labia moving from top to bottom with wash cloth that had been dipped in the water and cleanser squirted. Staff "BB" noticed resident #7 had a large amount of loose stool. Staff "BB" stated she probably should clean the resident 's stool first because it would be difficult to do catheter care. Staff "CC" standing in the resident 's left side began cleaning the stool while staff "BB" was holding the resident on her right side. Staff "CC" cleansed stool with several wash clothes dipped in the water and cleanser applied. When she finished cleaning resident's stool she changed her gloves, but did not wash her hands. At one point staff "CC " went out of the room to bring more wash clothes but still did not wash her hands before donning another pair of gloves. Staff "BB" cleansed resident's labia after the resident was placed on her back. By this time there was any visible water left in the basin. Staff "BB" had left one used wash cloth in the basin and dipped another washcloth in the bottom of basin and wiped off the catheter. The water in the basin was never changed or added. Neither aides had never washed their hands with several glove changes. Resident #7 had no secure or leg strap on her legs, pulling down to her right side where the drainage bag was connected. Staff "CC" took out the urine collection container from the drawer and drained the urine from the bag after wiping off the end with alcohol wipe. Staff "CC" carried the urine collection container into the bathroom to drain inside the toilet. Staff "CC" changed her gloves but did not wash her hands before she was ready to transfer the resident into a mechanical lift. The facility catheter care policy dated 7/1/08 reflected staff should provide privacy, wash hands and put on gloves, cleanse perineum with warm water and soap or facility specific perineal cleanser, cleanse at catheter insertion site, taking care not to pull on catheter advance further into urethra, rinse with warm water, pat dry with clean towel and secure tubing to leg. If resident had bowel movement, clean this area first. Wash hands and obtain clean equipment for catheter care. The nurse ' s notes dated 10/1/2012 through 10/28/13 reflected resident #7 had multiple catheter changes, starting with catheter size French 14 with 5 cc balloon to French 24 with 30 cc balloon due to leakage or blockage of urine. Resident #7 also had skin irritation including blisters on occasion from latex catheter, thus had to change to silicone catheter on 7/4/13. On 10/31/13 at 9:00 a.m., resident #7 stated the catheter was still leaking and had to wear the pull-ups to contain the urine. With larger sizes of catheter use the urethral opening could have stretched out, leading to more opportunity to introduce bacteria as well as stool contamination. ( ) According to the change of condition Minimum Data Set (MDS) assessment dated [DATE], Resident # 8 was a [AGE] year old male with [DIAGNOSES REDACTED]. According to Resident #8's care plan, "I have a catheter due to my [DIAGNOSES REDACTED]." According to Resident #8's Nursing progress notes dated 10/7/13 at 7:30 PM, reflected Resident #8 "was being transferred after bathing from chair back in to bed, Foley catheter bag became hooked on chair during porta lift transfer and the 16 fr (french) catheter with 30 ml (millimeter) saline balloon was pulled out." Resident was documented to have reported pain on a scale of 1-10 to be at a 4. Review of Resident #8's Nurse Progress notes dated 10/8/13 reflected there was blood in the urine. On 10/31/13 at 9:00 AM during an interview Unit Manager Registered Nurse (RN) G, reported an "Unusual Occurrence" report was not completed when a catheter was pulled "blue dot charting" was initiated. RN G reported blue dot charting meant the resident was monitored for signs and symptoms for unusual occurrences for 72 hours. There was no clear answer as to why an incident report had not been completed. Review of the Facility's Policy "Transfer Techniques," dated 7/1/08, failed to reflect any general instructions to safeguard resident equipment during resident transfers. ( ) According to the admission Minimum Data Set (MDS) assessment dated [DATE], Resident # 8 was a [AGE] year old male with [DIAGNOSES REDACTED]. Resident was assessed to have bowel incontinence and was frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement). Resident #8 was scored a (0) which indicated he was not on a managed toileting program to manage his bowel continence. Review of Resident #8's initial bowel and bladder evaluation dated 6/21/13 through 6/24/13 (4 days) reflected resident was documented on 6/21/13 continent of bowel 2 times, and incontinent 1 time, on 6/22/13 continent of bowel 2 times with had 1 incontinent episode, on 6/23/13 there was no documentation on the form, and on 6/24/13 was continent of bowel 1 time with no incontinent episodes. Resident #8's day 5-7 were not available in the clinical record. for evaluation. Review of Resident #8's Care Plans "I currently have no skin impairments, I but I am at risk due to generalized weakness.... bowel incontinence, catheter..." dated 7/2/13 reflected an intervention of cleanse my skin with soap and water and apply a moisture barrier cream after each incontinence." Review of Resident #8's Care plans failed to reflect any documented interventions to maintain bowel continence. Review of Resident #8's Resident Care Guide reflected resident was continent/incontinent and to be toileted every 2 hours. On 10/30/13 at 11:00 AM, Resident #8 was observed during AM, care to have been wearing an incontinent brief. Resident #8 stated to Certified Nurse Aide (CNA) M while she was cleaning his testicle area from feces, "do what you have to do I don't want it (feces) on there." On 11/1/13 at 8:50 AM, Social Service Director stated Resident #8 often called out to the staff, was anxious, was often heard and reported to have been heard "yelling because he needed help," and when he was incontinent was upset because he had been reported to have stated he had "shit myself"and "it was not a manly thing to do." Review of the Facility Policy " Incontinent Management," revised date 2/28/13, reflected "Purpose: To establish and maintain an individualized incontinence program that emphasizes resident dignity, restores and preserves elimination function and /or prevents complications. Procedure. 3. Document Bowel and Bladder continence and amount. 4. Analyze Bowel and Bladder information on Urinary Incontinence CAA." Review of Resident #8's admission information Bowel and Bladder assessment was incomplete. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 666. THIS CITATION HAS MULTIPLE DEFICIENT PRACTICE STATEMENTS. 1) BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PREVENT FALLS AND PROVIDE SUPERVISION IN 1 OF 7 SAMPLED RESIDENTS (#106 ), IN A TOTAL OF 7 SAMPLED RESIDENTS WITH RISKS FOR FALLS, RESULTING IN RESIDENT #106 EXPERIENCING A FALL FROM A MECHANICAL LIFT AND SUSTAINING A FRACTURE (BROKEN BONE). FINDINGS INCLUDE: RESIDENT #106 THE FACE SHEET REVEALED RESIDENT #106 WAS AN [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS ((MDS) dated [DATE], REVEALED RESIDENT #106 WAS SEVERELY COGNITIVELY IMPAIRED AND WAS TOTALLY DEPENDENT ON 2 FACILITY STAFF MEMBERS FOR TRANSFERS (MOVEMENTS FROM SURFACE TO SURFACE) WITH USE OF A MECHANICAL LIFT. THE PHYSICIAN ORDERS [REDACTED]. THE FACILITY INCIDENT REPORT DATED 4/23/2012 (UNTIMED) AND THE FACILITY INVESTIGATION REPORT DATED 4/30/2012 (UNTIMED), REVEALED RESIDENT #106 WAS ASSISTED TO BED BY 2 CERTIFIED NURSE AIDES (CNA'S , #11 AND #12) ON 4/22/2012 AT 6:30 P.M., WHEN THE POSTERIOR LOOP/STRAP OF THE LIFT BECAME DISCONNECTED, AND THE RESIDENT fell TO THE FLOOR. X-RAYS DONE AT THE FACILITY. THE RESIDENT INDICATED THE resident sustained [REDACTED]. THE RESIDENT CONTINUED CARE AT THE FACILITY, WITH AN OFFICE VISIT ON 4/24/2012 TO AN ORTHOPEDIC SPECIALIST CONSULTANT FOR FOLLOW UP CARE. THE FACILITY POLICY/ PROCEDURE, ENTITLED "MECHANICAL LIFT TRANSFER" DATED JULY 1, 2008, STATED "MECHANICAL LIFTS ARE USED TO SAFELY TRANSFER A RESIDENT UNABLE TO TRANSFER IN ANY OTHER MANNER." UNDER THE PROCEDURE PORTION OF THE DOCUMENT, IT STATED, "FOLLOW MANUFACTURER'S INSTRUCTIONS." THE MANUFACTURER'S INSTRUCTIONS/SAFETY SUMMARY FOR USE OF THE MECHANICAL LIFT UTILIZED BY THE FACILITY IN THE TRANSFER OF RESIDENT #106 ON 4/22/2012 AT 6:35 P.M., SPECIFIED, "BEFORE TRANSFERRING A PATIENT FROM A STATIONARY OBJECT (WHEELCHAIR, COMMODE OR BED), SLIGHTLY RAISE THE PATIENT OFF THE STATIONARY OBJECT AND CHECK THAT ALL SLING ATTACHMENTS ARE SECURE. IF ANY ATTACHMENT IS NOT CORRECT, LOWER THE PATIENT AND CORRECT THE PROBLEM, THEN RAISE THE PATIENT AND CHECK AGAIN." DURING AN INTERVIEW ON 5/17/2012 AT 9:55 A.M., CNA #11 SAID, "SHE (RESIDENT #106) WAS IN HER GERI CHAIR. ME AND ANOTHER CNA (#12)WERE GOING TO PUT HER TO BED. YOU NEED 2 PEOPLE. CNA #12 PUMPED THE LIFT UP. THE RIGHT SLING LOOP POPPED OFF. WHEN IT POPPED OFF, IT SOUNDED LIKE A WIRE UNRAVELING FAST. THE RESIDENT PLOPPED ONTO THE STILL RECLINED GERI CHAIR. SHE fell on TO THE LOWER HALF, THE FOOT REST PART OF THE CHAIR. HER WEIGHT ON THE FOOT REST OF THE CHAIR PUSHED THE CHAIR; IT WENT FLYING BACK. THE RESIDENT fell OFF, THE RIGHT SIDE, AND HER RIGHT ARM HIT THE DOOR KNOB AT THE ENTRY OF HER ROOM. THREE OF THE LOOPS WERE STILL ATTACHED, ONE WASN'T. WHEN SHE fell , SHE BOUNCED ON THE FLOOR DUE TO THE HEIGHT SHE WAS WHEN SHE fell TO THE FLOOR." DURING AN INTERVIEW ON 5/17/2012 AT 11:00 A.M., CNA #12 SAID, "WE (CNA #11 AND #12) WERE GOING TO LAY HER (RESIDENT #106) DOWN. SHE WAS IN A GERI CHAIR. WE TOOK HER TO HER ROOM. CNA #11 HOOKED UP THE TOP STRAPS, AND I DID THE BOTTOM STRAPS. I WORKED THE LIFT. SHE (RESIDENT #106) CLEARED THE CHAIR. ONE OF THE STRAPS CAME OFF. YOU COULD FEEL IT POP. THE STRAP DIDN'T BREAK; IT SLID OFF. THE RESIDENT fell AND SLID OFF THE BOTTOM HALF OF THE GERI CHAIR, TO HER RIGHT SIDE, AND HIT THE DOOR KNOB OF THE FRONT DOOR TO HER ROOM. THREE STRAPS WERE STILL IN PLACE WHEN SHE fell . I SAW THE RESIDENT AS SHE HIT THE FLOOR, HARD. SHE COMPLAINED HER RIGHT ARM WAS HURTING. I LOOKED AT THE LOOP; IT WASN'T BROKEN. IT WASN'T SECURED IN PLACE AS IT SHOULD'VE BEEN. WE USED THE SAME LIFT AND PAD TO PUT THE RESIDENT BACK TO BED. NEITHER OF US RE-CHECKED THE STRAPS AFTER SHE CLEARED THE CHAIR. THAT'S JUST EATING AT ME THAT NEITHER OF US DID THAT; WE'VE BEEN TRAINED THAT WE'RE SUPPOSED TO RE-CHECK THE STRAPS TO BE SURE THEY'RE SECURE, AFTER WE LIFT THE RESIDENT FROM THE SURFACE." 2) BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION WITH MEALS IN 1 OF 7 SAMPLED RESIDENTS (#108), IN A TOTAL OF 7 SAMPLED RESIDENTS WITH SUPERVISION NEEDS, RESULTING IN RESIDENT #108 NOT RECEIVING SUPERVISION WITH MEALS WITH THE POTENTIAL FOR ACCIDENTS AND WORSENED MEDICAL CONDITION. RESIDENT #108 THE FACE SHEET REVEALED RESIDENT #108 WAS A [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS ((MDS) dated [DATE], REVEALED RESIDENT #108 WAS SEVERELY COGNITIVELY IMPAIRED AND REQUIRED EXTENSIVE ASSISTANCE FROM FACILITY STAFF WITH EATING. DURING AN INTERVIEW ON 5/21/2012 AT 2:45 P.M., CNA #30 SAID, "I WAS ASSIGNED TO RESIDENT #108 ON 5/10/2012 FROM 2:30 P.M. TO 11:00 P.M. I SAW HER COME INTO THE SOUTH DINING ROOM, IN HER WHEELCHAIR. SHE WAS TAKEN TO TABLE #2; HER USUAL SPOT. I SAW THAT SHE HAD RECEIVED HER MEAL TRAY. THERE WERE NO COVERS ON THE TRAYS. I CONTINUED TO PASS TRAYS FOR ANOTHER 10 TO 15 MINUTES, EVEN WHEN I SAW THAT EVERYONE AT THE TABLE HAD THEIR TRAYS. I WAS THE LAST ONE TO FINISH PASSING TRAYS. RESIDENT #108 WAS EATING FROM HER TRAY. THERE WAS NO ONE AT TABLE #2 WHILE I CONTINUED TO PASS TRAYS TO OTHER TABLES. THE SOUTH DINING ROOM IS A SPECIAL DINING ROOM FOR RESIDENTS WHO NEED ASSISTANCE WITH MEALS. THEY'RE SUPPOSED TO BE SUPERVISED, TO LIFT CUPS TO THEIR MOUTHS, AND GET VERBAL CUES ALSO. THIS IS TO KEEP THEM SAFE. RESIDENT #108 DID HAVE SOUP ON HER TRAY AND SHE HAD HALF OF IT GONE WHEN I GOT BACK TO THE TABLE." DURING AN INTERVIEW ON 5/23/2012 AT 2:20 P.M., OCCUPATIONAL THERAPIST #21 SAID, "ON 8/11/2010, I ASSESSED RESIDENT #106 AS A MAXIMUM ASSIST WITH MEALS. THAT MEANS ANYTIME FOOD OR FLUIDS ARE AT THE TABLE A STAFF MEMBER SHOULD BE WITH HER TO SUPERVISE AT THE VERY LEAST, AND SHE SHOULD NEVER BE LEFT UNATTENDED. SHE IS STILL OK TO USE A KENNEDY CUP, WHICH HAS A LID, AND CONSUME A COLD BEVERAGE WITHOUT A STAFF MEMBER PRESENT AT HER TABLE TO SUPERVISE. AS OF 3/31/2012 RESIDENT #108 WAS EXTENSIVE ASSISTANCE WITH MEALS. A STAFF MEMBER, IN THE PRESENCE OF HOT FOODS AND HOT BEVERAGES/SOUP, SHOULD HAVE BEEN A THE TABLE WITH RESIDENT #108 ON 5/10/2012, WHEN THE TRAY WAS SERVED WITHOUT A LID TO THE RESIDENT. IT WAS NOT SAFE FOR A STAFF MEMBER NOT TO BE AT HER TABLE, SUPERVISING HER." DURING AN INTERVIEW ON 5/23/2012 AT 2:55 P.M., THE NURSING HOME ADMINISTRATOR SAID, "I EXPECT FACILITY STAFF TO PROVIDE THE ASSISTANCE REQUIRED FOR SAFETY, CARE, AND THE NEEDS OF THE RESIDENT."

This citation pertains to intake MI 661. This deficient practice has multiple (A & B) deficient practice statements. A. Based on observation, interview, and record review, the facility failed to ensure the safety and prevent the elopement in 1 of 7 sampled residents (Resident #101), who were identified as an elopement risk, resulting in an Immediate Jeopardy when, Resident #101, who was identified as an elopement risk and had a history of [REDACTED].#30, ambulating outside the facility approximately 213 feet from the front door without his WanderGuard on, as care planned. This deficient practice placed 21 additional residents, identified as elopement risks, at risk for serious harm, injury and/or death. Findings include: Resident #101: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #101 had moderate cognitive impairments and required supervision when ambulating on and off the unit. Review of the "Elopement and/or Exit Seeking Behavior Risk Analysis" Form, dated 10/26/11, revealed "Resident (Resident #101) is at Risk" for elopement, and has a "history of exiting facility". Review of the Elopement Risk Care Plan, dated 10/17/11, last updated 3/21/12, revealed Resident #101 had been identified as an elopement risk and a wanderer due to impaired safety awareness and a [DIAGNOSES REDACTED]." Per the Elopement Care Plan, Resident #101 ambulated independently throughout the facility and had a history of [REDACTED]. Interventions included: a "WanderGuard Alert" bracelet, and "Redirect me if you see me approaching exits". Review of the "Unusual Occurrence" Report, dated 3/11/12, revealed Resident #101 eloped from the facility at 2:05 PM. In an interview on 3/22/12 at 1:51 PM, CNA #10 stated that she last observed Resident #101 sitting in the lobby area, by the front door of the facility between 1:15 and 1:30 PM. In an interview on 3/22/12 at 2:42 PM, Registered Nurse (RN) #4 stated that she last observed Resident #101 standing in the "300 Hallway" with his walker at approximately 1:30 PM. Review of Resident #101's "Resident Care Guide" (undated), a care guide for nurses aides, revealed behaviors exhibited by Resident #101 included "exit seeking, wandering, and elopement risk" and interventions included an "exit guard device" (WanderGuard bracelet). Review of the "Behaviors" Care Plan, dated 10/17/11 and last updated 3/10/12, revealed Resident #101 had a history of [REDACTED]. In an interview on 3/22/12 at 1:51 PM, Certified Nurses Aide (CNA) #10 stated "I know he (Resident #101) has taken them (WanderGuard bracelet) off before, I don't know for sure when, but I do know that he had tooken (sic) it off before...I heard he had done it before". In an interview on 3/22/12 at 2:56 PM, when asked if Resident #101 had a history of [REDACTED].#5 stated, "I know they have had issues (removing WanderGuard) like that before, I have talked to him (Resident #101) about leaving it on and stuff...". Review of the Fall Care Plan, dated 9/26/11, revealed Resident #101 had been identified as at risk for falls, related to a history of falls, the "progression of Alzheimer's Dementia", as well as a [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], revealed Resident #101 had signs and symptoms of delirium with behaviors of inattention, and disorganized thinking. In an observation and interview on 3/22/12 at 10:15 AM, in the "Activities Room", Resident #101 stated he "just wanted to go on a walk, so I walked out the front door...I just wanted to get some exercise...they come looking for me". Resident #101 was observed seated with a four wheeled walker, adjacent to his person and appeared well groomed. In an interview on 3/22/12 at 3:48 PM, un-sampled Resident #30 reported "sometime after lunch" she saw Resident #101 outside in the parking lot and knew he shouldn't be outside by himself, so she went and told a "Nurse". Un-sampled Resident #30 was alert and oriented to person, place and time. Review of the Facility Witness Statement, dated 3/16/12, revealed CNA #8 documented that she was "told" by un-sampled Resident #30 that Resident #101 was outside and she "seen (sic) resident walking down facility driveway towards road". In an interview on 3/27/12 at 11:41 AM, CNA #8 confirmed that the written statement was true and accurate. CNA #8 stated she was "working the 400 Hall" on the day Resident #101 eloped, on 3/11/12. CNA #8 stated as she was coming down the hallway, "a resident (Un-sampled Resident #30) told me a resident (Resident #101) was outside..I ran into the room she pointed to and saw no one, so I ran down to the end of 400 and seen him (Resident #101) walking down the driveway, I yelled to get the other tech and then went to push open the door, but I was panicking and couldn't get the door open..." In an interview on 3/22/12 at 2:15 PM, LPN #6 stated at about 1:30 PM, an aide reported to her that Resident #101 was outside. LPN #6 stated, "We went out and found him walking in the driveway." LPN #6 stated when she escorted Resident #101 back into the facility, his WanderGuard did not sound, "The WanderGuard was on his bed with kid safety scissors". Review of the Nurse's Note, dated 3/11/12 at 2:35 PM, revealed at the time of Resident #101's elopement, "WanderGuards were not in place...when asked pt (Resident #101) how/why he took WanderGuards off, 'I cut them off with my scissors'." During the onsite investigation on 3/22/12 at 1:40 PM, CNA #12 identified the location to the Surveyor, where Resident #101 was found, in the driveway of the facility. Observations were made of the distance from the front door of the facility, to the location where Resident #101 was found, and measured by the surveyor to be approximately 194 feet. In an interview on 3/22/12 at 1:46 PM, Director of Nursing (DON) #1 stated a measurement was taken by the facility, using a wheeled measuring device of how far Resident #101 had eloped from the facility. DON #1 reported the measurement obtained was "213 feet". During the initial tour of the facility on 3/22/12, between 9:10 AM and 9:48 AM, all WanderGuards were tested for placement and functionality for residents identified as an elopement risk and who had an intervention of a WanderGuard. This surveyor, accompanied by facility staff, identified two residents with non-functional WanderGuards at 9:43 AM (Resident #102) and 9:45 AM (Resident #103). In an observation on 3/22/12, during the initial tour with Registered Nurse (RN) #3, starting at 8:49 AM, an activated WanderGuard bracelet was used to establish the functionality of all alarmed WanderGuard doors and exits, all were observed to be properly functioning. The DON #1 was notified on 3/23/12 at 5:00 PM of the Immediate Jeopardy that was identified on 3/22/12 and began on 3/11/12 as a result of the facility's failure to ensure the safety and prevent the elopement of Resident #101, who eloped unbeknownst to facility staff, on 3/11/12 at approximately 2:05 PM, and was observed by un-sampled Resident #30, ambulating outside the facility approximately 213 feet from the front door. On 3/26/12 at 10:00 AM the Surveyor confirmed that the facility staff completed the following to remove the Immediate Jeopardy: 1. Resident #101 was re-assessed for elopement risk on 3/12/12 and a Behavioral Management Meeting was held on 3/23/12 at 1:30 PM. Resident #101's WanderGuard was checked for proper placement and functioning on 3/11/12. Resident's careplans, careguide, and behavior log have all been updated. 2. Resident #102 was reassessed on 3/22/12 for possible elopement risk. IDT (Inter Disciplinary Team) determined resident #102 to no longer be an elopement risk. WanderGuard was therefore removed from resident. Careplans, careguide, and behavior log updated on 3/23/12 to reflect the changes. 3. Resident #103 had her WanderGuard replaced and is functioning correctly. Careplans, careguide, and behavior log reviewed and deemed appropriate. WanderGuard was replaced on the morning of 3/22/12. 4. 74 Residents identified through behavior management and/or elopement risk have had their rooms searched for potential sharp objects on 3/22/12. All issues were corrected. During the search toe nail clippers, scissors, a butter knife and a pocket knife were found. All items were removed and the pocket knife was given to the resident's family member for safe keeping with his permission. 5. Clinical Care Coordinators's conduct weekly audits of the medication administration records (MAR) to ensure WanderGuard checks are complete. Any identified areas will be addressed immediately. Last audit was completed on 3/23/12. 6. 121 residents were assessed utilizing the Elopement Risk Audit Tool on 3/23/12. No newly identified residents were noted to be at risk for elopement. 7. All four elopement books were updated 3/23/12. 8. In-servicing of all staff started on 3/23/12 regarding elopement and exit seeking policy. 54 of 159 are completed at this time. All on-coming staff will be in-serviced prior to the start of their shifts. 9. Resident #101 was given one-on-one supervision per facility staff on 3/23/12 at 7:30 PM. To be supervised 24 hours a day. 10. Physician orders [REDACTED]. 11. Weekend manager will review the behavior logs starting 3/24/12 to assure that all elopement/exit seeking concerns, comments or changes are followed up and addressed immediately. 12. Resident #101's family was contacted to pursue alternate placement to a locked unit. Although, the Immediate Jeopardy was removed on 3/23/12, 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 sustained compliance had not been verified by the State Agency and all staff had not yet been in-serviced. ( ) B. Based on observation, interview, and record review, the facility failed to ensure the functionality of safety devices (WanderGuard bracelets) in 2 of 24 residents, reviewed for WanderGuard functionality, from a total of 7 sampled residents, resulting in the potential for resident elopements. Resident #102: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #102 was a [AGE] year old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #102 had severe cognitive impairments and required extensive one-person physical assist with activities of daily living. Review of the "Elopement and/or Exit Seeking Behavior Risk Analysis" Form, dated 10/26/11, revealed the "Resident (Resident #102) is at Risk" for elopement as evidenced by verbalization of the desire to leave the facility and exhibits wandering "at times". In an observation on 3/22/12 at 9:43 AM, Resident #102 was observed to have a WanderGuard on her right wrist. RN #2 checked the WanderGuard for functionality and it was found to be malfunctioning. Resident #103 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #103 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #103 had severe cognitive impairments and required extensive staff assistance with activities of daily living. Review of the "Elopement and/or Exit Seeking Behavior Risk Analysis" Form, dated 8/10/11, revealed the "Resident (Resident #103) is at Risk" for elopement as evidenced by a history of elopements, attempts to leave the facility, verbalization of the desire to leave the facility and exhibits wandering "at times". In an observation on 3/22/12 at 9:45 AM, Resident #103 was observed to have a WanderGuard on her right wrist. RN #2 checked the WanderGuard for functionality and it was found to be malfunctioning. ( )