Every finding on record at Gladwin Nursing and Rehabilitation Community

This citation pertains to intake #3010300. Based on interview and record review, the facility failed to follow policy to ensure a safe leave of absence for 1 resident (R101) of 3 residents reviewed. Findings include:Review of a Face Sheet revealed R101 initially admitted to the facility on [DATE] with pertinent diagnoses which included dependence on oxygen, osteoarthritis, depression, and chronic respiratory failure. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R101, with a reference date of 3/14/2026 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12, out of a total possible score of 15, which indicated R101 had been moderately cognitively impaired. Review of R101's Progress Note in the Electronic Medical Record (EMR), dated 5/1/2026 at 12:38 PM revealed . R101 questioned this writer as to how much the (city) bus cost, writer responded that cost was unknown at this time and he could call and ask in the morning, he was fine with that. (R101) did let writer know he was going to go out again on Friday, writer will let oncoming nurse know of these plans, resident is not safe to go out by himself, he requires oxygen at all times and uses a wheelchair for any long distances or he get very SOB (short of breath). Further review of R101's Progress Notes on 5/5/2026 at 11:01 PM, revealed .(R101) reported to staff that he was LOA (Leave of Absence) today, for several hours. (facility) unsure of events that happened while LOA today. In in an interview on 5/26/2026 at 2:00 PM, the Social Service Director (SSD) H reported that the facility would assess residents upon admission to ensure they are safe for an independent leave of absence. SSD H reported that R101 was assessed to not go out alone on LOA's and stated that R101's sister usually transports him for LOA's. SSD H reported that R101 was his own person and able to make his own decisions. SSD H reported that although R101 was not safe to go on a LOA alone, she could not stop him from doing so. In a phone interview on 5/26/2026 at 2:30 PM, Family Member (FM) G reported that R101 had left the facility and boarded a (city) bus to travel to his home. FM G reported that R101 had been observed by his neighbor to be loading a 65-inch television into his truck and had no oxygen on. FM G reported that R101's neighbor loaded belongings into the truck and assisted him back to the facility. Review of R101's current Physician Orders on 5/26/2026 at 3:00 PM, revealed that R101 did not have an active order for a leave of absence at the time he left the faciity on 5/5/26. In an interview on 5/27/2026 at 9:33 AM, Certified Nursing Assistant (CNA) E reported that she signed out R101 on 5/5/2026 at 1:00 PM for a leave of absence (LOA). CNA E reported that R101 was only supposed to go to the bank and grocery store and return to the facility. CNA E explained that if a resident was not safe to go on a LOA a nurse would have alerted her to that information. CNA E reported that the Director of Nursing (DON) had assisted her with R101's oxygen tank prior to R101 leaving the facility. CNA E reported that R101 returned right before her last facility check which would have been 4:00 PM. In a telephone interview on 5/27/2026 at 9:45 AM, Licensed Practical Nurse (LPN) A reported that she would review a resident's physicians orders for a leave of absence order and if there were specific instructions for that leave of absence such as needed equipment, supervision, and medications. In an interview and record review on 5/27/2026 at 10:00 AM, the DON reported that R101 should have his care plan updated to reveal that he would not be safe for an independent LOA. The DON reported that upon review of R101's EMR there was no physician order for R101 to leave the facility on 5/5/2026. Review of facility policy/procedure Leave of Absence/Against Medical Advice, reviewed 01/25, revealed .the resident is his or her own responsible party, signed the themselves into the facility upon admission and has a Physician's order that enables them to have leave of absence.The resident may or may not be their own responsible party, have a guardian or a family member that request to take the resident out of the facility. The resident must have a Physicians order to leave the facility.the facility must be aware of when the resident is leaving, where they are going and their projected time of return.it is the Charge Nurse and/or Social Worker's responsibility to verify that the resident was appropriately signed out of the facility.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP) and failed to store linens in a manner that would prevent the spread of infection, resulting in the potential for increased risk of respiratory infection among all residents in the facility and resulting in the increased risk of adverse outcomes for residents.Water:On 01/06/2026 at 11:12AM, observed in kitchen, two water lines coming out of floor under a stainless-steel counter. One of the lines did not provide water to any equipment and was capped at the end, this line was over 12 inches long from the point it comes out of the floor. The other line branched off into two different areas, one of those lines that branched off was also capped off over 6 inches from the point it branched off, the other branched off and fed the coffee maker. In an interview on 01/06/2026 at 2:40PM, Maintenance Supervisor (MS) J disclosed he was unaware of these lines and has not been flushing them. In an observation on 01/06/2026 at 2:50PM, in the [NAME] Hallway B bathing room, two capped water lines coming out of the wall. Interview with MS J disclosed the removal of the tub was within the past year, currently the lines are not being flushed as there is no easy access to flush them. Review of the Water Pathogen Risk Reduction policy; states 5. Routine reassessment annually and when there are changes that could impact risk. Linen:In an observation on 01/06/2026 at 3:20 PM, in [NAME] Hallway A bathing room, there was a linen cart with clean linens stored on it, the covering used for the cart was a blue mesh that would allow for infiltration from airborne droplets from toilet being flushed, handwashing or possible bodily fluids. The linen cart was stored partially in front of the toilet, allowing access to the toilet and the handsink across the wall from the linen cart. In an interview on 01/06/2026 at 3:20PM, Maintenance Supervisor (MS) J stated the cart is stored in bathing room when the shower or toilet are not in use.

Based on observation, interview, and record review, the facility failed to address grievances for 1 resident (R30) out of 12 of residents reviewed.Findings included: Based on observation, interview and record review the facility failed to address grievances for 1 resident (R30) out of 12 of residents reviewed.Findings included:Review of R30's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included acute and chronic respiratory failure, pneumonia, chronic obstructive pulmonary disease, and sleep apnea. R30 was her own responsible party.R30 was observed in bed on 1/5/26 at 11:44 AM. R30 was using oxygen at 4 liters via an oxygen concentrator (machine). The oxygen concentrator and a breathing machine were at the end of R30's bed out of her eyesight and reach. R30 complained of staff taking off her breathing machine when she was not fully awake and not putting her nasal canula in place for her oxygen. R30 said this was a daily problem. R30 reported that new staff do not know how to provide care for her and the other day one of the nurses refused to hold her urinal for her. R30 said she does not currently have a back brace that fits right, and she keeps asking when she is going to get a brace as she cannot tolerate being out of bed long due to back pain. R30 was very upset and said she gets very worked up because no one listens to her.Review of R30's BEHAVIOR NOTE: dated 1/2/26 at 9:03 AM revealed, (R30's name) is with call light on. Agency CENA (Certified Nurse Assistant) in to answer call light. R30 tells CENA I need my pee cup. Per report from day shift CENA, R30 needs assist with applying urinal but can hold it (per agency CENA). Agency CENA assisted with placement and told R30 she would be back in a few minutes to empty it. R30 begins screaming at the CENA and throws the urinal at the CENA. R30 tells nurse that she can not use pee cup with out staff assistance. R30 says she would prefer to just pee in a diaper. R30 is swearing and screaming at nurse, pointing her finger in nurses face during this conversation.During an interview with Certified Nurse Aide (CNA) N on 1/6/26 at 8:32 AM, CNA N was asked about R30. CNA N said R30 can not hold her urinal and is frequently upset when new staff do not provide the care she needs. CNA N was aware of the incident when the Agency CNA did not hold the urinal. CNA N said the licensed nurses are aware of the concerns.During an interview with the Director of Nursing (DON) on 1/6/26 at 8:53 AM the DON was asked if she was aware of R30's concerns about staff not holding R30's urinal and reporting she can do it herself. The DON denied knowledge of R30 being upset with care and staff not holding her urinal during care. The DON reviewed R30's progress note dated 1/2/26 at 9:03 AM which revealed R30 was having behaviors and the agency nurse did not hold R30's urinal during care. The DON confirmed R30 cannot hold her own urinal and the staff involved need to be educated. The DON did not know anything about R30's back braces.During an interview with R30 on 1/6/26 at 9:13 AM, R30 said sometime this morning she woke up and her breathing machine was off, and she was not on oxygen. R30 said staff did not respond to her call light so she called the facility and told them if someone did not get in there immediately to put her oxygen on, she was going to call 911. Review of R30's cell phone outgoing phone log revealed that she had called the facility at 5:13 AM on 1/6/26. R30 was in bed at this time with her oxygen at 4 liters.During an interview with the Nursing Home Administrator (NHA) on 1/6/26 at 9:15 AM the NHA confirmed that R30 had made the same allegation to him about being left this morning without oxygen and he was in the process of investigating this and reporting it to the State.During an interview with the Director of Nursing (DON) on 1/6/26 at 9:36 AM the DON confirmed that she was just told about R30's allegation of being left with her breathing machine off and no oxygen earlier this morning. All documentation related to R30's respiratory assessment, treatments and breathing equipment was requested at this time.During an interview with the DON on 1/7/26 at 7:52 AM the DON said she was looking into the oxygen concern from 1/6/26 and did not have any information on R30's back braces other than the one she was admitted with. DON could not locate any information on the other braces R30 had received since admission.During an interview with the Nursing Home Administrator (NHA) on 1/7/26 at 8:03 AM the NHA said she was still investigating R30 allegation related to not having her oxygen in place on 1/6/26 and he said he did not have any concern forms from R30. He confirmed staff had not made him aware of R30 concern about staff refusing to hold her urinal during care or any other care concerns. He was aware R30 had several back braces since admission but was not aware she still did not have a back brace that met her needs.Review of R30's care plan dated 4/25/25 revealed, R30 requires use of BIPAP R/T (related to) 4/26/17 diagnosis of obstructive sleep apnea. The goal revealed, R30 use of BIPAP machine will assist her to breathe more easily and promote rest/sleep and prevent further rehospitalization d/t (due to) acute respiratory failure with hypoxia and hypercapnia (excessive carbon dioxide in bloodstream). Interventions included: BiPap machine setting will be preset by company supplier. There was no indication of when the BiPap was to be used or how much assistance R30 required with set up and use.Review of R30's ADL (activities of daily living) care plan dated 4/7/25 revealed she required assistance of 2 people and a mechanical lift for transfers. There was no indication how much assistance she needed to use her breathing machine. There was no indication she used a urinal.Review of R30 care plan dated 4/2/25 revealed, (R30's name) has potential for/actual pain related to lumbar compression fracture of L4, effect of chronic heart failure, adverse effects of DM (diabetes mellitus) and cardiac events. There was no indication a back brace was ever issued or used.Review of the facility Grievances/Concerns policy dated 1/2023 revealed, Purpose: To support each resident's right to voice grievances and ensure that a policy is in place to process grievance. Providing prompt actions to resolve grievances/concerns and to keep the resident appraised of progress toward resolution. Procedure: 4. Upon receipt of a grievance, an immediate action will be implemented to prevent further potential violation of any resident right while the alleged violation is being investigated. 5. If an alleged violation involving neglect, abuse, including injuries of unknown source, and or misappropriation of resident property is reported the facility will reference and follow Abuse & Neglect Procedures, Standards of Care Volume. A Grievance/Complaint Form was attached to the policy. Upon exit the facility did not provide any Grievance/Complaint Forms for R30.

Based on interview and record review, the facility failed to provide medications at discharge or attempt to assist with a safe discharge plan for 1 resident (R45) of 1 resident reviewed for discharge planning. Findings include:Review of an admission Record revealed R45 admitted to the facility on [DATE] with pertinent diagnoses which included chronic respiratory failure and repeated falls. Review of R45's Discharge Against Medical Advice document dated 10/12/2025 at 11:34 AM revealed he was discharged from the facility the morning of 10/12/2025 against medical advice (AMA) by Registered Nurse (RN) B. Review of R45's Progress Note dated 10/12/2025 written by RN B revealed R45 demanded to be discharged that morning so that he could take his medications the way he would like. RN B instructed R45 if he left AMA he would be discharged without medications, equipment, oxygen, home health services, or therapy. R45 left the facility with friends at 11:50 AM without medications or services. In a telephone interview on 1/7/2026 at 9:28 AM, RN B stated when residents leave AMA, We try to educate them to stay as much as possible, but sometimes they decide to go AMA, and we can't change their mind. We have been trained that when they go AMA, they go without anything. RN B confirmed R45 left the facility AMA the morning of 10/12/2025 without attempting to meet any of R45's discharge needs. RN B reported R45 had medication at the facility, but he was not given these medications upon his AMA discharge. In an interview on 1/7/2026 at 9:58 AM with the Director of Nursing (DON) and Regional Nurse A, the DON confirmed facility staff had been trained not to attempt to provide medication or services to residents when they discharge AMA. Regional Nurse A reported she would like to see an attempt to provide as much support and services as possible in AMA discharge situations.

Based on observation, interview and record review, the facility failed to provide showers as ordered for 1 resident (R50) out of 12 residents reviewed for care.Findings included:Review of R50's face sheet, no date, revealed he was an [AGE] year-old male admitted to the facility on [DATE] he had diagnoses that included: Sepsis, opioid use, spinal stenosis, heart failure and glaucoma. He was his own responsible party.R50 was observed in his room in a recliner on 1/5/26 at 10:36 AM. R50 had general care concerns and reported he had not had a shower since admission on [DATE] and when he requested one this morning, he was told his shower days are Wednesday and Saturday.During an interview with Certified Nurse Aide (CNA) N on 1/5/26 at 10:45 AM, CNA N confirmed that R50 had inquired about his shower this morning and she told him his shower days were Wednesday and Saturday. The Surveyor asked if she knew why R50 had not received a shower since admission and CNA N said she had no idea, but she would look into it and make sure he got a shower today.During an interview with the Director of Nursing (DON) on 1/6/26 at 11:49 AM, the DON reviewed R50's medical record to see if she could determine if R50 had a shower since admission. The DON could not locate any documentation indicating he had been offered a shower since admission. The DON said showers are assigned by room and R50 should have been offered showers on Wednesday and Saturday during the day shift. On admission the nurse is to create and order for this. The DON discovered the order was not entered correctly and proceeded to correct the order. The DON was aware R50 did receive a shower on 1/5/26 after the Surveyor inquired about R50's lack of showers. Upon exit no documentation was provided that showers were attempted during the first week of admission.

Based on observation, interview, and record review, the facility failed to assess, monitor and effectively treat the respiratory condition of 1 resident (R30) of 1 resident reviewed for respiratory care.Findings include:Review of R30's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included acute and chronic respiratory failure, pneumonia, chronic obstructive pulmonary disease, and sleep apnea. R30 was her own responsible party.R30 was observed in bed on 1/5/26 at 11:44 AM. R30 was using oxygen at 4 liters via an oxygen concentrator (machine). The oxygen concentrator and breathing machine were at the end of R30's bed out of her eyesight and reach. R30 complained of staff taking off her breathing machine when she was not fully awake and not putting her nasal canula in place for her oxygen. R30 said this was a daily problem.During an interview with R30 on 1/6/26 at 9:13 AM, R30 said sometime this morning she woke up and her breathing machine was off, and she was not on oxygen. R30 said staff did not respond to her call light so she called the facility and told them if someone did not get in there immediately to put her oxygen on, she was going to call 911. Review of R30's cell phone outgoing phone log revealed that she had called the facility at 5:13 am on 1/6/26. R30 was in bed at this time with her oxygen at 4 liters.During an interview with the Nursing Home Administrator (NHA) on 1/6/26 at 9:15 AM, the NHA confirmed that R30 had made the same allegation to him about being left this morning without oxygen and he was in the process of investigating this and reporting it to the State.During an interview with the Director of Nursing (DON) on 1/6/26 at 9:36 AM, the DON confirmed that she was just told about R30's allegation of being left with her breathing machine off and no oxygen earlier this morning. All documentation related to R30's respiratory assessment, treatments and breathing equipment was requested.During an interview with the DON on 1/7/26 at 7:52 AM, the DON said all the night shift staff had not been interviewed yet to determine what happened with R30 at 5:13 AM when she allegedly was left without oxygen. The DON reviewed R30's Electronic Medical Record (EMR) and could not find any respiratory assessments documentation or R30 being followed by a pulmonologist. The DON could not determine when R30's breathing machine had last been assessed or what breathing machine was currently in use. The DON said the equipment company providing the breathing machine was contacted and has provided them with a report on R30's equipment use. The DON was able to get into hospital records (not the facility records) and could see R30 was evaluated when she was in the hospital in September 2025 and specific settings for R30's AVAP machine (Average Volume Assured Pressure) were recommended. The DON had no way to confirm R30 had the breathing machine recommended by the hospital or if the machine was at the settings recommended.Review of R30's progress note dated 1/6/26 at 1:39 PM revealed, Recorded as late entry on 1/7/26 at 7:25 AM, Follow up with (R30's name) following the situation this morning. She reports that she called the facility two times. (R30's name) showed me what time she called. I saw the last time she called was at 5:13 am. She stated that she is calming down after being worked up this morning. She said she needs them to make sure she is awake and she puts on her O2 in the morning, she woke up with her CPAP in her hand, then proceeded to punch her hand to show me where it was. She was feeling anxious this morning when she felt like she needed air. Review of R30's Physician progress note dated 10/19/25 at 8:38 AM revealed, admission visits for exacerbation of acute on chronic hypercapnic hypoxic respiratory failure. 3. Chronic hypoxic hypercapnic respiratory failure requires BiPAP (Bilevel Positive Airway Pressure) pursuant to further diagnosis of obesity hypoventilation syndrome. No BiPap settings were documented. There was no indication of a change in equipment or setting changes as indicated when the DON reviewed R30's hospital notes from September 2026. (DON interview indicated R30 should have been on an AVAP machine, not a BiPAP machine).Review of R30's care plan dated 4/25/25 revealed, R30 requires use of BIPAP R/T (related to) 4/26-17 diagnosis of obstructive sleep apnea). Goal revealed, R30 use of BIPAP machine will assist her to breathe more easily and promote rest/sleep and prevent further rehospitalization d/t (due to) acute respiratory failure with hypoxia and hypercapnia (excessive carbon dioxide in bloodstream). Interventions included: BiPap machine setting will be preset by company supplier. There was no indication of when the BiPap was to be used or how much assistance R30 required with set up and use.Review of R30's ADL (activities of daily living) care plan dated 4/7/25 revealed she required assistance of 2 people and a mechanical lift for transfers. There was no indication how much assistance she needed to use her breathing machine.Review of R30's progress note dated 1/7/26 at 4:49 AM revealed, Resident asked RN (registered nurse) to remove CPAP (Continuous Positive Airway Pressure and administer the O2, it was completed and spo2 98% CPAP cleaned and stored. (physician note referred to BiPap, hospital records referred to AVAP, and this nurse indicated the machine was CPAP).Review of R30's medical equipment report dated 10/1/25 to 1/6/26 (provided to the facility on 1/7/26) revealed R30 had a Resumed AirView machine with settings at Mode iVAPS, Target Alveolar Ventilation 4.6 L/min, EPAP 10 cmH2O, Min PS 16 cm H2O, Mas PS 20 cmH20, Target Patient Rate 14 bpm.During an interview with the DON on 1/7/26 at 11:15 am, the DON said R30 did not currently have the machine that was recommended by the hospital in September 2025. The equipment company supplying the machine has Respiratory Therapists and they reviewed R30 equipment function report on 1/6/26. They reported that R30's breathing report showed improvement, and they would be out today to assess R30 and make equipment recommendations to R30's physician and set up a program for monitoring safety/use, ongoing assessment and respiratory care for R30. All hospital respiratory records and facility respiratory records were requested for a second time. Upon exit no hospital records for R30 were provided. No pulmonary physician notes were provided. No ongoing respiratory assessments were provided.

Based on interview and record review, the facility failed to consistently conduct and document care conferences for 1 resident (R8) of 2 residents reviewed for care conferences. Findings include: Review of a resident Face Sheet revealed R8 admitted to the facility on [DATE] with pertinent diagnoses which included cardiomegaly, major depressive disorder, restless legs syndrome, lymphedema, and morbid obesity. Review of R8's electronic medical record on 01/06/2026 at 3:01 PM showed no evidence that required quarterly care conferences were held in 2025 for R8 until August 19, 2025. In an interview and record review on 1/6/2026 at 3:27 PM the Social Worker (SW) G revealed that care conferences are scheduled quarterly (occurring every three months). SW G could not locate any care conferences for R8 prior to August 19, 2025. SW G confirmed the facility has met with R8, but SW G was terrible with documentation. Review of facility policy/procedure Resident's Rights to Participate in Planning Care, updated 5/30/18, revealed .The Resident, resident representative and/or family members as requested by the resident will be invited to attend all care conferences and review and request revisions to the care plan, which will be conducted.following the completion of an OBRA (Omnibus Budget Reconciliation Act) assessment (defined as a schedule of assessments that will be performed for a nursing facility resident on admission, quarterly, and annually) , OR as requested by the resident or resident representative.

Based on interview and record review, the facility failed to ensure the monthly drug regimen review recommendations for 1 resident (R40) of 5 residents reviewed were accurately addressed. Findings include: Review of a resident Face Sheet revealed R40 admitted to the facility on [DATE] with pertinent diagnoses which included chronic systolic (congestive) heart failure, cardiomyopathy, major depressive disorder, type 2 diabetes mellitus with diabetic polyneuropathy, and seasonal allergic rhinitis. Review of R40's Consultation Report recommendation dated 10/22/2025 revealed Please discontinue Loratadine. Review of the Physician's Response revealed a line through I accept the recommendation above, please implement as written. The Physician signature on the report was dated 10/28/25. Review of R40's Progress Notes dated 10/28/2025 revealed Pharmacy recommendation to stop Loratadine to avoid adverse reactions attributed to daily long-term use. Doctor gave okay to discontinue medication. Resident aware. Review of R40's Physician's Orders on 1/7/2026 at 10:33 AM revealed an active order for Loratadine tablet 10 mg once a day PRN (as needed) started 10/28/25. Further review of the electronic Medication Administration Record revealed Loratadine tablet 10 mg had been administered on 11/1/25, 11/2/25, 11/29/25, and 12/27/25. In an interview and record review on 01/07/2026 at 10:27 AM, the Director of Nursing (DON) reported R40's Consultation Report review recommendation dated 10/22/2025 had not been accurately addressed by the facility. The DON was unable to produce documentation that Loratadine should have been continued. Review of facility policy/procedure Medication Regimen Review, reviewed 06/01/24, revealed .facility should independently review each resident's medication regimen directly from the resident's medical record and with interdisciplinary care team members.to rule out any medication dispensing or administration errors .

Based on observation and interview, the facility failed to provide adequate access to the call light system, increasing the risk of possible adverse outcomes for residents who use the [NAME] Hallway A bathing room. Findings include: During an observation on 01/06/2026 at 3:45 PM, there was not a pull cord for the call light in the shower of the [NAME] Hallway A bathing room, not allowing accessibility for residents who may have fallen or could not reach the call light on the shower wall. In an interview on 1/6/26 at 3:45 PM, Maintenance Supervisor (MS) J indicated he was not aware the pull cord was missing, at that time he validated the call light was functional. MS J said the [NAME] Hallway A bathing room is generally used by residents in the Main hallway and [NAME] Hallway A.

Based on interview and record review, the facility failed to provide 1 Resident (R50) and his representative with a written and completed baseline care plan within 48 hours of admission of 4 residents reviewed for care plans.Findings included:Review of R50's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] he had diagnoses that included: Sepsis, opioid use, spinal stenosis, heart failure and glaucoma. He was his own responsible party and had an emergency contact.During an interview with R50 on 1/5/26 at 10:36 AM, R50 expressed concerns about his care and discharge plans. R50 said he had not received a care plan since administration.During an interview with Social Worker (SW) G on 1/6/26 at 11:39 AM, SW G was informed R50 had care and discharge concerns. SW G was asked about the baseline care plan, and she said nursing provided the baseline care plan. SW G reported they try to do a care conference within 72 hours but because of the holiday they did not get to do a care conference until 1/5/26. SW G said they do not provide a written care plan at the care conference.Review of R50's baseline care plan dated 12/29/25 revealed the Director of Nursing (DON) completed the baseline care plan, resident discharge goals, home, resident goals on admission for NF (nursing facility) stay, Rehab Services, Therapy Orders was blank, PT (physical therapy) was blank, OT (Occupational Therapy) was blank, ST (Speech Therapy) was blank, he was at risk of infection, Skilled resident utilizing their Medicare Benefit, and Medication, Matrix (electronic medical record system used by the facility).During an interview with the Director of Nursing (DON) on 1/7/26 at 11:00 AM, the DON reviewed R50's baseline care plan for R50 and confirmed she completed it. The care plan did not list R50's medications, it did not give the frequency of any therapy visits, there was no indication of nursing assistance being provided or assistance required for care and it did not give any indication R50's advocate was contacted or provided a copy of the care plan. There was no indication that R50 was provided with a written copy of his baseline care plan. The DON was asked if R50's advocate was contacted and she said no. The DON was asked if she provided R50 and his advocate a copy of his baseline care plan and she said, no.Review of the facility Baseline care plan policy, no date revealed, Intent: To ensure each resident receives necessary care and services upon admission. Completion and implementation of the baseline care plan within 48 hours of the resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the of the baseline care plan.

Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive respiratory care plan for 1 resident (R30) out of 1 resident reviewed for respiratory care.Findings included:Review of R30's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included acute and chronic respiratory failure, pneumonia, chronic obstructive pulmonary disease, and sleep apnea. R30 was her own responsible party.R30 was observed in bed on 1/5/26 at 11:44 AM. R30 was using oxygen at 4 liters via an oxygen concentrator (machine). The oxygen concentrator and breathing machine were at the end of R30's bed out of her eyesight and reach. R30 complained of staff taking off her breathing machine when she was not fully awake and not putting her nasal canula in place for her oxygen. R30 said this was a daily problem.During an interview with R30 on 1/6/26 at 9:13 AM, R30 said sometime this morning she woke up and her breathing machine was off, and she was not on oxygen. R30 said staff did not respond to her call light so she called the facility and told them if someone did not get in there immediately to put her oxygen on, she was going to call 911. Review of R30's cell phone outgoing phone log revealed that she had called the facility at 5:13 am on 1/6/26. R30 was in bed at this time with her oxygen at 4 liters.During an interview with the Nursing Home Administrator (NHA) on 1/6/26 at 9:15 AM, the NHA confirmed that R30 had made the same allegation to him about being left this morning without oxygen and he was in the process of investigating this and reporting it to the State.During an interview with the Director of Nursing (DON) on 1/6/26 at 9:36 AM, the DON confirmed that she was just told about R30's allegation of being left with her breathing machine off and no oxygen earlier this morning. All documentation related to R30's respiratory assessment, treatments and breathing equipment was requested.During an interview with the DON on 1/7/26 at 7:52 AM, the DON reviewed R30's Electronic Medical Record (EMR) and could not find any respiratory assessments documentation or R30 being followed by a pulmonologist. The DON could not determine when R30's breathing machine had last been assessed or what breathing machine was currently in use. The DON said the equipment company providing the breathing machine was contacted and has provided them with a report on R30's equipment currently in use. The DON was able to get hospital records (not the facility records) and could see R30 was evaluated when she was in the hospital in September 2025 and specific settings for R30's AVAP machine (Average Volume Assured Pressure) were recommended. The DON had no way to confirm R30 had the breathing machine recommended by the hospital or if the machine was at the settings recommended.Review of R30's Physician progress note dated 10/19/25 at 8:38 AM revealed, admission visits for exacerbation of acute on chronic hypercapnic hypoxic respiratory failure. 3. Chronic hypoxic hypercapnic respiratory failure requires BiPAP (Bilevel Positive Airway Pressure) pursuant to further diagnosis of obesity hypoventilation syndrome. No BiPap settings were documented. There was no indication of a change in equipment or setting changes as indicated when the DON reviewed R30's hospital notes from September 2026. (DON interview indicated R30 should have been on an AVAP machine, not a BiPAP machine).Review of R30's care plan dated 4/25/25 revealed, R30 requires use of BIPAP R/T (related to) 4/26/17 diagnosis of obstructive sleep apnea. The goal revealed, (R30) use of BIPAP machine will assist her to breathe more easily and promote rest/sleep and prevent further rehospitalization d/t (due to) acute respiratory failure with hypoxia and hypercapnia (excessive carbon dioxide in bloodstream). Interventions included: BiPap machine setting will be preset by company supplier. There was no indication of when the BiPap was to be used or how much assistance R30 required with set up and use. There was no indication of any ongoing respiratory assessments or monitoring of the BiPap machine functions/setting. There was no indication how they were to monitor the machine was in use when the resident was sleeping or how they would monitor or be alerted if it came off during sleep.Review of R30's ADL (activities of daily living) care plan dated 4/7/25 revealed she required assistance of 2 people and a mechanical lift for transfers. There was no indication how much assistance she needed to use her breathing machine.Review of R30's medical equipment report dated 10/1/25 to 1/6/26 (provided to the facility on 1/7/26) revealed R30 had a Resumed AirView machine with settings at Mode iVAPS, Target Alveolar Ventilation 4.6 L/min, EPAP 10 cmH2O, Min PS 16 cm H2O, Mas PS 20 cmH20, Target Patient Rate 14 bpm. (This machine did not have a care plan).During an interview with the DON on 1/7/26 at 11:15 am, the DON said R30 did not currently have the machine that was recommended by the hospital in September 2025. The equipment company supplying the machine has a Respiratory Therapists and they reviewed R30's equipment function report on 1/6/26. They reported that R30's breathing report showed improvement, and they would be out today to assess R30 and make equipment recommendations to R30's physician and set up a program for monitoring safety/use, ongoing assessment and respiratory care for R30. All hospital respiratory records and facility respiratory records were requested for a second time. Upon exit no hospital records for R30 were provided. No pulmonary physician notes were provided. No ongoing respiratory assessments were provided.

This citation pertains to intake #MI00151153 Based on observations, interviews and record review, the facility a failed to implement their hot liquid policy, accurately assess and implement a safe hot liquid program for 1 Resident (R1) of four residents reviewed, resulting in a second-degree burn caused by a hot liquid. Findings included: A second-degree burn damages the full thickness of the skin causing redness, swelling, blisters and intense pain. Review of R1's face sheet, no date, revealed he was [AGE] years old, admitted on [DATE]. He was on hospice. He had diagnoses that included dementia, metabolic encephalopathy (brain disorder causing brain dysfunction), diabetes mellitus type 2, and falls. Review of the facility Hot/Liquid Food Management policy dated 5/2019 and reviewed 1/2025 revealed, 4. Residents identified through the assessment process as at risk for injury related to exposure to hot liquids shall not be left unsupervised during meal service while pending completion of evaluation. Review of R1's admission Hot Food/Liquid assessment dated [DATE] revealed, yes, resident had poor hand control, yes, moderate to severe vision impairment, no, dementia, no, impulsive acts/short tempered or behavior concerns, he was not dependent feeding himself. The section under the assessment revealed, If any of the questions above are answered with a Yes, STOP! The resident is considered to be high risk for possible management of hot foods or fluids that could place them at risk for injury. The only box marked below this section was to have a cup with a lid. No other safety recommendations were made. Review of R1's progress note dated 3/25/25 at 2:39 PM revealed, R1 has been great during the day. He is friendly and talkative He has been in the dining room spending time with his daughter and wife. He as continued 1:1 from about the hours of 5p -9p. Nursing reports once he is in bed for the evening he does well. He has not been agitated or aggressive towards any residents. He only acts out when staff attempt to redirect him when exit seeking. Review of R1's progress note dated 3/25/25 at 8:35 PM revealed, At approximately 4:30 PM, ADON (Assistant Director of Nursing) got a cup of coffee for R1 from the kitchen. Coffee was poured from a less than half full pot and added 2 creams and 1 sweetener. Lid was placed on coffee cup and given to R1. Another resident wanted coffee so this nurse went to get a coffee for the other resident. When this nurse came out of the kitchen R1 was in the center of the dining room and coffee cup was on the floor. CNA (Certified Nurse Aide) changed R1, area on inner thigh was pink, she put cold washcloths on area. His nurse came in his room, seen it, notified (name of doctor) and was awaiting orders. 2030 (9:30 PM) returns to bed, tx (treatment) to heel completed, res (resident) with no c/o (complaint of) thigh areas/burn from earlier in day. Review of R1's progress note dated 3/26/25 at 5:46 AM revealed, No c/o (complaint of) pain to upper thigh area, Topical Silvadene (burn medication applied to the skin) applied just before shift change by previous nurse. No evidence of a wound assessment or additional treatment orders were in R1's medical record. Review of R1's Wound Information Observation History dated 4/7/25 at 3:50 PM revealed the current Director of Nursing (DON) documented, Burn type Partial thickness: redness, blistered, moist, painful, 2 areas of blisters, open measuring 3 x 2 cm 6x6 cm. Review of a Wound Management note for R1, Most Recent Documentation dated 4/17/25 at 11:15 AM, revealed, the wound was identified on 3/25/25 at 5:00 PM and measured 3.6 cm x 6.1 cm. Review of R1's altered skin integrity care plan dated 3/13/25 revealed, resident acquired altered skin integrity to right inner thigh-hot liquid spill. Approaches included 4/16/25 Resident, Family educated on risk benefit of regulated temperature to hot liquids & foods. Temps do not exceed 120 degrees. Review of the facility Hot Liquid ACTION PLAN/PNC (past noncompliance) date 3/26/25 revealed, Concern leading to AP (action plan) development. Facility identified that hot liquids are not monitored for temperature prior to leaving the dietary department. Facility identified that the dietary and nursing staff were not using the care plan and the care guides to identify interventions that were in place for residents who are at risk of injury from hot liquids. Facility actions resulted in resident having burns from a coffee spill. Standard of Practice included: Hot Liquids are not to be served at a temperature greater than 135 degrees F (Fahrenheit), unless care plan has specific identified alternatives. Dining room service with be supervised. Resident having meals in rooms will be monitored. Resident at high risk will require 1 to 1 supervision. The facility policy review revealed a water temperature burn guide that indicated at 3rd Degree burn can occur in 1 second with a temperature of 155 degrees, 2 seconds at 148 degrees, 5 seconds at 140 degrees, 15 seconds at 133 degrees, 1 minute at 127 degrees, 3 minutes at 124 degrees and 5 minutes at 120 degrees. During an interview with Dietary Aide (DA) J on 4/15/25 at 3:58 PM, J was not aware of any details of a resident having a coffee burn. J said the dietary manager was currently on vacation. J was aware of recent education and said she does not allow coffee out on the counter to be served until it is below 150 degrees. Thermometers were available for staff to get temperature readings prior to serving residents coffee. J said she does not serve the coffee and was not aware of the temperature requirements for the residents. One cup of coffee was poured, and temperature was 136.3 degrees. (See policy Temperature was to be below 135 degrees). CNA I was interviewed on 4/16/25 at 8:25 AM. CNA I was aware R1 had sustained a burn last month when he spilled hot coffee on himself. CNA I said the facility had lowered the serving temperature of the coffee to 140 degrees or less. She said R1 could have coffee in a regular cup with a lid in the dining room at 140 degrees or less. CNA I said R1 can have coffee in his room but was not sure at what temperature and did not mention the need to supervise him in either location. During an interview with the Director of Nursing (DON) on 4/16/25 at 10:37 AM, the DON did not have any incident or accident report for R1's thigh burn that occurred on 3/25/25. The DON said she started on 4/7/25 and became aware of the burn and stated on education and a plan of correction. She located kitchen logs that indicated the coffee temperature that day was around 170 degrees. The new policy allows the serving temperature of coffee to be 135 degrees. She said R1 was provided a special cup for his coffee with a lid that is more difficult to remove. She said all residents were evaluated and care plans were up to date. The DON said R1 was not his own responsible party, and they had not met with his responsible party to ensure they agreed to coffee at 135 degrees. The DON had a chart that indicated that a 3rd degree burn could occur in less than 15 seconds with a hot liquid at 133 degrees. Concern was raised that even with supervision how could the facility ensure staff could respond in under 15 seconds. The DON was also informed that interviews and observations did not confirm staff were serving at the proper temperature or were aware of special equipment for R1. The surveyor reviewed R1's admission hot liquid assessment with the DON and expressed concern as the boxes marked did not match progress notes or observations for items like vision, dementia and cognitive impairment. The DON was not able to indicate any instructions or rational for the discrepancy in the items marked. On 4/16/25 at 12:00 PM the kitchen brought a cart down the hall to serve meals to residents in their room. Staff ensured that coffee provided to resident in their room was under 120 degrees. During an observation on 4/16/25 at 12:10 PM, R4 was served lunch in her room with the DON present. R4 complained that the coffee was not hot enough. The DON said she would evaluate her for hot liquids with the use of a special cup to prevent spilling. (R4 had not been evaluted for hot liquids prior as indicated by DON). During a telephone interview with the Nursing Home Administrator (NHA) on 4/16/25 at 10:03 AM, the NHA confirmed that he was aware R1 had sustained a burn when he spilled coffee on himself on 3/25/25. The NHA said he was not aware of the extent of injury at the time. When he returned from his vacation, he was aware of the severity of burn, and he did not report it to the State Agency or start a plan of correction.

This citation pertains to intake # MI00151153 Based on interview and record review, the facility failed to report a resident-to-resident physical assault to local law enforcement and a second-degree burn sustained from an avoidable hot liquid spill for 2 residents (R1 and R2) out of 4 residents reviewed for abuse and neglect. Findings included: Review of the facility abuse policy dated reviewed 1/2025 revealed, Possible Indicators of Physical Abuse Includes but not limited to Burns, blisters or scalds on hands or torso. Facial injuries ., failure of staff to implement resident interventions, when residents have been assessed and interventions are care planned, failure to monitor, provide adequate supervision to ensure environmental hazards are not present including but not limited to: a. Access to hot water of sufficient temperature to cause tissue injury Reporting/Response. All alleged or suspected violations are reported immediately to the Administrator or Director of Nursing, which are responsible to notify required officials, including to the State Survey Agency, Adult Protective Services, Local Public Safety, Licensure Boards, Regional Director of Operations or Regional Clinical Directors (representative of governing board) and any other agencies in accordance with State law through established procedures. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involved abuse or result in serious bodily injury. Not later than 24 hours if the event that cause the allegation do not involve abuse and does not result in serious bodily injury .j. Begin investigation of the allegation. Procedure. 1. When staff (staff here refers to covered individuals) suspect a crime has occurred against a resident at the facility, they must report the incident to SSA (State Survey Agency) and local law enforcement. 2. Staff must report a suspicion of a crime to the state survey agency, SSA (State Survey Agency) and at least one local law enforcement entity within a designated time frame by e-mail, fax or telephone. The individual does not need to determine which local law enforcement entity. This will meet the individual's obligation to report. R2 (Resident-to-Resident Assault Incident) Review of R2's face sheet no date revealed, he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Autistic disorder (neurodevelopmental disorder characterized by repetitive, restricted and inflexible patterns of behavior, interest and activities as well as difficulties in social interaction and social communication), falls and weakness. Review of the facility reported incident dated 3/1/25 at 4:30 AM revealed the Nursing Home Administrator (NHA) notified the State Survey Agency (SSA) of an incident between R1 and R2 that occurred on 3/1/25 at 4:30 AM where R1 was observed hitting his roommate R2 with his water mug while R2 was still in bed. R2 sustained cuts and bruises to his face. R2 was sent to the emergency room for evaluation and treatment. R1 said was upset that his wife was not in the bed and a stranger was in the bed and that's why he was hitting him. The report revealed both R1 and R2 were both severely mentally impaired. The report did not indicate that the police were notified of this incident. Review of R2's progress note dated 3/1/25 at 5:17 AM revealed, At 0431, nurse heard R2 yelling to knock it off and went into bedroom to find R2 sitting up in bed, and his roommate (R1) hitting him with a water mug. Roommate pulled away immediately, who stated that he was trying to kill him because he was in his wife's spot. Attempted to reorientate roommate with no success. R2 has 2 lacerations on his left eye, red spot on his cheek bone, and a scratch on his chest along with a reddened area on left upper chest. Cleaned laceration and sent to name of emergency room for evaluation. Emergency contact called and notified along with provider and NHA (Nursing Home Administrator). Upon return R2 was moved to (room number). Review of R2's progress note dated 3/1/25 at 6:17 AM revealed, Per NHA not necessary to call police regarding incident. Review of R2's progress note date 3/13/25 at 3:13 PM revealed, name of R2 's family member had told him about the incident from this weekend involving R2 and he was concerned about if it got reported to anyone (i.e. the police, etc.). I explained that we reported the incident to the state immediately and they do an investigation. I explained where things stand with the investigation, and we do not believe that we could have prevented this unfortunately. Review of R2's progress note dated 3/14/25 at 4:42 PM revealed he was discharged to an assisted living facility. R1 (2nd Degree Hot Liquid Injury) A second-degree burn damages the full thickness of the skin causing redness, swelling, blisters and intense pain. Review of R1's face sheet, no date, revealed he was [AGE] years old, admitted on [DATE]. He was on hospice. He had diagnoses that included dementia, metabolic encephalopathy (brain disorder causing brain dysfunction), burn of second degree of right thigh, diabetes mellitus type 2, and falls. Review of R1's progress note dated 3/25/25 at 8:35 PM revealed, At approximately 4:30 PM, ADON (Assistant Director of Nursing) got a cup of coffee for R1 from the kitchen. Coffee was poured from a less than half full pot and added 2 creams and 1 sweetener. Lid was placed on coffee cup and given to R1. Another resident wanted coffee so this nurse went to get a coffee for the other resident. When this nurse came out of the kitchen R1 was in the center of the dining room and coffee cup was on the floor. CNA (Certified Nurse Aide) changed R1, area on inner thigh was pink, she put cold washcloths on area. His nurse came in his room, seen it, notified (name of doctor) and was awaiting orders. 2030 (9:30 PM) returns to bed, tx (treatment) to heel completed, res (resident) with no c/o (complaint of) thigh areas/burn from earlier in day. Review of R1's altered skin integrity care plan dated 3/13/25 revealed, resident acquired altered skin integrity to right inner thigh-hot liquid spill. Approaches included 4/16/25 Resident, Family educated on risk benefit of regulated temperature to hot liquids & foods. Temps do not exceed 120 degrees. Review of R1's Wound Information Observation History dated 4/7/25 at 3:50 PM revealed the current Director of Nursing (DON) documented, Burn type Partial thickness: redness, blistered, moist, painful, 2 areas of blisters, open measuring 3 cm X 6x6 cm. Review of a Wound Management note for R1, Most Recent Documentation dated 4/17/25 at 11:15 AM, revealed, the wound was identified on 3/25/25 at 5:00 PM and measured 3.6 cm x 6.1 cm. During an interview with the Director of Nursing (DON) on 4/16/25 at 10:37 AM. The DON did not have any incident or accident reports for R1's thigh burn that occurred on 3/25/25. The DON said she started on 4/7/25 and became aware of the burn and started education and a plan of correction. The DON said R1's burn was not reported to the State and that she was not working in the facility at the time of the burn. The DON was not aware why the facility did not report the burn. The DON was asked if the facility reported the physical altercation between R1 and R2 on 3/1/25 at 4:30 am to the police. The DON reviewed the facility investigation and could not locate any police notification. The DON said she was not working in the facility at that time and if she was, she would have reported this event to the police and confirmed that the facility policy would be to report the incident. During a telephone interview with the Nursing Home Administrator (NHA) on 4/16/25 at 10:03 AM, the NHA confirmed that he was aware R1 had sustained a burn when he spilled hot coffee on himself on 3/25/25. The NHA said he was not aware of the extent of injury and the time. When he returned from his vacation, he was aware of the severity of burn, and he did not report it to the State Agency, and he should have reported the burn. The NHA was asked if he reported physically altercation between R1 and R2 on 3/1/25 at 4:30 am to the police. The NHA said he did not report the incident due to the mental condition of the residents. The NHA was asked if the Criminal Justice Act or the facility policy gave exception to reporting to the police based on mental capacity he said, no. The NHA confirmed that physical assault with an object resulting in injury was suspicious of a crime.

This citation pertains to intake # MI00148940 Based on interview and record review, the facility failed to initiate an investigation into an allegation of an injury of unknown origin for one of three residents (Resident #1) reviewed. Findings: Resident #1 (R1) Review of a Face Sheet revealed R1 was an [AGE] year old female, admitted to the facility on [DATE] by Hospice for a two day respite stay, with pertinent diagnoses of Alzheimer's and Parkinson's. During an interview on 12/17/24 at 11:54 AM, the complainant/R1's DPOA (durable power of attorney) A stated that R1 was at the facility for two nights starting 12/6/24, and returned home on 12/8/24 with a swollen lip and bruising that R1 did not have prior to going to the facility. The complainant/R1's DPOA Aalso stated (a) that hospice was contacted the evening of 12/8/24 and a hospice nurse was sent to the home to assess the injuries that evening and (b) the facility was called and made aware of the concerns related to the injury of unknown origin. Review of a Hospice Encounter Note dated 12/08/24 at 9:06 PM revealed: PRN (as needed) visit for report of unaccounted bruising to right forearm and swelling to right lower lip. Patient (R1) noted to have swelling to right medial (middle) quarter of lower lip .no documentation of falls in chart or per facility staff. R1 did answer affirmative to the question of if she had fallen but unable to account for details. Review of a Hospice Encounter Note dated 12/09/24 at 1:30 PM revealed: (Hospice) Nurse asked to assess patients (R1) face and arm where the wounds were after patient (R1) being at (facility name) .Patient (R1) had a fat lip on the mouth, some bruising to the left side of the face and all up and down the right arm. (Complainant/DPOA A) had called the facility on 12/08/24 and spoke with (Medical Records Manager) MRM D who stated she would relay the concerns to the manager and social worker .(Complainant/DPOA A) told the hospice worker that the facility had not called her back .Hospice Social Worker (HSW) B reached out to the facility on [DATE] and was told there were no noted fall or injuries concerning R1 per facility records .hospice had tried contacting the facility many times without good report or response in phone calls and this has become an issue .patient (R1) not able to voice for sure what happened at the facility, (R1) has stories on if it was a fall or from being moved in the bed and is not going to be a good historian for this type of questions .(R1) has been having a harder time with ambulating and transfers since coming home from the facility. During an interview on 12/18/24 at MRM D stated that she may have heard something about R1 falling at the facility but could not recall for sure. MRM D acknowledged speaking with Complainant/DPOA A on 12/08/24 after R1 returned home. MRM D stated that the concerns were sent to the Administrator (ADM) and told Complainant/DPOA A that the Administrator would follow up with her tomorrow (12/09/24). During an interview on 12/18/24 at 12:30 PM, the Administrator stated that he did not call back R1's DPOA on 12/09/24, rather asked Social Worker (SW) E to handle it. The ADM also stated that an investigation into the allegation of an injury of unknown origin was not initiated. During an interview on 12/18/24 at 12:45 PM, Social Worker (SW) E stated that (a) she received a telephone call from HSW B on 12/09/24 about concerns regarding R1's care at the facility, and (b) then spoke with the Director of Nursing (DON) on 12/09/24, and the DON stated that R1 had not fallen at the facility. During an interview on 12/18/24 at 11:35 AM, the DON stated they following: (a) she was asked by SW E if R1 had sustained a fall or injuries while at the facility from 12/06/24 to 12/08/24, (b) she advised SW E that R1 had not fallen or sustained injuries while at the facility, (c) the DON did not interview any staff persons who worked 12/06/24 through 12/08/24, and (e) the DON did not initiate an investigation into an allegation of an injury of unknown origin. Review of the facility Abuse prevention Program Policy & Procedure reflected: (a) Injuries of unknown source-An injury will be classified as an injury of unknown source when the following criteria is met: (1) the source of the injury was not observed by any person, and (2) the source of the injury could not be explained by the resident, and (3) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time. Review of the facility policy Abuse Prevention Program 7 Components reflected: INVESTIGATION- The Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Investigations must be initiated immediately and concluded as soon as possible not to exceed (5) days.

Based on observation, interview, and record review, the facility failed to ensure call light systems were within reach for 2 of 6 resident's reviewed (Resident #142 and Resident #30). Findings: Resident #142 (R142) Review of a Face Sheet revealed R142 was an [AGE] year-old female, admitted to the facility on [DATE] for a 5 day hospice respite stay, and with pertinent diagnoses of vascular dementia. R142 required assistance from 1 staff person for bed mobility, transfers, and ambulating. During an observation on 10/07/24 at 10:43 AM, R142 laid in bed resting with eyes open and the call light sat at the foot of the bed tucked between the mattress and footboard, out of sight and out of reach of the resident. During an observation on 10/07/24 at 1:59 PM, R142 laid in bed resting with eyes open and the call light sat at the foot of the bed tucked between the mattress and footboard, out of sight and out of reach of the resident. During an interview on 10/08/24 at 8:40 AM, Certified Nurse Aide (CENA) H indicated that the expectation regarding call light placement was that anytime staff went into a room, staff were to check and make sure that the call light was within reach of the resident. Review of a Fall Risk Assessment completed 10/04/24 revealed that R142 was at high risk for a fall. Review of the EHR (electronic health record) for R142 reflected that the resident sustained an unwitnessed fall on 10/06/24. Review of R142's Care Plans showed the following interventions put in place by the facility to promote safety for the resident: (a) call light to be within reach, (b) encourage and remind to use call light to ask for assistance, and (c) provide verbal reminders to resident to call when needing assistance. Review of email communication from the Administrator on 10/09/24 at 3:09 PM reflected that the facility did not have a policy in place specific to the placement of call lights. Resident #30 Review of a Face Sheet reflected R30 was an [AGE] year old female with pertinent diagnoses of dementia and a recent fall with a spinal fracture and multiple rib fractures. During an observation on 10/07/24 at 11:14 AM, R30 laid in bed resting with her eyes open. The call light laid on the floor between the foot of the bed and the wall, out of sight and out of reach of the resident. Review of a Care Plan for R30 revealed the following safety interventions: (a) call light to be within reach and (b) encourage and remind the resident to use the call light.

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) and Contact-Based Precautions were implemented for two residents (R5 and R144) of 39 residents reviewed for infection control. Findings include: R5 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R5 was admitted to the facility on [DATE], with diagnosis of (but not limited to) Alzheimer's (short and long-term memory impairment), delusional disorder and pain in the right arm. Brief Interview for Mental Status (BIMS) reflected a score of 6 out of 15 which represented R5 had severe cognitive impairment. R6 required the assistance of 1-2 staff member with all activities of daily living. According to the physician orders with a start date of 10/3/24 a created date of 10/8/2024 reflected, Enhanced Barrier Precautions (targeted gown and gloves use) during high contact resident care activities. During an observation and interview on 10/7/24 at approximately 11:00 AM, R5 had a stop sign posted on the wall next to the door that indicated providers and staff must wear gloves and gowns for the following high-contact resident care activity, Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central lines, urinary catheter, feeding tubes, tracheostomy, wound care: any skin opening requiring a dressing. After entering R5's room this Surveyor observed Certified Nurse Assistant (CNA) B and CNA C completing a 2-assist transfer from the bed to the wheelchair. Both CNA's were wearing gloves and no gown (as the sign by the door instructed). When asked if they needed gowns while providing physical assistance to transfer, CNA B stated that they did not need to wear a gown and R5 was only on precaution for his foot wound. When asked to review the posting on the door with the Surveyor, CNA B stated that she didn't know she was supposed to wear a gown with transfers as the sign reflects. R144 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R144 was admitted to the facility on [DATE], with diagnosis of (but not limited to) subacute osteomyelitis, right ankle and foot. The admission assessment reflected R144 was alert and oriented and required staff assistance with all activities of daily living. During an observation on 10/07/24 at 10:55 AM, Licensed Practical Nurse (LPN) A entered R144's room, discontinued an antibiotic bulb from the PICC ( peripherally inserted central catheter) and flushed the catheter. LPN A did not don any PPE (personal protective equipment) prior to providing care and handling the PICC. During an observation on 10/7/24 at approximately 11:55 AM, a sign was posted on the entrance of R144's room that reflected Enhanced Barrier Precautions. During an observation on 10/8/24 at approximately 3:15 PM, the sign for Enhanced Barrier Precautions was removed and now R144 had a new sign that reflected, Contact Precautions that required gown and glove use for all providers upon entry to the room. According to the physician orders with a created date of 10/8/24 and a start date of 10/7/2024 reflected, Contact Precautions (gown and glove use with all cares) d/t (due to) right foot wound infection. During an interview on 10/9/24 at 9:15 AM, the Infection Control Preventionist (ICP) D stated that R144 was admitted on [DATE] with a MRSA (Methicillin-resistant Staphylococcus aureus) infection to the right foot. ICP D stated that EBP were implemented upon admission but after looking at the admission information should have been Contact based precautions so it was updated on 10/8/24.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 40 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, malodorous conditions, and decreased illumination. Findings include: On 11/08/23 at 08:55 A.M., An environmental tour was conducted with Nursing Home Administrator NHA. The following items were noted: Entrance Foyer: 8 of 16 overhead 4-foot-long fluorescent light bulbs were observed non-functional. Beauty Shop: The return-air ventilation exhaust grill was observed soiled with dust and dirt deposits. Occupational Therapy/Physical Therapy: The blue therapy table cushion was observed (worn, etched, scored, torn), exposing the inner Styrofoam padding. The therapy table cushion measured approximately 4-feet-wide by 8-feet-long. Living Room: The carpeting surface was observed stained and soiled, adjacent to the love seat. The soiled carpeting surface measured approximately 6-feet-wide by 8-feet-long. Nursing Station: The laminate countertop edge was observed missing at the corner. The missing laminate surface measured approximately 2-inches-wide by 18-inches-long. Team 1 Shower Room: 3 of 6 overhead 4-foot-long fluorescent light bulbs were observed non-functional. Team 1 Corridor: The drywall surface was observed damaged, adjacent to resident room [ROOM NUMBER]. The damaged surface measured approximately 6-inches-wide by 8-inches-long. The drywall surface was also observed damaged, adjacent to resident rooms [ROOM NUMBERS]. The damaged surface measured approximately 12-inches-wide by 12-inches-long. Soiled Utility Room: 3 of 4 overhead light assemblies were observed non-functional. Public Restroom: The hand sink cold water faucet valve was observed actuating extremely hard. The entire valve body assembly was also observed loose-to-mount. On 11/08/23 at 11:15 A.M., An interview was conducted with Nursing Home Administrator (NHA) regarding the facility maintenance concern request system. (NHA) stated: We have maintenance request forms at the nurses station. (NHA) further indicated: Staff sometimes will speak directly to the Maintenance Director for immediate assistance. On 11/08/23 at 02:40 P.M., An environmental tour of sampled resident rooms was conducted with NHA and Maintenance Director A. The following items were noted: 6: The restroom return-air-exhaust ventilation was observed non-functional. The drywall surface was observed (etched, scored, particulate), adjacent to Bed A. The Bed A landing strip was also observed soiled with encrusted food debris. 1 of 2 overhead light assemblies were additionally observed non-functional. Maintenance Director A indicated he would complete necessary repairs as soon as possible. 7: The restroom return-air-exhaust ventilation was observed non-functional. 11: The restroom return-air-exhaust ventilation was observed non-functional. 12: Two 12-inch-wide by 12-inch-long vinyl tile squares were observed severely worn and chipped, adjacent to Bed B. 13: The drywall surface was observed (etched, scored, particulate), adjacent to the Bed B headboard. The oscillating desk fan was also observed heavily soiled with dust and dirt deposits. 14: 2 of 2 overhead light assemblies were observed non-functional. The hand sink basin was also observed draining very slow. 15: 1 of 2 restroom overhead light assemblies were observed non-functional. 17: One 12-inch-wide by 12-inch-long vinyl flooring tile was observed (etched, scored, particulate). Three 12-inch-wide by 12-inch-long vinyl flooring tiles was also observed soiled with adhesive residue. The restroom return-air-exhaust ventilation was further observed non-functional. The restroom hand sink basin was additionally observed draining very slow. Maintenance Director A indicated he would complete necessary repairs as soon as possible. 19: The restroom hand sink basin was observed draining very slow. 1 of 2 restroom overhead light assemblies were also observed non-functional. The restroom return-air-exhaust ventilation was further observed non-functional. 20: The Bed A landing strip was observed (etched, scored, particulate), exposing the inner Styrofoam padding. 1 of 2 restroom overhead light assemblies were also observed non-functional. 22: The ceiling drywall surface was observed (moist, chipped, cracked). The damaged drywall surface measured approximately 12-inches-wide by 24-inches-long. Maintenance Director A indicated he would repair the damaged drywall ceiling surface as soon as possible. 25: The ceiling drywall surface was observed (chipped, cracked, stained) from previous moisture exposure. The damaged ceiling drywall surface measured approximately 24-inches-wide by 30-inches-long. The restroom hand sink faucet assembly aerator was also observed very loose-to-mount. 26: The restroom return-air-exhaust ventilation was observed non-functional. The drywall surface was observed (etched, scored, particulate), adjacent to the Bed A headboard. The damaged drywall surface measured approximately 20-inches-wide by 30-inches-long. The drywall surface was further observed (etched, scored, particulate), adjacent to Bed B. The damaged drywall surface measured approximately 12-inches-wide by 20-inches-long. Maintenance Director A indicated he would repair the damaged drywall surfaces as soon as possible. On 11/09/23 at 09:06 A.M., Record review of the Policy/Procedure entitled: Housekeeping Cleaning Schedules dated 01/2023 revealed under Policy: It is the policy of this facility to ensure residents live in a safe, clean, and sanitary environment and that staff are available to meet this need. Therefore, cleanings schedule will be posted to ensure a plan for the frequency and degree of cleaning is conducted per facility policy. On 11/09/23 at 09:15 A.M., Record review of the facility Maintenance Request Log Sheets for the last 90 days reflected no specific entries related to the aforementioned maintenance concerns. On 11/09/23 at 09:25 A.M., Record review of the Policy/Procedure entitled: Cleaning and Disinfecting Resident's Room dated (no date) revealed under Policy: To provide guidelines for cleaning and disinfecting resident's room to ensure sanitary conditions are maintained, to assist in preventing the spread of disease-causing organisms by keeping resident care equipment clean. Record review of the Policy/Procedure entitled: Cleaning and Disinfecting Resident's Room dated (no date) further revealed under Procedure: (1) Housekeeping surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. (2) Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 3 of 15 residents (R3, R13, and R34), resulting in incomplete and inaccurate medical records and the potential for providers not having an accurate and complete picture of the resident's stay at the facility. Findings include: Resident #3 (R3) A review of R3's Face Sheet, dated [DATE], revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's Face Sheet revealed multiple diagnoses that included dementia and anxiety. R3's Face Sheet also revealed he was on hospice services. A review of R3's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which indicated R3 was severely cognitively impaired. A review of R3's Pharmacist Drug Regimen Review forms, dated [DATE] to [DATE], revealed the pharmacist had made recommendations on [DATE] and [DATE]. However, the pharmacy recommendations were not located in R3's electronic medical record. During an interview on [DATE] at 03:45 PM, the Director of Nursing (DON) confirmed R3's pharmacy recommendations for [DATE] and [DATE] were not in his medical record. The DON stated the pharmacy recommendations should be filed under the sub tab Pharmacy in the Documents section of R3's electronic medical record. The DON stated she would see if she could locate the recommendations that the pharmacist made for R3. A copy of those recommendations, if they could be located, were requested from the DON. The DON verbally confirmed the request. During a second interview on [DATE] at 10:01 AM, the DON was able to provide a copy of R3's Pharmacy Consultation Report (the pharmacy recommendation form) for [DATE] which recommended that the physician discontinue R3's ABH cream (a combination cream containing lorazepam (Ativan), Benadryl, and Haldol used to decrease nausea in hospice residents) because this topical formulation is not FDA (Food and Drug Administration) approved and has not been adequately studied in controlled clinic trials to determine safety and effectiveness. The DON stated that R3's Pharmacy Consultation Report had been found in the physician's book waiting to be signed. The DON confirmed that the physician's book was not a part of any resident's medical records. She further stated she could not locate R3's Pharmacy Consultation Report for [DATE]. I don't know what happened to that one. The DON stated she would continue to look for it. A copy of R3's Pharmacy Consultation Report for [DATE] was requested from the DON, if it could be located. As of the completion of the survey and exit from the facility, the facility failed to provide this documentation. Resident #13 (R13) A review of R13's face Sheet, dated [DATE], revealed R13 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R13's Face Sheet revealed multiple diagnoses that included a cerebral infarction (brain bleed) and post-traumatic stress disorder (PTSD). A review of R13's MDS, dated [DATE], revealed a BIMS score of 14 which indicated R13 was cognitively intact. A review of R13's Pharmacist Drug Regimen Review forms, dated [DATE] to [DATE], revealed the pharmacist had made recommendations on [DATE] and [DATE]. However, the pharmacy recommendations were not located in R13's electronic medical record. During an interview on [DATE] at 03:45 PM, the Director of Nursing (DON) confirmed R13's pharmacy recommendations for [DATE] and [DATE] were not in her medical record. The DON stated the pharmacy recommendations should be filed under the sub tab Pharmacy in the Documents section of R13's electronic medical record. The DON stated she would see if she could locate the recommendations that the pharmacist made for R13. A copy of those recommendations, if they could be located, were requested from the DON. The DON verbally confirmed the request. During a second interview on [DATE] at 10:01 AM, the DON was able to provide a copy of two Pharmacy Consultation Reports on [DATE] for R13 which recommended that R13's physician provide an indication for the use of diphenhydramine (Benadryl) on a prn (as needed) basis and consider an alternative to its use due to the fact that diphenhydramine has strong and sedating effects and it stays in the bodies of older adults longer and that R13's physician discontinue her prn (as needed) Ativan (lorazepam) (a medication for anxiety) or add a date to stop the medication because the Centers for Medicaid and Medicare Services (CMS) requires that prn orders for non-antipsychotic psychotropic medications (medications that affect a resident mentally) be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. During the same interview on [DATE] at 10:01 AM, the DON was able to provide a copy of R13's Pharmacy Consultation Report for [DATE] which recommended that R13's physician discontinue her antipsychotic medication, Seroquel, or document a diagnosis for its use if he wanted R13 to continue taking the Seroquel. The DON stated that both of R13's Pharmacy Consultation Reports for [DATE] and R13's Pharmacy Consultation Report for [DATE] had been located in the physician's book waiting to be signed. The DON confirmed that the physician's book was not a part of any resident's medical records. Resident #34 (R34) A review of R34's Face Sheet, dated [DATE], revealed R34 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, R34's Face Sheet revealed multiple diagnoses that included a history of a pulmonary embolism (blood clot in the lungs), chronic (long-term) respiratory failure (when the air sacs in the lungs cannot release enough oxygen into the blood), acute (short-term) respiratory failure with hypoxia (inadequate oxygen level in the tissues due to low blood supply or low oxygen content in the blood), pneumonia, and pulmonary emphysema (a lung disease). A review of R34's MDS, dated [DATE], revealed a BIMS score of 9 which indicated R34 was moderately cognitively intact. A review of R34's Pharmacist Drug Regimen Review forms, dated [DATE] to [DATE], revealed the pharmacist had made a recommendations on [DATE]. However, the pharmacy recommendations were not located in R34's electronic medical record. During an interview on [DATE] at 03:45 PM, the Director of Nursing (DON) confirmed R34's pharmacy recommendation for [DATE] was not in his medical record. The DON stated the pharmacy recommendations should be filed under the sub tab Pharmacy in the Documents section of R34's electronic medical record. The DON stated she would see if she could locate the recommendation that the pharmacist made for R34. A copy of that recommendation, if it could be located, was requested from the DON. The DON verbally confirmed the request. During a second interview on [DATE] at 10:01 AM, the DON was able to provide a copy of two Pharmacy Consultation Reports on [DATE] for R34 which recommended that R34's physician reevaluate (possibly discontinue) the continued use of clopidogrel (a medication used to prevent blood clots) because R34 was also receiving Eliquis (apixaban) (another medication used to prevent blood clots) and using both medications at the same time may further increase the risk for serious, potentially fatal bleeding and that R34's physician discontinue his prn alprazolam (a medication for anxiety and panic disorders) or add a date to stop the medication because the Centers for Medicaid and Medicare Services (CMS) requires that prn orders for non-antipsychotic psychotropic medications (medications that affect a resident mentally) be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. The DON stated that both of R34's Pharmacy Consultation Reports for [DATE] had been located in the physician's book waiting to be signed. The DON confirmed that the physician's book was not a part of any resident's medical records. Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care . High quality documentation, however, is a necessary and integral aspect of the work of registered nurses in all roles and settings . (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org). Timely documentation of the following types of information should be made and maintained in a patient's EHR to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care- Assessments; Clinical problems; Communications with other health care professionals regarding the patient . Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org).

Based on interview and record review, the facility failed to ensure a resident's medication regimen was free from unnecessary medications for 1 of 5 residents (R34) reviewed for unnecessary medications, resulting in R34 receiving an unnecessary medication for an excessive duration of time and the potential for serious adverse effects. Findings include: Resident #34 (R34) A review of R34's Face Sheet, dated 11/9/23, revealed R34 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, R34's Face Sheet revealed multiple diagnoses that included a history of a pulmonary embolism (blood clot in the lungs), chronic (long-term) respiratory failure (when the air sacs in the lungs cannot release enough oxygen into the blood), acute (short-term) respiratory failure with hypoxia (inadequate oxygen level in the tissues due to low blood supply or low oxygen content in the blood), pneumonia, and pulmonary emphysema (a lung disease). A review of R34's MDS, dated [DATE], revealed a BIMS score of 9 which indicated R34 was moderately cognitively intact. A review of R34's Pharmacy Consultation Report, dated 9/20/23, revealed the pharmacist recommended that R34's physician reevaluate the continued use of clopidogrel (a medication used to prevent blood clots) because R34 was also receiving Eliquis (apixaban) (another medication used to prevent blood clots) and using both medications at the same time may further increase the risk for serious, potentially fatal bleeding. The pharmacist indicated that R34's physician either discontinue R34's clopidogrel or document an assessment of the risk versus benefit of its use with Eliquis and have the facility interdisciplinary team ensure ongoing monitoring of R34 for its effectiveness and potential adverse consequences (e.g., unusual bruising, bloody or black tarry stools, red or dark brown urine, abdominal pain or swelling, bleeding gums or nose). A further review of R34's Pharmacy Consultation Report related to the use of clopidogrel and Eliquis, dated 9/20/23, revealed the consultation report was signed by the physician on 11/8/23 (49 days after the pharmacist made the recommendation) and the physician checked the box I accept the recommendation(s) above, please implement as written in the Physician's Response section of the form. A review of R34's physician order, dated 11/8/23, revealed an order to discontinue R34's clopidogrel due to a pharmacy recommendation (49 days after the recommendation was made). A review of R34's Medication Administration Records, dated 9/20/23 to 11/9/23, revealed R34 received clopidogrel daily from 9/20/23 to 11/8/23. During an interview on 11/09/23 at 10:01 AM, the Director of Nursing (DON) stated R34's Pharmacy Consultation Reports were in the physician's book waiting to be signed. She indicated that was the reason why R34's Pharmacy Consultation Reports were addressed late. A review of the facility's Medication Regimen Review policy and procedure, dated 12/1/07 and last revised on 8/17/23, revealed, 12. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. A review of the State Operations Manual (SOM), revised 2-3-23, revealed, Frequency of physician visits . The resident must be seen by a physician at least once every 30 days for the first 90 days after admission . (F712- Effective: 10-21-22, Implementation: 10-24-22, p.461). Therefore, R34's Pharmacy Consultation Report, dated 9/20/23, should have been addressed by R34's physician no later than 10/20/23 (instead on on 11/8/23). Further more because the physician did not address R34's Pharmacy Consultation Report timely, R34 received both clopidogrel and Eliquis at the same time from at least 10/20/23 to 11/8/23 (19 days) which unnecessarily further increased his risk for serious, potentially fatal bleeding.

Based on interview and record review, the facility failed to ensure monthly pharmacy drug regimen review recommendations were reviewed by the physician and/or acted upon in a timely manner for 3 of 6 residents reviewed (R3, R13, and R34), resulting in the potential for the physician not knowing of a pharmacy recommendation, the potential for a delay in implementing a pharmacy recommendation, and the potential for adverse effects from medications that the pharmacy identified as potential medication issues. Findings include: Resident #3 (R3) A review of R3's Face Sheet, dated [DATE], revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's Face Sheet revealed multiple diagnoses that included dementia and anxiety. R3's Face Sheet also revealed he was on hospice services. A review of R3's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which indicated R3 was severely cognitively impaired. A review of R3's Pharmacy Consultation Report, dated [DATE], revealed the pharmacist recommended that R3's physician discontinue ABH cream (a combination cream containing lorazepam (Ativan), Benadryl, and Haldol used to decrease nausea in hospice residents) because this topical formulation is not FDA (Food and Drug Administration) approved and has not been adequately studied in controlled clinic trials to determine safety and effectiveness. However, R3's Pharmacy Consultation Report was not signed by a physician and there was not a physician response to the recommendation on the report. A review of R3's physician order, dated [DATE], revealed an order to discontinue R3's ABH cream (approximately 4.5 months after the pharmacist made the recommendation). However, there was not any indication of why the ABH cream was discontinued (e.g., a pharmacy recommendation, non-use over a period of time, or some other reason). A review of the facility's Medication Regimen Review policy and procedure, dated [DATE] and last revised on [DATE], revealed, Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided copies of the MRRs (Medication Regimen Reviews). 8. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR . 12. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. A review of the State Operations Manual (SOM), revised [DATE], revealed, Frequency of physician visits . The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter (F712- Effective: [DATE], Implementation: [DATE], p.461). Therefore, R3's physician should have addressed the Pharmacy Consultation Report, dated [DATE], no later than [DATE] (instead of on [DATE], purposefully or inadvertently). Resident #13 (R13) A review of R13's face Sheet, dated [DATE], revealed R13 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R13's Face Sheet revealed multiple diagnoses that included a cerebral infarction (brain bleed) and post-traumatic stress disorder (PTSD). A review of R13's MDS, dated [DATE], revealed a BIMS score of 14 which indicated R13 was cognitively intact. A review of R13's Pharmacy Consultation Report, dated [DATE], revealed the pharmacist recommended that R13's physician provide an indication for the use of diphenhydramine (Benadryl) on a prn (as needed) basis and consider an alternative to its use due to the fact that diphenhydramine has strong and sedating effects and it stays in the bodies of older adults longer. R13's Pharmacy Consultation Report was signed by the physician on [DATE] (44 days after the pharmacist made the recommendation) and the physician noted medication D/c'd (discontinued) as never used in the Physician's Response section of the form. A review of R13's Pharmacy Consultation Report, dated [DATE], revealed the pharmacist recommended that R13's physician discontinue her prn Ativan (lorazepam) (a medication for anxiety) or add a date to stop the medication because the Centers for Medicaid and Medicare Services (CMS) requires that prn orders for non-antipsychotic psychotropic medications (medications that affect a resident mentally) be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. R13's Pharmacy Consultation Report was signed by the physician on [DATE] (44 days after the pharmacist made the recommendation) and the physician noted PRN D/c'd in the Physician's Response section of the form. A review of R13's physician order, dated [DATE], revealed an order to discontinue diphenhydramine due to non-use. A review of R13's physician order, dated [DATE], revealed an order to discontinue lorazepam due to it being past 14 day stop date (33 days past). During an interview on [DATE] at 10:01 AM, the Director of Nursing (DON) stated R13's Pharmacy Consultation Reports were in the physician's book waiting to be signed. She indicated that was the reason why R13's Pharmacy Consultation Reports were addressed late. A review of the facility's Medication Regimen Review policy and procedure, dated [DATE] and last revised on [DATE], revealed, 12. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. A review of the State Operations Manual (SOM), revised [DATE], revealed, Frequency of physician visits . The resident must be seen by a physician at least once every 30 days for the first 90 days after admission . (F712- Effective: [DATE], Implementation: [DATE], p.461). Therefore, both of R13's Pharmacy Consultant Reports, dated [DATE], should have been addressed by R13's physician no later than [DATE] (instead of on [DATE]). Resident #34 (R34) A review of R34's Face Sheet, dated [DATE], revealed R34 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, R34's Face Sheet revealed multiple diagnoses that included a history of a pulmonary embolism (blood clot in the lungs), chronic (long-term) respiratory failure (when the air sacs in the lungs cannot release enough oxygen into the blood), acute (short-term) respiratory failure with hypoxia (inadequate oxygen level in the tissues due to low blood supply or low oxygen content in the blood), pneumonia, and pulmonary emphysema (a lung disease). A review of R34's MDS, dated [DATE], revealed a BIMS score of 9 which indicated R34 was moderately cognitively intact. A review of R34's Pharmacy Consultation Report, dated [DATE], revealed the pharmacist recommended that R34's physician reevaluate the continued use of clopidogrel (a medication used to prevent blood clots) because R34 was also receiving Eliquis (apixaban) (another medication used to prevent blood clots) and using both medications at the same time may further increase the risk for serious, potentially fatal bleeding. The pharmacist indicated that R34's physician either discontinue R34's clopidogrel or document an assessment of the risk versus benefit of its use with Eliquis and have the facility interdisciplinary team ensure ongoing monitoring of R34 for its effectiveness and potential adverse consequences (e.g., unusual bruising, bloody or black tarry stools, red or dark brown urine, abdominal pain or swelling, bleeding gums or nose). A further review of R34's Pharmacy Consultation Report related to the use of clopidogrel and Eliquis, dated [DATE], revealed the consultation report was signed by the physician on [DATE] (49 days after the pharmacist made the recommendation) and the physician checked the box I accept the recommendation(s) above, please implement as written in the Physician's Response section of the form. However, R34's physician did not indicate which recommendation that they wanted implemented (discontinue clopidogrel or continue its use with Eliquis with a risk versus benefit assessment and ongoing monitoring). A review of R34's physician order, dated [DATE], revealed an order to discontinue R34's clopidogrel due to a pharmacy recommendation (49 days after the recommendation was made). A review of R34's Pharmacy Consultation Report, dated [DATE], revealed the pharmacist recommended that R34's physician discontinue his prn alprazolam (a medication for anxiety and panic disorders) or add a date to stop the medication because the Centers for Medicaid and Medicare Services (CMS) requires that prn orders for non-antipsychotic psychotropic medications (medications that affect a resident mentally) be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. R34's Pharmacy Consultation Report was signed by the physician on [DATE] (49 days after the pharmacist made the recommendation) and the physician checked the box I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: change to scheduled TID (three times a day). A review of R34's physician order, dated [DATE], revealed an order to discontinue R34's prn alprazolam (49 days after the pharmacist made the recommendation) because it was changed from as needed to scheduled. A review of R34's physician order, dated [DATE], revealed an order to administer alprazolam 1 milligram (mg) every 8 hours (three times a day) for anxiety. During an interview on [DATE] at 10:01 AM, the Director of Nursing (DON) stated R34's Pharmacy Consultation Reports were in the physician's book waiting to be signed. She indicated that was the reason why R34's Pharmacy Consultation Reports were addressed late. A review of the facility's Medication Regimen Review policy and procedure, dated [DATE] and last revised on [DATE], revealed, For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected 12. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. A review of the State Operations Manual (SOM), revised [DATE], revealed, Frequency of physician visits . The resident must be seen by a physician at least once every 30 days for the first 90 days after admission . (F712- Effective: [DATE], Implementation: [DATE], p.461). Therefore, both of R34's Pharmacy Consultation Reports, dated [DATE], should have been addressed by R34's physician no later than [DATE] (instead on on [DATE]).

This citation refers to MI00126719 Based on interview and record review, the facility failed to prevent a fall for 1 of 3 residents (R11), resulting in R11 sustaining a fracture from a fall. Findings include: A review of R11's undated Face Sheet revealed R11 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R11's Face Sheet revealed multiple diagnoses that included dementia with behaviors, adult failure to thrive, left and right hip contractures, osteopenia (weak bones), and repeated falls. A review of R11's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/4/22, revealed R11 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) assessment that revealed R11 had short-term and long-term memory problems with inattention and disorganized thinking. In addition, R11 had severely impaired cognitive decision-making skills. A review of R11's MDS, dated [DATE], revealed R11 was totally dependent on two staff members for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and toileting. A review of R11's progress notes, dated 2/1/22 to 2/24/22, revealed the following: - Nursing note, dated 2/10/22, revealed, Bruises continue to the left great toe and right inner forearm. Treatment as ordered. Resident with no s/s of pain or discomfort this am. VSS (vital signs stable). Resident with a witnessed fall on 2/7. No changes noted. Will continue to observe for any changes. - LPN/RN note, dated 2/10/22, revealed, Resident is yelling out more often. Assessment shows right hip joint is more flexible than her baseline. Right hip Xray ordered. Roxanol (liquid morphine) given with effectiveness. - Interdisciplinary Team, dated 2/11/22, revealed, resident was lowered to floor on 2/7/22 related to staff rolling resident while providing pericare. Resident was rolled toward staff but was too close to edge of bed and slid off edge of bed and staff member had to lower resident to floor. Resident noted to have a bruise to left great toe and right upper extremity distal to elbow. Resident was noted to have suspicion for increased pain in right hip on 2/10/22, awaiting XR results. - DON (Director of Nursing) note, dated 2/11/22, revealed, R11 had a fracture noted below the trocanter of the right femur. A review of R11's Pelvis & Right Hip X-ray, dated 2/11/22, revealed R11 had an acute comminuted displaced fracture in the intertrochanteric region of the proximal right femur. In addition, R11's Pelvis & Right Hip X-ray revealed osteoporosis (a condition when bone strength weakens and is susceptible to fracture) was observed on the x-ray. A review of the facility's investigative file for R11's injury of unknown origin (that was reported to the state survey agency on 2/11/22) revealed a conclusion that R11's right femur fracture was the result of a possible spontaneous fracture when she was lowered to the floor on 2/7/22 with staff assistance. The investigation was initiated after R11 was noted to be yelling out more often than usual and a physical assessment revealed R11's right hip joint was more flexible than her baseline (on 2/10/22). A review of R11's Fall Event Report, dated 2/7/22, revealed while staff was providing care, R11 was rolled toward the nursing assistant, slid off the bed, and was lowered to the floor. In addition, R11's Fall Event Report revealed certified nursing assistant (CNA) N was the nursing assistant who was providing the care to R11. In addition, R11's Fall Event Report revealed staff educated (under interventions section of the report). During an interview on 10/26/22 at 11:00 AM, CNA N stated on 2/7/22 R11 slipped off the bed. She stated she was probably changing R11 when she slipped off the bed, but she could not remember the exact details of the incident. CNA N stated she remembered she was moving R11 onto her side in bed by herself, CNA N's knees were against the bed, R11 slipped off the side of the bed, and rolled onto her knees. CNA N stated she then lowered R11 to the floor because she could not push R11 back into bed by herself. She also stated R11 did not smack onto the floor and have a hard fall. CNA N stated after she lowered R11 to the floor she told the nurse. During an interview on 10/26/22 at 11:00 AM, CNA N stated she did not remember if R11 was care planned for one or two people assist for bed mobility and/or toileting prior to R11 being lowered to the floor. She stated she did remember that R11 was very light and they would only use one person to roll her in bed. She also stated R11 was very contracted and could not assist with moving from side-to-side in bed. In addition, CNA N stated, They did make a big deal out of us only using one person for her. After this happened, we got education that we really needed to use two people for her and other residents like her. I even had to go into [name of former DON]'s office, she (the former DON) shut the door, and said she was educating me. But she kept asking me questions like what would you do in this situation? and other things like that. It seemed more like she was testing me than educating me. A review of R11's Alteration in ADL's (activities of daily living) Care Plan, dated 9/4/15, revealed R11 was a two-person assist with bed mobility (initiated 9/4/15). In addition, R11's care plan revealed she was totally dependent on staff for toileting needs (initiated 6/2/15). However, it did not reveal how many staff members were needed to assist R11 with toileting. But R11's most recent MDS at the time of the fall (dated 2/4/22) did reveal two staff members were needed.

Based on observation, interview and record review, the facility failed to notify the physician for 1 (Resident #20), resulting in an ineffective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #20 admitted to the facility on [DATE] and has pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) indicated she is cognitively intact. During an observation on 8/24/21 at 11:00 a.m., Resident #20 was in her room in her wheelchair and both eyes were slightly swollen, and the left eye was red and irritated in appearance. The eye lid looked to have an exposed top layer of skin with scant frank red blood noted and her eyelashes were matted with a dry crusty drainage. Resident #20 reported she had an eye infection. Review of an Order Summary for Resident #20 revealed on 7/28/21 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 8/25/21 at 3:30 p.m., The Director of Nursing (DON) reported that Certified Nursing Assistant (CNA) D is responsible for making appointments and setting up transportation for residents. CNA D reported he had been trying to make an ophthalmology appointment for Resident #20 for a couple weeks and has called about 13 places and not able to find an opening for the resident because the offices he called were unable to accommodate her larger wheelchair. CNA D is unable to provide any documentation to show any attempt was made to make an appointment for Resident #20. When questioned about the documentation, CNA D reported he did not know he needed to document his attempts to find an ophthalmologist. In an interview on 8/25/21 at 4:11 p.m., the DON reported CNA D did tell her he was having a hard time making an appointment for Resident #20 and did not notify the physician. When queried about the residents' eye having potential skin breakdown and the DON did not agree. We went to Resident #20's room and the resident was laying down in bed and her left eye was matted shut with obvious dry crusty drainage. The DON had a CNA apply a wet and warm cloth to the residents' eye to help open it and after a few minutes the eye still would not open. They periorbital area was swollen, and the left outer upper eye lid was red, and inflamed with obvious irritation. The resident complained of pain in her eye. In an interview on 8/26/21 at 7:00 a.m., Registered Nurse (RN) E' reported Resident #20 was starting [MEDICATION(S)] eye drops today when pharmacy drops it off. The resident was in her wheelchair at this time in the hallway and the RN E reported she did not see any open areas on the residents' eye but did say her eye was very red. In an interview n 8/26/21 at 9:30 a.m., the DON reported she did not see any open areas on Resident #20's eye lid but did notice some green drainage yesterday but not the day before. So she obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When queried about why the physician was not notified before this survey, the DON reported the physician already knew about Resident #20's eye and that was why he ordered the ophthalmology consult. The DON reported the physician did order new medication for the residents' eye last night. During an observation on 8/26/21 at 10:49 a.m., Resident #20 was laying in bed with a CNA by her side. Her left eye is swollen shut and unable to open. Has a warm wet washcloth on her eye and complains of pain at a 5 out of 10 scale. The DON reported the pharmacy had not been here yet with the residents' new medication that was ordered last night. The DON reported the pharmacy will usually make a drop off in the afternoon. The DON reported the resident did not receive any new medication that was ordered last night. Review of the July Medication Administration Record and the Treatment Administration Record (MAR and TAR) for Resident #20 revealed: Ordered 7/1/21, warm compress to left eye as tolerated four times a day. [MEDICATION(S)] Lid Scrub Plus (eyelid cleanser combination), administer 1 pad three times a day, discontinued 7/21/21. [MEDICATION(S)] ([MEDICATION(S)]-[MEDICATION(S)]-dexameth) ointment ordered 2 drops in both eyes ordered 7/31/21 and discontinued on 8/6/21. Review of the August MAR/TAR for Resident #20 revealed: [MEDICATION(S)] 500 mg twice a day for eye infection, ordered 8/5/20 to 8/12/20. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Left eye [CONDITION(S)] and drainage not improved since last visit.Plan: Patient is counseled and encouraged to notify staff of any concerns. Orders given for [MEDICATION(S)] (antibiotic) 500 mg 2 po BID x 7 days for [CONDITION(S)] . Review of a Nursing Progress Note dated 8/9/21 for Resident #20 revealed: Staff member called Resident's ophthalmologist multiple times and have not been able to get through, Staff member will continue to call. Review of a Nursing Progress note dated 8/9/21 for Resident #20 revealed: Resident resting in bed, white milky drainage noted from left eye . Review of a Nursing Progress note dated 8/18/21 for Resident #20 revealed: (Treatment) continues for eye infection, minimal drainage noted. Warm compresses to left eye continues. Review of a Nursing Progress note dated 8/22/21 for Resident #20 revealed: (Treatment) continues for eye infection, yellow drainage noted. Warm compresses to left eye continues. Review of a Nursing Progress note dated 8/25/21 for Resident #20 revealed: Resident noted to have green discharge from left eye this afternoon. (Physician) notified and orders received.

Based on observation, interview and record review, the facility failed to provide care and services for 1 (Resident #20), resulting in an ineffective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #20 admitted to the facility on [DATE] and has pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) indicated she is cognitively intact. During an observation on 8/24/21 at 11:00 a.m., Resident #20 was in her room in her wheelchair and both eyes were slightly swollen, and the left eye was red and irritated in appearance. The eye lid looked to have an exposed top layer of skin with scant frank red blood noted and her eyelashes were matted with a dry crusty drainage. Resident #20 reported she had an eye infection. Review of an Order Summary for Resident #20 revealed on 7/28/21 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 8/25/21 at 3:30 p.m., The Director of Nursing (DON) reported that Certified Nursing Assistant (CNA) D is responsible for making appointments and setting up transportation for residents. CNA D reported he had been trying to make an ophthalmology appointment for Resident #20 for a couple weeks and has called about 13 places and not able to find an opening for the resident because the offices he called were unable to accommodate her larger wheelchair. CNA D is unable to provide any documentation to show any attempt was made to make an appointment for Resident #20. When questioned about the documentation, CNA D reported he did not know he needed to document his attempts to find an ophthalmologist. In an interview on 8/25/21 at 4:11 p.m., the DON reported CNA D did tell her he was having a hard time making an appointment for Resident #20 and did not notify the physician. When queried about the residents' eye having potential skin breakdown and the DON did not agree. We went to Resident #20's room and the resident was laying down in bed and her left eye was matted shut with obvious dry crusty drainage. The DON had a CNA apply a wet and warm cloth to the residents' eye to help open it and after a few minutes the eye still would not open. They periorbital area was swollen, and the left outer upper eye lid was red, and inflamed with obvious irritation. The resident complained of pain in her eye. In an interview on 8/26/21 at 7:00 a.m., Registered Nurse (RN) E' reported Resident #20 was starting [MEDICATION(S)] eye drops today when pharmacy drops it off. The resident was in her wheelchair at this time in the hallway and the RN E reported she did not see any open areas on the residents' eye but did say her eye was very red. In an interview on 8/26/21 at 9:30 a.m., the DON reported she did not see any open areas on Resident #20's eye lid but did notice some green drainage yesterday but not the day before. So she obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When queried about why the physician was not notified before this survey, the DON reported the physician already knew about Resident #20's eye and that was why he ordered the ophthalmology consult. The DON reported the physician did order new medication for the residents' eye last night. During an observation on 8/26/21 at 10:49 a.m., Resident #20 was laying in bed with a CNA by her side. Her left eye is swollen shut and unable to open. Has a warm wet washcloth on her eye and complains of pain at a 5 out of 10 scale. The DON reported the pharmacy had not been here yet with the residents' new medication that was ordered last night. The DON reported the pharmacy will usually make a drop off in the afternoon. The DON reported the resident did not receive any new medication that was ordered last night. Review of the July Medication Administration Record and the Treatment Administration Record (MAR and TAR) for Resident #20 revealed: Ordered 7/1/21, warm compress to left eye as tolerated four times a day. [MEDICATION(S)] Lid Scrub Plus (eyelid cleanser combination), administer 1 pad three times a day, discontinued 7/21/21. [MEDICATION(S)] ([MEDICATION(S)]-[MEDICATION(S)]-dexameth) ointment ordered 2 drops in both eyes ordered 7/31/21 and discontinued on 8/6/21. Review of the August MAR/TAR for Resident #20 revealed: [MEDICATION(S)] 500 mg twice a day for eye infection, ordered 8/5/20 to 8/12/20. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Left eye [CONDITION(S)] and drainage not improved since last visit.Plan: Patient is counseled and encouraged to notify staff of any concerns. Orders given for [MEDICATION(S)] (antibiotic) 500 mg 2 po BID x 7 days for [CONDITION(S)] . Review of a Nursing Progress Note dated 8/9/21 for Resident #20 revealed: Staff member called Resident's ophthalmologist multiple times and have not been able to get through, Staff member will continue to call. Review of a Nursing Progress note dated 8/9/21 for Resident #20 revealed: Resident resting in bed, white milky drainage noted from left eye . Review of a Nursing Progress note dated 8/18/21 for Resident #20 revealed: (Treatment) continues for eye infection, minimal drainage noted. Warm compresses to left eye continues. Review of a Nursing Progress note dated 8/22/21 for Resident #20 revealed: (Treatment) continues for eye infection, yellow drainage noted. Warm compresses to left eye continues. Review of a Nursing Progress note dated 8/25/21 for Resident #20 revealed: Resident noted to have green discharge from left eye this afternoon. (Physician) notified and orders received. Review of the Care Plan for Resident #20 revealed no person centered care plan developed/implemented to focus on her individual needs including but not limited to her eye infection and care of her eye.

Based on Observation, interview and record review, the facility failed to notify physician and have physician oversight in 2 (Resident #19 and Resident #28) resulting in hospitalization due to dehydration [MEDICAL CONDITION]. Findings include: Resident #19 Review of the Admission Minimum Data Set ((MDS) dated [DATE] for Resident #19 revealed he had an admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) indicated he is cognitively intact and requires limited assistance of one staff for transfers. Pertinent [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Ordered 7/21/19 and unsigned by physician as of this survey. Other orders for this resident were not signed for such as asthma/respiratory medications and [MEDICATION NAME] (antianxiety medication). In an interview on 9/10/19 at 2:45 p.m., Resident #19 reported he was in the hospital not too long ago and [MEDICAL CONDITION] and a urinary tract infection and was recently on antibiotics. Review of a Nursing Progress Note dated 7/14/19 for Resident #19 revealed: Resident continues to be red and moist under panniculus. Slight odor noted. Areas cleansed and [MEDICATION NAME] powder applied with pillow case in place. (sic) Review of a Nursing Progress Note dated 7/15/19 for Resident #19 revealed: (Recorded as Late Entry on 07/16/2019 01:37 AM) Resident is A&Ox4 and able to communicate needs to staff. Underbelly was washed, dried, and [MEDICATION NAME] powder applied. Area is red. Resident grimaces when area is washed. (sic) Review of a Nursing Progress Note dated 7/18/19 for Resident #19 revealed: At 1200, CNA called for nurse. Upon entering residents room, resident was on his stomach on the floor next to his bed. His left arm was hooked onto the grab bar while his right arm was hooked onto the trashcan. His blanket was tangeled on his feet. The draw sheet and puddle pad were on the floor soaked with urine. The fitted sheet was noted to have urine on it. He was noted to be very SOB. ROM WNL. He did not have on any footwear. He was noted to be incontinent of urine. Neuros initiated. Resident was very weak and unable to stand with assist. Hoyer lift used to assist him back to bed. Resident says he was trying to get up to go to the bathroom to urinate because he couldn't find his urinal. He says he became dizzy and fell out of the bed. His urinal is noted to be in the trash. He denies pain at this time. On call notified. Continue to monitor. Have NP see in the AM. Resident instructed to ask for assistance with ADLs. (sic) Review of a Nursing Progress Note dated 7/18/19 for Resident #19 revealed: At 220, resident requested to go to the bathroom. CNA (Certified Nursing Assistant) and nurse assisted him to the bathroom. He had a bowel movement. Once he came out of the bathroom, he says he wanted to go to the hospital. He says he is too weak to stand and he feels he should go. Upon assessment, BBS (lung sounds) show wheezes. O2 (oxygen) 91% on 4 1/2 liter. He is very shaky and restless. BS (bowel sounds) active x 4. Resident has on a brief per his request. Spoke with on call, gave verbal order to send to (hospital) (sic) Review of a Nursing Progress Note dated 7/21/19 for Resident #19 revealed: Resident arrived back to facility via facility transport and staff. VSS (vital signs stable & afebrile. DX (diagnosis): [MEDICAL CONDITION]. Resident has a large red area extending from the groin up to the belly button that was outlined with a sharpie. Requested 6 months of physician progress notes [REDACTED]. No record of a Physician visit or oversight between these dates. The progress notes had a fax date at the bottom of the pages of 9/12/19. Review of the Progress Notes revealed the practitioner had no knowledge of Resident #19 having redness, tenderness or pain in panniculus or abdominal folds. Review of an Inpatient Discharge Summary from the hospital dated 7/21/19 for Resident #19 revealed: . presented to the ED (emergency department) with fever, weakness, cough, dyspnea (difficult or labored breathing), and abdominal pain.He's from the Nursing home where he was noted to have a temp of 102.1 F (Fahrenheit). He was noted to have skin changed in the abdomen that may represent [MEDICAL CONDITION] in the ED. Hospital Course:[MEDICAL CONDITION] secondary to pneumonia and [MEDICAL CONDITION]: in addition to pneumonia, the patient had cutaneous candidiasis with possible bacterial superinfection in the groin and abdomen. (sic) In an interview on 9/12/19 at 1:38 p.m., Nurse Practitioner (NP) J reported she was not aware Resident #19 had any pain or redness in his abdominal folds or groin prior to his hospitalization . Resident #28 Review of a Face Sheet revealed Resident #28 is an [AGE] year old male originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #28 was cognitively intact and required extensive assistance of 2 people for transfers, independent with set up only for eating, and weighed 246 pounds with an unknown weight loss. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #28 had a Brief Interview for Mental Status (BIMS) indicating he is severely cognitively impaired and is totally dependent on 2 staff for transfers and limited assistance of 1 staff for eating. Weight was 225 pounds and section K : Weight Loss: Loss of 5% or more in the last month or 10% or more in the last 6 months, box 2 was marked for Yes, not on a physician prescribed weight loss regimen. Review of Resident #28's weights are as follows: 3/6/19 weight was 240.6 pounds, 4/5/19 weight was 240.6 pounds, 5/5/19 weight was 246.6 pounds, 6/6/19 weight was 249.4 pounds, 7/11/19 weight was 243.8 pounds, 8/20/19 weight was 222.1 pounds, 9/8/19 weight was 225.8 pounds. A 6.15% weight loss noted in 6 months, an 8.90% weight loss from 7/11/19 to 8/20/19. Review of the facility's Weight Variance Report for Resident #28 revealed that between 3/14/19 and 9/8/19 Resident #28 has had variations in weight loss. On 3/14/19 the resident weighed 238.30. On 5/31/19 Resident weighed 258.8. On 8/30/19 resident weighed 221.0. On 9/8/19 weighed 225.80. During an observation and an interview on 9/11/19 at 3:47 p.m., Resident #28 laid in bed and asked this surveyor when lunch was because he was hungry and reported he did not eat yet. No water noted in his room or within reach. In an interview on 9/11/19 at 3:49 p.m., Certified Nursing Assistant (CNA) G reported she was not Resident #28's CNA, but reported he refused his lunch today and will refuse many times because he likes to sleep in. In an interview on 9/11/19 at 4:05 p.m., CNA F reported Resident #28 had physical therapy before lunch and was tired, so he slept through lunch. CNA F reported she was not aware he was hungry and said they will get him up and get him something to eat. CNA F reported the kitchen will hold his tray until he wants it, but she did not check on him after lunch to see if he wanted his lunch. In an interview on 9/11/19 at 4:25 p.m., Certified Dietary Manager (CDM) P reported Resident #28 was sleeping more lately and not eating. CDM P reported medication changes were done and he has had some [MEDICAL CONDITION]. She reported they started him on Mighty Shakes nutrition supplement. CDM P reported the facility has weekly stand up meetings to address residents with weight loss but was not able to provide a root cause for Resident #28's weight loss. When queried if she was aware that Resident #28 gets physical therapy right before lunch which can possibly make the resident tired, she was not aware. When queried about how supplements are charted as given to residents who receive them, CDM P reported they probably include it as part of their liquid intake amount at mealtime. Staff did not the chart supplements given to residents or the acceptance/intake of the supplement. CDM P reported the CNA's add the Mighty Shakes to the resident's trays at mealtime and Resident #28 started mighty shakes on 8/21/19. CDM P reported she orders the supplements and provides a copy of the order to the physician to sign off on it but was not able to provide documentation that showed the physician is aware of supplements and/or physician orders [REDACTED].#28's weight loss interventions requested at this time. Review of a Nurse Practitioner Progress Note dated 6/6/19 for Resident #28 revealed: . He was calling out because he did not want anyone to forget Him for breakfast. It was 0100. Review of a Dietary Progress Note for Resident #28, dated 7/30/19, revealed: Quarterly assessment completed. no chewing or swallowing difficulties. current diet is a regular, regular diet with regular liquids. continues to eat meals in the dining room for set up, and encouragement. Oral intake is refused-100%, on average being 75-100%, does request additional food/fluids at times. BMI is 38.04. no recent lab results. At nutritional/hydration risk r/t: (related to)HX (history) of significant wt changes, [MEDICAL CONDITION], fluid shifting, [MEDICAL CONDITIONS] stage IV, variable oral intake, meal/supplement refusals, at times additional request for food at mealtimes, current medications with side effects, abnormal labs, and edentulous. wt (weight) on 07/18/19 was 250.2. wt history is variable by 1-13# there is no significant wt changes noted per MDS. Hot liquids/food assessment completed, encourage clothing protector, and no recommendations from OT (occupational therapy) therapy at this time. will review and update current plan of care. (sic) Review of a Nurse Practitioner Progress Note dated 8/14/19 for Resident #28 revealed: . resident that is being seen as a f/u of UTI (urinary tract infection) . Nurse called this provider on Tuesday reporting yelling out; he started on Bactrim yesterday. Assessment/Plan: 1. Acute [MEDICATION NAME] without hematuria, Stopped Bactrim and started Keflex 500 mg (milligrams) . Culture grew. Review of a Nurse Practitioner Progress Note dated 8/20/19 for Resident #28 revealed: (Resident #28) is presenting with intermittent moments of confusion. Currently being treated for [REDACTED]. Labs show lactic acidosis and dehydration. Review of a Nursing Progress Note for Resident #28 dated 8/20/19 revealed: Resident alert to self occasionally. He will make eye contact occasionally when name called. Speech is slow. He has been yelling out with personal cares and any little touch. Accepting medications crushed in pudding. Resident receives routine [MEDICATION NAME] with little effect. He continues to yell out after administration of [MEDICATION NAME]. He ate oatmeal and drank 480ml of water for nurse. He refused lunch. Would not open mouth and refused fluids. Just let water run down the side of his mouth. (sic) Review of Physician order [REDACTED]. Special Instructions: weight decline, overall health condition, meal refusals, poor appetite. Three times a day, ordered 8/21/19 and discontinued 8/23/19. Review of a Nurse Practitioner Note dated 8/21/19 for Resident #28 revealed: . resident being seen today as a f/u (follow up) of confusion and lactic acidosis. (Resident #28's) son did not want to send (Resident #28) to the hospital. He did agree to IV (intravenous) fluids. Nurse reports that (Resident #28) has Perked Up since having IV fluids. Nurse reports that he did eat dinner and breakfast this morning. Twenty-nine pound weight loss since 8/12/19. Review of all Physician/Practitioner Progress notes for Resident #28 for the last 6 months provided by the facility revealed the last time the physician had seen the resident was on 5/20/19 and none of the progress notes address Resident #28 refusing meals or beverages until 8/19/19. Review of a Dietary Recommendations form dated 8/21/19 for Resident #28 revealed: mighty shakes (nectar) to meal trays. Rationale: Weight down decline overall health condition, meal refusals, poor appetite, increased behaviors. Review of a Dietary Note dated 8/21/19 for Resident #28 revealed: in review of current wt (weight) report, wt on 08/20/18 was 222.1, wt is variable by 1-29#. there is a significant wt change per the MDS guidelines. suspect several factors play a role, along with maintaining a stable wt may be difficult r/t: recent decline in health condition, acute illness with ABT, decrease in oral intake, increased pocketing episodes with recent changes to a mechanically altered diet, increased assistance with meals-dependent on feeding at this time, refusals to open mouth for medications/food/fluids, recent medication changes, increased sleepiness-difficult to awake up per staff, meal/supplement refusals, [MEDICAL CONDITION], fluid shifting, [MEDICAL CONDITION], acute kidney disease, [MEDICAL CONDITION], poor appetite at times, current medications with side effects, and abnormal labs. SLP down grade diet to a pureed diet with nectar thick liquids r/t dysphagia, pocket episodes, per staff at times liquids will, just run out of his mouth. recommendation is to have mighty shakes (nectar) added to meal trays. Currently being placed at the assist table for additional cueing, encouragement, and physical assistance, oral intake has declined to refused to 50%. Family is aware. Currently on IV therapy . (sic) Review of a Nurse Practitioner Progress Note dated 8/23/19 for Resident #28 revealed: BMP (basic metabolic panel) reviewed. Resident labs continue to worsen. Metabolic acidosis, [DIAGNOSES REDACTED]s elevated, AKI (acute kidney injury) on CKD ([MEDICAL CONDITION]). Needs inpatient attention. Review of a Hospital Discharge Summary dated 8/25/19 for Resident #28 revealed: . He was admitted with a [DIAGNOSES REDACTED]. Patient was placed on intravenous fluid hydration and creatinine has significantly improved with improvement in the [MEDICAL CONDITION]. (sic) Review of a physician progress notes [REDACTED].#28 revealed: pt was having increased confusion and was found to be dehydrated with confusion in ER (emergency room ) last weekend with NA (sodium) 153. This was corrected with IV (intravenous) fluids and patient seems to be close to baseline today, fair abilities with conversation and questioning and no acute complaints. weight 224 lb (pounds) 11.2 oz (ounces) . (sic) Review of a Dietary Recommendations form dated 9/12/19 for Resident #28 revealed: 2+ 90 ml (milliliters) BID (twice a day). Rationale: Oral intake variable, mighty shakes are hit and miss. Review of a meal ticket for Resident #28 dated 9/10/19 revealed: Lunch: Mech Soft (mechanical soft), allergies [REDACTED]. (sic) No supplements noted on ticket. In an interview on 9/12/19 at 11:18 a.m., the Director of Nursing (DON) reported she would expect supplements to be charted separately and just found out yesterday that the staff document the mighty shakes as part of the residents total fluid intake. By documenting the total fluid intake, it was not a way to show that the residents had their supplements. The DON expected staff to follow up with residents who decline their meals at the designated mealtimes. The DON reported that Resident #28 is part of the discussion during the standup meetings. Informed the DON this surveyor was still waiting for the timeline of interventions for Resident #28 and physician documentation. Review of a Timeline requested for the last 6 months from CDM P for Resident #28 revealed: 8/13/19 UA (urinalysis) positive, IV (intravenous) fluids started, yelling out with ADL (activities of daily living) cares, pain med given, lethargic/ slow verbal stimuli. 8/19/19 confusion. 8/20/19, SLP (speech therapy) downgrade diet to pureed with nectar thick. Ate oatmeal for breakfast, refused lunch, would not open mouth for food or liquids, water given, water ran downside of mouth. 8/21/19, Requesting water, consumed without difficulties (nectar thick). Dietary note along with recommendations for mighty shakes to meal trays. Ate 25 % breakfast . refused lunch (would not open his mouth). Supper time 25% at assist table appears to be perking up. 8/22/19, RD (registered dietician) noted. 8/23/19 sent to ER (emergency room ) for eval/admitted . 8/25/19, returned from hospital, admitted with bilateral [MEDICAL CONDITION]. 8/27/19, Hospital return note from CDM oral intake continues to be poor. 8/28/19 SLP upgraded liquids to thin. 8/30/19 SLP upgraded diet to mechanical soft with thin liquids. 9/3/19 CDM noted oral improvement 50-75% of meals. 9/6/19 2+ bilateral [MEDICAL CONDITION]. 9/8/19 decrease appetite still noted increase sleeping noted per staff. 9/12/19 Mighty shakes hit/miss oral intake up and down. 9/12/19 2+ supplements started. (sic) Review of the Medication Administration Record [REDACTED]. The Director of Nursing reported she did not know where this part of the MAR indicated [REDACTED] Mighty shakes nectar thick with meal trays. Three times a day. Ordered 8/21/19 - open ended. Nursing signatures noted on 8/21/19 through 8/23/19 to indicate the resident's intake of the supplement. 1L (liter) 0.9% NS (normal saline) @50 ml (milliliters/hr-1L total to be infused, once, ordered 8/13/19. Sodium Chloride 0.9% [MEDICATION NAME] solution; Amount to Administer 60 ml/hr (milliliters per hour) subcutaneous every hour, ordered 8/20/19-open ended and received 8/20/19 through 8/22/19. [MEDICATION NAME] Concentrate- Schedule II solution (an opioid that causes extreme drowsiness); 100 mg/5ml (20 mg/ml); Amount to Administer: 0.25 ml; oral every 6 hours, ordered 8/19/19 and received it 8/19/19 through 8/22/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. Keflex ([MEDICATION NAME]) (an antibiotic) 500 mg capsule twice a day. DX (diagnosis) UTI (urinary tract infection, ordered 8/14/19 to 8/20/19. Bactrim (antibiotic) 400-80 mg; every 12 hours, DX: UTI, ordered 8/13/19 and discontinued 8/14/19. Resident #28 received 3 doses. In an interview on 9/12/19 at 5:52 p.m., the Nurse Practitioner (NP) J reported Resident #28 was started on Bactrim on 8/13/19 and then started Keflex when the cultures came back because he had a [MEDICATION NAME] allergy. NP J was reporting by memory and thought that Resident #28 did start on an antibiotic before the results came back. The Regional Nurse Consultant L reported both antibiotics should have been but on the infection control tracking log. Requested the culture and sensitivity twice at this time and only received progress notes with a summarized report. At 6:06 p.m., NP J reported the culture for Resident #28 revealed he was resistant to Bactrim and that the office had the information and was reviewing it. Review of a Urine Culture summary form with a collection date of 8/12/19 for Resident #28 revealed: Culture: > 0 COL/ML (colonies per milliliter) /GROUP B STREPT[NAME][NAME]CUS AGALACTIAE (PREDICTABLE RESISTANCE TO [MEDICATION NAME]/SULFA (Bactrim) (treatment of [REDACTED]. Last resulted 8/13/19. Fax date on the bottom of the form has a print date of 9/12/19 at 5:35 p.m. Review of a Nurse Practitioner Progress Note dated 8/14/19 for Resident #28 revealed: Assessment/Plan: 1. Acute [MEDICATION NAME] without hematuria. Stopped Bactrim and started Keflex 500 mg (milligrams) Q 12 x 7 days. (every 12 hours). Culture grew. Review of Physician/Nurse Practitioner Progress notes for Resident #28 for Review of a Care Plan for Resident #28 revealed: Problem: . Nutritional/Hydration risk . Start date 6/25/18, revised 8/27/19 to provide adaptive equipment as ordered. Approach: provide mighty shakes to meal trays 6/25/18 . Encourage fluids at bedside with activities 6/25/18 . Offer substitutes if consumes <50% of meal 6/25/18. Weigh every month and/or PRN (as needed), notify DR. of significant change 6/25/18 . Problem: At risk for falls 6/25/19, . Approach: . Encourage res. to go to meals 30 min. before time 1/8/19. No care plan for eating assistance or other interventions noted. Review of a Certified Nursing Assistant (CNA) Care Guide for Resident #28 revealed: Diet: Mech soft liquids AM MEAL ONLY ASSIST TABLE. Dining Location: MDR (main dining room). Dining assistance: PRN (as needed). No supplements noted on care guide and no adaptive equipment noted.

Based on observation, interview, and record review, the facility neglected to provide basic care and isolated one resident (Resident #12), resulting in unmet care needs with psychosocial harm, potential for skin breakdown, potential for dehydration, and the potential for unmet care needs and isolation for all dependent residents. Findings include: diagnosed with [REDACTED].#12 admitted to the facility 10/25/91. The Minimum Data Set (MDS) for Resident #12 dated 5/20/19, indicated the Resident suffered severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3. The MDS further reflected Resident #12 required 2 or more staff to assist with bed mobility, transfers, and hygiene. Resident #12 resided in the second bed in last room at the end of a hall. On 9/11/19 at 8:34 AM, a partially pulled curtain hid Resident #12 in the darkened room from view unless walking well into the room. Laying on his left side in a low bed, Resident #12 faced a wall. A call light or call light cord was not visible. A fall mat lay between the low bed and a rolling table and a small dresser. A carrot (a therapy device placed in a hand to prevent or mitigate contractures) rested on the top of the rolling table. On the top of the dresser was a full water cup dated 9/11/19, and an unopened bottle of Coca-Cola. On 9/11/19 at 11:17 AM, the position of Resident #12 remained unchanged in the darkened room with the curtain partially pulled. The full water cup, cola, and therapy carrot remained in the same positions. Brown tinged saliva saturated one half of the pillow that the resident's face was laying on. A saturated plaid-patterned incontinence pad lay under the Resident. No call light or call light cord was visible. The resident did not respond or open his eyes to questions. Observations conducted that same day at 12:25 PM, 1:50 PM, and 2:48 PM, revealed Resident #12 and the room remained in the same position and condition as earlier noted. This included the exact location of the full beverages and the carrot and the absence of an accessible call light. The pillow and plaid incontinence pad were more saturated with each observation. At 3:39 PM on 9/11/19, just before Certified Nursing Assistant (CNA) shift change, Resident #12 remained in the same position on his left side but had freshly changed bedding. A soft-touch call light was available to the Resident. Both the water cup and cola remained full and in the same positions as previously observed. Review of the Care Plan for Resident #12 reflected a Problem that, Resident experiences incontinence, with interventions to, Encourage fluid intake, and Provide incontinence care after each incontinence episode. The Problem of .at risk for skin breakdown include the interventions to, assist to turn and reposition every two hours, keep clean and dry as possible. Minimize exposure to moisture, and Keep linens clean, dry, and wrinkle free. The Problem of Resident's participation and functioning level does fluctuate, include, call light to be within reach. Review of the Doctor's Order for Resident #12 reflected an order on 8/16/19, to apply a therapy carrot to right hand every morning as tolerated. A review of the Electronic Medical Record (EMR) Progress Notes conducted at 4:58 PM on 9/11/19 did not reveal any entries for 9/11/19. The record did not reveal documentation that Resident #12 had refused to get out of bed for breakfast or the noon meal, refused water or beverage, placement the therapy carrot in his hand, or refused to reposition or have bedding changed. The EMR did not reflect an assessment due to laying on wet bedding. During a document review conducted on 9/11/19 at 5:30 PM, the facility daily CNA sheet (untitled) for Resident #12 displayed information if the Resident had been continent or incontinent. The form reflected Resident #12 had been continent every shift from 9/1/19 through 9/10/19. However, no CNA documentation was entered for 9/11/19. Similarly, the section titled, ADL (Activities for Daily Living) Cares reflected morning and evening care was documented as completed for every shift to date except 9/11/19. Review of the facility document titled Daily CNA Assignment Sheet for 9/11/19, reflected the assignment of CNA F to the room of Resident #12. During an interview conducted on 9/11/19 at 3:43 PM, CNA F reported she was the caregiver assigned to Resident #12 and was assisted by CNA G. CNA F reported Resident #12, who requires two staff for assistance, usually gets up for meals but did not today. CNA F acknowledged the lack of care Resident #12 received during the day of 9/11/19. CNA F stated she was, just busy, and it was, one day where it was one thing after another, one call light after another. CNA F reported she felt the facility was well-staffed. CNA F reported the facility had provided abuse training and she knew the reporting process for any suspicion of abuse. During an interview conducted 9/11/19, at 4:04 PM, CNA G reported Resident #12 required two staff for assistance and the Resident, can't really help with care. CNA G reported Resident #12 can activate a touchable call light (activated by a light touch) when he needs assistance. CNA G reported her assignment did not include Resident #12 but that her and CNA F work together as they are the CNA's assigned the Team 1 hall. CNA G indicated the facility is well-staffed. CNA G did not comment when told of the observations of the care of Resident #12 on 9/11/19. CNA G reported the Resident declined to get up for breakfast and that the Resident did not respond to her two other times she had been in the room that day. CNA G indicated she understood the facility abuse policy. CNA G reported that neglect and isolation were the same thing; people need to be with people. Review of the employee files for CNA F and CNA G revealed: - Current Certified Nurse Aide certificates - A record of Clinical Skills Competency - Signed Acknowledgment and Agreement to Promote and Protect the Rights of Each Resident, (undated for CNA G) - A signed, Abuse Zero Tolerance acknowledgement of completed education on the Elder Justice Act and the facility abuse policy. Also, the definitions of the 7 types of abuse, including neglect and self-neglect and that abuse can cause mental anguish. Lastly, an understanding of the reporting requirements for the suspicion of a reportable event was included in this signed document. - Signed Nurse Assistant Job Description that outlines, Qualifications Generally that a Nurse Assistant . Must have a sincere and caring interest in the elderly. The Job Description listed a variety of care duties, an expectation to comply with resident rights, and to report all violations immediately. During an interview conducted 9/12/17, at 10:42 AM, Licensed Practical Nurse (LPN) D acknowledged she was the charge nurse on the Team 1 hall on 9/11/19. LPN D reported she had learned, during report from the night shift on the morning 9/12/19, that Resident #12 had not received any care the previous day shift and had spent the entire day in bed. LPN D reported that on 9/11/19, the CNA staff did not tell her the workload prevented them from completing resident care. LPN D reported her responsibility of monitoring the CNA's included ensuring vital signs were obtained and that resident rooms are ok. LPN D reported the Director of Nursing (DON) often checks on the CNA's. Review of the Job Description for Registered Nurses (RN) and Licensed Practical Nurses (LPN) provided by the facility, last reviewed 4/2010, reflected the General Purpose of this title and position included, Directly supervises the nursing assistants in the delivery of nursing care. On page 2 of 7 under the heading of Essential Job Functions, Section A, reflected that the nurse will, assume responsibility and accountability for directly managing and monitoring the care and services provided by the nursing assistants. Section D, page 4 of 7 dictates the nurse is to, Follow . policies and procedures, Ensure that resident care and services are being provided in a manner that adequately reflects . And on pages 4 and 5 of 7 under section F, titled Resident Rights Function the Job Description indicates the nurse is to, know, comply with, and ensure that all nursing assistants know and comply with the Resident Bill of Rights, and, Report immediately all violations of Resident's Rights. Review of the facility Abuse Prevention Program Policy and Procedure, revised 11/2018, indicated an intention to, Safeguard our residents to be free from abuse, neglect ., This includes but is not limited to freedom from . involuntary seclusion . The facility policy defines Abuse as the willful infliction of injury, unreasonable confinement .with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation of an individual . of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish. The facility policy defines neglect as , the failure of the facility, its employees . to provide goods and services to a resident .The Facility policy defines Willful, as used in the definition of abuse means the individual must have acted deliberately, not that the individual intended to inflict harm or injury. The facility policy defines Involuntary seclusion as, separation of a resident from other residents .or confinement to her/his room .against the resident's will . The facility policy defines an Alleged violation as a situation or occurrence known to staff but has not yet been investigated that could be related to resident mistreatment, neglect or abuse. The facility policy indicates Immediately means as soon as possible .but not later than 2 hours .if the events .involve abuse or . The facility policy reflected Possible Indicators of Neglect as failure to implement care planned interventions, and, the failure to provide necessary care . resulting in neglect .but may also affect the psychosocial well-being of the resident. Review of the staff interviews indicated CNA F and CNA G were aware that Resident #12 was not receiving, and did not receive, care and services as indicated by the Nurse Aid Job Description and the Resident's Care Plan. On 9/12/19, LPN D had acknowledged she did not monitor the CNA's but was aware of an allegation of possible neglect from the night shift report she had received several hours earlier. During an interview conducted 9/12/19, at 11:00 AM, the DON reported it was an expectation that the CNA's check on each resident approximately every two hours. The DON continued that CNA's should ensure residents have water and a call light in reach. The findings during the day shift on 9/11/19, for Resident #12 that included: unchanged positioning, wet bed and pillow, and call light and water out of reach were revealed to the DON. The DON indicated that this was the first she had heard of this. The DON indicated that no staff, the day shift CNA's or nursing staff, or the night shift, had reported to her that Resident #12 had not received care or services or had remained in his bed without a call light the previous day. On 9/11/19 at 5:20 PM, Resident #12 was observed lying in bed on the left side, awake. Resident was undressed and covered with a blanket. The bed pad was dry. Resident #12 was difficult to understand but he was able to confirm he was asking for food. When surveyor stated, I bet you are hungry, you've been in bed all day Resident #12 began to cry. During an interview on 9/12/19 at 7:00 PM, this surveyor discussed concerns identified with Resident #12 with the Administrator. The Administrator was not aware of the situation occurring despite another surveyor reporting it to the DON that same day eight hours earlier.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent weight loss and dehydration in 1 (Resident #28) of 13 residents reviewed, resulting in significant weight loss, dehydration, hospitalization , and a urinary tract infection. Findings include: Review of a Face Sheet revealed Resident #28 is an [AGE] year old male originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #28 was cognitively intact and required extensive assistance of 2 people for transfers, independent with set up only for eating, and weighed 246 pounds with an unknown weight loss. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #28 had a Brief Interview for Mental Status (BIMS) indicating he is severely cognitively impaired and is totally dependent on 2 staff for transfers and limited assistance of 1 staff for eating. Weight was 225 pounds and section K : Weight Loss: Loss of 5% or more in the last month or 10% or more in the last 6 months, box 2 was marked for Yes, not on a physician prescribed weight loss regimen. Review of Resident #28's weights are as follows: 3/6/19 weight was 240.6 pounds, 4/5/19 weight was 240.6 pounds, 5/5/19 weight was 246.6 pounds, 6/6/19 weight was 249.4 pounds, 7/11/19 weight was 243.8 pounds, 8/20/19 weight was 222.1 pounds, 9/8/19 weight was 225.8 pounds. A 6.15% weight loss noted in 6 months, an 8.90% weight loss from 7/11/19 to 8/20/19. Review of the facility's Weight Variance Report for Resident #28 revealed that between 3/14/19 and 9/8/19 Resident #28 has had variations in weight loss. On 3/14/19 the resident weighed 238.30. On 5/31/19 Resident weighed 258.8. On 8/30/19 resident weighed 221.0. On 9/8/19 weighed 225.80. Review of a Nurse Practitioner Progress Note dated 6/6/19 for Resident #28 revealed: . He was calling out because he did not want anyone to forget Him for breakfast. It was 0100. During an observation and an interview on 9/11/19 at 3:47 p.m., Resident #28 laid in bed and asked this surveyor when lunch was because he was hungry and reported he did not eat yet. No water noted in his room or within reach. In an interview on 9/11/19 at 3:49 p.m., Certified Nursing Assistant (CNA) G reported she was not Resident #28's CNA, but reported he refused his lunch today and will refuse many times because he likes to sleep in. In an interview on 9/11/19 at 4:05 p.m., CNA F reported Resident #28 had physical therapy before lunch and was tired, so he slept through lunch. CNA F reported she was not aware he was hungry and said they will get him up and get him something to eat. CNA F reported the kitchen will hold his tray until he wants it, but she did not check on him after lunch to see if he wanted his lunch. In an interview on 9/11/19 at 4:25 p.m., Certified Dietary Manager (CDM) P reported Resident #28 was sleeping more lately and not eating. CDM P reported medication changes were done and he has had some [MEDICAL CONDITION]. She reported they started him on Mighty Shakes nutrition supplement. CDM P reported the facility has weekly stand up meetings to address residents with weight loss but was not able to provide a root cause for Resident #28's weight loss. When queried if she was aware that Resident #28 gets physical therapy right before lunch which can possibly make the resident tired, she was not aware. When queried about how supplements are charted as given to residents who receive them, CDM P reported they probably include it as part of their liquid intake amount at mealtime. Staff did not the chart supplements given to residents or the acceptance/intake of the supplement. CDM P reported the CNA's add the Mighty Shakes to the resident's trays at mealtime and Resident #28 started mighty shakes on 8/21/19. CDM P reported she orders the supplements and provides a copy of the order to the physician to sign off on it but was not able to provide documentation that showed the physician is aware of supplements and/or physician orders [REDACTED].#28's weight loss interventions requested at this time. Review of a Dietary Progress Note for Resident #28, dated 7/30/19, revealed: Quarterly assessment completed. no chewing or swallowing difficulties. current diet is a regular, regular diet with regular liquids. continues to eat meals in the dining room for set up, and encouragement. Oral intake is refused-100%, on average being 75-100%, does request additional food/fluids at times. BMI is 38.04. no recent lab results. At nutritional/hydration risk r/t: HX of significant wt changes, [MEDICAL CONDITION], fluid shifting, [MEDICAL CONDITIONS] stage IV, variable oral intake, meal/supplement refusals, at times additional request for food at mealtimes, current medications with side effects, abnormal labs, and edentulous. wt on 07/18/19 was 250.2. wt history is variable by 1-13# there is no significant wt changes noted per MDS. Hot liquids/food assessment completed, encourage clothing protector, and no recommendations from OT therapy at this time. will review and update current plan of care. (sic) Review of a Nurse Practitioner Progress Note dated 8/14/19 for Resident #28 revealed: . resident that is being seen as a f/u of UTI (urinary tract infection) . Nurse called this provider on Tuesday reporting yelling out; he started on Bactrim yesterday. Assessment/Plan: 1. Acute [MEDICATION NAME] without hematuria, Stopped Bactrim and started Keflex 500 mg (milligrams) . Culture grew. Review of a Nurse Practitioner Progress Note dated 8/20/19 for Resident #28 revealed: (Resident #28) is presenting with intermittent moments of confusion. Currently being treated for [REDACTED]. Labs show lactic acidosis and dehydration. Review of a Nursing Progress Note dated 8/20/19 revealed: Resident alert to self occasionally. He will make eye contact occasionally when name called. Speech is slow. He has been yelling out with personal cares and any little touch. Accepting medications crushed in pudding. Resident receives routine [MEDICATION NAME] with little effect. He continues to yell out after administration of [MEDICATION NAME]. He ate oatmeal and drank 480ml of water for nurse. He refused lunch. Would not open mouth and refused fluids. Just let water run down the side of his mouth. (sic) Review of Physician order [REDACTED]. Special Instructions: weight decline, overall health condition, meal refusals, poor appetite. Three times a day, ordered 8/21/19 and discontinued 8/23/19. Review of a Nurse Practitioner Note dated 8/21/19 for Resident #28 revealed: . resident being seen today as a f/u (follow up) of confusion and lactic acidosis. (Resident #28's) son did not want to send (Resident #28) to the hospital. He did agree to IV (intravenous) fluids. Nurse reports that (Resident #28) has Perked Up since having IV fluids. Nurse reports that he did eat dinner and breakfast this morning. Twenty-nine pound weight loss since 8/12/19. Review of a Dietary Recommendations form dated 8/21/19 for Resident #28 revealed: mighty shakes (nectar) to meal trays. Rationale: Weight down decline overall health condition, meal refusals, poor appetite, increased behaviors. Review of a Dietary Note dated 8/21/19 for Resident #28 revealed: in review of current wt report, wt on 08/20/18 was 222.1, wt is variable by 1-29#. there is a significant wt change per the MDS guidelines. suspect several factors play a role, along with maintaining a stable wt may be difficult r/t: recent decline in health condition, acute illness with ABT, decrease in oral intake, increased pocketing episodes with recent changes to a mechanically altered diet, increased assistance with meals-dependent on feeding at this time, refusals to open mouth for medications/food/fluids, recent medication changes, increased sleepiness-difficult to awake up per staff, meal/supplement refusals, [MEDICAL CONDITION], fluid shifting, [MEDICAL CONDITION], acute kidney disease, [MEDICAL CONDITION], poor appetite at times, current medications with side effects, and abnormal labs. SLP down grade diet to a pureed diet with nectar thick liquids r/t dysphagia, pocket episodes, per staff at times liquids will, just run out of his mouth. recommendation is to have mighty shakes (nectar) added to meal trays. Currently being placed at the assist table for additional cueing, encouragement, and physical assistance, oral intake has declined to refused to 50%. Family is aware. Currently on IV therapy . (sic) Review of a Nurse Practitioner noted dated 8/21/19 for Resident #28 revealed: . resident being seen today as a f/u (follow up) of confusion and lactic acidosis. (Resident #28's) son did not want to send (Resident #28) to the hospital. He did agree to IV (intravenous) fluids. Nurse reports that (Resident #28) has Perked Up since having IV fluids. Nurse reports that he did eat dinner and breakfast this morning. Twenty-nine pound weight loss since 8/12/19. (sic) Review of a Nurse Practitioner Progress Note dated 8/23/19 for Resident #28 revealed: BMP (basic metabolic panel) reviewed. Resident labs continue to worsen. Metabolic acidosis, [DIAGNOSES REDACTED]s elevated, AKI (acute kidney injury) on CKD ([MEDICAL CONDITION]). Needs inpatient attention. Review of a Hospital Discharge Summary dated 8/25/19 for Resident #28 revealed: . He was admitted with a [DIAGNOSES REDACTED]. Patient was placed on intravenous fluid hydration and creatinine has significantly improved with improvement in the [MEDICAL CONDITION]. (sic) Review of a physician progress notes [REDACTED].#28 revealed: pt was having increased confusion and was found to be dehydrated with confusion in ER (emergency room ) last weekend with NA (sodium) 153. This was corrected with IV (intravenous) fluids and patient seems to be close to baseline today, fair abilities with conversation and questioning and no acute complaints. weight 224 lb (pounds) 11.2 oz (ounces) . (sic) Review of a Dietary Recommendations form dated 9/12/19 for Resident #28 revealed: 2+ 90 ml (milliliters) BID (twice a day). Rationale: Oral intake variable, mighty shakes are hit and miss. Review of a meal ticket for Resident #28 dated 9/10/19 revealed: Lunch: Mech Soft (mechanical soft), allergies [REDACTED]. (sic) In an interview on 9/12/19 at 11:18 a.m., the Director of Nursing (DON) reported she would expect supplements to be charted separately and just found out yesterday that the staff document the mighty shakes as part of their total fluid intake, and by documenting the total fluid intake, it was not a way to show that the residents had their supplements. The DON expected staff to follow up with residents who decline their meals at the designated mealtimes. The DON reported that Resident #28 is part of the discussion during the standup meetings. Informed the DON this surveyor was still waiting for the timeline of interventions for Resident #28 and physician documentation. Review of a Timeline requested for the last 6 months from CDM P for Resident #28 revealed: 8/13/19 UA (urinalysis) positive, IV (intravenous) fluids started, yelling out with ADL (activities of daily living) cares, pain med given, lethargic/ slow verbal stimuli. 8/19/19 confusion. 8/20/19, SLP (speech therapy) downgrade diet to pureed with nectar thick. Ate oatmeal for breakfast, refused lunch, would not open mouth for food or liquids, water given, water ran downside of mouth. 8/21/19, Requesting water, consumed without difficulties (nectar thick). Dietary note along with recommendations for mighty shakes to meal trays. Ate 25 % breakfast . refused lunch (would not open his mouth). Supper time 25% at assist table appears to be perking up. 8/22/19, RD (registered dietician) noted. 8/23/19 sent to ER (emergency room ) for eval/admitted . 8/25/19, returned from hospital, admitted with bilateral [MEDICAL CONDITION]. 8/27/19, Hospital return note from CDM oral intake continues to be poor. 8/28/19 SLP upgraded liquids to thin. 8/30/19 SLP upgraded diet to mechanical soft with thin liquids. 9/3/19 CDM noted oral improvement 50-75% of meals. 9/6/19 2+ bilateral [MEDICAL CONDITION]. 9/8/19 decrease appetite still noted increase sleeping noted per staff. 9/12/19 Mighty shakes hit/miss oral intake up and down. 9/12/19 2+ supplements started. (sic) Review of the Medication Administration Record [REDACTED]. The Director of Nursing reported she did not know where this part of the MAR indicated [REDACTED] Mighty shakes nectar thick with meal trays. Three times a day. Ordered 8/21/19 - open ended. Nursing signatures noted on 8/21/19 through 8/23/19 to indicate the resident's intake of the supplement. 1L (liter) 0.9% NS (normal saline) @50 ml (milliliters/hr-1L total to be infused, once, ordered 8/13/19. Sodium Chloride 0.9% [MEDICATION NAME] solution; Amount to Administer 60 ml/hr (milliliters per hour) subcutaneous every hour, ordered 8/20/19-open ended and received 8/20/19 through 8/22/19. [MEDICATION NAME] Concentrate- Schedule II solution (an opioid that causes extreme drowsiness); 100 mg/5ml (20 mg/ml); Amount to Administer: 0.25 ml; oral every 6 hours, ordered 8/19/19 and received it 8/19/19 through 8/22/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. Keflex ([MEDICATION NAME]) (an antibiotic) 500 mg capsule twice a day. DX (diagnosis) UTI (urinary tract infection, ordered 8/14/19 to 8/20/19. Bactrim (antibiotic) 400-80 mg; every 12 hours, DX: UTI, ordered 8/13/19 and discontinued 8/14/19. Resident #28 received 3 doses. Review of a Care Plan for Resident #28 revealed: Problem: . Nutritional/Hydration risk . Start date 6/25/18, revised 8/27/19 to provide adaptive equipment as ordered. Approach: provide mighty shakes to meal trays 6/25/18 . Encourage fluids at bedside with activities 6/25/18 . Offer substitutes if consumes <50% of meal 6/25/18. Weigh every month and/or PRN (as needed), notify DR. of significant change 6/25/18 . Problem: At risk for falls 6/25/19, . Approach: . Encourage res. to go to meals 30 min. before time 1/8/19. No care plan for eating assistance or specific adaptive equipment, or other interventions noted. Review of a Certified Nursing Assistant (CNA) Care Guide for Resident #28 revealed: Diet: Mech soft liquids AM MEAL ONLY ASSIST TABLE. Dining Location: MDR (main dining room). Dining assistance: PRN (as needed). No supplements noted on care guide and no adaptive equipment noted.

This citation refers to intake #MI 784 Based on observation, interviews, and record review, the facility failed to prevent an elopement and complete a thorough investigation relating to an elopement for one resident (#11) out of three residents identified as an elopement risk. This deficient practice resulted in an Immediate Jeopardy when Resident #11, a known elopement risk, exited the building on 9/3/18 at approximately 4:00 PM unbeknownst to staff, walked down a steep hill and out onto a 55 mile per hour road. Resident #11 was found approximately 10 minutes later and approximately one tenth of a mile from the facility. This deficient practice placed Resident #1 and two other residents who were assessed as being at risk for elopement at risk for serious harm, injury and/or death from hazards outside the facility. Findings include: A review of the facility policy titled Elopement Prevention and Management Program, dated 8/2017 revealed the facility goal It is the policy of this facility that personnel who have residents under their care are responsible for knowing the location of those residents (minimum hourly), and in the case of a missing resident, ensuring appropriate action is taken. A review of the facility's Resident's at Risk for Elopement binder (contained pertinent resident information, used to identify residents who are at risk for elopement) on 9/12/18 at 10:00 AM. The Director of Nursing (DON) stated the binders were located at both nursing stations. Resident #11 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set assessment dated [DATE], Resident #11 was independent with transfers, bed mobility, hygiene needs, and ambulated independently with a four wheeled walker. This same assessment indicated Resident #11 was severely cognitively impaired. Review of fall risk dated 5/24/18 showed that Resident #11 was coded as a 7 and identified as a high fall risk. Review of an Elopement risk assessment dated [DATE] showed that Resident #11 was identified as an elopement risk. An elopement care plan dated 8/13/18 revealed, Resident is at risk for elopement from facility r/t (related to) Alzheimer dementia, comments how she is leaving and going home the next day, will pack up her personal items thinking she is leaving. Episodes at night of thinking her family is coming to get her and becomes irritated when explanation is given that she will be spending the night with us. Multiple observations were made on 9/12/18 and 9/13/18 of Resident #11 ambulating throughout the facility using a four wheeled walker. Review of facility Incident/Accident Report, dated 9/3/18, reflected, .Family from another resident alerted staff that (Resident #11) was outside. They accidently allowed her outside when exiting facility . Review of facility investigation revealed statements from the Licensed Practical Nurse (LPN) A, Certified Nursing Assistant (CNA) B, LPN C, and one of five witnesses, Visitor E. Visitor E's statement dated 9/3/18 read, I (Visitor E) stepped outside the facility 9/3/18 to my car. Another couple were behind me. No alarms were beeping. When walking to my car I noticed a pt (patient) with (stuffed animals) in her walker, heading down the driveway. The other couple (husband) ran inside to get help. My grandson and my niece ran after her to keep any cars from hitting her. They kept her safe on the side of the road. The MA's ran out and escorted her back to the facility. The facility did not obtain names or interview the other four witnesses (Visitor H, I, J, and K) to this event. Review of Progress notes dated 9/3/09, authored by LPN A, read, At 405pm today a young boy came to nurses station. stated his grandmother send him in to let someone know they believe a resident followed them out the door. At 408 staff was making their way down the driveway to the road. resident could be seen. with two other women for the young mans family. staff easily walked resident back into the building. resident was assessed by this writer while team 2 nurse contacted DON, NP, and resident daughter. resident denies pain and discomfort. no skin issues noted. resident placed one on one while awake and q15 min checks when asleep. During a phone interview on 9/13/18 at 1:26 PM, CNA D stated she had last seen Resident #11 at 4:00 PM, during shift change, on 9/3/18. During a phone interview on 9/12/18 at 9:30 AM, Visitor E stated, .We were going out (of the facility), my grandson and niece was coming out and we saw (Resident #11) at the end of the driveway and she made a bee line across the road. There was another man and lady with a baby and small child coming out (of the facility) and I told them to go get staff. My grandson and niece ran after her (Resident #11). Sometimes that door sticks on the carpet, I bet whoever went out in front of us must not have noticed the door didn't shut. I told my niece to run before she (Resident #11) got hit. I am glad she got back in safely. The door caught that rug the other day and stayed open when we took my dad out . During an interview on 9/12/18 at 11:40 AM, LPN A stated her responsibilities to an elopement include ensuring the resident is safe and back in the facility, do an assessment (of the resident), ask pertinent questions, notify family, doctor and director of nursing. (And to) do 15 minute checks (on the resident) and associated paperwork. LPN A also stated at this time, A head count of all residents are done when the alarm goes off and no one is seen outside. LPN A indicated she did not know who reported that Resident #11 was outside. The policy titled Elopement Prevention and Management Program, dated 8/2017, included a Elopement Follow Up Record which contains questions such as Did staff or another resident leave? If so, who saw them and how did they get out of the building? Please describe circumstances including the resident went out and Where was the resident found and what time? This document was not completed following the incident occurring on 9/3/18. During an interview on 9/12/18 at 5:00 PM, Visitor H stated she witnessed the event with Resident #11 on 9/3/18 and stated, We were standing there for quite a while (outside the main entrance to the facility) and she (Resident #11) came out and headed down that hill toward the road. There were no alarms. She came out by herself. We weren't sure if she was supposed to be out, so we went up to her and she said she was going to her mom's. A man came out and he was who told staff she was outside . During an interview on 9/12/18 at 5:05 PM, Visitor I stated he had witnessed the event with Resident #11 on 9/3/18 and stated, .she was bolting for the street. I didn't see her (Resident #11) come out (of the building) .she was heading down the street and we (with Visitor H) ran to be with her (Resident #11) . During an interview on 9/12/18 at 1:30 PM, CNA B, the CNA that assisted Resident #11 back into facility, stated, When I went outside I seen family standing around. It wasn't until I got to the road that I could see the resident with two other people. She was just about to the first driveway .She was on the opposite side of the road (from the facility). On 9/13/18 at 1:20 PM, ten days after the incident, the Administrator stated she had identified the family that reported the incident to the staff. The family was identified as Visitor J and K. A handwritten document was provided to this surveyor reflecting an interview by the Administrator on 9/13/18 at 1:15 PM and read, When (Visitor J and K) exited the building they saw another family talking in driveway. They saw resident going down driveway. (Visitor K) ran back in for help and (the) other family sent someone to be with resident. The Administrator stated this family did not see Resident #11 exit the building. On 9/13/18 at 1:35 PM a message was left with Visitor J, there was no return call by the end of the survey. A facility tour on 9/12/18 at approximately 9:50 AM revealed postings at the front main entrance alerting visitors to check with the nurse before opening the door for someone. The front door alarmed when opened without entering a pin on the lock keypad. The alarm was disabled and the door held open for one minute before another alarm sounded. Staff were noted to respond to each alarm. The door did catch slightly on the entry way rug when opened wide. An interview with the Administrator that same day at 10:00 AM revealed the facility did not have video surveillance or use any electronic wandering devices. Another interview on 9/12/18 at 11:05 AM, the Administrator stated, Our whole investigational premise was based on (Visitor E's) statement. That they (the visitors) were with her the whole time .I wasn't here when it happened .She (Visitor E) made it sound, during our discussion, that the resident went out with them and the other family as a group . On 9/12/18 at 5:40 PM, the Administrator was informed verbally that an Immediate Jeopardy (IJ) had been identified. On 9/13/18 at 4:00 PM, a written notification was provided to the Administrator. The IJ began on 9/3/18 for failing to prevent an elopement and perform a thorough investigation regarding the elopement. This deficient practice has the potential to affect all 3 residents who are assessed as being at risk for elopement at risk for serious harm, injury and or death from hazards outside the facility. On 9/17/18, it was verified that the following interventions had been put into place and were effective to remove the immediacy: On 9/3/18 Resident #11 was assessed by the LPN, there were no injuries. Resident #11's physician, the Director of Nursing and Resident #11's responsible party were notified. Resident #11 was placed on one to one supervision until 9/5/18. Resident #11 remains on hourly checks as of 9/14/18. On 9/12/18- The Elopement book identified three residents identified to be an elopement risk. It was verified that signs were posted at the entrances notifying visitors to check with staff before letting anyone through the doorway. It was verified that letters were sent and received by a family member. On 9/13/18 it was verified that the DON re-assessed all residents in the facility for wander and/or elopement risks. On 9/17/18 - Logs were reviewed verifying that door alarms were checked on 9/4/18 and daily alarm checks began on 9/11/18. Front entry rug was removed from doorway. Education by the Regional Clinical Director for the Administrator and DON was verified. Education by the Administrator and DON for the clinical staff was verified as started on 9/12/18. There were four additional staff members requiring education as of 1:10 PM. Elopement drills performed on 9/5/18 and daily beginning 9/12/18 through 9/16/18 were verified. Although the Immediate Jeopardy (J) was removed on 9/14/18, the facility remained out of compliance at a scope of isolated and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency.

Based on interview and record review, the facility failed to provide appropriate treatment and care for a Resident (Resident #12) with incontinence and frequent urinary tract infections [MEDICAL CONDITION], of 12 residents reviewed for care, resulting in the delay of personal care, frequent pain, discomfort, repeated treatment for [REDACTED]. Findings include: Resident #12 was a [AGE] year old female was originally admitted to the facility 9/6/16 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated , 5/25/18 reflected Resident #12 was cognitively intact but required extensive assistance with toileting and was incontinent of stool. On 7/24/18 at 8:35 AM an interview was conducted with Resident #12 in her room. Resident #12 reported slow call light response to request for toileting assistance that had resulted incontinence. Resident #12 reported this delay occurred every couple of days. Resident #12 reported she can't hold her stool and goes in her bed. Resident #12 stated that it makes her feel bad. Resident #12 reported she had waited, sitting in stool, for 20 minutes at times. Resident #12 reported she has a clock and indicated she has watched the time she has had to wait. Resident #12 reported staff were aware that she cannot hold her stool but told her they were busy with other residents and it was beyond their control .they can't help it, which they can't. They don't have enough help here. The Resident reported this had happened at different times of the day. Resident #12 reeported she has had recurrent urinary tract infections [MEDICAL CONDITION]. The Resident reported she was currently on antibiotics for this. Review of the laboratory test collected 4/27/18, and reported on 4/30/18 reflected a Urinalysis test with a result of white blood cells (WBC) too numerous to count, and a culture that reflected the organism detected to be escherichia coli (E-coli) of greater than (>)100,000 col/ml. Review of the laboratory test collected 6/10/18, and reported on 6/13/18 reflected a Urinalysis result of an elevated WBC count, and a culture that reflected the organism detected to be E-coli of >100,000 col/ml. Review of the laboratory test collected 7/12/18, and reported on 6/13/18 reflected a Urinalysis result of an elevated WBC count, and a culture that reflected the organism detected to be E-coli of >100,000 col/ml. Review of the Physician/Provider progress note dated 4/30/18, reflected that the Provider acknowledged the organism of the UTI to be E-coli, ordered an antibiotic and encouraged the Resident to drink more water. Review of the Physician/Provider progress note dated 6/12/18, reflected that the Provider documented, [MEDICAL CONDITION]: positive for flank pain and would, reassess after treatment of [REDACTED]. Review of the Physician/Provider progress noted at 6/19/18, reflected that the Provider acknowledged the Resident was under treatment for [REDACTED]. The note did not indicate the lab results of 6/13/18 had been reviewed. Review of the Physician/Provider progress note dated 7/12/18, reflected that the Provider had reviewed recent labs and documented, flank pain, malodorous urine, burning with urination . and was awaiting culture and sensitivity (C & S) test of a urine specimen. Review of the Physician/Provider progress note dated 7/17/18, did not reflect that the Provider had reviewed the results of the recent labs and C&S but did document that the Resident was incontinent, The Provider documented a [DIAGNOSES REDACTED]. The note did not reflect any documentation or comment of the recent lab and past labs completed for UTI's with the organism identified as E-coli. A more distant review of a Physician/Provider progress note dated 2/26/18 reflected Resident #12 was being readmitted to the facility following an emergency room encounter that revealed Resident #12 had, E-coli UTI /[MEDICAL CONDITION] (infectious organisms in the blood stream). On 7/25/18 at 10:55 AM an interview was conducted with Facility Physician (FP) M. It was discussed with FP M that Resident #12 had frequent UTI's and that E-coli was consistently identified through urine C&S and that the Resident had complained of slow call light response to personal care. FP M reported a change of care needs would be indicated to a regular check and change, not just check . During the above interview Assistant Director of Nursing (ADON) S was present. ADON S reported that, at times, Resident #12 had been resistant to peritoneal care and that this had been addressed on the Care Plan for the Resident. Review of the Activities for Daily Living (ADL) Care Plan for Resident #12 was reviewed. The Care Plan, initiated on 9/6/16, reflected Resident #12 had a self care deficit related to several issues that included limited mobility. The Care Plan acknowledged on 2/19/17 that the Resident was incontinent of bowel ., and had, total dependence on staff . of toileting/elimination needs. The Care Plan reflected a general statement that the Resident could be resistive to cares/ assistance. The intervention implemented 9/6/16 to address this was to reapproach or seek assistance. The Care Plan did not reflect any interventions were reviewed, attempted or implemented since (MONTH) (YEAR). Review of the Acute Care Plan - Infections for the dates 5/1, 6/13, 6/21, and 7/19 all reflected Resident #12 was being treated for [REDACTED]. During the survey, no other Care Plans were found during the survey to address the elimination needs, causative UTI history, and concerns of Resident #12.

Based on observation, interview and record review, the facility failed to prevent falls in 1 (#4) resident and failed to properly transfer residents 1 residents (# 3) from 5 residents reviewed for personal care form a total sample of 6 residents resulting in a preventable fall with a fracture for resident #4 and potential for injury for resident #3. Findings include: Resident #3 had following Diagnoses: [REDACTED]. falls and subsequent injury care plan, dated 6/3/2008. According to the Minimum Data Set (MDS) with an assessment reference date of 7/30/15, Resident #3 ' s cognition was severely impaired. On 9/2/15 at approximately 2:00 PM Staff G Restorative Certified Nursing Assistant (RCNA), and Staff Q Certified Nursing Assistant (CNA) entered Resident #3's room to assist Resident #3 to the toilet using a total lift device. Staff G donned lift sling around resident and attached the sling to the lift device using the green loops. Resident #3 ' s spouse instructed Staff G and Staff Q to use the red loops to toilet his wife. Staff G looked at the STNA Care Sheets (Nurse Assistant care plan), and continued on with the lift without changing the green loop color/position. STNA Care Sheets, dated 8/28/15, instructions were printed on the bottom of the page, Sling loop colors: Red 90 degrees= sitting, Yellow 70 degrees= reclining, Green 30 degrees= laying. Resident #3 was lifted in the total lift device in a lying, 30 degree position. The Director of Nursing (DON) Staff B was interviewed on 9/2/15 in the social workers office, at approximately 4:15 PM and stated the red loop attached to the sling, for the total lift device, should be used when toileting a resident. Staff G and Staff Q lifted Resident #3 from the wheelchair and wheeled Resident #3' to the shared bathroom. Resident #3 was lowered partway over the toilet in a lying (30 degree) position. Resident #3 was crying and kicking the lift device with bare feet. Staff G removed his brief soiled with bowel and urine. Resident #3 was lowered to the toilet, but was in a reclined position. Staff G lifted the sling around Resident #3 ' s back to adjust position on toilet. Resident #3 cried out, No, no, no as Staff G brought the sling up under Resident #3 ' s arms. Staff Q and Staff G then repositioned the resident on the toilet in a sitting position. Resident #3 was lifted with the total lift, again in a reclined position, and began crying when Staff G wiped the bowel from Resident #3 with toilet paper. Resident #3 was placed back into the wheelchair and was again repositioned by Staff G and Q under the arms into a sitting position. The staff failed to follow the recommended sling loops. Resident #4 was readmitted [DATE] following surgery on the left hip after a fall with fracture on 8/28/15, history of right hip surgery following a fracture April 2015, Senile Dementia, Osteoarthritis, Ischemic heart disease, Hypertension, and history of Herpes Complex, as noted on Physical Therapy Plan of Care dated 9/2/15. According to the Incident/Accident Report, on 8/27/15 at 8:15 PM, Resident #4 was observed sitting on the floor next to a wheelchair and was unable to verbalize the reason for the fall. Prior to the incident, Resident #4 was noted as sitting in the hallway in a wheelchair just outside the dining room. The same report indicated Resident #4 was last assisted to the bathroom before dinner and Resident #4 was found to be incontinent of bowel. The Post Fall Assessment & Investigation dated 8/28/15, revealed possible cause of fall was related to toileting and Resident #4 was toileted last at 5:45 PM., 2 1/2 hours prior to the fall. The same investigation indicated a 3 day Bowel and Bladder Tracking as an intervention to prevent further occurrences. The STNA CARE SHEETS (Nurse Assistant Care Plan) dated 8/28/15 indicated Resident #4 was at high risk for falls and was to be toileted upon arising, before and after meals, at bedtime, as needed, and to check with night rounds. Resident #4 was not toileted after the evening meal. According to a Statement Form, signed 8/27/15, attached to the Incident/Accident Report dated 8/27/15; staff reported while doing care on Resident #4, a bruise was noted on the left forearm. Resident #4 stated left arm was snagged on the sling from the lift and that the bruise was reported to the nurse. According to the Minimum Data Set (MDS) with an assessment reference date of 5/1/15, Resident #4's cognition was severely impaired. The Incontinence Monitoring Record dated August 2015, was started on 8/27/15 at 7:00 p.m. on the Bladder Tracking half of the document. There was no documentation on the Bowel Tracking half of the document until 8/28/15 at 6:00 AM. and absent documentation from 7:00 PM-10:00PM. Instructions on the bottom of this same document instructed staff to check the resident every hour for a period of 3 days to establish a pattern. The Flowsheet/Daily Care dated August 2015 indicated Resident #4 was incontinent of a medium size bowel movement, between 6:00 AM. and 6:00 PM., this was not reflected on the Incontinence Monitoring Record. Incident/Accident Report dated 8/29/15 at 2:05 AM., revealed Resident #4 was observed on the floor at the end of the bed with a soiled brief around ankles. According to the Fall Staff Statement dated 8/29/15, the Certified Nursing Assistant (CNA) indicated that they were returning from lunch and was told Resident #4 was on the floor. Fall Event page of the investigation, dated 8/29/15, indicated Resident #4 complained of pain and the left leg was found to be externally rotated. Resident Progress Notes dated 8/29/15 at 1:23 p.m., revealed that Resident #4 had been admitted to the hospital and surgery was planned due to a left hip fracture. Resident Progress Notes dated 9/2/15 at 11:52 AM. indicated Resident #4 was readmitted to the facility with 2 incisions closed with staples. ( )