Every finding on record at Grand Oaks Nursing Center

Based on interview and record review, the facility failed to ensure that weights were obtained in accordance with physician orders for 3 residents (Resident #63, #26, and #35), out of 5 residents reviewed for the provision of nursing services.Findings: Resident #63 (R63) Review of an admission Record revealed R63 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure. Review of R63's Order Summary dated 5/1/26 revealed, Daily weight. See Torsemide (diuretic medication) order for weight gain 4-5lbs in a day. every day shift for CHF (congestive heart failure) and Torsemide Oral Tablet 20 MG Give 1 tablet by mouth as needed for Weight gain 1 tablet prn (as needed) for weight gain of 4-5lbs daily. Review of R63's May Treatment Administration Record revealed: On 5/3/26 R63's weight was 133.2 pounds. On 5/4/26 no weight was obtained for the reason Hold/See Progress Notes. The progress note revealed waiting on weight to be done. On 5/5/26 R63's weight was 138.2 pounds (5 pounds since previous weight). Review of R63's May Medication Administration Record revealed no doses of the as needed torsemide were administered. Review of R63's Electronic Medical Record revealed no documentation that a weight was obtained and documented for R63 on 5/4/26. There was no documentation that the provider was notified of the 5-pound weight gain. Resident #26 (R26) Review of an admission Record revealed R26 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure. Review of R26's Order Summary dated 4/8/26 revealed, Daily Weight r/t (related to) CHF every day shift for Heart failure and Bumex Oral Tablet 2 MG (Bumetanide) Give 2 mg by mouth every 24 hours as needed for weight gain of 3 pounds in a day or 5 pounds in a week. Review of R26's April Treatment Administration Record revealed: On 4/28/26 R26's weight was 177.5 pounds. On 4/29/26 no weight was obtained with no documentation for the rationale of the missed weight. On 4/30/26 R26's weight was 182.5 pounds (5 pounds since previous weight). Review of R26's April Medication Administration Record revealed no doses of the as needed Bumex were administered. Review of R26's Electronic Medical Record revealed no documentation that a weight was obtained and documented for R26 on 4/2926. There was no documentation that the provider was notified of the 5-pound weight gain. During an interview on 05/06/2026 at 3:16 PM, the Director of Nursing (DON) confirmed that R63 and R26 had missed weights as well as 5-pound weight gain. The DON reported that she would be reviewing the PRN (as needed) diuretic orders with the provider to ensure diuretic medications were administered safely and consistently. The DON reported she would be educating the licensed nurses on following the providers orders as they were written. On 5/6/26 at 12:52 PM a request for a policy for congestive heart failure was requested. No policy was received prior to survey exit. Review of the facility policy, Medication Administration by the Various Routes last revised December 2024 revealed, .e. Take vital signs as indicated if the medication administration is contingent upon the results. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, A weight gain of 0.9 to 1.4 kg (2–3 lb) in 1 day indicates fluid-retention problems. daily weight is measured at the same time of day and on the same scale (Ball et al., 2019). This allows an objective comparison of subsequent weights. Accuracy of weight measurement is important because health care providers base medical and nursing decisions (e.g., drug dosage, medications) or changes. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 558). Elsevier Health Sciences. Kindle Edition. R35 A review of R35's admission Record, dated 5/6/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R35's admission Record revealed they had multiple diagnoses that included congestive heart failure, chronic obstructive pulmonary disease (COPD), and chronic kidney disease. A review of R35's Weights and Vitals Summary, dated 4/20/26 to 5/4/26, revealed R35 had a 102.4-pound significant weight gain from 4/24/26 (223.6 pounds) to 4/29/26 (326 pounds). This weight gain resulted in a 45.8% change in weight within five days. A review of the facility's Weight Management Policy & Procedure, dated April 2015, revealed that in the event of a patterned or significant weight loss or weight gain the IDT (Interdisciplinary Team) team is responsible for assessing and implementing individualized interventions. A review of R35's electronic medical record (EMR), dated 4/20/26 to 5/4/26, failed to reveal any documentation that R35's weight gain was addressed and/or that R35 was assessed for a significant change in their weight and the effects it could have on their health (e.g., swelling, difficulty breathing, shortness of breath on exertion). During an interview on 5/6/26 at 10:58 AM, the DON stated someone should have done a re-weight when they noticed that R35 appeared to have a 102.4-pound weight gain in five days. She stated R35 was re-weighed last night, and they weighed 227 pounds which was more consistent with what they had been weighing prior to 4/29/26. The DON further stated R35 should have been re-weighed soon after the weight gain was recorded instead of six days later. She stated based on what R35's weights were and what their weight was yesterday, she thought that the nurse must have fat fingered the weight when she entered it on 4/29/26. The DON stated she thought R35's 326-pound recorded weight was inaccurate and R35 probably weighed 226 pounds on 4/29/26 instead of the recorded 326 pounds since R35 had not shown any physical signs of a sudden significant weight gain (e.g., difficulty breathing; increased shortness of breath with exertion; increased sudden swelling in the arms, legs, face). During a second review of R35's Weights and Vitals Summary, dated 5/6/26, verified that R35 weighed 227-pounds on 5/5/26 at 5:11 PM. In addition, it was noted after they were weighed on 5/5/26 that R35's weight for 4/29/26 had been struck out with the reason being Incorrect Documentation. 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, retrieved on 7/27/25).

Based on observation, interview and record review, the facility failed to implement interventions and complete treatments for 1 resident (R16) with an unstageable pressure ulcer out of 2 residents reviewed for pressure ulcers. Findings Include:Resident #16 (R16)Review of an admission Record reflected R16 admitted to the facility with abnormal posture, weakness, muscle wasting and atrophy and dementia. Review of a Care Plan initiated 12/01/2025 reflected R16 had Altered functional mobility and ADLs (Activity of Daily Living) with interventions that included SKIN CARE INTERVENTIONS: . Heel boots at all times Date Initiated: 12/01/2025, revised on 5/4/2026. During an observation on 05/04/2026 at 10:00 AM, R16 was observed in her wheelchair in the common area and appeared to be sleeping. Heel boots were not in place. During an observation on 05/04/2026 at 11:40 AM, R16 was still sleeping in the wheelchair in the common area, heel boots were not in place. During an observation on 05/04/2026 at 1:19 PM, R16 was observed seated in the common area on the unit, and heel boots were not in place. During an observation on 05/06/2026 at 9:17 AM, R16 was observed in the common area seated in her wheelchair, heel boots were not in place. Review of Interdisciplinary Documentation dated 4/28/2026 reflected Resident appears to have PI (pressure injury) to right heal (sic); 6cm x 3.5cm. It appears to have had a large blister open. Center has dark discoloration with blanchable redness surrounding. Area is tender to touch. 4x4 foam border dressing applied. Message left for CCC (Clinical Care Coordinator).Review of Interdisciplinary Documentation dated 5/4/2026 reflected R16's responsible party was notified of the newly identified pressure ulcer, six days after the discovery of the pressure ulcer. Review of the April 2026 Medication Administration Record/Treatment Administration Record (MAR/TAR) reflected Cleanse right heel, pat dry. Apply betadine and heel cup. Secure with kerlex every day shift for PI (Pressure Injury) starting 4/30/26, two days after the pressure injury was identified. The treatment was NOT documented as done. Review of the May 2026 MAR/TAR reflected Cleanse right heel, pat dry. Apply betadine and heel cup. Secure with Kerlex every day shift for PI (Pressure Injury) starting 4/30/26. The treatment was NOT documented as done until 5/5/2026. During an observation on 05/06/2026 at 9:21 AM, the Director of Nursing (DON) removed the dressing from R16's right heel and assessed the wound. Certified Nurse Aide (CNA) E assisted the DON by elevating R16's right foot during the procedure. The DON used wound cleanser to clean the area and reported the wound had progressed from a stage 2 pressure injury to an unstageable wound due to the presence of eschar (a thick, dry, black or brown layer of dead tissue that covers a severe wound such as a third degree burn or pressure ulcer) covering the majority of the wound bed. The wound measured 3 centimeters (cm) x 3 cm x 0.2 cm. The DON applied Betadine and a new heel cup, secured with kerlix. Upon completion of the procedure, R16's heel boots were not applied. During a follow-up interview on 5/6/2026 at 9:40 AM, the DON reviewed the clinical record and confirmed that R16's April and May 2026 MAR/TARs did not reflect the dressing changes had been done as ordered until 5/5/2026. The DON speculated that the order had been entered incorrectly and did not show up on the TAR. The DON reported that her expectation is that residents and/or resident's responsible party are notified by the end of the nurse's shift if the clinical change was not an emergency.

Based on interview and record review, the facility failed to ensure Binding Arbitration was explained in a manner understood by residents and/or resident representatives and obtain adequate informed consent prior to entering into a binding arbitration agreement for 1 resident (R62) out of 3 residents reviewed for arbitration. Findings Include:Review of an admission Record reflected R62 admitted to the facility from a hospital on 4/26/2026 for orthopedic aftercare. R62 was listed as their own responsible party. During an interview on 05/06/2026 at 1:20 PM, R62 reported that he had no idea what a binding arbitration agreement was. R62 did not recall signing the agreement and said his son handles all these matters and these things are over his head.Review of a Voluntary Binding Arbitration Agreement reflected that R62 signed the agreement on 4/27/2026 and reflected R62 initialed agreement with 20. Understand the Binding Agreement to Arbitrate. The Resident or his/her Representative acknowledges that they fully understand this Binding Arbitration Agreement. During an interview on 05/06/2026 at 1:42 PM, the Nursing Home Administrator (NHA) reviewed arbitration agreements with the surveyor, and it was identified that R62 signed both the acceptance and the declination of the binding arbitration agreement. During the interview with the NHA on 5/6/2026 at 1:42 PM, Administrative Assistant (AA) G reported that she was responsible for explaining binding arbitration to Residents and/or Resident Representatives upon admission. AA G said she did not know she needed to tell Residents/Resident Representatives they had 30 days to change their mind about agreeing to binding arbitration in writing. Both the NHA and AA G reported that they believed the binding arbitration could be reversed at any time and reported they didn't know a whole lot about it (Binding Arbitration). AA G said a binder with admission contract details included a copy of the Binding Arbitration agreement, however, upon review of an admission Binder, a description of binding arbitration was not found. The NHA reported the facility needed to do a much better job at educating staff and residents when offering binding arbitration agreements. Review of an unsigned copy of the facility Voluntary Binding Arbitration Agreement reflected, You are strongly encouraged to consult with an attorney or a trusted advisor before signing this agreement. You have the opportunity to ask questions before signing this document. Please do not hesitate to ask any questions that you may have. The Resident/Resident's Legally Authorized Representative, by signing this agreement, also acknowledges that he/she has been informed and understands the entire agreement including that: a. Care, diagnosis, or treatment will be provided whether or not the Resident signs the agreement to arbitrate; b. The agreement may not be submitted to a Resident for approval when the Resident has been deemed incompetent by two physicians; c. The decision whether or not to sign the agreement is solely a matter for the Resident's (or the Resident's legally authorized representative) determination without any influence; d. The agreement waives the Resident's right to a trial in court for any future malpractice claim the Resident may have against the healthcare provider, absent revocation of the agreement consistent with state law.

Based on interview and record review, the facility failed to ensure controlled drugs were administered in accordance with physician orders and nursing professional standards of practice for 4 residents (Resident #52, #17, #26, and #68) out of 15 residents reviewed for medication administration.Findings:Resident #52 (R52)Review of an admission Record revealed R52 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: restlessness and agitation.Review of R52's Order Summary dated 4/22/26 revealed, Ativan Gel Apply to wrists topically every 4 hours as needed for anxiety.Review of R52's Controlled Drug Receipt/Record/Disposition Form revealed that a dose of the Ativan gel was dispensed on 4/28/26 at 6:19 PM. There was no documentation that the Ativan gel had been wasted (would include a note of wasted with a secondary nurses signature).Review of R52's Electronic Medication Administration Record (EMAR) revealed that the dose of Ativan gel dispensed on 4/28/26 at 6:19 PM was not documented as administered.Review of R52's Electronic Medical Record revealed no documentation indicating an additional nurse had witnessed the disposal of R26's Ativan gel. Resident #17 (R17)Review of an admission Record revealed R17 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: weakness and difficulty in walking.Review of R17's Order Summary dated 2/17/26 revealed, traMADol HCl Oral Tablet 50 MG Give 1 tablet by mouth every morning and at bedtime for pain.Review of R17's Controlled Drug Receipt/Record/Disposition Form revealed:On 4/22/26 a dose of Tramadol was dispensed at 7:05 AM. There was no additional dose of Tramadol dispensed on 4/22/26.On 4/30/26 a dose of Tramadol was dispensed at 8:03 AM. There was no additional dose of Tramadol dispensed on 4/30/26.On 5/2/26 a dose of Tramadol was dispensed at 8:09 AM. There was no additional dose of Tramadol dispensed on 5/2/26.Review of R17's April EMAR revealed that on 4/22/26 and 4/30/26, 2 doses (morning and bedtime) were documented as administered.Review of R17's May EMAR revealed that on 5/2/26 2 doses (morning and bedtime) were documented as administered. Resident #26 (R26)Review of an admission Record revealed R26 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain. Review of R26's Order Summary dated 4/3/26 revealed, LORazepam Oral Tablet 0.5 MG (Ativan) Give 0.25 mg by mouth one time a day for anxiety. To be administered at 4:00 PM.Review of R26's Controlled Drug Receipt/Record/Disposition Form revealed:On 4/17/26 at 3:47 PM a dose of Ativan was dispensed. There was no documentation that the Ativan had been wasted.On 4/28/26 at 3:36 PM a dose of Ativan was dispensed. There was no documentation that the Ativan gel had been wasted.Review of R26's April EMAR revealed that on 4/17/26 and 4/28/26 the doses of Ativan had been refused by R26.Review of R26's Electronic Medical Record revealed no documentation indicating an additional nurse had witnessed the disposal of R26's Ativan. Resident #68 (R68)Review of an admission Record revealed R68 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: right femur fracture.Review of R68's Order Summary dated 4/23/26 revealed, oxyCODONE HCl Oral Tablet 5 MG Give 1 tablet by mouth every 4 hours as needed for pain take one tablet by mouth every 4 hours as needed for pain.Review of R68's Controlled Drug Receipt/Record/Disposition Form revealed:On 4/27/26 (no documented time) a dose of Oxycodone was dispensed. There was no documentation that the Oxycodone had been wasted.On 4/29/26 at 8:35 AM a dose of Oxycodone was dispensed. There was no documentation that the Oxycodone had been wasted.On 4/29/26 at 5:53 PM a dose of Oxycodone was dispensed. There was no documentation that the Oxycodone had been wasted.Review of R68's April EMAR revealed that the doses of Oxycodone dispensed on 4/2726 (no documented time), 4/29/26 at 8:35 AM, and 4/29/26 at 5:53 PM were documented as administered.During an interview on 05/06/2026 at 3:16 PM, the Director of Nursing (DON) confirmed the medication errors/discrepancies for R52, R17, R26, and R68. The DON reported that the expectation was for the licensed nurses to follow professional standards of nursing practice for medication administration and reported she had recently completed an in-service/education regarding medication administration with them. The DON reported she would be reeducating the licensed nurses regarding following the providers' orders as they are written as well as administering medications following the facility protocol and professional standards of nursing practice.Review of the facility policy, Medication Administration by the Various Routes last revised December 2024 revealed, .3. Documentation of as needed or p.r.n. medication will occur in the e-MAR directly after administration and include indicated clinical assessment, pain scale if indicated, and therapeutic effectiveness.l. Document after administering the medication and before proceeding to the next resident.n. If a dose of medication is withheld or refused, the nurse will note that on the eMAR (electronic medication administration record.Review of the facility policy, Controlled Medication Storage, Security & Disposition last revised March 2024 revealed, .2. When a dose of controlled medication is removed from the container for administration but is refused by the resident or not given for any reason, it is not placed back into the container. It is destroyed in the presence of two licensed nurses. The disposal is documented on the narcotic count verification sheet.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, The seven rights of medication administration include the right medication, right dose, right patient, right route, right time, right documentation, and right indication. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 705). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions for 1 resident (R16) out of 15 residents reviewed for infection control. Resident #16 (R16)Review of an admission Record reflected R16 admitted to the facility with diagnoses that included a stage 2 pressure ulcer. Review of R16's entire Care Plan initiated on 12/01/2025 did not reflect R16 was in Enhanced Barrier Precautions (EBP).Review of Interdisciplinary Documentation dated 4/28/2026 reflected Resident appears to have PI (pressure injury) to right heal (sic); 6cm x 3.5cm. It appears to have had a large blister open. Center has dark discoloration with blanchable redness surrounding. Area is tender to touch. 4x4 foam border dressing applied. Message left for CCC (Clinical Care Coordinator). Further review of the Progress Notes did not reflect R16 had been placed in EBP due to having an open wound. Review of R16's Orders in the Electronic Medical Record (EMR) did not reflect R16 required EBP. During an observation on 05/06/2026 at 9:21 AM, the Director of Nursing (DON) removed the dressing from R16's right heel and assessed the wound. Certified Nurse Aide (CNA) E assisted the DON by elevating R16's right foot during the procedure. The DON used wound cleanser to clean the area and reported the wound had progressed from a stage 2 pressure injury to an unstageable wound due to the presence of eschar (a thick, dry, black or brown layer of dead tissue that covers a severe wound such as a third degree burn or pressure ulcer) covering the majority of the wound bed. The wound measured 3 centimeters (cm) x 3 cm x 0.2 cm. The DON applied Betadine and a new heel cup, secured with kerlix. The DON and CNA E did not don the required personal protective equipment (PPE) required for EBP during the high contact resident activity. During a follow-up interview on 5/6/2026 at 11:00 AM, the DON acknowledged R16 would require EBP due to the presence of a wound. Review of the facility policy and procedure for Enhanced Barrier Precautions revised March 2025 reflected, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs). Enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).

This citation pertains to intake 2677566. Based on observation, interview, and record review, the facility failed to ensure the appropriate assessing, monitoring, documenting, and care planning reflected the needs, cares, and services required for one (R2) of 4 residents reviewed for quality of care. Findings include:Resident #2 (R2)Review of a Face Sheet revealed R2 originally admitted to the facility on [DATE] with pertinent diagnoses of diabetes, congestive heart failure (CHF), hernia, chronic kidney disease, benign prostatic hyperplasia (enlarged prostate), major depressive disorder, weakness, and needs for assistance with personal care. Review of the Minimum Data Set (MDS) dated [DATE] for R2 revealed he was cognitively intact. During an observation and an interview on 1/27/26 at 2:30 PM, R2 was observed sitting in a wheelchair with his hair disheveled and notable scabbing on his head. R2 reported he scratches his head because it itches. R2 reported he had been in the hospital for a hernia repair but was tired at this time to elaborate anymore. Hernia/Pain/HospitalizationReview of a Hospital emergency room notes for R2 dated 11/28/25 revealed: . presents for right inguinal hernia. I was able to easily reduce the hernia with gentle pressure. I advised continued outpatient discussion with primary care, . Strict return precautions given, discharged stable condition. No documentation or clarification in the EMR (electronic medical record) of what the strict precautions were. Review of a Nursing Progress note dated 11/29/25 for R2 revealed: After visit summary from hospital visit-[Physician] - I recommend ordering a hernia [NAME] which can be found over the counter at the pharmacy and may help keep the hernia in place. If the hernia returns reduce as soon as possible. Continue to follow-up with his outpatient providers for further monitoring and management. No documentation shows there was any follow up to R2 receiving a hernia [NAME] and no further assessments/monitoring of R2s hernia. Review of a Nursing Progress note dated 12/2/25 at 3:36 PM for R2 revealed: Resident stated his hernia is out. Physician ordered one time dose of 2 Norco 5/325 (narcotic). Resident laid down in his bed and HOB (head of bed) lowered feet raised. At this time we believe that his hernia is back in. Scrotum has returned to baseline size and area soft with palpation. Review of a Nursing Progress note dated 12/2/25 at 4:01 PM for R2 revealed: Resident stated his hernia was out again. PRN (as needed) Norco administered. Resident placed in bed with head down and feet up. Resident continues to put his feet down and head up and is requesting more Norco at this time. There was no documentation of ongoing assessments and monitoring of hernia. Review of a Nursing Progress note dated 12/29/25 for R2 revealed: Nursing noted residents abdomen distended with brown emesis. order to send resident to ED (emergency department) for eval and treatment. Review of an emergency room Hospital medical records for R2 dated 12/29/25 revealed: Diagnosis at time of disposition: 1. Small bowel obstruction 2. Right inguinal hernia 3. Pneumatosis intestinalis (gas filled cysts inside the intestinal tract) 4. AKI (acute kidney injury) . chief complaint of inguinal pain at the site of his known hernia, also with vomiting and diarrhea.He is complaining of abdominal pain, nausea. He states that his hernia has been out for a couple of days, that usually he is able to self reduce, but has been unable to get it to go back in currently. R2 was transferred to another Hospital Emergency Department. Review of an emergency room Hospital Discharge Summary with an admission date of 12/29/25 to discharge of 1/2/26 for R2 revealed: Presenting Problem: Small bowel obstruction and Right inguinal hernia. Hospital Course: . CKD 3 (stage III chronic kidney disease), prior stroke with right-sided residual deficits, type 2 diabetes, hypertension, coronary artery disease, known right inguinal hernia who presented to the emergency department on 12/29/2025 as a transfer from [Emergency Room] for small bowel obstruction and incarcerated inguinal hernia. Patient was high risk for procedure and conservative management was pursued. Patient was prescribed scrotal support belt which helped with the abdominal discomfort. Also of note, Nephrology was consulted for AKI on CKD, this is likely prerenal in the setting of small-bowel obstruction, this did improve and he was started on Lasix as well as Farxiga for GDMT for heart failure with reduced ejection fraction. Review of a Practitioner Progress note dated 1/6/26 for R2 revealed: SBO (small bowel obstruction) 2/2 Recurrent incarcerated (right) inguinal hernia (a hernia that won't move back) . [NAME] (lower extremities) 1-2+ edema bil [NAME] (bilateral lower extremities) below knees . The Practitioner documented the A/P (assessment and plan) for R2 was 1. SBO and incarcerated right inguinal hernia, 2. CHF. Review of a Nursing Progress Note dated 1/7/26 for R2 revealed R2 went to the hospital with complaints of pain due to his hernia and had a solid hard scrotum that was larger than usual and painful. No documentation in the EMR indicates ongoing assessments of R2 hernia prior to hospitalization on 12/29/25. In an interview on 1/29/26 at 10:42 AM, the Director of Rehab (DR) C reported R2 has severe arthritis with limited range of motion in his shoulders, knees, and wrists. It was hard for him to do therapy because of it and his complications with his hernia popping out with activity. R2 has had several hospitalizations that interfered with making progress. In December R2 was fitted for a reclining wheelchair to ease the pressure from his hernia that would also cause pain and discomfort. Review of the Care Plan for R2 revealed a Focus for: .has some areas of concern including a (history) Hernia with repair, .Diabetes, Congestive Heart Failure and (R2) is healing from a wound. The medications associated with the above Diagnosis can contribute to weight, Fluid and Intake Fluctuations for the resident. Congestive Heart Failure can raise fluids levels for (R2) and cause weight shifts. Constipation and the bowel obstruction can effect (sic) (R2's) intake levels due to him feeling full or not wanting to eat. Last revised 6/23/25. This Care Plan is not focused or clear on the specific concern/condition.Interventions: No interventions for R2's hernia, and no update since return from hospital on 1/11/26 post hernia repair. LabsReview of laboratory results dated [DATE] for R2 revealed a high level of potassium at 6.0 (normal 3.4-5.0) and an eGFR (glomerular filtration rate) of 39 (normal is >=60), indicating stage III kidney disease. On 9/19/25 labs were redrawn and R2's potassium was 5.0 and eGFR was 5.0. Review of a Practitioner Progress note dated 9/23/25 for R2 revealed: . a/p (assessment and plan): Hyperkalemia (high potassium): Added Lokelma (a potassium lowering drug) 5 mg . CKD3b. This is the last potassium monitoring in the medical records. Review of a Nursing Progress note dated 12/28/25 for R2 revealed: Stated he is feeling a little better but still didn't want to take Lokelma. Review of an Order Summary for R2 revealed several orders for Lokelma from July 2025 to January 2026. No potassium labs in the EMR to reflect ongoing monitoring and stability of this medication. Review of the January Medication Administration Record (MAR) Orders for R2 revealed the following active orders unless otherwise indicated:Sodium Chloride- Give 1 gram by mouth one time a day for hyponatremia.Lokelma- 5 GM (grams), Give 1 packet by mouth one time a day for elevated potassium. No documentation indicating ongoing assessment/monitoring of sodium and potassium levels with altering medications and no indication R2 is stable on these medications. In an interview on 1/29/26 at 12:43 PM, the Director of Nursing (DON) was asked about R2s high potassium last checked in September the DON reported R2 had been in and out of the hospital frequently and the physician has access to the labs done in the hospital. The Physician will direct when a recheck is to be done. Skin/WoundsReview of a Skin Assessment dated 1/21/26 for R2 revealed BLE (bilateral lower extremities) are red and dry with scratch marks on them. Bilateral heels are boggy and blanching and are floating with blue boots on. Surgical area on abdomen is healing well with no concerns to note. Posterior thighs are red and excoriated. Review of the January Medication Administration Record (MAR) Orders for R2 revealed the following active orders unless otherwise indicated:Bag Balm External ointment, apply to BLE topically every morning and at bedtime for skin integrity, discontinued 1/6/26.[NAME] External Lotion 0.5-0.5% (Camphor & Menthol). Apply to BLE mix with Bag Balm topically two times a day for pruritis (itchy skin).Apply skin prep to outer left heel every shift for wound care, started 1/13/26.Open area on right heel. Wash daily with wound wash, pat dry, apply Thera-honey to open area and cover with comfort foam border dressing 3x3 two times a day for until area no longer open and discontinued on 1/11/26. Review of the Care Plan for R2 revealed a Focus for:. history of skin impairment. admitted to the facility with MASD to right posterior thigh . last revised 4/18/25. No risk/pressure ulcer focus. No interventions for wound on heel, suprapubic exit site excoriation, or MASD. No interventions for prevention of skin/wound history. Review of the Care Plan for R2 revealed a Focus for:ADL's (Activity of Daily Living) last revised 1/12/26 revealed: SKIN CARE INTERVENTIONS: Inspect skin with bathing and care. Heels elevated in bed. Report impaired skin integrity to Charge Nurse. Protective Sleeves/or long-sleeved shirt as accepted by the resident. Apply barrier cream with incontinence care PRN (as needed). Reposition frequently as accepted by resident. Resident to wear blue boot while in bed to aid skin integrity. Initiated 12/1/25. Review of the medical record revealed there was no Care Plan for Pruritis or itchy skin.In an interview on 1/29/26 at 12:43 PM, the Director of Nursing (DON) was asked about what boggy heels meant, the DON reported they are soft and squishy, not firm and indicates a concern that may need to be assessed. Boggy heels could mean something different for everyone. It could also be normal for that resident. When questioned about the orders for Medi-honey on a wound, the DON was not clear what kind of wound he had either. The nurses are to report any new wounds to the Clinical Coordinator so they can verify, assess and know how to proceed with treatments. The DON reported they do not use the Braden Scale to predict pressure ulcers and verified there is no care plan for pressure ulcers, but there is an entry for skin concerns. The DON reported the Care Plan should reflect the resident. The DON went to assess R2 after this interview. CHFReview of the January Medication Administration Record (MAR) Orders for R2 revealed the following active orders unless otherwise indicated:Furosemide (Lasix) (diuretic) 20 mg (milligrams), twice a day for hypertension.Midodrine HCL (hydrochloride) 5 mg given three times a day for hypotension (low blood pressure), started 1/4/26 and discontinued 1/11/26. No parameters were given.Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 5 mg by mouth every 8 hours as needed for a MAP (mean arterial pressure) < 65 for up to 20 days, ordered 1/11/26.General diet . fluid restriction- 2 liters a day. Review of weights for R2 revealed the following weights included but not limited to:1/3/26- 169.9 pounds (lbs)1/6/26- 171.8 lbs (the day before hospital)1/11/26- 177.6 lbs (the day R2 returned from the hospital)1/24/26- 174.2 lbs1/25/26 -179.6 lbs1/26/26 - 168.8 lbs Review of the EMR revealed no ongoing monitoring for assessments for congestive heart failure and no Care Plan focus or interventions. In an interview on 1/29/26 at 12:43 PM, the Director of Nursing (DON) reported R2 is to be on fluid restrictions but is not compliant. The facility does not have a CHF protocol for managing CHF, but R2 did get weighed often. The DON did not have a baseline reference weight for R2 but reported his baseline is around the mid 175 pounds. The DON verified there was no specific care plan interventions for CHF. When questioned about the orders for Midodrine to be given as needed with a MAP < 65 for up to 20 days, ordered 1/11/26, the DON reported that the order sounded like the order came from the hospital based on the parameters for a MAP. The DON reported that it is not usually an order a Nursing Home would have, and not confident staff knew how to calculate this. The DON reported she was going to investigate this further. The previous order for Midodrine was discontinued on 1/11/26 and agreed there should be blood pressure parameters. Suprapubic CatheterIn an interview on 1/28/26 at 10:15 AM, Medication Technician (MT) I reported she is also a CNA (Certified Nursing Assistant) and does cares for R2. MT I reported R2 has a suprapubic catheter and was not sure why the MAR shows R2 has a foley catheter. MT I reported R2 did not have any excoriation at his catheter exit site. In an interview on 1/28/26 at 10:30 AM, an Agency Licensed Practical Nurse (LPN) H was questioned to clarify R2's catheter. LPN H reported R2 did have very dry skin and reported R2 has a Foley catheter and not a suprapubic catheter. LPN H verified the electronic medical records (EMR) reflected R2 had a Foley catheter. R2 was out of the facility at this time, but LPN H later clarified that R2 did have a suprapubic catheter. Review of the January Medication Administration Record (MAR) Orders for R2 revealed the following active orders unless otherwise indicated:Foley Catheter (urinary catheter) care every day shift, change the Foley Cath securement device weekly and as needed, ordered 1/12/26.Foley Cath Care every shift, empty drainage bag every shift and record output.Foley Cath Care as needed ___ (no size documented) French Foley Catheter with 30 cc (cubic centimeters) saline balloon, change as needed.Suprapubic Cath Care. Securement device on left anterior thigh. Drainage tubing to be run down pant leg when up in chair. Every shift empty catheter drainage bag and record output.Cleanse suprapubic site with soap and water, pat dry and apply T-sponge every day shift for skin integrity, discontinued 1/11/26. In an interview on 1/28/26 at approximately 10:35 AM, R2 lifted his shirt where a suprapubic catheter was observed with no T-sponge in place and the surrounding skin was red and excoriated. R2 reported he just has very dry skin. R2 went on to talk about his past hospitalizations due to his hernia that would not go back in. The last hospitalization R2 said he had a high-risk surgery done to hopefully fix the problem. R2 verified a long time ago he did have sepsis from an infected catheter and not too long ago he had swelling in his groin area that was very painful. Review of the Care Plan for R2 revealed a Focus for:ADL's (Activity of Daily Living) last revised 1/12/26 revealed: TOILETING/ELIMINATION: Foley catheter to drainage. Maintain drainage bag placement below bladder. Catheter care with soap and water with AM/PM care and PRN. Maintain a closed drainage system; report diminished output to the Charge Nurse and any skin integrity concerns. Avoid dependent loops in the drainage tubing. Initiated 12/1/25. Review of the medical record reveals R2 does not have Foley catheter. Review of the elimination Care Plan for R2 revealed a Focus for: has the potential for altered elimination related to: (R2) has a diagnosis of obstructive reflux uropathy resulting in impaired bladder emptying. A suprapubic catheter is in place to ensure continuous bladder drainage and prevent overdistention, reflux, or renal complications. Despite adherence to infection prevention protocols, aseptic catheter care and routine monitoring, the presence of an indwelling urinary catheter inherently increases the risk for UTI (urinary tract infection), bacteriuria, and urethral irritation. This risk is considered unavoidable due to the residents underlying medical condition that necessitates catheter use for bladder management and comfort. Last revised 10/29/26. No interventions for a suprapubic catheter. In an interview on 1/29/26 at 12:43 PM, the Director of Nursing (DON) was asked about R2's suprapubic catheter. The DON reported R2 should have had a T-sponge in place and if the skin surrounding the area was excoriated, staff should start with soap and water to clean the area first and then move up to other options if that was not working. The DON expects staff to monitor, assess and document findings. If there is anything abnormal, then she would expect a short-term care plan to be in place. The DON was informed about the conflicting orders for a Foley catheter instead of a suprapubic catheter and the Care Plan reflecting a Foley catheter. The DON reported that it should not be that way as we discussed the importance of Agency Staff being able to know how to care for a resident based on appropriate orders, care planning, and documentation. In an interview on 1/29/26 at approximately 1:15 PM, the DON reported she followed up with R2 and verified R2 did not have any wounds on his heels. R2's suprapubic catheter site should be documented and monitored. Any labs for residents are resident specific and depends on how long they were on a medication and the residents' baseline. Review of R2's Care Plans revealed they are showing incorrect information or missing information pertaining to the resident's current medical status and do not include pertinent interventions per medical orders. Further review of R2's Care Plans reveals no Care Plan for Chronic Kidney Disease (CKD) for R2, hyperkalemia, hyponatremia, and prostatic hyperplasia.

This pertains to intake 2716089.Based on observation, interview, and record review, the facility failed to protect Resident#1 (R1) for the right to be free from verbal and physical abuse by Ancillary Service Provider the Podiatrist.Findings include:A review of the facility's Identification of Abuse, policy and procedure, reviewed/revised 3/19, revealed, abuse the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of the facility's Identification of Abuse, policy and procedure, reviewed/revised 3/19, revealed, Psychological, Mental or Verbal Abuse: Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.Resident#1 (R1)Review of an admission Record reflected Resident #1 (R1) admitted to the facility with pertinent diagnoses of. ALZHEIMER'S DISEASE, DEMENTIA, OSTEOARTHRITIS, ANXIETY DISORDER, MUSCLE WEAKNESS, UNSTEADINESS ON FEET, AUDITORY AND VISUAL HALLUCINATIONS. A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 12/23/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 01 which revealed R1 was severely cognitively impaired. Review of R1's record revealed she is not her own responsible party; the Resident's daughter is her DPOA and decision maker. Resident is care planned for one assist w/ ADLS, she transfers and ambulates independently. Resident uses a 4-wheeled walker. On 1/27/26 at 11:40 AM, R1 was observed to be fully dressed and had her shoes. She was sitting on the side of the bed with her walker in front of her. Resident was carrying on a conversation with herself and did not acknowledge or engage with this surveyor after several attempts to converse were made. Resident appeared calm, content, and was visibly free from bruises. During an interview on 1/27/26 at 1:05 PM, Certified Nurse's Aide (CNA) A stated, I was working in the resident room next door with PT assisting in doing a transfer. We heard, some thumping, yelling, loud male voice and another thump against the wall. Once resident was secured, I went into the hallway to go get a gait belt when I witnessed, (Name of R1) was 3 feet from the bed coming towards this guy. I am directly behind this guy, and I see him push (Name of R1) and she fell onto her bed. I couldn't intervene in time. I saw one arm make contact with (Name of R1). I'm not sure if both his arms made contact. This guy then reaches down, grabs his stuff and tries to get past me. (Name of R1) was yelling at him to get out. I had heard him tell her, Don't f*ck*ng hit me. CNA A further stated, I yelled down the hall to get administration because I had witnessed him abusing (Name of R1). CNA A stated, This guy was trying to get past me so he could get down the hallway and leave. I told him to stay, and I instructed him he was not going by other residents until he was escorted by administration. It was about that time Director of Rebab (DOR) C came in and went to check on and comfort (Name of R1) who was yelling and crying. CNA A revealed this all happened in less than a minute's time and that R1 was pretty agitated the rest of my shift. R1 was assessed by the nurse. During an interview on 1/27/26 at 2:28 PM, DOR C stated she was doing a therapy evaluation with Physical Therapy Assistant (PTA) D and CNA A in the room next door to R1. She stated she heard someone yelling and heard a muffled man's voice yelling and swearing when the CNA went to grab a gait belt. DOR C stated, I heard a man swearing and clearly heard him say, Do not F*ck*ng lay hands on me again. She then stated she heard male voices yelling and CNA A stating R1 needs help and that he witnessed abuse. She stated I walked in the hallway and saw CNA A blocking the Podiatrist and trying to prevent him from leaving and going down the hall. I squeezed past them and found R1 on her bed. Her glasses were strewn across her face, her arms were flailing/swinging in the air, and she was yelling, crying, physically upset. I calmed her down then went and found the (Clinical Care Coordinators CCC's) and DON. I ended up helping DON do a skin assessment on her. During the assessment she was clearly upset, she said someone was beating on her with a hammer. By the end of the day, she was back to baseline. During an interview on 1/27/26 at approximately 3:15 PM, PTA D stated she, DOR C and CNA A were assisting another resident when they heard scuffling, loud noises, and yelling when CNA A went to grab a gait belt. CNA A immediately came back and reported to DOR C as a manager that a man is abusing R1. DOR C told everyone to stay put and then CNA A was heard very firmly telling the man to stay here. PTA D then stated I know now it was a doctor that CNA A was talking to in the hallway. I heard the aggression in this doctor's voice, and I heard him yelling and swearing. PTA D further stated she heard R1 yelling and R1 was upset. Review of an interview conducted by the DON on 12/31/25 at 11:23AM, Entered (Name of R1's) room and observed her sitting on the edge of the bed hugging her stuffed dog. (Name of R1) was tearful and resistant to touch. (Name of DOR C) sat next to (Name of R1) and hugged her providing support. With (Name of DOR C's) support (Name of R1) did allow for observations of her forearms, sides, abdomen and lower left extremity. Redness was observed on her left forearm in a broad irregular shape. No observation of what appeared to be fingerprints. While assessing (Name of R1) she did not answer questions asked but continued to hug her dog and when attempting to assess other areas she would shoo me away. Towards end of the assessment (Name of R1) was asked by (Name of DOR C) if she was feeling better. (name of R1) reported to (Name of DOR C) at this time They were in here beating me with hammers (Name of R1) appeared more relaxed and less tearful at the end of the attempted interview and assessment. Review of a Short Term Care Plan dated 12/31/25, reflected a Potential for a latent injury. Assess L (left) forearm and Rt. Wrist. Record review of a progress note dated 1/2/26 at 15:26, On 12/31/25 Staff reported hearing raised voices coming from (Name of R1's) room. Upon staff approach, the podiatrist was observed yelling at (Name of R1). (Name of R1) was attempting to ambulate past the podiatrist in her room when staff reported her being pushed back onto her bed. Staff immediately intervened. The podiatrist was removed from the room and escorted to the Director of Nursing office. A post-incident assessment was completed as tolerated. (Name of R1) allowed assessment of bilateral forearms, sides, and left lower extremity. No redness, swelling, or skin alterations were observed to the face. (Name of R1) reported right wrist pain; however, she was observed to flex, extend, and rotate the wrist without signs of pain, including facial grimacing or negative verbalization. (Name of R1) accepted support and reassurance from staff. She verbalized, They were beating me with hammers. Staff provided continued emotional support and remained with (Name of R1) until agitation and anxiety resolved. Hospice was requested for a visit. Notifications were made to the Administrator, Director of Nursing, Hospice, Physician, (Name of Ancillary Service Provider Company), (Name of) DPOA, and (Name of) County Sheriff.During an interview on 1/28/26 at 11:02 AM, R1's DPOA revealed, I was aware of a verbal thing that happened between the podiatrist and my mom. They (staff) reported she was not hurt but had a scrape on her arm. I guess my mom hit him and he pushed my mom onto the bed. I ended up talking to the sheriff and decided not to press charges. The sheriff told me that they were making a report and that the podiatrist would be banned from coming back onto the property. I think the podiatrist handled my mom's negativity wrong, I think he needs more training to deal with Alzheimer's patients or he needs another job. During an interview on 1/28/26 at 11:35 AM, the DON stated, I was pulled out of a meeting by (DOR C) and told that an incident occurred. Before I could get down the hallway, my Unit Managers (CCC's) were bringing him (doctor/podiatrist) down to my office. The doctor claimed (Name of R1) assaulted him. He said she hit and kicked him while she was still sitting on the bed, and then he tipped her leg back while she was on the bed. (CNA A) said he saw him shove her onto the bed. The doctor said she assaulted him, and I did observe some pink on the side of his head, but it went away while we were waiting for the sheriff to show up. The DON revealed that while waiting for the sheriff to show-up, the Doctor wanted to leave and wanted to know when the sheriff department would get there. He also wanted to continue to see the rest of the residents on his list or leave. The DON said she told him he had to stay there and he continued to explain why he felt what he did was appropriate. She stated that he didn't seem to think or act like it was a big deal. The DON further revealed she did not do a full skin assessment because (R1) would not allow them to and as they were attempting to assess what they could she started getting more upset and agitated. She then stated that R1 did not have any concerning behaviors receiving care by the doctor prior to this and this was the first time she was aware of a problem. The DON stated that he (doctor/podiatrist) would go into resident rooms by himself because a lot of the residents he saw were bedbound and more comfortable being seen in their rooms. The DON stated as result of this incident, all ancillary services will now have a staff member with them. During an interview on 1/28/25 at approximately 3:45 PM, the Nursing Home Administrator (NHA) revealed they only had one other resident complaint about the doctor/podiatrist the day of this incident. The other resident complained the doctor had an attitude and was rude. The rest of the residents (approximately 20) seen that day had no concerns. The NHA further revealed that she had heard from the company the podiatrist works for earlier today and they wanted to know when he could come back into the facility. The DON stated, I informed them that he would not be welcomed back to our building.

Based on observation, interview, and record review, the facility failed to ensure call lights were left within reach of 2 residents (R30 and R22) of 2 residents reviewed for availability of call lights. Findings include: R30 Review of an Admission Record revealed R30 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and weakness. Review of a Minimum Data Set (MDS) assessment for R30, with a reference date of 2/25/2025 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated R30 was moderately cognitively impaired. Further review of same MDS assessment revealed R30 required staff assistance with transfers. Review of a current functional mobility Care Plan interventions for R30, initiated 1/9/2024, directed staff that R30 required staff assistance with ambulation and directed staff to maintain personal items within her reach and encourage her to use her call light to alert staff of needs. In an observation and interview in R30's room on 3/18/2025 at 1:48 PM, R30 was in her wheelchair and her call light was hanging from the wall and out of her reach. R30 stated, I can't reach that. In an observation in R30's room on 3/19/2025 at 8:41 AM, R30 was in her wheelchair and her call light was on her bed and under her pillow, out of reach. In an observation and interview in R30's room on 3/19/2025 at 11:34 AM, R30 was in her wheelchair and her call light was on her bed and under her pillow, out of reach. R30 reported she did not know where her call light was located. In an observation in R30's room on 3/19/2025 at 11:45 AM, R30 was in her wheelchair and her call light was on her bed and under her pillow, out of reach. Registered Nurse (RN) G asked R30 if she knew where her call light was and R30 reported she was unable to find it. RN G clipped R30's call light to her blouse and asked R30 if she was able to press the call light. R30 responded by pressing the call light successfully. In an observation and interview in R30's room on 3/20/2025 at 8:59 AM, R30 was in her wheelchair and her call light was attached to her bed, out of reach. R30 reached for her call light and was unable to reach it. R30 stated, can you move it closer?. In an observation in R30's room on 3/20/2025 at 9:02 AM, the DON asked R30 if she could reach her call light. R30 tried to reach her call light and was unable. The DON moved R30's wheelchair closer to her bed where she could reach her call light. In an interview on 3/20/2025 at 9:05 AM, the DON reported R30 was able to use her call light and staff should leave the call light within reach. R22 Review of an Admission Record revealed R22 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and weakness. Review of a Minimum Data Set (MDS) assessment for R22, with a reference date of 1/6/2025 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated R22 was moderately cognitively impaired. Further review of same MDS assessment revealed R22 required staff assistance with transfers and ambulation. Review of a current functional mobility Care Plan intervention for R22, with a revision date of 4/11/2024, directed staff that R22 required staff assistance with ambulation. Another intervention revised 12/16/2024 directed staff to remind R22 to use her call light and leave it within reach. In an observation and interview in R22's room on 3/18/2025 at 12:25 PM, R22 was sitting in a bedside chair, and her call light was coiled up on her bed a few feet away and out of reach. R22 reported she did not know where her call light was located. In an interview on 3/20/2025 at 9:07 AM, the Director of Nursing (DON) reported R22 was dependent on staff assistance for ambulation and able to use her call light.

Based on interview and record review, the facility failed to follow policies and procedures and implement appropriate antibiotic stewardship for two (R39 and R48) of two residents reviewed for antibiotic stewardship and failed to have an affective system in place for assessing, monitoring and preventing unnecessary antibiotic usage. Findings include: Review of a policy titled Antimicrobial Stewardship last revised on 3/2020 revealed: It is the policy of this facility to utilize various antimicrobial stewardship strategies to improve the quality of antimicrobial therapy, minimize antimicrobial resistance, and optimize clinical outcomes. The facility will utilize antimicrobial stewardship strategies in combination with infection prevention and control efforts to limit the emergence and transmission of antimicrobial-resistant pathogens. Purpose: To preserve the effectiveness of antimicrobials, reduce avoidable adverse effects, minimize healthcare associated infection, and limit the emergence and transmission of antimicrobial-resistant pathogens. Definition: Antimicrobial resistance is a serious public health concern related to the emergence of multi-drug resistant microbial species for which there is no effective antimicrobial agents and the paucity of new antimicrobials being developed. Antimicrobial drugs include agents for treating bacterial, viral, fungal and parasitic infection. 2. Antimicrobial therapy should only be prescribed if clinically indicated according to signs and symptoms of infection and /or sepsis. 2b. Prompt antibiotic administration for septic residents can save lives; make every attempt to obtain appropriate cultures prior to administering antimicrobials. c. Residents who receive antimicrobial therapy are at increased risk of colonization and infection with Clostridium difficile, MRSA, and other multi-resistant pathogens. Residents should not be subject to this increased risk without reasonable evidence of infection or established prophylactic benefit. d. Document indications for antimicrobial therapy in the interdisciplinary note and or medication administration record including the indication for treatment. 3. Residents with orders for anti-infective medications will be screened for appropriate agent selection. 4. The infection control practitioner, pharmacist and / or licensed nurses will perform a prospective audit evaluating antibiotic orders to provide direct intervention and prescriber feedback if the order is deemed inappropriate for the condition, culture and sensitivity, renal function, and / or presentation of signs and symptoms. Resident #39 (R39) Review of a Face Sheet revealed R39 originally admitted to the facility on [DATE] and readmitted on [DATE] after a hospitalization . Pertinent diagnoses include cerebral infarction (stroke), vascular dementia, and chronic kidney disease. Review of the Electronic Medical Record (EMR) for R39 revealed he has frequent Urinary Tract Infections (UTI's) and benign prostatic hyperplasia (BPH) and a history of urethral strictures. Review of a Hospital Record dated 1/18/25 for R39 revealed: Assessment & Plan: Severe sepsis. Source influenza, pneumonia, urinary tract infection. Recurrent UTI (urinary tract infection). Multiple UTIs in the past. Recently admitted [DATE] for sepsis due to urinary tract infection positive for Pseudomonas (bacterial infection). Urinalysis performed on 1/15 culture data returned positive for Enterococcus faecalis. Yesterday was started on amoxicillin. - At present antibiotics include cefepime and vancomycin. -Acute kidney injury superimposed on stage 3b chronic kidney disease. Assessment & Plan: . Likely prerenal due to fairly significant dehydration on arrival. -Urinary retention. Assessment & Plan: Has seen Urology. There was concern on of bladder mass seen on a renal ultrasound (sic). Cystoscopy performed 11/25/24 with no mass present. - continue Flomax. Review of the October 2024 Infection Control Resident Surveillance record revealed R39 was listed on the following dates: On 10/7, a urinary tract infection (UTI). The culture result was aerococcus. Treatment was 3 grams (gm) Fosfomycin x 1 dose. On 10/17, a UTI with pseudomonas culture. Treatment was Cipro 500 mg twice a day X 10 days. This month does not reflect the following antibiotics administered to R39: ceftriaxone on 10/3/24, amoxicillin on 10/14/24, and Cipro on 10/26/24 for UTI's as reflected in the Order Summary. Review of a Short Term Care Plan Urinary Tract Infection for R39 dated 10/14/24 revealed: UTI McGeer Criteria Review: Both 1 & 2 criteria must be met: (circle) (1) Acute dysuria; swelling or tenderness of the teste, epididymis or prostrate, Fever or Leukocytosis AND at least one of: Acute costovertebral angle tenderness, suprapubic pain, hematuria, increased incontinence, urgency or frequency. (2) >/=1000,000 CFU's/ML identified species of Microorganism:_____. Fever was circled and weakness was written in. Ordered medication: Amoxicillin 500 mg three times a day for 7 days and changed on 10/17/24 to Cipro 500 mg twice a day for 10 days. Review of an Order Summary from 10/1/24 to 3/31/25) for R39 revealed several orders for antibiotics as follows: -Amoxicillin 500 mg (milligrams) three times a day, ordered 10/14/24 and ended 10/21/24 for a UTI. -Amoxicillin-Pot Clavulanate (Augmentin) 875-125 mg two times a day ordered 1/17/25 and ended 1/24/25 for UTI. -Bactrim 800-160 mg ordered one time for 11/25/24 prior to cystoscopy. -Ceftriaxone Sodium (Rocephin) injection 1 GM (gram) intramuscularly one time a day ordered 2/24/25 to 3/3/25 for UTI. - Ceftriaxone Sodium injection 1 GM (gram) intramuscularly one time ordered 10/2/24 and 10/3/24 for fever. -Cipro (Ciprofloxacin) 250 mg, two tablets every 12 hours, ordered 11/12/24 to 11/17/24 for UTI. -Cipro 250 mg twice a day, ordered 11/26/24 to 12/3/24 for UTI. -Cipro 500 mg twice a day, ordered 10/17/24 for PSA (prostate specific antigen) UTI. -Cipro 500 mg twice a day, ordered 10/20/24 to 10/27/24 for PSA UTI. -Doxycycline Hyclate 100 mg twice a day for two days, ordered 1/24/25 to 1/26/25 for pneumonia. - Doxycycline Hyclate 100 mg twice a day, ordered 1/22/25 to 1/26/25 for UTI for 3 days and only given on 1/23/25. -Fosfomycin Tromethamine oral Packet 3 gm one time ordered 10/7/24 for UTI. -Levofloxacin 500 mg once a day for elevated temperature, ordered 1/15/25 to 1/22/25. Review of the November 2024 Infection Control Resident Surveillance record revealed R39 was listed on the following dates: On 11/12/24, a UTI with pseudomonas aeruginosa. Treatment was Cipro 500 mg twice a day for 5 days. On 11/26/24, a UTI diagnosed by urologist (no cultures). Treatment was Cipro 250 mg twice a day for 7 days. On 11/25/24, Bactrim 800-160 mg ordered one time prior to cystoscopy. (Not reflected on tracking) Review of the December 2024 Infection Control Resident Surveillance record revealed R39 had no antibiotics. Review of the January 2025 Infection Control Resident Surveillance record revealed R39 was listed on the following dates: On 1/16/25, a UTI with enterococcus faecalis. Treatment was Augmentin twice a day for 7 days. On 1/23/25, a LRI (lower respiratory infection). Treatment was Doxycyline twice a day for 3 days. This did not reflect the hospital record that shows R39 had a UTI that was positive for pseudomonas. This month did not reflect the Levofloxacin 500 mg once a day for elevated temperature on 1/15/25. Review of the February 2025 Infection Control Resident Surveillance record revealed R39 was listed on the following dates: 2/22/25, a UTI with Provencia Stuartii. Treatment was Rocephin 1 gm x 7 days. In an interview on 3/20/25 at 11:06 AM, the Infection Control Preventionist/Licensed Practical Nurse (LPN) B reviewed her antibiotic tracking and trending report and was not correct/complete and LPN B agreed that it was not correct. A timeline was requested for R39 which reflected incorrect tracking and trending of his antibiotic use. No interventions or plans to prevent future UTI's or sepsis for R46 was revealed during this interview. Resident #46 Review of the EMR for R46 revealed he was discharged from the hospital 10/18/24 with antibiotics. In an interview and record review on 3/20/25 at 11:06 AM, the Infection Control Preventionist/Licensed Practical Nurse (LPN) B reported R46 was discharged from the hospital on antibiotics in October but did not have it tracked on the antibiotic tracking sheet. She reported she only works part time and the Clinical Coordinator, or the Director of Nursing (DON) will follow up on the appropriateness of antibiotics for residents when she is not there. She reported her system of tracking on the clinical dashboard disappears after a few days and may not have seen the antibiotics for residents if the system timed out. Another instance may be if the residents get an antibiotic over the weekend, she would not be able to follow up. Further review of the antibiotic tracking revealed one resident in October 2024 was ordered Ceftin 500 mg twice a day on 10/31/24 for a UTI with no culture and qualifying symptoms of fatigue and increased incontinence. In December 2024 another resident on 12/17/24 was ordered Keflex 500 mg twice a day for 7 days for a UTI with no culture and qualifying symptoms of altered mental status. LPN B reported the facility is to follow the McGeers Criteria for antibiotic stewardship.

Based on observation, interview and record review, the facility failed to follow physician orders and provide timely incontinence care, and appropriately document and treat MASD (moisture associated skin damage) for one (R6) of two residents reviewed for bowel and bladder. Findings include: Review of a Face Sheet revealed R6 originally admitted to the facility on [DATE] and has pertinent diagnoses of morbid obesity, dementia and mixed incontinence. Review of the Minimum Data Set (MDS) dated [DATE] revealed R6 is moderately cognitively impaired, has limited range of motion on bilateral lower extremities, and is dependent on staff for toileting and mobility. She is always incontinent of bowel and bladder. Review of the Care Plan for R6 revealed: ELIMINATION: Wears incontinence products, check and change before and after meals, HS [at bedtime] with rounds and prn (as needed), assist when verbal or non-verbal indicators communicate toileting needs. Last revised 7/27/24. SKIN: Apply barrier cream with incontinence care prn; inspect skin with bathing and care; report impaired skin integrity to charge nurse. Last revised 3/16/25. Incontinence care with protective barrier ointment as indicated. initiated 2/1/23. During an observation 3/19/25 at 8:30 AM, R6 was observed in the assisted dining room for breakfast in her Broda chair. At 11:50 AM she was observed in the community room watching television. During an observation and an interview on 3/19/25 at 12:11 PM, R6 observed in the community room. Certified Nursing Assistant (CNA) K was asked when R6 will be toileted next and reported when R6 is done with her lunch. During an observation and an interview on 3/19/25 at 1:15 PM, CNA K and CNA L transferred R6 to bed via Hoyer lift. When R6 was lifted from her Broda chair, the chair was wet, and the sling was saturated with urine as well as her brief. There was a notable strong urine smell. Her brief was removed and a large area on her buttocks was red, macerated and blanchable. Her left upper thigh had one golf ball sized red macerated/excoriated area, and another tennis ball sized red macerated/excoriated area, and both were blanchable. CNA K reported R6 gets barrier cream twice a day and did not apply any cream to the resident after providing peri care at this time. R6 was then transferred back to her Broda chair when CNA K finished care. In an interview on 3/19/25 at 1:30 PM CNA K reported she thinks she last toileted R6 before breakfast but could not remember and reported R6 should not have gone that long without being toileted. CNA K reported R6 should be toileted every 2 hours and reported it was too hard to toilet her that often. CNA K reported she did not apply any barrier cream to R6 because she did not have any available. Review of the March 2025 Treatment Administration Record (TAR) for R6 revealed orders for barrier cream to be applied to MASD located to groin and bilateral posterior thighs every shift until resolved. Another order to apply moisture barrier cream every shift and as needed to bilateral posterior thighs excoriation. No start date on the TAR. Review of the Care Plan revealed no interventions for MASD. Review of the Bowel and Bladder Elimination task charting from 2/19/25 to 3/19/25 (a 30 day period) for R6 revealed she is toileted an average of 2-4 times a day with periods of 10-12 hours of no toileting in between. Review of a Skin assessment dated [DATE] for R6 revealed her right rear thigh to have MASD. Skin is pink dry and intact, site is healed, skin blanchable, free of odor or s/s (signs and symptoms) of infection. Preventative measures remain in place. (sic) In an interview on 3/20/25 at 12:43 PM, the Director of Nursing (DON) reported her expectation are residents are to be toileted at the bare minimum every 2 hours. Staff are to inform the nurse of any new skin conditions and apply barrier cream when needed. The skin assessment should have been this week and recognized the skin assessments for R6 do not reflect her conditions. Review of a policy titled Skin at Risk Assessment Documentation, Staging & Treatment last revised 1/2020 revealed: It is the policy of this facility to assess resident risk factors for the development of impaired skin integrity and intervene as indicated utilizing the admission assessment, plan of care, and Minimum Data Set as formal assessment tools. It is the policy of this facility to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred. Weekly measurements and narrative assessments are conducted on existing pressure injuries. Purpose: To provide prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. b. C.N.A. reporting of abnormal skin inspections to the charge nurse c. Application of skin barrier ointment with incontinence care to form a protective coating to prevent skin maceration.

Based on observation, interview and record review, the facility failed to provide appropriate hand hygiene during peri care for two (R6 and R48) of two residents reviewed for incontinence care. Findings include: Resident #6 (R6) Review of a Face Sheet revealed R6 originally admitted to the facility on [DATE] and has pertinent diagnoses of morbid obesity, dementia and mixed incontinence. Review of the Minimum Data Set (MDS) dated [DATE] revealed R6 is moderately cognitively impaired, has limited range of motion on bilateral lower extremities, and is dependent on staff for toileting and mobility. She is always incontinent of bowel and bladder. During an observation and an interview on 3/19/25 at 1:15 PM, CNA K and CNA L provided incontinence care for R6. CNA K removed the urine saturated Hoyer sling and urine saturated brief from R6. When CNA K completed incontinence care, she used the same gloves to put on a new brief, put new clothes on, and touched several other common surfaces in the room. In an interview on 3/19/25 at 1:30 PM CNA K acknowledged she did not change her gloves or sanitize her hands while providing incontinent care and moving from dirty to clean surfaces. CNA K reported her gloves were not visibly soiled. When asked if urine is dirty, CNA K reported yes and said she is really bad at that. Resident #48 (R48) Review of a Face Sheet for R48 revealed she originally admitted to the facility on [DATE] with pertinent diagnoses of morbid obesity, diabetes, and urine retention. During an observation and an interview on 3/18/25 at 12:12 PM, CNA M and CNA N provided peri care/catheter care for R48 who currently has a yeast infection and is in enhanced barrier precautions. CNA M checked her pockets for barrier cream with the same soiled gloves used for peri care. She then applied a new clean brief and touched other inanimate objects in the room before removing gloves and sanitizing her hands. In an interview on 3/18/25 at 12:22 PM, CNA M was queried about her hand hygiene during peri care for R48. CNA M paused and nodded yes, indicating she should have changed her gloves and sanitize her hands. In an interview on 3/20/25 at 11:06 AM, Licensed Practical Nurse (LPN)/Infection Control Nurse B reported staff are to perform hand hygiene when moving from dirty to clean surfaces during incontinence/peri care. LPN B reported she has not done any hand hygiene audits lately and staff get hand hygiene education at least annually with their competencies. Review of a hand Hygiene policy last revised 9/2022 revealed: It is the policy of this employer for staff members to frequently perform hand hygiene to It is the policy of this employer for staff members to frequently perform hand hygiene to assist with prevention / reduction of the spread of infection. The employer promotes hand hygiene using recognized techniques as the single most effective means of reducing the risk of cross-infection. Indications: 1. Hands may be cleaned using liquid soap and water or alcohol hand rub. a. Hands should be cleaned before and after work b. Before and after meals c. Before and after caring for different residents d. After using the restroom e. After handling contaminated environmental objects f. After sneezing or coughing 2. When to use liquid soap and water a. When hands are visibly soiled or potentially contaminated with dirt or organic material (e.g., following removal of gloves) b. Before preparing or eating food c. After using the toilet d. After caring for a resident with a diarrheal illness Review of the Clinical Safety: Hand Hygiene for Healthcare Workers. Clean Hands, Centers for Disease Control, 27 Feb. 2024, www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, accessed 20, Mar. 2025 revealed: KEY POINTS: Protect yourself and your patients from deadly germs by cleaning your hands. All healthcare personnel should understand how to care for and clean their hands. Why it matters: Hand hygiene protects both healthcare personnel and patients. Recommendations: Know when to clean your hands: Immediately before touching a patient. Before performing an aseptic task . Before moving from work on a soiled body site to clean a body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, bodily fluids, or contaminated surfaces. Immediately after glove removal.

Based on interview and record review, the facility failed to ensure significant changes in weight were reviewed by the medical provider for 2 residents (R30 and R17) of 5 residents reviewed for nutrition services. Findings include: R30 Review of an Admission Record revealed R30 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and weakness. Review of R30's weights in the electronic medical record (EMR) revealed her weight was 203.2 on 2/13/2025, 188.1 on 3/4/2025, 185.3 on 3/6/2025, and 184.1 on 3/17/2025. Review of R30's Progress Note dated 3/6/2025 at 8:39 AM revealed Dietary Manager F noted R30 had a 7.5% weight loss. Further review of the EMR did not reveal documentation that this weight loss was reviewed by the medical provider. Review of R30's Progress Note dated 3/18/2025 at 11:38 AM revealed Registered Dietician (RD) H noted R30 had significant weight loss for 1 month. Further review of the EMR did not reveal documentation that this weight loss was reviewed by the medical provider. In an interview on 3/20/2025 at 11:07 AM, the Director of Nursing (DON) reviewed the EMR and reported R30's recent weight loss was significant and should have been referred to the medical provider for review when reviewed by Dietary Manager F on 3/6/2025 and by RD H on 3/18/2025. In an interview on 3/20/2025 at 11:49 AM, the DON reported she had reviewed the EMR and there was no documentation that R30's recent significant weight loss had been reviewed by a medical provider. Review of facility policy/procedure Change in Resident Condition Physician/Family Notification, revised 3/2021, revealed .The health care practitioner will be promptly notified when . The resident has a significant change in physical, mental, or psychosocial status . 31771 Resident #17 (R17) R17 R17 Review of the Electronic Medical Record (EMR) reflected R17 originally admitted to the facility 6/2/23 with pertinent diagnoses that included Congestive Heart Failure (CHF) and Morbid Obesity. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R17 was cognitively intact. On 3/19/25 at 12:19 PM an interview was conducted with R17 in her room. R17 reported a desire to lose weight. R17 reported she had spoken with the Food Service Department and the medical provider and reported she was not getting any help with weight loss. Review of the EMR Weight Summary for R17 reflected nine weights obtained from 10/15//24 to 1/29/25 each followed by a weight warning- of weight increases with each weight. Each weight warning included comparative weight increases ranging from 7.5% to 12.9% from previous weights. Review of the medical record did not reflect documentation the medical provider had been notified of the Resident's weight changes. Review of the EMR reflected Resident encounters with the medical provider on 2/10/25 and 3/12/25. The documentation reflected the Resident's current weight along with other vital signs. However, no documentation was found that the medical provider was aware or notified of the weight changes. During an interview conducted 3/20/25 at 9:56 AM Physician Assistant (PA) J reported he expects to be notified of Resident weight changes. During an interview conducted 3/19/25 at 1:30 PM Registered Dietician (RD) H reported an entry in the medical record is expected when a resident had a notable weight change. RD H reported the provider was to be notified and the provider was expected to document in the medical record they were notified. RD H acknowledged she could not find documentation the medical provider was notified and that it is very surprising there isn't something in the record about the weight changes for R17. As of survey exit no additional information was provided by the facility.

This citation pertains to intake M100150227. Based on interview and record review, the facility failed to treat a resident in a dignified manner for one (R27) of three residents reviewed for dignity. Findings include: Review of a Facility Reported Incident (FRI) revealed on 1/31/25, a Certified Nursing Assistant (CNA) P went into R27's room and asked the resident Why you mean muggin' me? It was reported the staff member and R27 began arguing back and forth until CNA P left the room. R27 told CNA P to get over himself and he then jumped in the air and stated, I just got over myself. R27 told CNA P she was going to write him up and he answered, Good, can't wait. I see flaming daggers come out of your eyes. In an interview on 3/20/25 at 9:07 AM, R27 reported CNA P was not abusive, but he insulted her intellect and injury and would not elaborate any more because she already told the facility and did not want to stir up any problems. Review of a Corrective Action Form for the incident dated 1/31/25, CNA P was permanently dismissed from his position at the facility for severe violation of conduct/behavior on 2/10/25. There was no further action documented to prevent further occurrences from staff.

Based on observation, interview and record review, the facility failed to develop or implement care plan interventions for two (R6 and R39) of 20 residents reviewed for care plans. Findings include: Resident #6 (R6) Review of a Face Sheet revealed R6 originally admitted to the facility on [DATE] and has pertinent diagnoses of morbid obesity, dementia and mixed incontinence. Review of the Minimum Data Set (MDS) dated [DATE] revealed R6 is moderately cognitively impaired, has limited range of motion on bilateral lower extremities, and is dependent on staff for toileting and mobility. She is at risk for pressure ulcers but did not have any at the time of this assessment. During an observation and an interview on 3/19/25 at 1:15 PM, R6 was in bed for cares and her socks and puff boots were removed. There were 3 pressure ulcers observed on her left lateral foot. Certified Nursing Assistant (CNA) K placed R6's socks back on her feet and put the puff boots back on her before transferring back to her chair. When asked about repositioning or offloading R6 who is dependent on cares, CNA K reported that would be really hard because of her contractures and the fact that she is sitting in a chair (Broda chair). Review of a Skin Assessment for R6 dated 3/15/25 revealed: -Stage II pressure wound on left outer ankle, measured 1.1 x 0.7 x 0.1 cm (centimeters) -Stage II pressure wound on left lateral foot, measured 0.4 x 0.4 x 0.1 cm. Review of the Care Plan for R6 revealed no focus for active or prevention of pressure ulcers or leg contractures. Review of the Care Plan for R6 revealed interventions: -Assess postural alignment, weight distribution, sitting balance, & pressure redistribution on admit and prn (as needed). Initiated 2/1/23. -Encourage pressure relieving boots on at all times while in bed and up in chair. Initiated 1/31/23 and revised on 3/16/25. Resident #39 (R39) Review of a Face Sheet revealed R39 originally admitted to the facility on [DATE] and has pertinent diagnoses of dementia, cerebrovascular disease, and chronic kidney disease. Review of the Electronic Medical Record (EMR) for R39 revealed he has frequent Urinary Tract Infections (UTI's) and benign prostatic hyperplasia (BPH) and a history of urethral strictures. Review of the Point of Care task documentation for bowel and bladder elimination for R39 revealed he is documented having 18 episodes of incontinence from 2/19/25 to 3/19/25 (a 30 day look back during this survey) and toileted an average of three times a day. Review of the ADL Care Plan for R39 revealed: ABLE TO LEAVE ON TOILET: No. AMBULATION: SBA (stand by assist) with 4 WW (wheeled walker) and gait belt.

Based on interview and record review, the facility failed to formulate and implement personalized Care Plan revisions for one facility resident (R17) of two residents reviewed with documented significant weight changes. Findings: R17 Review of the Electronic Medical Record (EMR) reflected R17 originally admitted to the facility 6/2/23 with pertinent diagnoses that included Congestive Heart Failure (CHF) and Morbid Obesity. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R17 was cognitively intact. On 3/19/25 at 12:19 PM an interview was conducted with R17 in her room. R17 reported a desire to lose weight. R17 reported she feels the facility is not giving enough support to help her with this. Review of the EMR Weight Summary for R17 reflected nine weights obtained from 10/15//24 to 1/29/25 each followed by a weight warning of weight increases with each weight. Each weight warning included a notation of comparative weight increases ranging from 7.5% to 12.9% from previous weights. Review of the Progress Notes for R17 reflected an entry on 12/2/24 Spoke with (name of R17) about her wanting to have small portions at her mealtimes. (name of R17) wanted to have this change due to expressing the need to lose weight. Ticket and Care Plan to Show small portions. Review of the Care Plan Focus of (name of R17) has the potential for an altered nutritional status primarily (related to) conditions associated with morbid obesity, CHF . Review of the Goals for this Care Plan Focus reflect (name of R17) will be provided adequate nutrition ., early identification and adjustment of her food consistency .early identification and treatment of abnormal glucose levels, And (name of R17) has a goal for gradual weight loss of 40 -50 pounds (lbs.) date initiated 6/6/23 and revised on 2/14/25, Review of the Interventions implemented for this Care Plan Focus to reach the Goals do not reveal any new interventions or revisions since 7/6/23 and did not reflect small portions as documented on 12/2/24. The Interventions reflected to Assess and document and to Evaluate laboratory levels, and Evaluate significant weight changes . and to follow orders. The interventions did not reveal any personalized, measurable actions or updated and revised efforts toward the Resident's stated desire to lose weight or to address the documented weight increases. During an interview conducted 3/20/25 at 9:56 AM Physician Assistant (PA) J reported the weight gain for R17 was a legit weight gain and was not fluid. Review of the EMR Interdisciplinary Care Conference Documentation dated 2/26/25 at 9:03 AM reflected documentation by Nursing, Social Work, and a Registered Dietician. The documentation reflected R17 was Responsible and had Decision Making Capability. Section 1 identified as a Summary of Person-Centered Review of Measurable Goals and Individuated Interventions contains objective clinical information. The documentation reflected R17 was obese and, without input from the Resident, attributed her weight to Chronic Heart Failure and medications, Many of these can contribute to weight and fluid fluctuations. No documentation was identified that R17 participated in or was encouraged to voice what her concerns were or what she wanted. Although the medical record contained information of a significant weight gain the documentation of the Care Conference did not include a plan to revise the Care Plan with measurable or personalized goals or interventions. As of survey exit no additional information was provided by the facility

Based on interview and record review, the facility failed to follow through the continuity of care of frequent urinary tract infections for one (R39) of one reviewed for quality of care. Findings include: Review of a Face Sheet revealed R39 originally admitted to the facility on [DATE] and has pertinent diagnoses of dementia, cerebrovascular disease, and chronic kidney disease. Review of the Electronic Medical Record (EMR) for R39 revealed he has frequent Urinary Tract Infections (UTI's) and benign prostatic hyperplasia (BPH) and a history of urethral strictures. Review of a Hospital Record dated 1/18/25 for R39 revealed: Assessment & Plan: Severe sepsis. Source influenza, pneumonia, urinary tract infection. Recurrent UTI (urinary tract infection). Multiple UTIs in the past. Recently admitted [DATE] for sepsis due to urinary tract infection positive for Pseudomonas (bacterial infection). Urinalysis performed on 1/15 culture data returned positive for Enterococcus faecalis. Yesterday was started on amoxicillin. - At present antibiotics include cefepime and vancomycin. -Acute kidney injury superimposed on stage 3b chronic kidney disease. Assessment & Plan: . Likely prerenal due to fairly significant dehydration on arrival. -Urinary retention. Assessment & Plan: Has seen Urology. There was concern on of bladder mass seen on a renal ultrasound (sic). Cystoscopy performed 11/25/24 with no mass present. - continue Flomax. Review of a Consultation Report- Record of Consultation Services from Urology for R39 dated 10/28/24 revealed:1) Recurrent UTI 2) Moderate Urine Retention 3) History Urethral Stricture. Plan for cystoscopy in the urology office and kidney ultrasound. Review of an Order Summary from 10/1/24 to 3/31/25) for R39 revealed several orders for antibiotics as follows: -Amoxicillin 500 mg (milligrams) three times a day, ordered 10/14/24 and ended 10/21/24 for a UTI. -Amoxicillin-Pot Clavulanate (Augmentin) 875-125 mg two times a day ordered 1/17/25 and ended 1/24/25 for UTI. -Bactrim 800-160 mg ordered one time for 11/25/24 prior to cystoscopy. -Ceftriaxone Sodium injection 1 GM (gram) intramuscularly one time a day ordered 2/24/25 to 3/3/25 for UTI. - Ceftriaxone Sodium injection 1 GM (gram) intramuscularly one time ordered 10/2/24 and 10/3/24 for fever. -Cipro (Ciprofloxacin) 250 mg, two tablets every 12 hours, ordered 11/12/24 to 11/17/24 for UTI. -Cipro 250 mg twice a day, ordered 11/26/24 to 12/3/24 for UTI. -Cipro 500 mg twice a day, ordered 10/17/24 for PSA (prostate specific antigen) UTI. -Cipro 500 mg twice a day, ordered 10/20/24 to 10/27/24 for PSA UTI. -Doxycycline Hyclate 100 mg twice a day for two days, ordered 1/24/25 to 1/26/25 for pneumonia. - Doxycycline Hyclate 100 mg twice a day, ordered 1/22/25 to 1/26/25 for UTI for 3 days and only given on 1/23/25. -Fosfomycin Tromethamine oral Packet 3 gm one time ordered 10/7/24 for UTI. -Levofloxacin 500 mg once a day for elevated temperature, ordered 1/15/25 to 1/22/25. -Sodium Chloride Intravenous (IV) Solution 0.9% (sodium chloride), use 100 ml/hr (milliliters per hour), use 500 ml intravenously one time only for bolus ordered 10/3/24. -Bumetanide (Bumex) (diuretic) 1 mg once a day every other day, ordered 11/12/24 to 1/11/25. -Bumex 1 mg every 24 hours as needed for LE (lower extremity) edema, ordered 1/11/25 to 1/20/25. -Bumex 1 mg every 24 hours as needed for LE (lower extremity) edema, ordered 1/22/25. -Tamulosin 0.4 mg once a day, ordered 11/12/24 prostate. Flomax (Tamulosin) 0.4 mg at bedtime for BPH (benign prostatic hyperplasia) ordered 1/22/25. Review of a urinalysis collected 10/15/24 for R39 revealed it was positive for protein (normal is negative), trace blood (normal is negative) Urine leukocyte esterase result small (normal is negative), WBC (white blood cells) result 50 (normal 0-5), hyaline casts result 1.16 (normal <3). Culture was pending, and no results in EMR. Was documented on form for R39 to have a new order for a Urology referral on 10/16/24. Review of a urinalysis collected 10/28/24 for R39 from a urine catheter revealed there was a trace of blood detected, and RBC (red blood cells) results were a 9 (0-3 is normal). Review of a urinalysis collected 11/19/24 for R39 revealed it was negative for infection. Review of a urinalysis collected 2/22/25 for R39 revealed it was positive for infection and the cultures resulted >= 100,000 CFU/mL Providencia stuartii (A) a gram-negative bacterium. Review of the Point of Care task documentation for bowel and bladder elimination for R39 revealed he is documented having 18 episodes of incontinence from 2/19/25 to 3/19/25 (a 30 day look back during this survey) and toileted an average of three times a day. Review of the ADL Care Plan for R39 revealed: ABLE TO LEAVE ON TOILET: No. AMBULATION: SBA (stand by assist) with 4 WW (wheeled walker) and gait belt. ELIMINATION: . Prompt and assist, prn (as needed), with toileting before and after meals, with AM and HS (morning and evening) cares, and with rounds prn. Assist when verbal or non-verbal indicators communicate toileting needs. Assist with incontinence care as needed. Review of the requires OT (occupational therapy) related to decline in function secondary to: re-admit to facility after hospitalization due to UTI with sepsis Care Plan for R39 revealed: will perform toileting with SBA or better. Review of the Care Plan for R39 revealed no focus for urinary strictures or frequent UTI's. In an interview on 3/20/25 at 11:06 AM, the Infection Control Preventionist/Licensed Practical Nurse (LPN) B was queried about R39's frequent UTI's and potential root causes, and care assessments. LPN B reported R39 was seen by urology and diagnosed with a urinary stricture. When queried about the results from the cystoscopy and the kidney ultrasound that was planned from urology, she could not find any results and reported she will provide them. LPN B reported he is independent, continent and is independent when toileting, despite the care planning indicating differently. LPN B reported staff should be documenting his fluid intake. No information for root cause of frequent UTI's. In an interview on 3/20/25 at 1:34 PM, the Director of Nursing (DON) was notified of still needing the Urology consultation documentation for R39. Review of a Timeline for R39 provided by LPN B revealed there is frequent antibiotic use for UTI's and no follow up from Urology or planned interventions for frequent UTIs to improve the quality of care and prevent sepsis. Review of a Nurse Supervisor Job description revealed: The primary functions and responsibilities of this position are as follows: (You will be evaluated on your ability to perform these functions competently with minimal supervision and/or reminders. 1. Follow established standards of nursing practices and implement facility policies and procedures. 2. Supervise and evaluate all direct resident care and initiate corrective action as necessary. 20. Perform and document comprehensive assessment of residents as assigned. 21. Develop and implement an accurate comprehensive care plan based on each resident's needs and his/her comprehensive assessment. 24. Competently perform basic nursing skills. 34. Document resident progress notes as required/Electronic Documentation is provided as assigned. 35. Document daily notes on unstable residents, Medicare residents and recently admitted residents.

Based on observation, interview and record review, the facility failed to follow physician orders, prevent pressure ulcers, accurately assess and document, and implement treatment for one (R6) of two residents reviewed for pressure injuries. Findings include: Resident #6 (R6) Review of a Face Sheet revealed R6 originally admitted to the facility on [DATE] and has pertinent diagnoses of morbid obesity, dementia and mixed incontinence. Review of the Minimum Data Set (MDS) dated [DATE] revealed R6 is moderately cognitively impaired, has limited range of motion on bilateral lower extremities, and is dependent on staff for toileting and mobility. She is at risk for pressure ulcers but did not have any at the time of this assessment. Review of a Skin Assessment for R6 dated 3/15/25 revealed: -Stage II pressure wound on left outer ankle, measured 1.1 x 0.7 x 0.1 cm (centimeters) -Stage II pressure wound on left lateral foot, measured 0.4 x 0.4 x 0.1 cm. Review of a Healthcare Provider Wound Assessment note dated 3/15/25 for R6 revealed: Lt (left) Ankle Stage II pressure ulcer on L (Lateral) ankle: - Measures 1.1 cm x 0.7 x 0.1 cm. Lt Lateral foot Stage II pressure ulcer: - 0.4 x 0.4 x 0.1 cm. Reviewed current wound orders. Review of the March 2024 Treatment Administration Record (TAR) for R6 revealed the following orders: -Cleanse left outer ankle and left lateral foot with NS (normal saline), pat dry and apply comfort foam border dressing, every day shift every 3 days. Started 3/18/25. (3 days after provider assessment/orders) -Blue boots on at all times to prevent further breakdown to feet. Started on 3/16/25. During an observation on 3/19/25, R6 was observed in her Broda chair at 8:30 AM with puff boots on her bilateral lower extremities. Her left leg is contracted. She was observed in the same position in the Broda chair at 11:50 AM she is in the community room watching television. During an observation and an interview on 3/19/25 at 1:15 PM, R6 was in bed for cares and her socks and puff boots were removed. There were 3 wounds with dark scabbed like appearances observed on her left lateral foot and no dressings in place. Certified Nursing Assistant (CNA) K placed R6's socks back on her feet and put the puff boots back on her before transferring back to her chair. The nurse was not notified of a missing dressing. When asked about repositioning or offloading R6 who is dependent on cares, CNA K reported that would be really hard because of her contractures and the fact that she is sitting in a chair (Broda chair). Review of the Care Plan for R6 revealed no focus for active pressure ulcers or leg contractures. Review of the Care Plan for R6 revealed interventions: -Assess postural alignment, weight distribution, sitting balance, &pressure redistribution on admit and prn (as needed). Initiated 2/1/23. -Encourage pressure relieving boots on at all times while in bed and up in chair. Initiated 1/31/23 and revised on 3/16/25. In an interview on 3/20/25 at 12:43 PM, the Director of Nursing (DON) reported she expects staff to report any new skin conditions to the nurse and confirmed R6 is to have a border foam dressing on the pressure ulcers on her left lateral foot. The DON confirmed the skin assessments documented in the computer are not accurate. The DON reported the Care Plan does reflect R6 was already to have the puff boots as an intervention, but she is more receptive now to having them on her feet, which is why no new intervention was put into place. Review of a policy titled Skin at Risk Assessment Documentation, Staging & Treatment last revised 1/2020 revealed: It is the policy of this facility to assess resident risk factors for the development of impaired skin integrity and intervene as indicated utilizing the admission assessment, plan of care, and Minimum Data Set as formal assessment tools. It is the policy of this facility to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred. Weekly measurements and narrative assessments are conducted on existing pressure injuries. Purpose: To provide prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. To limit the development of avoidable pressure ulcers and provide evidenced based guidance on effective strategies to promote pressure ulcer healing. 6. The following guidelines are reviewed and implemented as indicated for each individual risk factors: a. Daily skin inspections with am and pm care e. Rehabilitation consultation to improve mobility, promote movement and receive recommendations for positioning support. f. Use of pressure relieving devices, i.e., chair cushions, pressure reduction mattresses, low air loss mattresses k. Change the residents position every 2 hours and more frequently if redness or irritation of the skin develops q. Implement standing orders for impaired skin and / or consult the physician prn for treatment and orders for impaired skin integrity. 8. Individualize the resident goals and interventions as documented on the plan of care. 10. Document the appearance of the wound with considerations to the physical characteristics as applicable to the resident;

This citation pertains to intake M100147971. Past non-compliance was accepted for this citation. Plan identified below. Based on interview and record review, the facility failed to ensure 11 residents (R3, R4, R5, R6, R7, R8, R9, R11, R12, R13, and R14) of 16 residents reviewed, were provided medications as ordered, resulting in medication not given as ordered. Findings include: Review of a Facility Reported Incident (FRI) revealed 15 residents received all their medications for the day at one time on the morning of 10/31/24 by Licensed Practical Nurse (LPN) E. Through the facility's investigation, Licensed Practical Nurse (LPN) A went to R7s room at 10:15 AM and the resident had a blank stare and could not speak. R7 was not aroused with physical stimulation and was brought out to the nurse's station for an assessment. LPN E was R7s assigned nurse this day. The Director of Nursing (DON) was notified of R7's change of condition and checked the medication cart to find R7's medications were not there for the 8 AM, 12 PM, or the 6 PM orders. The DON reviewed all the medication carts and saw missing medications for the residents in LPN E's care for the day. The facility report reflected LPN E later confessed to giving all medications scheduled during her shift at once to the residents in her care on 10/31/24. LPN E reported she did it for time management but denied giving R7 medications. R7 was sent to the hospital for evaluation. The FRI report also mentioned R14 receiving 10 units of short acting insulin at 7:15 AM, and she was symptomatic at 8:30 AM at the nursing station. Her blood sugar was checked, and it was 48 (normal is 60-100 for non-diabetics). The LPN A immediately walked the resident to the dining room for breakfast. Resident #7 (R7) Review of a Face Sheet for R7 revealed she admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, psychotic disorder, and dementia. In an interview on 11/19/24 at 11:00 AM, LPN A reported she went to visit R7 in her room on 10/31/24 around 10:00 AM and saw R7 in her room, not responsive with her eyes opened and tears coming out of her eyes. LPN A reported she had never seen her like that and started to assess her. LPN A reported she was prompted to have the DON check the medication carts to see if the daily medications were in the cart because of an incident on 10/23/24 when LPN A took over the medication cart from LPN E who had already given a resident all her daily medications. LPN A said she did not tell the DON about the incident but did educate LPN E on the potential harm of giving resident medications all at once. When the DON checked the medication carts on 10/31/24, there were no day shift medications in the cart for the residents in LPN E's care and they had to call the physicians to let them know. Review of the Hospital Medical Record for R7 dated 10/31/24 revealed she had a diagnosis of an accidental overdose and acute cystitis (inflammation of the bladder). It seems the nurse this morning gave all of her daily medications rather than just her morning dosages. she seemed a bit more tired than usual. after completing evaluation the dosage of medication that you took beyond your normally prescribed dosage is not particularly harmful in these quantities . In addition we do see you have a urinary tract infection. (sic) Review of the October Medication Administration Record (MAR) for R7 revealed on 10/31/24, LPN E signed off giving all her 8:00 AM medications. The Carbidopa-Levodopa (to treat tremors associated with Parkinsons disease) 25/100 mg (milligrams) is ordered to be given at 8:00 AM, 12:00 PM and 6:00 PM but documented as not receiving the 12:00 PM or 6:00 PM doses. Pramipexole Dihydrochloride (for restless leg associated with Parkinsons disease) is ordered to be given at 8:00 MA, 12:00 PM, and 6:00 PM, and is documented as not given at 12:00 PM and the 6:00 PM. Resident #14 (R14) Review of a Face Sheet for R14 revealed she admitted to the facility on [DATE] with pertinent diagnoses of diabetes and schizoaffective disorder. In an interview on 11/20/24 at 12:07 PM, LPN A was questioned about the incident on 10/31/24 with R14. LPN A reported R14 came out to the nursing station around 8:15 AM with complaints of feeling dizzy. LPN A knew she was diabetic, and she did not receive her breakfast tray yet. LPN A checked R14's blood sugar and it was 43, so she immediately took the resident to the dining room to get her some food. LPN A reported she educated LPN E and told the Director of Nursing (DON) about it. Review of the October MAR for R14 revealed on 10/31/24 she received her 8:00 AM medications but did not receive her Gabapentin (for walking difficulty) 200 mg at 4:00 PM, Metformin 1000 mg (for diabetes) at 4:00 PM, Sodium Chloride at 4:00 PM, Humalog (insulin) 10 units at 5:00 PM, Seroquel (for schizoaffective disorder) 200 mg at 4:00 PM. The Humalog is documented as given at 7:14 AM. Breakfast trays start at 8:00 AM. Resident #3 (R3) Review of the October MAR for R3 revealed on 10/31/24 he received all his 8:00 AM medications including his Coreg (Carvedilol) (blood pressure medication) 4:00 PM dose was documented as not given. Resident #4 (R4) Review of the October MAR for R4 revealed on 10/31/24 she received all her 8:00 AM medications including acetaminophen 500 mg and the 4:00 PM dose is documented as not given. Senna-Docusate tablet 8.6-50 mg, give 2 tablets twice a day for constipation is documented as given at 8:00 AM, and documented not given at 4:00 PM. Resident #5 (R5) Review of the October MAR for R5 revealed on 10/31/24 he received all his 8:00 AM morning medications and his Atorvastatin 40 mg (for high cholesterol) is documented as not given at 6:00 PM, Apixaban (anticoagulant) 5 mg ordered twice a day is documented as not given at 4:00 PM, PreserVision (multivitamin with minerals for macular degeneration) ordered twice a day and documented as not given at 4:00 PM. Bumetanide 1 mg (diuretic) ordered twice a day and the 1:00 PM dose is documented as not given. Resident #6 (R6) Review of the October MAR for R6 revealed on 10/31/24 he received all his 7:00 AM and 8:00 AM medications. His Metformin (diabetic medication) 1000 mg tablets ordered twice a day is his 4:00 PM dose is documented as not given. Benztropine Mesylate (for extrapyramidal symptoms and movement disorder) 2 mg ordered three times a day and documented as not given at 12:00 PM. Resident #8 (R8) Review of the October MAR for R8 revealed on 10/31/24 she received all her 8:00 AM medications. Her Metoprolol Tartrate (for blood pressure) ordered twice day, was documented as not given at 4:00 PM. Pantoprazole (antiulcer) 40 mg ordered twice a day and was documented as not given at 4:00 PM. Resident #9 (R9) Review of the October MAR for R9 revealed on 10/31/24 he received his 7:00 AM and 8:00 AM medications. He was ordered Preservision 2 caps twice a day the 4:00 PM dose is documented as not given. Systane eye drops is ordered three times a day and the 12:00 PM dose is documented as not given. Resident #11 (R11) Review of the October MAR for R11 revealed on 10/31/24 he received his 8:00 AM morning medications. He was ordered Furosemide (diuretic) 40 mg twice a day and his 1:00 PM dose is documented as not given. Potassium Chloride 10 milliequivalents (mEq) ordered twice a day and his 1:00 PM dose is documented as not given for the 1:00 PM dose. Buspirone 10 mg (for anxiety) ordered three times a day and the 2:00 PM dose is documented as not given. Resident #12 (R12) Review of the October MAR for R12 revealed on 10/31/24 she received her 8:00 AM medications but her Tylenol 650 mg is documented as not given at 11:00 AM and 3:00 PM. Resident #13 (R13) Review of the October MAR for R13 revealed on 10/31/24 she received her 8:00 AM medications. Her Potassium Chloride 10 mEq at 4:00 PM and her Bumetanide 1 mg (diuretic) at 4:00 PM is documented as not given. During an observation and an interview on 11/19/24 at 2:15 PM, LPN B reported medications come from the pharmacy in packages with the ordered times of the medications in one package. If a person gets 8:00 AM medication, all those medications would be in one package. Some residents will have more than one package of medications because they get medications at different times of the day. LPN B reported she is the nurse for R14 and reported short acting insulin (Humalog) should not be given until at least 15 minutes before meals. Anytime longer than that is too long, and the residents would need a snack or something if meals are delayed. Breakfast trays will start getting served at the dining room at 8:00 AM. In a telephone interview on 11/20/24 at 11:17 AM, LPN E reported she did make a medication error on 10/31/24 by giving a resident more than the amount of medication than she should have. She felt the best way to avoid this from happening again was to remove herself and so she resigned. When asked if she gave more medications than she should have to more than one resident, she reported I won't answer that, then said there may be more than one resident. She could not remember the residents she gave more than the ordered number of medications. LPN E admitted she was wrong for giving those medications but said it was not with malicious intent. In an interview on 11/20/24 at 1:00 PM, the DON reported she was not made aware of LPN E giving a resident a full day of medications at once on 10/23/24 until the incident on 10/31/24 when R7 had a change in condition. LPN A suggested checking the medication cart to see if all her medications for the day were given. The DON checked the medication carts and the daily medications for the residents in LPN E's care were gone. She could not find them and confirmed the pharmacy did deliver them to the facility. She had LPN E sit in her room while she investigated it. At first LPN E denied giving the residents their afternoon medications early but then admitted she did do it for time management. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included .: 1. On 10/31/24 the facility identified a concern with a staff member giving all day shift medications in the morning to several residents. 2. R7 was transferred to the hospital for evaluation. 3. The DON audited all 4 medication carts in the facility on 10/31/24 and found 14 residents' who were in LPN E's care had afternoon medications missing in the cart . 4. The Medical Director was notified and ordered the monitoring of residents and their vital signs. 5. Poison Control was notified. 6. All responsible parties were notified. 7. On 10/31/24, LPN E was suspended pending investigation and then resigned later that day. 8. Police were notified. 9. Pharmacy consultant was notified. 10. All residents were identified to be at risk. 11. On 11/1/24 the facility immediately started educating nursing staff about medication administration. 12. The facility will continue to audit resident medications. 13. Continue ongoing medication administration educations. 14. The facility will continue to follow up with their Quality Assurance meetings. On 11/2024, this surveyor reviewed documentation, conducted interviews and made observations the preceding interventions were completed prior to the abbreviated survey. A determination of past non-compliance was approved by the state agency as of 11/1/24. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation refers to MI00146957. Based on interview and record review, the facility failed to report an allegation of mental and verbal abuse in a timely manner to the state survey agency for 1 of 6 residents (R5) reviewed, resulting in allegations of abuse not being reported timely to the state survey agency, all allegations of abuse not being accurately and completely reported to the state survey agency, the potential for allegations of abuse not being investigated timely, the potential for abuse to go undetected, and the potential for residents not being protected from abusive individuals. Findings include: A review of R5's Admission Record, dated 10/7/24, revealed R5 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 5's Admission Record revealed multiple diagnoses that included bipolar disorder and need for assistance during personal care. A review of R5's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/8/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R5 was cognitively intact. During an interview on 10/3/24 at 4:20 PM, R5 stated about a month ago a nurse named [first name of nurse] (R5 stated she did not know the nurse's last name but described her as the one with the long hair because there's two [first name of nurse]'s) yelled at her and intimidated her. R5 stated, she got right up and close to me. She was yelling at me telling me I had to do things on my own. R5 stated she felt the nurse was just talking loudly and was trying to encourage her to do things on her own. She stated she did not like the way the nurse spoke to her. I was crying. I was scared she would hit me. R5 further stated she asked [first name of nurse] if she was going to hit her and [first name of nurse] told her no, but she could if she wanted to and there's nothing she could do about it. R5 told her she was scared of her and [first name of nurse] told her that she could always call her husband (R5's) and tell him he could pick her up on the bench outside. [First name of nurse] told her she would take her outside and put her on the bench so he could pick her up. She stated she reported this to a nurse (she did not remember the nurse's name) and she was told it would be taken care of. R5 stated since then, [first name of nurse] has been nicer to her. However, she stated no one had spoken to her about her allegations or followed-up with her since she reported them to the nurse. During an interview on 10/3/24 at 4:30 PM, the Director of Nursing (DON) was informed of the conversation with R5 and the allegations. The DON was informed that R5 stated a nurse named [first name of nurse] had yelled at her, was close to her face, and R5 felt scared and intimidated by her. The DON was also informed that the nurse had stated she could hit R5 if she wanted to and had told R5 if she did not like it at the facility, R5 could call her husband and she would put R5 outside on a bench for him to pick her up. The DON identified the nurse as Licensed Practical Nurse (LPN) I and stated she was aware that R5 had accused LPN I of yelling at her. The DON stated LPN I had been educated. The DON further stated she was not aware that LPN I had told R5 she could hit her if she wanted to or that LPN I had told R5 that her husband could come and get her after she put her outside. The DON stated she would gather all the information she had on R5's previous complaint that LPN I had yelled at her, including any education that was provided to LPN I and that she would provide a copy to me. I also requested that the DON follow-up with me about what the facility's plan was and their actions related to the allegations that LPN I had told R5 she could hit her if she wanted to; that she could put her outside on a bench for her husband to pick her up if she did not like it at the facility; and that she (R5) was saying LPN I had yelled at her, scared her, and intimidated her (continuing issue or past issue that was resolved). The DON verbalized understanding. During an interview on 10/7/24 at 1:00 PM, the Nursing Home Administrator (NHA) stated she had spoken with R5 on 10/3/24 with the DON but did not indicate if this was before or after the DON was notified by me of the allegations R5 had made against LPN I. She stated she asked R5 about the nurse and what had happened with the nurse allegedly yelling at her. The NHA stated R5 did not mention that the nurse had threatened to hit her or have her call her husband and have him pick her up. She stated R5 has a personal protection order (PPO) against her husband, so she wouldn't be calling him to pick her up anyway. The NHA stated R5 has an extensive psychiatric history and that these allegations are a part of her psychiatric diagnosis. She stated R5 makes accusations when she is undergoing a mental crisis. We have to send her back and forth to the psych facility as she cycles (goes from no behaviors to behaviors related to a mental crisis). The NHA stated Thursday (10/3/24) was the first time she heard about the nurse threatening to hit R5 or have someone come and get her if she does not like it at the facility. She stated she will start an investigation now that I mentioned something to her. A review of R5's electronic medical record, dated 7/30/24 to 10/7/24, failed to reveal any mention that R5 had made an accusation against staff or yelling at her, scaring her, intimidating her, threatening her with physical harm, or telling her she can leave the facility if she does not like it there. A review of [name of the State's Facility Reported Incident System] on 10/7/24 at 3:30 PM, failed to reveal that the facility had reported the allegations of verbal abuse that R5 made against LPN I (yelling at her, intimidating her, and/or threatening her] either recently or in the past. During an interview on 10/7/24 at 3:40 PM, the NHA was informed I had a concern that R5 stated a nurse had yelled at her up close, had scared and intimidated her, and had told her she could hit her if she wanted to. She was also informed I was concerned that the nurse had threatened R5 by telling her if she did not like it at the facility then R5 could call her husband to come pick her up and the nurse would put her on a bench outside for him. The NHA was also informed I was concerned that there did not seem to be any documentation an investigation had been started (or investigated in the past) or that R5 had made the allegations, even though the NHA had stated earlier that she would be starting an investigation. The NHA stated she was also concerned about this. The NHA further stated she had just spoken with R5 again prior to this interview. She stated R5 had told her that these allegations had occurred sometime in the winter. The NHA also stated that she had spoken to R5 several times about these allegations since 10/3/24 and R5 changed or varied her statement. She stated R5 changed when the incident occurred (i.e., recently vs. months ago) and/or the number/type/severity of allegations (e.g., yelling vs speaking loudly; one allegation of the nurse yelling at her close to her face vs the nurse yelling close to her face, telling her she could hit her if she wanted, and telling her she can call her husband and have him pick her up after the nurse puts her outside for him) when she had spoken to her. The NHA stated she has had a difficult time based on her interviews with R5 figuring out what the allegations actually were or when they occurred in order to investigate them. I requested any documentation that she may have regarding these allegations and what the facility has done or will do (e.g., documentation of R5's interview or staff interviews, report to the state survey agency, etc.). The NHA verbalized understanding. A review of [name of the State's Facility Reported Incident System] revealed the facility reported to the state survey agency on 10/7/24 at 4:33 PM (4 days after the incident was reported to the DON and 3.5 hours after it was again reported to the NHA by the surveyor) that R5 stated a nurse (LPN I) yelled at her in the past few weeks, month, when there was snow on the ground and denied any physical contact. The facility reported they were aware of the allegation on 10/3/24 at 4:30 PM. However, the facility failed to report that the surveyor had notified them of this allegation and that R5 had also reported that LPN I had also told her she could hit her if she wanted to, that R5 felt scared and intimidated by LPN I, and that LPN I had told R5 she could put her outside on a bench for her husband to pick her up if she did not want to stay at the facility (possibly when it was snowy and cold outside if it occurred at the same time that R5 stated the nurse yelled at her). Therefore, the facility failed to accurately and completely report all allegations of abuse on their initial report to the state survey agency. A review of the facility's Identification of Abuse Policy and Procedure, revised March 2019, revealed mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered a type of mental abuse. Examples listed in the facility's policy for psychological, mental, or verbal abuse include harassing a resident; yelling or hovering over a resident, with the intent to intimidate; and threatening residents. A review of the facility's Abuse/Suspected Abuse: Crime Investigation and Reporting Policy and Procedure, revised February 2023, revealed, 8 . the facility will report all alleged violations (allegations) to the state survey agency and all other agencies as required and take all necessary corrective actions depending on the results of the investigations . 9. Reports are submitted online into the [name of the State's Facility Reported Incident System]: (1) Immediately but no later than 2 hours if the alleged violation involves abuse .

This citation refers to MI00143988. Based on interview and record review, the facility failed to maintain complete, timely, and accurate medical records for 1 of 4 residents (R4), resulting in the potential for providers not having an accurate, complete, and timely picture of the resident's stay at the facility. Findings include: A review of R4's Admission Record, dated 5/22/24, revealed R2 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R4's Admission Record revealed multiple diagnoses that included Dementia. A review of R4's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/13/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) assessment which revealed R4 had short-term and long-term memory problems with inattention and disorganized thinking. R4's BIMS assessment also revealed R4 had severely impaired cognitive decision making skills. A review of the facility's investigation report, dated 4/12/24, revealed on 4/4/24 at 6:45 PM, R4 became agitated and grabbed R3's arm which resulted in scratches. After she (R4) was redirected away from R3 she walked over and slapped R2 in the back of head before she could be redirected. Resident (R4) was successfully redirected to another area of the building. Resident (R4) will be accompanied by staff member until no continued observation of heightened agitation. A review of R4's progress notes, dated 4/1/24 to 5/21/24, revealed the following: - Interdisciplinary Documentation, dated 4/5/24, revealed, Collaboration with provider regarding constipation and observed increased agitation with bowel movements. Review of [name of R4] BM (bowel movements) over the last 30 days initially show irregularity with increased regularity over the last 14 day look back period. Interviews with staff indicate increased agitation with direction and assistance using toilet. [Name of R4] observed at times guarding her stomach when having bowel movements. [Name of R4] at times requires multiple approaches for medication administration which includes her Senna (a laxative). [Name of R4] does take Miralax (another laxative) daily. Review of medications and order to change senna capsule to a liquid to promote increased compliance. 4 oz (ounces) of prune juice to be added to each meal tray to help promote regularity. Increased fluid intake promoted with use of sensory engagement staff. Staff to encourage 240 ml (milliliters) each shift in addition to meal trays. Frequent routine toileting while participating in the sensory engagement room. Further review of implemented changes to be assessed with provider at next visit. Ativan (a sedative) tablet changed to Ativan gel to encourage compliance as [name of R4] often times will spit the pills out and other times requires multiple approaches by different staff members to be accepting of her medications. [Name of R4] spent a significant amount of time in the sensory engagement room and is observed to be more easily re-directed in areas of decreased stimulation. - Interdisciplinary Documentation, dated 4/12/24, revealed, BIM:99 (an incomplete resident interview assessment of cognitive status), observed by [Name of Social Worker (SW) B] on 4/10/2024 regarding unusual occurrence that took place on 4/4/2024. [Name of R4] displays relaxed body and facial expression, she is engaging in the sitting area folding laundry and arranging flowers in a basket. No psychosocial distress observed. A further review of R4's medical record, dated 4/1/24 to 5/23/24, failed to reveal any mention of the incident on 4/4/24 in R4's medical record, except for the Interdisciplinary Documentation note by SW B on 4/12/24 that she observed R4 regarding unusual occurrence that took place on 4/4/2024 and No psychosocial distress observed. However, the Interdisciplinary Documentation note by SW B did not mention what the unusual occurrence was (e.g., fall, resident-to-resident altercation- all events that the facility documents as unusual occurrences). During an interview on 5/22/24 at 12:15 PM, Social Worker (SW) B stated that if an incident occurs (e.g., a resident-to-resident altercation) then it should be documented in a progress note in the resident's record that it affects. During an interview on 5/22/24 at 4:00 PM, the Director of Nursing (DON) was informed that the surveyor could not locate a note regarding the incident (unusual occurrence) on 4/4/24. She stated she would look into it and see if she could locate one. The DON stated sometimes her Interdisciplinary Documentation note for a supervisory investigation of an unusual occurrence/collaboration with the provider is the note that specifies the incident. She stated if she cannot find a note, then she will do a late entry progress note. The DON stated her expectation is that the nurse should have written a progress note about the incident when it occurred on 4/4/24. During a second interview on 5/22/24 at 4:05 PM, the DON stated her Interdisciplinary Documentation note dated 4/5/24 was regarding the incident on 4/4/24. She stated even though the note does not specify that it was addressing the resident-to-resident incident, it was a collaboration with the physician that included the incident. The DON stated the collaboration with the provider addressed R4's increased agitation with bowel movements and constipation. She stated they found this out when they did their investigation into the incident on 4/4/24. The DON further stated that she knows her own documentation had been lacking in detail, but she had been working on it. 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 . Documentation is sometimes viewed as burdensome and even as a distraction from 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, retrieved on 5/28/24). Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care . 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, retrieved on 5/28/24).

Based on observations, interviews and record reviews, the facility failed to have clear tube placement orders, failed to track formula intake, failed to provide fluids in accordance with orders and failed to follow nursing standards of practice for 1 Resident (R51) sampled for tube feeding, resulting in weight loss, dehydration, and medication errors. Findings include: Review of R51's face sheet dated 3/30/23 revealed he initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnosis that included: dementia, epilepsy, gastronomy status, congestive heart failure, weakness, muscle wasting and atrophy, colostomy status, dysphagia (difficulty swallowing), cognitive communication deficit and need for assistance with personal care. Per review of R51's MDS (Minimum Data Set) dated 3/7/23, he coded for a weight loss of 5% or more in the last month of loss of 10% or more in the last 6 months. A care plan focus related to nutrition revealed: [R51] has an altered nutritional status .NPO with tube feed dependence to meet 100% of nutrition/hydration needs. [R51] at times does not get the full amount of TF order because he pulls his g-tube out . with a last revised date of 3/16/23. Interventions included evaluate laboratory values in relation to nutritional needs prn. There were no progress notes that revealed concerns with R51 recently pulling out his feeding tube or full tube feed order not being administered. Review of R51's MAR (medication administration record) for March revealed the tube feed is ordered Osmolite 1.5 @ 65 ml/hr. Flush every 4 hours with 220 ml. Kangaroo pump continuous feed. The MAR did not reveal any documentation of any actual amounts of tube feed formula administered. The MAR also only had entries for Day, Evening and Night instead of every 4 hours, which would be 6 times a day flushes. If the MAR is accurate and R51 is only getting flushes 3 times a day, they have a deficit of at least 660 ml of fluid a day versus what the physician and dietician have ordered. Review of R51's Enteral Nutrition Review dated 3/8/23 revealed R51's estimated Fluid Need: TOTAL / WATER VOLUME / DAY 30-35ml water/kg = 2133-2488 (ml's). Review of R51's care plan revealed he is bed bound, dependent on the staff for all aspects of care. He continues to be NPO (nothing by mouth) . with a initiated date of 1/21/23. R51's care plan also refers to a related intervention Flange Placement-5 with a last revised date of 3/6/23. Review of R51's orders revealed Check flange placement-5 prior to administering feeding or medications via PEG tube. This order was active as of 3/6/23. It was not abundantly clear what placement-5 meant. The MAR had a section to document in cm but on 3/6/23 evening no was documented, 3/6/23 night: 0, 3/9/23 Evening and 3/10/23 Day were marked 3 but review of the MAR revealed no medications or tube feeding held on those days. No corresponding progress notes were viewed that explained these entries. A progress note on 3/26/23 by charge nurse U: Gtube in place with 5 inch tube measure. On 3/29/23 at 10:00 AM, R51 was observed in bed with his eyes open. Registered Nurse (RN) K spoke to R51, but he did not respond to her. RN K had supplies ready to connect a new bottle of tube feeding formula. The feeding tube pump was running at 65 ml an hour and showed 3022 ml had been infused and 220 ml of water had been infused. RN K was asked if she reset the pump when connecting a new bottle of formula and where she documented the formula and water intake. RN K said R51 was on a continual 24-hour feed, so they did not need to record formula or water intake and she does not regularly reset the pump. The amount of 3022 ml infused at a 65 ml rate would be approximately 46.5 hours of running time. RN K placed her stethoscope on R51's lower abdomen to listen for bowel sounds while the tube feeding was connected and running at 65 ml an hour. RN K shut the feeding tube off and disconnected the tube feeding. RN K placed a paper measuring tape that measured up to 14 cm in length along R51's feed tube, starting at the portion coming from his abdomen. The tube was longer than the measuring tape. RN K said the portion of the tube showing was supposed to be 5 cm long. RN K said because it was out more than 5 cm, she would have to call the doctor. After calling the doctor, RN K said she did not have her glasses on when she measured the tube, and she was supposed to look for a mark on the tube. RN K said she measured it again and it was still out too far, so the physician wanted R51 sent to the emergency room to check his feeding tube placement. Review of R51's Physician Order dated 3/29/23 at 11:15 AM, Hold tube feed .until abdominal x-ray report read. An observation was made of R51 on 3/30/23 at approximately 8:55 AM and his tube feed was not running. An interview with RN (Registered Nurse) K at approximately 8:56 AM on 3/30/23 confirmed that R51's tube feed had been disconnected since approximately 10:30 AM the previous day. R51 had been sent to the emergency room the previous night to confirm placement of the tube but they had not completed the correct tests. RN K spoke to the physician this morning, and they were ordering another x-ray. RN K stated she had not had time to put in the order yet due to being busy passing medications on two halls. R51 had not received fluid nor nutrition or properly administered critical medications for approximately 22 hours. On 3/30/23 at approximately 9:00 AM the NHA (nursing home administrator) was informed of the concerns that R51 had not received food or nutrition for about 22 hours. The NHA stated the ER did not do an x-ray as ordered last night and they have a stat (urgent) x-ray order to get this done to verify tube placement. The NHA was informed an interview was just completed with RN K and she was too busy at this time to enter the new order for R51. The NHA stated she would check with the nurse immediately. On 03/30/2023 at 9:20 AM an interview was completed with RD (Registered Dietician) E Reported she had not been notified that R51 had been without fluids/tube feeding since 3/29/23 at approximately 10:30 AM. RD E reported she would expect to be notified if fluids/feeding had to be stopped for more than a couple of hours. RD E was asked if it was concerning that he had been without nutrition for nearly a day and she stated, you and I wouldn't go 24 hours without drinking. On 3/30/23 at 9:35AM an interview was completed with RN J and the NHA and they reported just spoke with RD E regarding R51. R N J reported the x-ray from last night showed the tubing was laying over the stomach, so they need a contrast x-ray to confirm placement, which was the point of sending him to the ER last night. R51 returned from the hospital last night without any documentation. The nursing staff that contacted the ER staff reported they flushed it and it was fine without any further diagnostic testing. The recent elevated K (Potassium) and BUN (blood urea nitrogen) was reviewed with RN J and she verified further dehydration could cause additional increase in K and BUN. RN J stated R51's nurse was communicating with physician at this time regarding possible IV for fluids if he is not sent out to the hospital. Review of R51's Medication Administration Record (MAR) with RN J revealed R51's 9:00 PM medications were administered on 3/29/23: atorvastatin (cholesterol medication) and melatonin (sleep supplement) after an order to hold peg tube at 11:15 AM on 3/29/23. Further review of the MAR revealed R51 did not receive his valproic acid for history of seizures on 3/29/23 at 3:00 PM, 3/29/23 11:00 PM, and 3/30/23 7:00 AM. R51 did not receive his eliquis (anticoagulant medication to prevent blood clots and stroke) on 3/29/23 4:00 PM and 8:00 AM on 3/30/23. Corporate Nurse J reported during the interview on 3/30/23 at 9:35 AM that R51 has not had recent seizures but verified R51 had not received his seizure medications for approximately 24 hours. Corporate Nurse J reported she had a call out to the nurse that documented she had administered the Atorvastatin and melatonin. The NHA (Nursing Home Administrator) confirmed by email on 4/4/23 at 2:50 PM that she had not yet received a return phone call from the nurse who documented administering medications on the evening of 3/29/23. Per facility provided policy Enteral Tube Feeding with a last revised date of February 2021 revealed: Assess for placement of feeding tube prior to each intermittent feed, medication administration. At 10:11 AM on 3/30/23, EMS (emergency medical services) arrived to transport R51 to the hospital. On 3/30/23 at 10:10 AM a follow up interview was completed with RD E regarding R51. RD E stated R51 did receive flushes in the ER last night, so has had some fluid and would anticipate the ER will assess him for hydration or follow-up labs would be completed when he returns. RD E stated she would recommend additional bolus flushes to be completed to ensure R51 does not become further dehydrated. RD E stated R51's initial high potassium level was 5.2 on 3/14/23 and the follow up lab was 4.9 the following week, which is still close to a high level with a normal range of 3.4-5.0. It was discussed that the BUN level was also high at 28 mg/dL (normal range is 8-20) on 3/14/23, but this lab test was not repeated. RD E stated she could not determine a dietary reason for the elevated levels and at this time the physician would need to weigh in on why these levels may be elevated and intervene. RD E stated the ordered formula nutrition, and the flushes should be adequate to maintain his nutrition and hydration status, so she was at a loss. A review of progress notes for R51 revealed a note made by RD E on 3/21/23: Assessment requested due to a high potassium level of 5.2. Unsure of cause at this time for high potassium. [R51] only receives 3139 mg of potassium daily in the full ordered amount of enteral feeding (Osmolite 1.5 60ml/hr x 24 hrs) and then an added 20 mg in his 30 ml of prostat daily. The DV of K+ is 3500-4700 mg. Sometimes low fluid volume can result in high K+ levels but [R51] gets 2414 ml of water per day between free water in his formula and the 220ml q 4 hours in flushes, This provides 34ml/kg body weight which meets his ideal hydration recommendations. waiting on repeat K+ level to re-assess. An additional follow up interview was completed with RD E on 3/30/23 at 11:47 AM. RD E had reviewed her emails and stated she did not personally contact the physician but assumed they would be reviewing her notes and the labs as well. RD E stated she had emailed the DON (Director of Nursing) on 3/21/23 about a repeat potassium lab and did not realize that they had already ordered it. R51's labs from 1/11/23 were also reviewed at this time with RD E and they revealed elevated sodium levels of 148 (normal range 134-146), Chloride level of 114 (normal range 98-112), Glucose level of 189 (normal range 70-99) and BUN of 36 (normal range of 8-20). RD E was asked if she was aware of why a repeat lab had not been done to follow up on these and she stated that R51 had been sent to the hospital due to these labs and believed they had an infection at that time. Review of a hospital discharge summary dated 1/21/23 revealed that upon discharge R51 continued to have high glucose levels (113), BUN levels (21), potassium levels (6.0), and low calcium levels on 1/20/23. A follow up interview was completed with the NHA on 3/30/23 at approximately 2:30 PM regarding R51. The NHA stated R51 had returned from the hospital and the tube feed placement had been verified. The NHA was asked if any lab work had been completed and she stated that she believed just an x-ray had been done. The NHA stated labs were ordered for the next lab day for R51. At the time of exit the labs had not yet been completed for R51.

Based on observations, interviews, and record review, the facility failed to prevent, complete weekly assessments and treat pressure ulcers for 2 Residents (R55 and R64), resulting in R64 developing multiple pressure ulcers (including 2 unstageable ulcers) and the potential for R55's pressure ulcers to delay in healing and develop infection. Findings include: Review of R64's face sheet dated 3/30/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: cerebral palsy, abnormal posture, dementia, diabetes mellitus II, neuromuscular dysfunction of blader, need for assistance with personal care, and weakness. He was not his own responsible party. R64 was observed on 3/28/23 at 1:13 PM on his right side in bed. R64 was observed on his right side in bed on 3/29/23 at 9:00 AM. R64 was observed on 3/29/23 at 2:20 PM in bed on his right side. R64 was cooperative with rolling to his left side with the assistance of Certified Nurse Aide (CNA) J. R64's heels were in contact with his mattress (no heel float device in place). R64' left ankle was wrapped with kerlix (medical dressing) dated 3/29/23. There was a wet spot on R64's sheet where his left heel was in contact with his mattress. There were no positioning devices or heel float equipment located in R64's room at this time. CNA J said R64 prefers to stay on his right side in bed. CNA J said R64 is asked if he wants to be repositioned every 2 hours, but he wants to stay on his right side. R64 has a Foley catheter in place so he doesn't require frequent changes. R64's television and bedside table are both located on the right side of his bed. CNA J was asked if the facility had attempted to switch the television location and bedside table location when offering to turn him in bed and CNA J was not aware of any attempts to relocate items in R64's room to encourage position changes. CNA J was not aware of any devices attempted to float his heels or reposition him. During an interview with Registered Nurse (RN) M on 3/29/23 at 3:10 PM the Surveyor shared the observation and interview information obtained on 3/29/23 at 2:20 PM. RN M reviewed R64's medical records and was not able to locate any documentation that showed R64's guardian was aware of any repositioning concern, pressure ulcer concerns or any attempts using different devices or attempts to encourage R64 to stay in any position except his right side in bed. Documentation indicated there were wounds on the left buttock versus the right buttock which did not match the observation. Notes also indicated there were wounds on the right heel versus the left that did not match the observations. There were missing weekly wound measurements in the medical record during this interview. RN M said she wound investigate the wounds and provide a timeline with wound measurements, treatments and interventions attempted. On 3/30/23 at 11:00 AM, R64 was on his right side in bed. RN M and the Certified Nurse Aide instructor (CNAI) rolled R64 on his left side. R64 left buttock skin was intact. R64's right buttock had two dime size open areas over his ischium, one was covered with dark eschar and the other was partial thickness. R64's left heel had two dime size open areas, one with dark eschar covering it and the other was partial thickness. The skin on his right heel was intact. No positioning devices or pillows were in the room. Review of the facility timeline for R64's wounds revealed he was admitted to the facility on [DATE] and he had venous ulcers to both lower extremities. His skin issues resolved on 6/8/22. R64's left heel ulcer opened on 8/1/22. On 2/5/23 wound documentation revealed no skin issues. Review of the wound timeline for R64 revealed, Upon presentation of the left heel wound it was defined as unstageable. Multiple stages were given to the wound by different nurses. The wound was unstageable throughout the evolution of the wound until 1-10-23, staging of the wound should not have been considered due to sloughing with inability to view the wound bed entirely. Wound measurements on 1/10/23: 1/2 cm x0.4 cm x0.2 with no sloughing, clean open tissue with scant serous drainage is the appropriate stage of the wound. Review of the facility wound timeline for R64 revealed Right buttock pressure ulceration: Chart reviewed reveals this area is chronic and cycles with opening and closing due a (sp) history of pressure ulcer put him at higher risk of having the area open due to damage, injury, or pressure, because of the loss of tensile strength of the overlying tissue. Tensile strength of the skin overlying a closed pressure ulcer is 80% of normal skin tensile strength. Review of the facility wound timeline for R64 documented the right buttock was open on 8/30/22 and healed on 10/26/23 and reopened on 3/21/23. Review of R64's wound timeline revealed R64's clinical and cognitive condition reveals skin impairment is unavoidable related to his chronic IAD (incontinence-associated dermatitis) to his scrotum/testes, impaired mobility, fecal incontinence, chronic indwelling catheter, diabetes with microvascular changes with the potential for delayed wound healing, potential to decline cares and treatment, frequently scratches skin with his fingernails, and actual impairment on admission. He is dependent on the staff for all weight bearing activities including clothing management, personal hygiene, and bed mobility. He is dependent on mechanical lift for all transfers. Non-compliance is document with position changes. During encouragement and assistance with positioning notably causing him physical and emotional distress. [R64] has the propensity to physically strike out at staff during positioning and concerns, mitigate his risk factors, and promote optimal quality of life. On 3/29/23 at 2:20 PM the surveyor requested documentation of R64's notification and involvement in the concern for R64's resistance to reposition and any documentation of different approaches or attempts to reposition R64 related to his skin breakdown. Any documentation of different equipment or room arrangements to encourage repositioning as R64 is not his own responsibility party. No information was located at this time or prior to exit. R64 was cooperative with rolling in bed and with all care on all observation made during the survey. Review of R64's care plan revealed, R64's clinical condition reveals skin integrity impairment is expected and unavoidable related to chronic IAD to his scrotum/testes, impaired bed mobility, fecal incontinence, chronic indwelling catheter, diabetes with microvascular changes with the potential for delayed wound healing, potential to decline care and treatment, frequent scratches skin with his fingernails, history of actual impairment on admission, decreased understanding of the importance of eating due to intellectual disability and dementia and uses of mediation that could contribute to lethargy, date initiated 3/29/22. All interventions placed were dated 2022. There was no indication of a need to reapproach or what approach works best due to his intellectual impairment when R64 refuses. R64's heels were to be off-loaded with pillows (all observation during the survey R64's heels were in contact with the mattress and no positioning pillows were located in his room.) The care plan did not indicate R64 would not stay positioned on his left side and did not give any indication what staff should do when R64 would not allow repositioning in bed. There was no indication R64 was no longer tolerating being up in a chair. Review of R64's left heel wound measurements revealed, - 1/2/23 - 0.5 x 0.4 cm x 0.2 - stage II. - 1/10/23 - 1.2 x 0.4 x 02 - no stage given, increased in size. No change in treatment or new interventions. - 1/16/23 - 0.9 x 0.3 x 0.2 - no stage given, no new treatment or interventions. - 1/22/23 - 0.9 x 0.5 x 0.2 cm - no stage given, no new treatment or interventions. - Next measurement 2/3/23 (12 days since last measurement) 1.0 x 0.5 x 0.2, no stage, no new treatment or intervention. - Next measurement 2/13/23 (10 days since last measurement). Now has 2 open areas. 1) 1.0 x 0.8 x 0.4 and 2) 0.3 x 0.3 x 0.1 - No stages given. No indication that the second open area is new. No indication of new treatment or interventions. - 2/20/23 (documented as right heel vs left heel no wound ever actually noted on right heel since admission and no indication this was a new wound. Assume this was an error in charting). 3 x 4 and now a stage III. Note for this wound indicated this was his right heel and that the 2 previous wounds noted this is one wound now. Wound is increasing in size no new treatment or intervention documented. - 3/3/23 - 11 days since last measurement. This note was not locked until 3/29/23 during the survey. This wound was also noted to be left heel in measurement area and no clarification in the note area. Measured 1 x 2 no depth given - stage III. - 3/7/23 - This note was locked on 3/7/23. This wound was noted as left heel. 1 x 1 - No depth and no stage given. No new treatment or intervention was given. - 3/10/23 - no measurement provided, Indicated left heel wound. - 3/15/23 - noted as left heel 1 x 0.7, no stage given, no indication of new treatment or intervention. - 3/21/23 - noted as locked 3/30/23 during the survey. Again, noted as left heel 0.1 x 0.1 - Now noted as a stage II verse stage III. No new treatment or intervention given. - 3/31/23 - Left heel wound indicated but no measurements. See observation during the survey. No wounds on right heel. Left heel had two wounds that were dime size, and one was covered with eschar. Review of right buttock wound measurements: - 3/21/23 - noted on left buttock. See observation notes R64 did not have any wounds on left buttock. This is believed to be an error in documentation. This note was as locked on 3/30/23 (during the survey). It measured 0.4 x 0.4 - stage II. There was no indication this was a new wound. No indication of a new treatment or intervention. - 3/31/22, 10 day later, two wounds noted, 1) 0.5 x 0.4, no depth, but noted, suspected deep tissue injury. 2) 1.5 x 0.5 - no stage and no depth. Observation during the survey, one wound was covered with eschar. 38659 R55 Review of face sheet dated 3/30/23 for R55 revealed they most recently admitted to the facility on [DATE] and previously admitted to the facility on [DATE] with diagnosis that included: cellulitis of right lower limb, pressure ulcer of sacral region, need for assistance with personal care, repeated falls and history of falling. Review of a Minimum Data Set (MDS) assessment for R55, with a reference date of 2/11/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R55 was cognitively intact. Review of R55's orders revealed an order with a start date of 3/24/23: Left Foot Wound: apply Urgotul contact layer to open wound, apply silbersorb gel/Collagen powder mixed to area covered by contact layer, cover with ABD pad, wrap with kerlix, secure with tape. **If no Urgotul, apply silversorb directly to wound bed per wound clinic** An interview was completed with R55 on 3/28/23 at approximately 11:47 AM in her room. R55 confirmed she had a wound on the top of her left foot. She stated staff change the dressing every day and it had not been changed yet today. R55 stated it was important to put ointment on the foot, keep it clean and keep it moist. R55 consented to have her wound care observed. On 3/28/23 at 1:40 PM, wound care to R55's top left foot was observed being completed by Registered Nurse (RN) L. RN L retrieved this surveyor from the conference room, knocked on the door and opened it and then continued on to the medication cart to collect her supplies that were laid out on a tray on the cart. RN L entered R55's room and placed the tray on R55's uncleaned bedside table and began donning gloves. No hand hygiene was observed. RN L sanitized scissors and directed R55 to place her foot on an unclean wheelchair pad on a wheelchair next to the bed. RN L began cutting off the bandage with the scissors. She placed the dirty scissors back on the side table, She sprayed to wound with saline and dabbed the wound with gauze. RN L then removed her gloves and placed the gauze in the gloves and went to the bathroom to wash her hands, she instructed R55 that she could put her bare foot back on the floor until she returned. After washing her hands, she donned gloves, placed the cap back on the saline container and opened a packet with a pad to place on the wound. She sanitized the scissors to begin, but then repeatedly placed the scissors back on the unclean table as the pad was trimmed and re-trimmed to fit the wound. RN L squeezed silversorb gel ointment directly on the wound and then spread with a sterile q-tip, RN L sprinkled collagen powder over the gel (versus mixing the collagen powder with the silversorb). The trimmed pad was placed on the wound and then the foot was wrapped with gauze. As RN L wrapped R55's foot, they continually dragged the gauze on the unclean wheelchair pad. RN L did not have tape, and opened the resident's side table drawer to locate some, the tape was placed and then RN L took a pen from her pocket and dated the tape. RN L then removed her gloves and went to the bathroom to wash her hands. RN L came out with a wet paper towel and wiped down R55's bedside table. RN L was asked if there was cleanser on the paper towel and she confirmed it was just water. During an interview with RN L directly after the wound care observation, she was asked if there was anything she should have done differently with the wound care and she stated I probably should have used a clean barrier on the table and a clean towel under her foot. During an observation and interview with R55 in her room on 3/30/23, the pressure ulcer on the top of her left foot was discussed. R55 was viewed to have no dressing on her left foot and the foot was in a gray fuzzy slipper, the uncovered wound was in contact with the slipper. R55 stated during the night the gauze wrap got tight and staff helped her remove it. The staff did not try to re-wrap it and stated it would be better to be open to air for the night. R55 said staff were going to rewrap her foot sometime this morning. R55 took her foot out of the slipper to show that it was completely uncovered and the wound looked very dry (standard of care would be to keep the wound moist for wound healing). R55 then placed her foot back into the slipper. R55 was asked about the wound care observation on 3/28/23. She confirmed that staff usually sprinkle the collagen powder over the ointment and do not mix it before, she stated they said it has to be that way to work the best. R55 was asked if staff generally put down a clean towel or pad before doing wound care and she stated that they do not.

This citation pertains to intake # MI000- 2. Based on observation, interview, and record review, the facility failed to monitor the hydration status for 1 resident (Resident #5) and failed to make water accessible or offer water regularly to 3 residents (Resident #6, Resident #7, and Resident #8), resulting in the need for emergency care and hospitalization for Resident #5 and the potential for complications of dehydration for Resident's #6, #7, and #8. Findings: Resident #5 (R5) Review of a Face Sheet revealed R5 was a [AGE] year old female, admitted to the facility on [DATE] for rehabilitation and strengthening, with pertinent [DIAGNOSES REDACTED]. Review of a Brief Interview for Mental Status (BIMS) indicated that R5 had severe cognitive impairment. Review of a history and physical, dated 3-24-20, revealed R5 was nonverbal, dependent upon assistance for feeding and was a two person assist. R5 was discharged to another facility on 05/08/20 to be closer to family. Review of a Progress Note dated 04/15/20, indicated staff has to anticipate (R5's) needs. Review of a Progress Note dated 04/16/20, indicated that R5 requires staff assisting with fluids. Review of Progress Note dated 04/24/20, indicated that R5 requires assist with fluids. Review of Progress Note dated 04/27/20, indicated that for R5 fluids encouraged with poor intake this shift. Review of Progress Note dated 04/28/20, indicated that R5's fluid intake poor, encouraged. Review of a Medication Administration Record, [REDACTED]. Order details: [MEDICATION NAME]-sodium chloride solution 5-0.9% 60 milliliters per hour intravenously every shift to promote hydration 2000 milliliters total. Review of a Short Term Care Plan for Urinary Tract Infection, dated 4/30/20, revealed that the care plan was implemented due to fever, leukocytosis, and overall decline. R5 was prescribed the [MEDICATION NAME] 5 days. Review of the medical records for R5 revealed there was not a short term care plan for the resident while receiving IV fluids. During an interview on 07/27/20 at 10:35 A.M. the administrator indicated not needing a care plan for the administration of IV fluids because we have a doctors order. The administrator also indicated that the facility did not have anything specific for IV fluids or hydration in the short term care plans. Review of the facility policy/procedure Care Planning Process: Admission, Comprehensive & Short Term, last updated 11/2017, revealed the following 3. Care Plans are initiated to address interventions for prevention of functional decline, rehabilitative and restorative care, health maintenance issues, skin care, discharge potential, safety and wandering / exit seeking behavior, nutritional, psychosocial, and comfort. Short Term Care Plans: 1. Short term care plans may be implemented to assist with more intensive specialized limited term needs. Review of a facility Follow Up Question Report, dated 03/20/20-05/08/20, revealed the following fluid intake percentages for R5 at each meal: 5/3/20- dinner- 25% fluids accepted, 5/4/20-dinner-0% fluids accepted (resident refused), 5/6/20-breakfast-0% fluids accepted (resident refused), 5/6/20-lunch-50% fluids accepted, 5/6/20-dinner-25% fluids accepted, 5/7/20-breakfast-0% fluids accepted, 5/7/20-lunch-0% fluids accepted (resident refused), 5/7/20-dinner-25% fluids accepted, 5/8/20-breakfast-50% fluids accepted, 5/8/20-lunch-25% fluids accepted, and 5/8/20-dinner-0% fluids accepted. Review of a Recapitulation of Stay, dated 05/04/20, indicated that R5 does well with liquid nutrition. Review of a Discharge Summary, dated 05/05/20, and completed via telemedicine, indicated that R5 had not been eating or drinking very well, had been losing weight, and was recently treated with an IV (intravenous fluid) for hydration. Staff reported that oral intake was poor. A nurse had reported that R5 had a white coating on the tongue and mucosal membranes. No nursing progress notes were located in the medical record for R5 on 05/06/20, 05/07/20, or 05/08/20. An RD (registered dietician) Review progress note, dated 05/08/20, the date of R5's discharge, was the only progress note located in the medical record on the day of discharge. The Recapitulation of Stay and Discharge Summary had been completed days prior to R5's discharge from the facility: 05/04/20 and 05/05/20 respectively. During an interview on 07/27/20 at 10:48 A.M., the Director of Nursing (DON) reported that after reviewing R5's medical record, the DON could not locate any documentation that described R5's mental status and disposition on 05/08/20, the day of discharge. The DON stated the exact time of R5's discharge from the facility on 05/08/20 was unknown. R5 was discharged to another nursing facility that was closer to family. Review of an ambulance run sheet, dated 05/08/20, indicated that R5 was transported to another facility to be closer to family, however, on arrival to the second facility, R5 was obtunded and unresponsive. R5 was sent to the emergency room for evaluation. Review of hospital records show that R5 was admitted to the emergency room (ER) on 05/08/20 at 10:32 P.M., under the care of doctor W. Review of the initial Physical exam done on R5 by doctor W, completed in theER on [DATE], disclosed the following: Physical Exam Head: Normocephalic and atraumatic. Right Ear: External ear normal. Left Ear: External ear normal. Nose: Nose normal. Parched mucous membranes. No moisture in mouth or nose Additional documentation by doctor W on 05/08/20 in the ER. Due to the nature of this patient's presentation, there were was a high probability of sudden, clinically significant, or life-threatening event which required my emergent intervention and constant monitoring. The patient was reexamined and progress was re-evaluated in response to emergent therapies. Additional documentation regarding R5, by doctor W on 05/09/20 at 2:23 A.M. in the ER. I am doubtful patient persistent is related [MEDICAL CONDITION]. I believe it is more a reflection of profound dehydration with a lactic acidosis of 4.5 sodium of 176 acute renal injury with BUN 95 and creatinine 3.6 Review of an Incident Investigative Report, generated on 05/14/20, and submitted by doctor W disclosed the following: Patient transferred from (nursing home) to (new facility) to be closer to home .upon arrival to (new facility) patient was noted to be obtunded and not responsive. Patient presented to the emergency room . I evaluated the patient. Patient exhibited severe clinical dehydration. Patient's laboratory testing also reflected severe dehydration. Patient's sodium was 176, normal range is 134-146. Patient's kidney function had a BUN of 95 with a creatinine 3.6, normal range for BUN is 8-20 and normal range for creatinine is 0.5-1.1. It is my professional opinion as a family medicine/emergency medicine physician that this individual had no access to free water for several days for the sodium to be as elevated and the kidney functions to be this elevated. This is not the first time I have had patients from this extended care facility show up in the emergency department with extreme and severe dehydration due to lack of water. Patient was not on medications, that in my opinion, would cause such significant dehydration. Review of hospital records divulged the following information on the History and Physical for admission, dated 05/09/20: PHYSICAL EXAMINATION VITAL SIGNS: Temperature 38.4; heart rate on presentation 125, later 93; respirations 24, later 18; blood pressure 129/96, pulse ox 88% on room air, improved to 93% on 2 L. GENERAL: She is disheveled, nonverbal. HEENT: Nasooropharynx, edentulous with severe dry mucous membranes. Dry coating on tongue. NEUROLOGIC: She is lethargic and moans with movement, nonverbal, moves all 4 extremities to pain. LABORATORY DATA Urinalysis with blood, many bacteria, 7 white blood cells. Labs reveal a procalcitonin of 3.04. ABG, 7.41/35/103/97%. I am not clear if that is on 2 L or on room air. [MEDICATION NAME] level low at 37. Ammonia level 22. TSH level is 1.66. White blood count is 15.5, hemoglobin is 15.7, platelets are 244. BUN is 95, creatinine is 3.66. Baseline is normal. Glucose is 314, sodium is 176, [MEDICATION NAME] 20, chloride is 135. Lactic acid is 4.5, repeat is 4.4. Liver enzymes essentially normal. Magnesium 3.1. IMPRESSION 1. Severe dehydration. 2. [MEDICAL CONDITION]. 3. Acute kidney injury. 4. [MEDICAL CONDITION] ? underlying pneumonia LABORATORY DATA Urinalysis with blood, many bacteria, 7 white blood cells. Labs reveal a procalcitonin of 3.04. ABG, 7.41/35/103/97%. I am not clear if that is on 2 L or on room air. [MEDICATION NAME] level low at 37. Ammonia level 22. TSH level is 1.66. White blood count is 15.5, hemoglobin is 15.7, platelets are 244. BUN is 95, creatinine is 3.66. Baseline is normal. Glucose is 314, sodium is 176, [MEDICATION NAME] 20, chloride is 135. Lactic acid is 4.5, repeat is 4.4. Liver enzymes essentially normal. Magnesium 3.1. PLAN: She will be admitted to the hospital. She will be placed on telemetry with serial neurologic exams. She will receive gentle hydration with slow correction of her sodium. She is in no condition to be able to take any oral intake. She will receive an NG tube to get her medications including her [MEDICATION NAME], which is subtherapeutic. We will monitor her renal function. I suspect this is all from dehydration. Review of a Discharge Summary, dated 05/20/20, and dictated by doctor V, revealed the following: 69 y/o (year old) WF(white female) married ECF(extended care facility) resident patient with known PMH (past medical history) of [MEDICAL CONDITION] with significant dementia who is non-verbal and bedridden. She was admitted by Telemedicine on 5/9/2020 for Acute [MEDICAL CONDITION] with severe [MEDICAL CONDITION] (high sodium level), and acute [MEDICAL CONDITION] (damage that affects the brain). She was profoundly dehydrated. She received IVF's (intravenous fluids) to manage the dehydration and [MEDICAL CONDITION]. Her labs were monitored every 3 hours to assist in treating the high sodium, but not too quickly. It took considerable amount of time to resolve the [MEDICAL CONDITION] and the [MEDICAL CONDITION]. She had an NGT (nasogatric tube) tube early on in the admission for free water hydration as well as medication administration. Resident (R6) Review of a Face Sheet revealed R6 was [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS), dated 05/04/20 revealed a score of 7 out of 15 which indicates severe cognitive impairment. During an observation on 07/23/20 at 10:25 A.M., R6 was resting in bed with eyes closed. The bedside table was pushed up to the head of the bed, fluid cup on bedside table, out of reach of R6. Staff entered the room to get R6 up for the day. During an interview on 07/23/20 at 1100 A.M., R6 stated that her mouth was very dry, lips appeared dry and cracked, and she had not yet had anything to drink today. R6 indicated that when staff was just in to get her up for the day, staff did not offer her anything to drink. Fluids remained out of reach of R6 on the bedside table. Review, at 11:15 A.M. on 07/23/20, of an Electronic Medication Administration Record [REDACTED]. Documentation for first shift on 07/23/20, for this order, was already signed off as completed by nursing. During an observation on 07/27/20 at 8:55 A.M. R6 was up and breakfast was on the bedside table out of reach. Call light was wrapped around the bedrail, also out of reach of R6. Observed on the breakfast tray were three 8 ounce cups of fluid, untouched. R6 stated that she was not sure where the food was, I can't see it. R6 also stated that she had ordered eggs and toast for breakfast but must not have gotten the toast. When this surveyor advised R6 that there was toast on the breakfast tray, R6 responded oh really, it's there? R6's mouth and lips appeared dry and cracked. Review of a Care Plan for R6 revealed the FOCUS: (R6) has the potential for altered mobility and ADL's related to: decreased mobility r/t history of left femur fracture with surgical repair, legally blind, hx falls, dementia, non-ambulatory. (R6) has generalized weakness and decreased mobility. (R6) is unable to propel her w/c independently and transfers with mechanical lift and two person assist. She utilizes a tilt in space w/c to promote proper body alignment and improved posturing as well as socialization. Assist rails utilized on bed to promote enhanced bed mobility. Review of a Care Plan for R6 revealed the GOAL: (R6) will be clean, fall risks managed, well groomed, and appropriately dressed, and continue to meet the highest practicable functional independence possible. Review of a Care Plan for R6 revealed the INTERVENTIONS: ASSISTIVE DEVICES: food in bowls, built up silverware, abductor pillow between knees when in bed for hip alignment. Clip call light to (R6's) shirt as she desires. Keep bedside table near her and explain where her drink of choice is. 2 pillows under head for increased cervical support. Head support, padded arm rests and left lateral trunk supports in chair. EATING: Provide set up assist as desired by the resident prn. Inform resident where foods are on the plate utilizing clockmethod and provide physical assistance as requested. Resident #7 (R7) Review of a Face Sheet revealed R& was a [AGE] year old female, originally admitted to the facility on ,[DATE]//15, with pertinent [DIAGNOSES REDACTED]. Review of a BIMS revealed R7 had severe cognitive impairment. Review of an Occupational Therapy note dated 06/25/20, indicated that R7 has been total assist with self feeding secondary to hand contractures. During an observation on 07/23/20 at 10:18 A.M., R7 was in bed, resting with eyes closed. Water cup was on bedside table, out of reach of R7 and was noted to be 1/2 full. Staff entered and exited R7's room without offering any water. During an observation on 07/23/20 at 2:31 P.M., R7 was in bed, resting with eyes closed. Water cup was on bedside table, out of reach of R7 and was noted to still be half full. Staff entered and exited R7's room without offering any water. During an observation on 07/27/20 at 9:10 A.M., R7 was seated in the hallway with a table and a cup of water set in front of her. The 8 ounce cup of water was full and had a straw. Multiple observations were made between 9:10 A.M. and 11:00 A.M. of staff walking past R7 and not offering any fluids. Resident #8 (R8) Review of a Face Sheet revealed R8 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a physician progress notes [REDACTED]. Review of a Nutrition assessment dated [DATE], revealed that R8 utilized a kennedy cup at bedside for water pass. During an observation on 07/23/20 at 10:41 A.M., R8 was up in the wheelchair, kennedy cup was on the bedside table, out of reach of R8, full of fluid, and the top part of the straw was covered with paper. During an observation on 07/23/20 at 2:40 P.M., R8 was in bed resting with eyes closed, kennedy cup was on the bedside table, out of reach of R8, full of fluid, and the top part of the straw was still covered with paper. This would indicate that R8 had not taken a drink from the cup of water since the morning water pass. During an observation on 07/27/20 at 9:15 A.M., R8 was sitting up in the wheelchair, kennedy cup on TV stand, out of reach, full of fluid, and the top part of the straw had the paper cover still on it. During an observation on 07/27/20 at 10:50 A.M. R8 was sitting up in the wheelchair, kennedy cup on the TV stand, out of reach, full of fluid and the top of the straw had the paper cover still on it. During an interview on 07/27/20 at 11:20 A.M., RN Y indicated that anytime an aid or nurse in in a resident's room, fluids should be offered. During an observation on 07/27/20 at 1:30 P.M., R8 was in bed resting with eyes closed, call light was clipped to the bedding just below R8's knee, kennedy cup on bedside table, full of liquid, and the straw still had the paper cover on. This would indicate that R8 had not taken a drink from the kennedy cup since the morning water pass. During an interview on 07/27/20 at 1:47 P.M., CNA X stated that the expectation was for staff to offer fluids to residents anytime staff are in the rooms.

This citation pertains to intake # MI000- 6. Based on interview and record review, the facility failed to assess and supervise one resident's (Resident #1) ability to safely smoke outside, resulting in resident #1 catching fire, suffering second and third degree burns, and subsequently dying from complications of the thermal burns. Findings include: Resident #1 (R1) Review of a Face Sheet revealed R1 was a [AGE] year old female who admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Physician Determination of Decision Making Capabilities, first signature dated 4-22-20 and second signature dated 5-21-20, revealed that R1 was deemed no longer capable of making her own decisions, thus activating the DPOA (durable power of attorney) on record from 11/16/06. The reason given for this determination was BIMS-9. Review of a facility nursing progress note dated 07/06/20, time stamped 17:10, and written by Licensed Practical Nurse (LPN) B divulged Resident was noted to be sitting outside smoking a cigarette. Upon looking outside the window to check on her it was noted that her blouse was on fire. This writer responded immediately calling for CENAs on the hallway to assist. Blouse was pulled off resident before any [MEDICAL CONDITION] result. Hair on the left side of the head noted to be singed, burn marks noted to left side of upper chest, left shoulder, left ear and neck. EMS notified. Wet dressings applied [MEDICAL CONDITION] to EMS leaving with resident. Resident was alert and orientated x 4. Review of an emergency department nursing note dated 07/6/20 at 7:19 P.M., revealed Pt presented to ED [MEDICAL CONDITION] left side of face, ear, lower lip chin, neck, left shoulder, chest, top of left breast, left palm and left fingertips. Blisters noted to chin, ear lobe, left shoulder, left palm and 4 of her left fingertips. Brown, yellow and black discoloration noted to large portion of left anterior chest. Provider at bedside documenting burns. Review of a hospital history and physical for admission disclosed that R1 suffered 5.5% TBSA (total body surface area) 2nd and 3rd [MEDICAL CONDITION] her left shoulder, left hand palm and 4 fingers on the left hand, left chest wall, left side of neck and chin, hair was singed on head and left eye lashes, and left side of face. R1 was admitted to the hospitals burn unit. R1 was pronounced dead at the hospital burn unit on 07/15/20 at 9:01 P.M. Death Certificate indicated cause of death for R1 was accident-medical complications [REDACTED]. Review of R1's complete care plans revealed that R1 did not have a care plan for smoking. Review of Progress Notes for R1 from 06/30/20 to 07/06/20 revealed no documentation related to R1's LOC (level of consciousness), alertness or orientation, nor sleep hygiene or duration of sleep. Review of an Interdisciplinary Note, dated 07/01/20 disclosed the following narrative:R1 has altered mobility and ADL's in relation to her [DIAGNOSES REDACTED]. An expected insidious decline in her condition is unavoidable . Other symptoms that interfere with mobility such as fatigue, [DIAGNOSES REDACTED], dizziness and [MEDICAL CONDITION], numbness, and lack of coordination are to be expected . She is receiving extensive weight-bearing assistance with bed mobility, transfers, clothing management, toilet use, and personal hygiene . (R1) has complaints of pain daily, is prescribed [MEDICATION NAME], and [MEDICATION NAME] sulfate . (R1) is prescribed [MEDICATION NAME] daily for her agitation .(R1) is predisposed to falls and injury in relation to her impaired judgement due to her [DIAGNOSES REDACTED]. During an interview on 07/20/20 at 7:40 P.M., LPN B indicated that residents usually smoke out by the road but with COVID, things were more lenient with smoking and so smoking was allowed outside the door at the end of the hallway. LPN B then indicated that during the late afternoon of July 6th, an aid took R1 out the door at the end of hallway so R1 could smoke. LPN B indicated that R1 was outside, within view of LPN B, and that (the LPN) looked away for just a minute and looked back and saw R1 on fire. LPN 'B stated that she had spoken with Occupational therapist/Therapy Manager (OTR) H earlier that day about whether R1 was capable of going outside to smoke because she was sleepy. LPN B reported seeing R1 outside, before the fire, and R1 appeared to be smoking an unlit cigarette for several minutes. I never saw her (R1) do that before. During an interview on 07/20/20 at 7:51 P.M., Certified Nurse Aid (CNA) G reported working with R1 on July 6th and that R1 was sleepy that day and had been acting really sleepy the past few days. CNA G indicated that while taking R1 outside to smoke, R1 attempted to light the cigarette while in the building. CNA G divulged that she told R1 not to smoke inside and to wait until they got outside to smoke. CNA G also indicated that R1 had not attempted to light a cigarette indoors before (that CNA G was aware of). During a second interview on 07/20/20 at 8:15 P.M., LPN B stated that OTR H asked if it was safe for R1 to be out smoking because R1 was so sleepy. LPN B then indicated that OTR H was told that if R1 can wheel herself down the hallway then R1 was ok to go out and smoke. Review of a facility policy Smoke Free Facility, last revised December 2014, revealed the Procedure: 2. The facility will not provide an outdoor designated smoking area on facility property. The United States Fire Administration has determined- based on data from the National Fire Incident Reporting System, The National Fire Protections Association (NFPA), the National Center for Health Statistics, and the State Fire Marshal's Offices- that by far the leading cause of residential fires that result in fatalities in older adults is smoking. During an interview on 07/21/20 at 11:55 A.M. CNA K indicated working with R1 the morning of July 6th, that R1 was pretty sleepy and tired, and that staff had to help R1 out the side door to smoke. During an interview on 07/22/20 at 9:20 A.M., LPN N stated that a resident who was sedated, lethargic or sleepy should not be allowed outside to smoke. Review of a 15 minute check charting document, dated 07/23/20, for 3 residents residing on Pine hall, revealed that at 10:51 A.M., the last notations were made by staff at 9:30 A.M. Review of a 15 minute check charting document, dated 07/27/20, for 2 residents on Hickory that were listed as fall risks, revealed that at 11:05 A.M., the last notations made by staff were at 9:30 A.M.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents by not implementing care plan interventions to prevent an avoidable fall in one resident (Resident #3) of nine residents reviewed for adequate supervision out of a total sample of 15 residents. This deficient practice resulted in Resident #3 experiencing a fall which resulted in a hip fracture and increased pain. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 is an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to this assessment, Resident #3 scored 3/15 on the Brief Interview for Mental Status (BIMS) examination, indicative of severe cognitive impairment. Resident #3 was assessed as needing extensive assist with one staff for transfers, ambulation, and toileting. A review of Resident #3's care plans revealed that on 7/10/15 interventions put in place were: Able to leave on toilet: No . Transfer: One assist . Ambulation: Does not ambulate . The undated document, Incident Summary was reviewed and read, in part: CNA (Certified Nurse Aide A) states that she was assisting (Resident #3) in the common bathroom. When performing hygiene for (Resident #3) she got BM (bowel movement) on her gloves so she went to the sink to get a new pair of gloves. When she (CNA A) turned back around, (Resident #3) was sitting on the floor on her buttocks in front of the toilet .X-ray ordered .Results: There is a fracture involving left femoral neck with displacement. The age of the fracture is acute . Per the incident report submitted to the State Agency on 11/11/17, Resident #3's fall occurred on 11/11/17 at 5:00 p.m. During an interview conducted with CNA A on 11/15/17 at 9:15 a.m., she stated: I put her (Resident #3) on the pot (toilet) .I got BM on my gloves so I walked over to the sink and got (new) gloves .I heard her (Resident #3) screaming and turned around and she was sitting on the floor next to the toilet .her wheelchair was pushed away .It looked like she (Resident #3) tried to self transfer .I should have known .I should have known better than to walk away . When asked by this Surveyor if she was aware Resident #3's care plan indicated she was not to be left alone on the toilet, CNA A indicated she was aware of this care plan intervention that Resident #3 was not to be left alone on the toilet. CNA A confirmed she could not see Resident #3 from the sink. CNA A stated, I think she's (Resident #3) doing alright, only thing that's changed is her pain. She has a lot more pain. An observation was made of Resident #3 on 11/14/17 at 2:50 p.m. She was groomed and lying in her bed. Staff were trying to reposition her in her bed and she moaned, cried out, and tried pushing them away. She appeared to have increased pain with movement. A review of Resident #3's Medication Administration Records dated 10/1/17 through 11/30/17 showed that Resident #3 showed increased use of her as needed pain medication, as follows: 10/27/17 at 7:53 a.m. for pain level of 10 10/30/17 at 12:21 p.m. for pain level of 7 10/31/17 at 12:05 p.m. for pain level of 7 11/01/17 at 11:11 a.m. for pain level of 5 11/06/17 at 9:00 a.m. for pain level of 0 at 2:15 p.m. for pain level of 8 11/07/17 at 9:39 a.m. for pain level of 9 11/09/17 at 10:00 a.m. for pain level of 5 11/11/17 at 8:15 a.m. for pain level of 5 at 12:25 for pain level of 10 at 11:12 p.m. for pain level of 5 11/12/17 at 7:00 a.m. for pain level of 0 at 11:36 a.m. for pain level of 4 at 7:48 p.m. for pain level of 7 11/13/17 at 1:22 a.m. for pain level of 5 at 6:45 a.m. for pain level of 5 at 10:45 p.m. for pain level of 0 at 2:45 p.m. for pain level of 8 at 9:15 p.m. for pain level of 8 11/14/17 at 1:33 a.m. for pain level of 5 at 3:41 p.m. for pain level of 4 11/15/17 at 1:30 a.m. for pain level of 2 In an interview with the Director of Nursing (DON) on 11/15/17 at 10:15 a.m., she confirmed that Resident #3 had a fall which resulted in a left hip fracture and increased pain. This fall happened when CNA A had turned to change her soiled gloves and left Resident #3 unsupervised on the toilet. This Surveyor asked if there were gloves near the toilets and the the DON replied that she was definitely going to look into it now. On 11/16/17 at 1:35 p.m. the DON showed this Surveyor that a wall pocket with gloves, had been installed near the toilets in both common bathrooms.

This citation pertains to MI# 207 Based on observation, interview, and record review, the facility failed to provide appropriate care following a fall for 1 (#104) of 5 total sampled residents, from a total sample of 5 residents, resulting in Resident #104 experiencing a delay in treatment for [REDACTED]. Findings include: Record review of Resident #104's minimum data set ((MDS) dated [DATE] reflected a [AGE] year old male with cognitive skills for daily decision making as severely impaired never or rarely making decisions. A [DIAGNOSES REDACTED]. Record review of Resident #104's incident/accident report dated 1/4/12 at 11:30 AM reflected that Resident #104 was "observed on the floor in the south day room and that staff heard resident #104 go from crouching position onto the floor, landing softly on floor before they could turn around and intervene". Record review of Resident #104's potential for altered mobility and ADL (activity of daily living) care plan dated 12/7/11 reflected that the resident ambulated independently. Resident #104's range of motion was independent and there was to be a sensor alarm on Resident #104 while he was in bed. In an interview on 1/30/12 at 9:13 AM, unit manager nurse registered nurse (RN) #4, reflected that Resident #104 had no alarms before his fall and that he self ambulated. Unit manager RN #4 revealed that floor staff had reported that Resident #104 had a gait change a few days prior to his fall and that no new interventions were initiated. Record review of Resident #104's nurse note dated 1/4/12 at 11:00 PM noted that residents gait while transferring from wheelchair to bed was weak and unsteady. Licensed Practical Nurse (LPN) #14 noted that safety was maintained while the resident was in wheelchair. Record review of Resident #104's nurse note dated 1/4/12 at 1:45 PM reflected that the resident was observed on the floor in the day room. LPN #11 noted that staff had witnessed the resident in a slightly crouched position and heard him land on the floor before they turned around to intervene. In an interview on 1/27/12 at 1:37 PM, licensed practical nurse (LPN) #11 revealed that she assessed Resident #104 on 1/4/12 (after the fall) and that there was no facial grimacing or wincing. LPN #11 stated that Resident #104 was assisted up and that staff had some trouble getting him to stand. LPN #11 stated that she worked on 1/8/12 when x-rays were done and revealed an acute femoral fracture and that Resident #104 was sent out to a hospital on [DATE]. LPN #11 stated that Resident #104 did self ambulate prior to his fall. Record review of Resident #104's nursing note dated 1/5/12 at 6:40 PM reflected that the resident was up in a wheelchair for supper/meal and that resident #104 was showing signs of upper extremity weakness, difficulty holding plastic cup of juice. The nurse noted that staff had reported difficulty transferring and that three staff members assisted for safety, gait was noted as unsteady and weak with no signs or symptoms of pain. Record review of nurse note dated 1/6/12 at 2:35 PM reflected that the resident #104 was grimacing upon palpation of the right hip and that the physician was notified and x-rays were ordered. In a second interview on 1/30/12 at 11:40 AM, unit manager RN #4, while reviewing resident #104's medical record, revealed that the resident fell on [DATE] and was noted unsteady with gait post fall, on 1/6/12 a physician order [REDACTED]. The unit manager RN #4 stated that Resident #104 was not cognitively intact enough to acknowledge pain. Record review of the x-ray company log located at the nursing station and reviewed by the state surveyor and unit manager RN#4 revealed that on 1/6/12 resident #104 was ordered a chest and right hip x-ray ASAP (as soon as possible) and that the x-rays were not done until 1/8/12. Record review of the right hip x-ray, that was ordered on [DATE], revealed that it was not performed until 1/8/12 (4 days post fall) and that the x-ray results revealed a complete femoral neck fracture without displacement. #

This citation pertains to MI# 009, MI# 207 Based on observation, interview, and record review, the facility failed to ensure that safety devices were in place and functioning and to prevent falls in 1 (#101) of 5 total sampled residents, from a total sample of 5 residents, resulting in Resident #101 sustaining a fracture. Findings include: Resident #101: Record review of Resident #101's minimum data set ((MDS) dated [DATE] reflected a [AGE] year old female with cognitive skills for daily decision making as moderately impaired with poor decisions, cues and supervision required. Record review of Resident #101's incident/accident report dated [DATE] at 4:00 PM reflected that the staff heard a commotion and entered Resident #101's room to observe Resident #101 laying on her right side with complaints of pain. Emergency medical services (EMS) were notified and transferred the resident to local hospital for evaluation. Record review of the facility investigation summary report (undated) reflected that Resident #101 was admitted to the facility following a fall at home resulting in an inoperable fracture to the right femur and that Resident #101 wore an immobilizer brace to the right leg. Record review of local hospital records dated [DATE] revealed that Resident #101 was seen for a fall: found by staff on floor next to bed today. Patient's chief complaint left shoulder pain, also wound on face and left hip pain. Patient with right femur fracture ,[DATE] and no surgery done, patient poor candidate. Family wants to have x-rays, repair of wounds and pain treatment. Record review of Resident #101's fall potential assessment dated [DATE] revealed that Resident #101 scored a 14 and that a score above a 10 should have prompt interventions put in place. Record review of Resident #101's fall care plan dated ,[DATE] revealed that the Resident #101 was to have a personal alarm on her bed and her wheelchair. In an interview on [DATE] at 10:30 AM, registered nurse (RN) #7 revealed that she was the charge nurse on [DATE]. RN #7 stated that she was called to Resident #101's room and that the resident was lying on the floor on her right side and crying out in pain. RN #7 stated that staff immobilized Resident #101 and that there was an abrasion to the left cheek. RN#7 revealed that Resident #101 did have a personal alarm in bed and in the wheelchair, but that there was no alarm sounding. RN#7 stated that Resident #101 was noted to fiddle with her personal alarm and try to remove it from her clothes. RN #7 stated that Resident #101 was getting more mobile and lucid and becoming more active. In an interview on [DATE] at 10:45 AM, licensed practical nurse (LPN) #6 revealed that she heard Resident #101 screaming and entered her room to find her lying on the floor on her right side with her head at the foot of the bed. LPN #6 stated that she was the first staff person into the room and that Resident #101 was crying and said that she hurt. LPN #6 stated that Resident #101 was hurt on the left side but was lying on her right side. LPN #6 stated that Resident #101's alarm was not sounding nor was it attached to the resident. LPN #6 stated that the alarm was on the bed fastened to the bed frame but not sounding and not attached to Resident #101. LPN #6 revealed that on the evening prior to the fall([DATE]), Resident #101 was in the day room trying to remove the clip/circle attachment (that attaches the personal alarm) from her clothes. Resident #101 was deceased at the time of the investigation. #

This citation pertains to MI# 138 Based on observation, interview and record review, the facility failed to meet the professional standard of quality of nursing care in 1 (#101) of 4 sampled residents out of a total sample of 4, resulting in the facility staff failing to assess Resident #101 for over 12 hours after being notified that Resident #101 spilled hot liquids on his left thigh, and failing to assess and document for burns, blisters, and pain or discomfort of the resident. Findings include: Record review of the facility accident/incident report dated 5/25/11 at 7:15 AM revealed resident #101 was noted to have an elongated fluid filled blister and 2 other fluid filled blisters to left inner thigh. There were no measurements of the blisters noted. The incident/accident report noted the incident was resident reported and that the resident was unsure of what time the incident occurred on 5/24/11. Observation on 5/31/11 at 11:15 AM, during a treatment of [REDACTED]. Triple antibiotic ointment was applied and the area was covered with a bandage. An interview on 5/31/11 at 11:20 AM, with resident #101 revealed, "I asked for hot tea, it was set on the table in front of me, too close to the edge and I bumped it I guess. My pants were bunched up and it soaked into my pants, it left red blister marks. The blisters popped. I felt the warmth when it first happened, doesn't hurt now, but it was uncomfortable the first few days". Observation of the noon meal on 5/31/11 in the north side dining room revealed resident #101 to be seated at a table with three other residents. Resident #101 stated that it was his usual table and table mates and that's where the spill occurred, but he couldn't recall the date. Observations of the meal revealed that the table mate directly across from resident #101 would push on the table and make one edge of the table rise upward at a tilt and sloshed uncovered beverages on the table. Resident #101, #102 and #103 were all seated at the same table with hot beverages and had pink thermal cups with plastic lids with a straw. There was hot cocoa in the cups with straws. An interview on 5/31/11 at 2:00 PM, with the certified nurse assistant #10 revealed that she handed resident #101 a Styrofoam cup and informed him that it's hot........she (dietary aide) stated that dietary got in trouble for not serving him hot enough liquids."I gave the Styrofoam cup of hot tea to resident #101 and started to serve the meals. No there was no lid on it". Further interview with CNA #10 revealed that another CNA made him aware that resident #101 had spilt his tea and needed to be changed. The CNA stated that he took resident #101 to the bathroom and changed his clothes and stated that there was a red area approximately 8 inches by 4 inches to the left thigh, just red and sticky to the touch but no blisters at that time. The CNA stated that he informed registered nurse #4 about the spill and that the area was red and sticky. CNA #10 stated that he put resident #101 to bed later that evening about 8:00 PM, , changed his clothes, checked his leg and it was red. CNA #10 stated that he did not see the nurse look at the leg or do an incident report. CNA #10 stated that he forgot to tell the night shift CNA's of the burn. CNA #10 stated that he was not supervising or assisting resident #101 at the time of the spill because he was passing meal trays to other residents and that he did not see the spill. An interview on 6/1/11 at 11:15 AM with registered nurse #4 revealed: "Family members requested that his beverages be hotter. So the CNA came to me and said that (resident #101) spilled his tea on his leg, but I was in the middle of sending out a resident to the hospital, then I forgot. No, I didn't see the leg/burn. I forgot about it. I didn't look or assess it. I didn't do anything, but I take responsibility for it. I was fired, it cost me my job. I should of had another nurse go and check on it, assess it. I didn't realize it (Styrofoam cup) was heated up in the microwave. Incident report I didn't do it, I just forgot. No, no assessment, no note, and no I didn't look at the leg. No, I didn't tell the next shift, I just forgot it". The facility staff was aware of the spilled hot liquid and burn to the left inner thigh on 5/24/11, but the assessment and treatment were done 12 hours post incident. #

This citation pertains to MI# 138 Based on observation, interview and record review, the facility failed to ensure that the residents environment remains as free from accident hazards as possible for 1 (#101) of 4 sampled residents out of a total sample of 4, resulting in second degree burns with blisters to resident #101 when a dietary aid reheated liquids in a Styrofoam cup in the microwave, failed to temp the liquid and served it to the resident, and the facility failed to assess the residents ability to handle hot liquids, which resulted in burns to the left thigh when the resident tipped the cup over into his lap. Findings include: Record review of the facility accident/incident report dated 5/25/11 at 7:15 AM revealed resident #101 was noted to have an elongated fluid filled blister and 2 other fluid filled blisters to the left inner thigh. There were no measurements of the blisters noted. The incident/accident report noted that the incident was resident reported and that the resident was unsure of what time the incident occurred on 5/24/11. Record review of resident #101's minimum data set ((MDS) dated [DATE] revealed a [AGE] year old male with impaired vision. A functional status with eating of 1) needing supervision-oversight, encouragement or cueing 2) setup. Functional range of Motion was noted as impaired on both sides to upper and lower extremities. Nutritional approaches included mechanically altered diet that requires change in texture of food or liquids. Record review of the nutrition risk assessment dated [DATE] revealed a known history of Parkinson's and dementia. Nutrition summary notes dated 5/19/11 revealed the resident complained that his nectar thick liquids were not hot enough for him to drink and that liquids may need to be re-heated some as the thickening process tends to cool the liquids down. Record review of resident #101's nutrition care plan dated 5/6/11 revealed that on 5/19/11 the resident complained of hot liquids "not hot enough". Care plan notes also revealed on 5/19/11 that staff was to check with resident #101 just prior to meal regarding desired fluids as resident #101 had been requesting hotter hot liquids. The care plan did not indicate how to re-heat the liquids or at what temperature would be safe for the resident. On 5/25/11 (after the resident was burned) it was noted to temp hot fluids prior to serving to resident. An interview on 6/1/11 at 10:45 AM, with dietary aide #5 revealed "We had an in-service put out in the kitchen that (resident #101) complained of not hot enough liquids. Last week or so it was in the communication book, I signed the in-service and its care planned also. On 5/24/11 dinner meal, Resident #101 wanted hot tea. He's a nectar thick liquid, put it in a Styrofoam cup with no lid. Micro waved it for 20 seconds. I set it on the counter. While I finished putting the food items in the steam table. A certified nurse assistant (CNA) came and got the cup and took it to him with no lid. And then a CNA told me that he spilt it and got burned. It was before I started serving the meal, before 6:00 PM. The dietary aide was asked if she had taken temperatures of the hot liquids. Stating: "We never temped hot coffee/hot water and I started in August 2010. We temp juice, milk and foods. I think it was a 20 ounce Styrofoam cup that spilt into his lap". The dietary aide was asked if she was aware of a facility re-heating policy and she stated that she was not aware of any hot liquid or re-heating policy. Record review of facility food temperature logs of the dinner meal, from March 6th through May 25th, revealed there were no temperatures taken on hot liquids. An interview on 5/31/11 at 2:00 PM, with certified nurse assistant #10 revealed that he was handed a Styrofoam cup for resident #101 and was told to inform him that it's hot........she (dietary aide) stated that dietary got into trouble for not serving him hot enough liquids. "I gave the Styrofoam cup of hot tea to resident #101 and started to serve the meals. No there was no lid on it". Further interview with CNA #10 revealed that another CNA made him aware that resident #101 had spilt his tea and needed to be changed. The CNA stated that he took resident #101 to the bathroom and changed his clothes and stated that there was a red area approximately 8 inches by 4 inches to the left thigh, but no blisters at that time just red and sticky to the touch. The CNA stated that he informed the registered nurse #4 about the spill and that the area was red and sticky. CNA #10 stated that he put resident #101 to bed later that evening about 8:00 PM, changed his clothes, checked his leg and it was red. CNA #10 stated that he did not see the nurse look at the leg or do an incident report. CNA #10 stated that he forgot to tell the night shift CNA's of the burn. CNA #10 stated that he was not supervising or assisting resident #101 at the time of the spill because he was passing meal trays to other residents and did not see the spill. An interview on 5/31/11 at 2:15 PM, with CNA #11 revealed that on 5/24/11 around 6:00 PM he was flagged down by resident #101 waving his hands and Resident #101 said that he dumped the hot tea into his lap and then CNA #11 told CNA #10 that resident #101 needed changed because he spilled it all over his pants. CNA #11 stated that he was new and orientated to the CNA position; he stated that he was not supervising or assisting the resident when the spill occurred and he did not see the resident spill the hot tea. Record review of resident #101's safety care plan dated 5/6/11 revealed the resident had weakness and decreased mobility, and cognitive impairment. Interventions included: Monitor environment for safety hazards throughout the day and remedy situation. Observation of the noon meal on 5/31/11 in the north side dining room revealed resident #101 to be seated at a table with three other residents. Resident #101 stated that it was his usual table and table mates and that's where the spill occurred, but he couldn't recall the date. Observations of the meal revealed that the table mate directly across from resident #101 would push on the table and make one edge of the table rise upward at a tilt and sloshed uncovered beverages on the table. Resident #101, #102 and #103 were all seated at the same table with hot beverages in pink thermal cups with plastic lids with a straw. There was hot cocoa in the cups with straws. An interview on 5/31/11 at 11:20 AM, with resident #101 revealed, "I asked for hot tea, it was set on the table in front of me, too close to the edge and I bumped it I guess. My pants were bunched up and it soaked into my pants, it left red blister marks. The blisters popped. I felt the warmth when it first happened, doesn't ' t hurt now, but it was uncomfortable the first few days". Record review of resident #101's medical record revealed there to be no assessment or evaluation for handling hot liquids prior to the incident. Record review of the nurse notes dated 5/24/11 revealed that there was no assessment of the left thigh burn area or assessment of pain related to the burn. An interview on 6/1/11 at 11:15 AM, with registered nurse #4 revealed: "Family members requested that his beverages be hotter. So the CNA came to me and said that (resident #101) spilled his tea on his leg, but I was in the middle of sending out a resident to the hospital, then I forgot. No, I didn't see the leg/burn. I forgot about it. I didn't look or assess it. I didn't do anything, but I take responsibility for it. I was fired, it cost me my job. I should of had another nurse go and check on it, assess it. I didn't realize it (Styrofoam cup) was heated up in the microwave. Incident report I didn't do it, I just forgot. No, no assessment, no note, and no I didn't look at the leg. No, I didn't tell the next shift, I just forgot it". #

THIS CITATION PERTAINS TO INTAKE NUMBER MI 432 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY MONITOR BLOOD GLUCOSE LEVELS FOR ONE (#502) OF FIVE SAMPLED RESIDENTS, WHO HAD A DOCUMENTED HISTORY OF [DIAGNOSES REDACTED] (LOW BLOOD SUGAR), RESULTING IN RESIDENT #502 HAVING A CRITICALLY LOW BLOOD SUGAR LEVEL, AND A FALL WITH FRACTURE. FINDINGS INCLUDE: ON 4/25/11 AT 12:35 P.M., DURING AN INITIAL TOUR OF THE FACILITY, RESIDENT #502 WAS OBSERVED IN HER ROOM AWAKE, LAYING IN HER BED. FURTHER OBSERVATION REVEALED A REDDENED SCAR TO THE CENTER OF RESIDENT #502'S FOREHEAD. RESIDENT #502 WAS NON VERBAL AND WAVED HER HAND FOR STAFF TO LEAVE THE ROOM. ACCORDING TO THE FACILITY'S FACE SHEET, RESIDENT #502 WAS INITIALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. FURTHER REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #502 ALSO HAD [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] DESCRIBED RESIDENT #502 AS HAVING MODERATELY IMPAIRED COGNITION WITH POOR DECISION MAKING AND REQUIRED CUES AND SUPERVISION. THE MDS FURTHER REVEALED THAT RESIDENT #502 HAD LONG AND SHORT TERM MEMORY PROBLEMS AND REQUIRED LIMITED TO EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, DRESSING, EATING, PERSONAL HYGIENE, BATHING AND TOILETING. A REVIEW OF THE FACILITY'S INCIDENT/ACCIDENT REPORT DATED 4/11/11 REVEALED THE FOLLOWING: "...THE NURSE RESPONDED TO ALARM, OBSERVED RESIDENT (#502) ON FLOOR, FACE DOWN WITH HEAD SURROUNDED BY BLOOD... LACERATION ON FOREHEAD. NOSE APPEARS CROOKED. PUPILS EVEN AND REACTIVE. HIPS ARE NOT CAUSING RESIDENT (#502) PAIN. ACTIVE ROM (RANGE OF MOTION) IN ALL EXTREMITIES WITHOUT PAIN..." THE INCIDENT/ACCIDENT REPORT FURTHER REVEALED THAT RESIDENT #502'S BS WAS "39 MG/DL" (BLOOD SUGAR, MILLIGRAMS PER DECILITER). (THE NORMAL BLOOD SUGAR RANGE IS 70-110). "...IMMEDIATE CORRECTIVE ACTION: GAVE [MEDICATION NAME] 1 MG/ML (MILLIGRAM PER MILLILITER) TO RAISE BS. APPLIED ICE TO INJURIES ON THE HEAD. COMPLETED NEURO (NEUROLOGICAL) CHECKS. STARTED QID (FOUR TIMES A DAY) RBS (RANDOM BLOOD SUGAR)..." A REVIEW OF THE EMERGENCY MEDICAL SYSTEM (EMS) RUN SHEET DATED 4/11/11, REVEALED THAT EMERGENCY MEDICAL PERSONNEL WAS DISPATCHED TO THE FACILITY FOR A REPORT OF "TRAUMA INJURY, DIABETIC SYMPTOMS, VISUAL BLEEDING." THE EMS REPORT DOCUMENTED: "...EMS CREW ARRIVED TO FIND A [AGE] year OLD FEMALE COMPLAINING OF FALL WHICH BEGAN ON MONDAY APRIL 11... EVENTS LEADING TO ILLNESS: PT (PATIENT) HAD LOW BS OF 39 MG/DL FALLING OUT OF BED HITTING HEAD ON FLOOR... THE FACILITY GAVE [MEDICATION NAME] INJECTION, RECHECKED SUGAR NOW 65 MG/DL UPON ARRIVAL, WE FOUND 1 1/2" LACERATION TO FOREHEAD. PATIENT WAS TRANSFERRED TO HOSPITAL..." A REVIEW OF THE PHYSICIAN ED (EMERGENCY DEPARTMENT) REPORT DATED 4/11/11 REVEALED "...HAD A FALL OUT OF BED AT THE FACILITY, WAS FOUND TO HAVE LOW BLOOD SUGAR, HAS A LACERATION IN THE MIDDLE OF HER FOREHEAD WHICH HAS TOTAL LENGTH 6 CM (CENTIMETERS) AND OBVIOUS DEFORMITY TO THE NOSE..." EMERGENCY DEPARTMENT COURSE: "...A TOTAL OF 8 SUTURES ARE USED. HER NOSE IS REALIGNED MANUALLY. Diagnosis: [REDACTED]. ACCORDING TO THE HOSPITAL DISCHARGE INSTRUCTION SUMMARY SHEET DATED 4/11/11, RESIDENT #502 WAS RECOMMENDED "...2 HOUR BLOOD SUGAR CHECKS UNTIL SEEN BY PHYSICIAN, SUTURES OUT IN ONE WEEK..." A REVIEW OF A PHYSICIAN'S PROGRESS NOTE DATED 9/6/10 DOCUMENTED THE FOLLOWING: "...BECAUSE HER INTAKE IS SO VARIABLE IT IS HARD TO PREDICT AND SHE IS HARD TO TREAT. IF WE GET AGGRESSIVE IN TERMS OF GLYCEMIC CONTROL THEN SHE HAS FREQUENT EPISODES OF [DIAGNOSES REDACTED], WHICH I THINK IS EVEN MORE DANGEROUS..." A REVIEW OF A PHYSICIAN'S PROGRESS NOTE DATED 9/13/10 DOCUMENTED THE FOLLOWING: "...I AM GOING TO STOP THE QID (FOUR TIMES DAILY) CHECKS. IT IS A BIT EXCESSIVE AND I THINK IT IS A QUALITY OF LIFE ISSUE AT THIS POINT... ON SECOND THOUGHT, I AM GOING TO PUT HER ON LOW DOSES OF [MEDICATION NAME] INSULIN THREE TIMES A DAY, BEFORE MEALS. WE WILL CONTINUE QID CHECKS FOR A LITTLE BIT LONGER BUT I THINK THE GOAL IS TO GET HER OFF QID CHECKS..." A physician's orders [REDACTED]." (BRAND NAME EQUIPMENT USED FOR BLOOD GLUCOSE MONITORING) A REVIEW OF THE physician's orders [REDACTED]. "...MONITOR FOR S/S (SIGN AND SYMPTOMS) OF [DIAGNOSES REDACTED]..." "...RBS (RANDOM BLOOD SUGAR) PER NURSES DISCRETION..." THERE WAS NO DOCUMENTATION IN RESIDENT #502'S CLINICAL RECORD THAT INSTRUCTED THE NURSING STAFF TO DISCONTINUE RANDOM BLOOD SUGAR CHECKS, AND THERE WAS NO DOCUMENTATION THAT INSTRUCTED NURSING STAFF TO DISCONTINUE MONITORING FOR SIGNS AND SYMPTOMS OF [DIAGNOSES REDACTED]. "[MEDICATION NAME] (RAPID ACTING INSULIN) 100 UNIT/ML (MILLILITER), INJECT 3 UNITS SQ (SUBCUTANEUS) IN THE MORNING 0700..." "[MEDICATION NAME] 100 UNIT/ML, INJECT 6 UNITS SQ TWICE DAILY (LUNCH/SUPPER), 1130, 1700..." "[MEDICATION NAME] (LONG ACTING INSULIN) 100 UNIT/ML VIAL, INJECT 40 UNITS SQ ONCE DAILY, 0730..." A physician's orders [REDACTED]. A REVIEW OF THE FACILITY'S "STANDING ORDERS" UPDATED 1/2010, DID NOT ADDRESS THE FREQUENCY OF MONITORING OF BLOOD SUGARS IN RESIDENTS WITH HISTORIC HYPOGLYCEMIC EPISODES. A REVIEW OF RESIDENT #502'S "NUTRITION" CARE PLAN UPDATED 2/8/11, REVEALED THE FOLLOWING INTERVENTION: "...INSULIN AND ORAL AGENTS AS ORDERED PER PHYSICIAN FOR BLOOD SUGAR CONTROL AND MONITOR FOR S/S (SIGNS AND SYMPTOMS) OF HYPER AND [DIAGNOSES REDACTED]..." THERE WAS NO CARE PLAN THAT ADDRESSED THE DIABETIC MANAGEMENT OF SYMPTOMS OF HYPER OR [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #502'S MEDICATION OBSERVATION RECORD (MORS) FOR THE MONTH OF APRIL 2011 REVEALED THAT NO BLOOD SUGAR CHECKS HAD BEEN PERFORMED FROM 4/1/11 TO 4/5/11. A RBS (RANDOM BLOOD SUGAR) WAS PERFORMED ON 4/6/11 AND REVEALED A BS LEVEL OF 49 MG/DL. A REPEAT LEVEL REVEALED A READING OF 44 MG/DL. THERE WERE NO OTHER DOCUMENTED ACCUCHECKS PERFORMED UNTIL 4/9/11 WHICH REVEALED A BS LEVEL OF 239 MG/DL. A REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #502'S BLOOD SUGAR HAD NOT BEEN CHECKED ON 4/6/11 UNTIL AFTER SHE HAD BEEN ADMINISTERED TWO DOSES OF HER PRESCRIBED INSULIN AT 7:30 A.M. AND 11:30 A.M.. FURTHER REVIEW OF THE APRIL 2011 MORS REVEALED DOCUMENTATION ON THE BACK, THAT RESIDENT #502 HAD NOT RECEIVED HER PRESCRIBED INSULIN ON 4/9/11 AT 7:30, AND 5:00 P.M., HOWEVER, INITIALS WERE PLACED NEXT TO RESIDENT #502'S PRESCRIBED INSULIN DOSES WHICH INDICATED THAT THE 7:30 A.M. DOSE OF INSULIN HAD IN FACT BEEN ADMINISTERED. THE MORS ALSO REFLECTED THAT RESIDENT #502 HAD ALSO RECEIVED HER 11:30 A.M. DOSE OF INSULIN AS SCHEDULED THERE WAS NO DOCUMENTED EVIDENCE IN THE CLINICAL RECORD THAT ACCUCHECKS HAD BEEN PERFORMED AFTER 11:30 A.M. ON 4/9/11. FURTHER REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #592 HAD A DOCUMENTED HISTORY OF HYPOGLYCEMIC EPISODES WHICH REFLECTED THE FOLLOWING LOW BLOOD SUGAR READINGS: 3/3/11 34 MG/DL 4/6/11 49 MG/DL; RETAKEN REVEALED 4/6/11 44 MG/DL 4/11/11 39 MG/DL 4/11/11 65 MG/DL ON 4/25/11 AT 12:38 P.M., DURING AN INTERVIEW, LPN #1 REPORTED "...SHE (#502) fell on THE AFTERNOON SHIFT. SHE fell FORWARD AND HIT HER HEAD ON THE FLOOR. SHE HAD BLOOD SUGAR TROUBLE BEFORE THE FALL..." ON 4/25/11 AT 2:07 P.M., DURING AN INTERVIEW, CNA #1 REPORTED "...I SAW HER (#502) LAYING FACE DOWN ON THE GROUND NEXT TO HER BED WITH BLOOD EVERYWHERE... WE STARTED SOPPING UP BLOOD ON THE FLOOR. RN #1 CHECKED HER BLOOD SUGAR AND IT WAS 39. RN #1 CALLED EMS..." CNA #1 FURTHER REPORTED THAT "...RN #1 GAVE RESIDENT #502 HER MEDICATIONS BEFORE THE FALL..." WHEN ASKED IF SHE (CNA #1) OBSERVED IF RN #1 HAD CHECKED RESIDENT #502'S BLOOD SUGAR, CNA #1 SAID, "I CAN'T SAY." ADDITIONALLY, CNA #1 REPORTED THAT RESIDENT #502 "...HAD BEEN REFUSING TO EAT AND DRINK AND WANTING TO DIE. THE NURSES HAD TO GIVE HER [MEDICATION NAME] SHOTS..." ON 4/25/11 AT 2:48 P.M., DURING AN INTERVIEW, LPN #3 REPORTED "...I WAS FIRST TO ARRIVE TO HER (#502) ROOM..." WHEN QUERIED ABOUT RESIDENT #502'S CONDITION, LPN #3 SAID "...SHE WASN'T MOVING. I CALLED OUT HER NAME BUT SHE DIDN'T RESPOND..." WHEN ASKED IF SHE (LPN #3) ASSESSED RESIDENT #502'S AIRWAY, BREATHING OR PULSE, LPN #3 SAID "...I DIDN'T CHECK HER PULSE OR ANYTHING..." WHEN ASKED WHY SHE (LPN #3) DIDN'T ASSESS RESIDENT #502 TO DETERMINE RESPONSIVENESS OR THE SEVERITY OF HER INJURIES, LPN #3 SAID "I'M NOT SURE." ON 4/25/11 AT 2:57 P.M., DURING AN INTERVIEW, RN #1 REPORTED "...I WAS HER (#502) ASSIGNED NURSE THE DAY SHE fell . SHE WAS ON THE FLOOR WITH BLOOD FROM HER HEAD. THERE WAS SO MUCH BLOOD. I CHECKED HER BLOOD SUGAR AND IT WAS 39 SO I GAVE HER [MEDICATION NAME], (A HORMONE THAT RAISES THE LEVEL OF GLUCOSE IN THE BLOOD THAT RESULTED FROM [DIAGNOSES REDACTED]), IM (INTRAMUSCULAR) IN HER RIGHT ARM. SHE WASN'T MOVING BUT SHE DID MOAN SLIGHTLY..." RN #1 FURTHER REPORTED "...SHE HAD A LACERATION TO HER FOREHEAD... SHE DEFINITELY NEEDED SUTURES... I CALLED THE DOCTOR..." WHEN ASKED HOW OFTEN RESIDENT #502'S BLOOD SUGARS WERE CHECKED, RN #1 SAID "...SHE (#502) WASN'T ON ANY BLOOD SUGAR CHECKS THEN, THEY WERE ONLY PRN (AS NEEDED) CHECKS... I KNOW HER (#502) AND SHE LOOKED FINE..." WHEN ASKED WHY RESIDENT #502 WAS NOT ON REGULARLY SCHEDULE BLOOD SUGAR CHECKS IN LIGHT OF HER HISTORY OF [DIAGNOSES REDACTED] (LOW BLOOD SUGAR), RN #1 SAID "...WE (REFERENCED THE NURSES) DON'T SET UP REGULAR BLOOD SUGAR CHECKS. BUT I SET THEM UP AFTER SHE (#502) fell ..." RN #1 FURTHER REPORTED "...I REALLY DON'T KNOW THE ANSWER TO THAT. I DON'T KNOW WHY WE COULDN'T HAVE HER ON REGULAR BS CHECKS. IN HIND SIGHT, THAT SHOULD HAVE BEEN IN HER REGULAR PLAN OF CARE..." WHEN ASKED OF THE LAST TIME RESIDENT #502'S BS HAD BEEN CHECKED, RN #1 SAID "...I HADN'T CHECKED IT ON THAT SHIFT... I GAVE HER [MEDICATION NAME] (INSULIN) 6 UNITS AT 5:00 P.M. BUT I DIDN'T CHECK HER BS BEFORE I GAVE IT... SHE HAD BECOME HYPOGLYCEMIC BEFORE AND I HAD TO GIVE HER [MEDICATION NAME] TO RAISE HER BS UP..." ADDITIONALLY, RN #1 STATED, "...IF SHE (#502) WAS ON BS CHECKS, SHE WOULD'VE HAD HER BS CHECKED AT 4:00 P.M., BEFORE HER FALL..." RN #1 COULD NOT EXPLAIN WHY SHE FAILED TO ASSESS RESIDENT #502'S BS BEFORE ADMINISTERING HER INSULIN IN LIGHT OF HER (#502) HISTORY OF HYPOGLYCEMIC EPISODES. ON 4/26/11 AT 11:35 A.M., DURING AN INTERVIEW WITH THE CLINICAL COORDINATOR (RN #3), SHE REPORTED, "..I WENT INTO HER ROOM AFTER SHE fell AND SHE WAS PRONE (FACE DOWN) WITH HER HEAD TURNED SIDEWAYS... HER ARM WAS VERY CLAMMY AND COOL... I'VE KNOW HER BEFORE AND SHE HAS HAD LOW BS IN THE PAST... IT'S TYPICAL OF HER... SHE GETS CLAMMY AND COOL... SHE WAS NOT ON SCHEDULED BS CHECKS, SHE WAS ONLY PRN... THE DOCTOR DOESN'T ORDER THEM VERY OFTEN... HER HgbA1C (TEST THAT MEASURES THE PERCENTAGE OF BLOOD GLUCOSE IN THE BLOOD FOR THE LAST THREE MONTHS) WAS LOW SO THE DOCTOR SAID DO THEM (BS CHECKS) PRN..." THE CLINICAL COORDINATOR (RN #3) COULD NOT EXPLAIN WHY RESIDENT #502'S BS HAD NOT BEEN MONITORED IN LIGHT OF HER HISTORIC HYPOGLYCEMIC EPISODES. ON 4/27/11 AT 9:25 A.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) SAID "...I INTERVIEWED THE STAFF AND RN #1 TOLD ME THAT "SHE KNOWS HER" (#502)... IF I DIDN'T SEE HER SWEATING, I WOULDN'T CHECK HER BLOOD SUGAR EITHER..." ON 4/27/11 AT 9:50 A.M., DURING AN INTERVIEW, PHYSICIAN #1 SAID, "...YOU CAN'T TREAT JUST BY LABS (LABORATORY VALUES) OR BY JUST LOOKING AT THE RESIDENTS. YOU HAVE TO ASSESS. YOU CANNOT GO BY THE HgbA1C ALONE. IT'S ALL INDIVIDUALIZED... SHE (#502) CAN'T ALWAYS VOCALIZE HOW SHE FEELS..." PHYSICIAN #1 FURTHER STATED, "...I TEND TO LEAN TOWARD REGULAR ACCUCHECKS (BS CHECKS), THEN IF THEY'RE OUT OF CONTROL, I ORDER THEM TO BE DONE QID (FOUR TIMES A DAY). IF THEY'RE CONTROLLED, MAYBE BID (TWICE A DAY) THEN DOWN TO ONCE A MONTH..." ON 4/27/11 AT 10:20 A.M., DURING A SUBSEQUENT INTERVIEW, THE DON SAID "...WE USE hgbA1C IN PLACE OF ACCUCHECKS... WE HAVE STANDING ORDERS FOR NURSES TO CHECK THE RESIDENT'S BLOOD SUGARS AT THEIR DISCRETION..." ON 4/27/11 AT 11:05 A.M., AN INTERVIEW WAS CONDUCTED WITH THE MEDICAL DIRECTOR (MD). WHEN ASKED WHY RESIDENT #502 DID NOT HAVE REGULAR ACCUCHECKS ORDERED IN LIGHT OF HER HYPOGLYCEMIC EPISODES, THE MD SAID, "...THE GUIDELINES SUGGEST THAT ACCUCHECKS BE DONE ONCE A WEEK... I TRY TO BE LESS [MEDICATION NAME] TO TRY TO IMPROVE ON QUALITY OF LIFE..." THE MD FURTHER STATED "...THE HgbA1C ALONE, SHOULD NOT BE USED TO ASSESS THE CURRENT BLOOD SUGAR LEVEL..." A REVIEW OF THE FACILITY'S "ASSESSMENT AND MANAGEMENT OF DIABETES" POLICY DATED 1/2006 REVEALED THE FOLLOWING: "...IT IS THE POLICY OF THIS FACILITY TO UTILIZE A SYSTEMATIC APPROACH TO DIABETES MANAGEMENT INCLUDING: REVIEW OF GLYCEMIC CONTROL..." "...FOLLOW STANDING ORDERS OR INDIVIDUALLY ORDERED PARAMETERS FOR PHYSICIAN NOTIFICATION OF HYPO OR HYPERGLYCEMIC EPISODES..." "...BLOOD GLUCOSE LEVELS, SUGGESTED MONITORING: ZERO TO TWICE A WEEK WITH GOOD CONTROL; 2-4 TIMES DAILY FOR INSULIN OR POOR CONTROL..."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 351 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT ONE (#501) OF FIVE SAMPLED RESIDENTS, WHO WAS IDENTIFIED AT RISK FOR FALLS, WAS ADEQUATELY SUPERVISED WHILE IN HIS BATHROOM, RESULTING IN A FALL WITH FRACTURE. FINDINGS INCLUDE: ACCORDING TO THE FACILITY ' S ADMISSION RECORD, RESIDENT #501 WAS INITIALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT #501 HAD MODERATELY IMPAIRED COGNITION AND HAD LONG AND SHORT TERM MEMORY PROBLEMS. ACCORDING TO RESIDENT #501 ' S CARE AREA assessment dated [DATE], RESIDENT #501 WAS " ...AT RISK FOR FALLS AND HAS HAD FALLS IN THE PAST ... HE IS IMPULSIVE AT TIMES AND HAS POOR SAFETY AWARENESS D/T (DUE TO) DEMENTIA ... HE REQUIRES VISUAL SUPERVISION WHEN OUT OF ROOM FOR INAPPROPRIATE BEHAVIORS ... " THE MDS dated 2/15/11 INDICATED THAT RESIDENT #501 REQUIRED LIMITED TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING TRANSFERS, DRESSING PERSONAL HYGIENE, BATHING AND TOILETING. A REVIEW OF RESIDENT #501 ' S CLINICAL RECORD REVEALED A FALLS RISK SCORE OF 24. (A SCORE GREATER THAN 10 REFLECTED A HIGH RISK FOR FALLS). RESIDENT #501 ' S FALL POTENTIAL ASSESSMENT DOCUMENTED " ...THE HIGHER THE SCORE, THE GREATER THE RISK FOR FALLS... RESIDENTS WITH A SCORE ABOVE 10 SHOULD HAVE PROMPT INTERVENTIONS IN PLACE ... " THE FACILITY ' S INCIDENT/ACCIDENT REPORT DATED 4/8/11, REVEALED " ...RESIDENT OBSERVED LEANING TO LEFT WHILE SITTING ON TOILET, LOST BALANCE AND fell TO THE FLOOR, BUMPING LEFT SIDE OF HEAD, RESIDENT HAS LARGE HEMATOMA AND LACERATION TO LEFT SIDE OF HEAD, AREA BLEEDING AND PAINFUL TO RESIDENT ... " CORDONING TO RESIDENT #501 ' S HOSPITAL RECORDS DATED 4/8/11, RESIDENT #501 PRESENTED TO THE emergency room WITH CHIEF COMPLAINT OF FALL AND WAS TREATED IN THE emergency room FOR [DIAGNOSES REDACTED]. A REVIEW OF A HOSPITAL RADIOLOGY REPORT DATED 4/8/11 REVEALED THAT A CHEST X-RAY (CXR) WAS PERFORMED DUE TO " SHORTNESS OF BREATH", " FALL INJURY " , " PAIN AFTER TRAUMA." THE RESULTS OF THE CXR REVEALED " ...THE POSTERIOR RIGHT SEVENTH RIB FRACTURE APPEARS ACUTE ... " A REVIEW OF RESIDENT #501 ' S CLINICAL RECORD REVEALED THAT RESIDENT #501 HAD FALLS ON THE FOLLOWING DATES: ON 1/12/11, " ...OBSERVED SITTING ON THE FLOOR BETWEEN HIS W/C (WHEELCHAIR) AND BED ... " ON 1/26/11, " ...PT (PATIENT) OBSERVED LYING ON FLOOR NEXT TO BED, REPORTED HE TRIED TO SELF TRANSFER CHAIR TO BED ... " A REVIEW OF RESIDENT #501 ' S ADLS CARE PLAN, DATED 10/19/07, REVEALED THE FOLLOWING: " ...NEEDS ASSISTANCE WITH ADLS RELATED TO DECREASED MOBILITY, FATIGUE POTENTIAL AND POTENTIAL FOR CONFUSION, SUPPORTED BY COPD, MODERATE MENTAL RETARDATION, DIABETES MELLITUS AND DEMENTIA ... " THE FOLLOWING INTERVENTIONS WERE LISTED: " ...SAFETY: VISUAL SUPERVISION WHEN HE (#501) IS OUT OF ROOM ... " " ...DO NOT LEAVE ALONE IN BATHROOM ... " ON 4/25/11 AT 1:55 P.M., AN INTERVIEW WAS CONDUCTED WITH THE FACILITY'S ADMINISTRATOR WHO REPORTED, "...WE FEEL THE AIDE (CNA #2) SHOULD NOT HAVE LEFT THE RESIDENT ALONE. SHE SHOULD HAVE PULED THE CALL LIGHT AND ASKED FOR HELP..." ON AT 4/25/11 AT 3:34 P.M., REGISTERED NURSE (RN#2) REPORTED " ...I WAS DOING A MEDICATION PASS AND I HEARD SOMEONE YELL " I NEED HELP! I WENT RIGHT TO HER (CERTIFIED NURSING ASSISTANT #2) (CNA #2). SHE SAID RESIDENT #501 fell . I SAW HIM (#501) ON THE FLOOR ... " RN #2 FURTHER REPORTED " ...HE (#501) WAS BLEEDING FROM HIS HEAD AND HE COMPLAINED OF PAIN. I COMPLETED THE PAPERWORK AND I CALLED THE DOCTOR AND EMERGENCY MEDICAL SYSTEM (EMS) ... I WAS HIS ASSIGNED NURSE. HE WAS LEFT ALONE ... " WHEN ASKED IF RESIDENT #501 WAS STABLE ENOUGH TO BE LEFT ALONE AND UNATTENDED IN THE BATHROOM, RN #2 SAID " NO, HE (#501) WAS ALERT TO PERSONAL ONLY AND HE WAS COGNITIVELY IMPAIRED... I TOLD CNA #2 THAT SHE SHOULDN'T HAVE LEFT HIM ALONE ... " ON 4/25/11 AT 3:49 P.M., DURING AN INTERVIEW, CNA #2 REPORTED THE FOLLOWING: " ...HE (#501) HAD HIS LIGHT ON TO GO TO THE BATHROOM. I TRANSFERRED HIM TO THE TOILET USING A GAIT BELT (DEVICED USED TO ASSIST IN SAFE TRANSFER OR AMBULATION OF PATIENTS). I GOT HIM ON THE TOILET AND NOTICED HIS BRIEF WAS WET. I TURNED MY BACK ON HIM FOR A MINUTE TO GET HIM A BRIEF FROM THE CLOSET ... WHEN I WENT BACK INTO THE BATHROOM, HE WAS LEANING OVER AND FALLING TO THE FLOOR ... " WHEN ASKED IF RESIDENT #501 WAS TO BE LEFT ALONE WITHOUT SUPERVISION, CNA #2 SAID " NO. " WHEN ASKED WHY RESIDENT #501 WAS LEFT UNATTENDED IN THE BATHROOM, CNA #2 SAID " ...IT WASN'T VERY SMART... HE SEEMED LIKE HE WOULD BE OKAY ... I SAW HIM FALL ... FROM NOW ON, I'LL PULL THE CALL LIGHT AND ASK FOR HELP ... " ON 4/27/11 AT 9:20 A.M., AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) WAS CONDUCTED. WHEN ASKED WHY RESIDENT #501 WAS LEFT ALONE IN HIS BATHROOM UNATTENDED AND UNSUPERVISED, THE DON SAID " ...SHE (CNA#2) JUST MADE A MISTAKE ... INSTEAD OF USING THE CALL LIGHT TO CALL FOR HELP, SHE STEPPED OUT OF THE BATHROOM TO GET A DRY BRIEF ... " A REVIEW OF THE FACILITY ' S " FALLS POTENTIAL PROTOCOL " (UNDATED) REVEALED " ..IT IS THE POLICY OF THIS FACILITY TO ENSURE THE SAFETY OF ALL RESIDENTS BY THE PREVENTION OF FALLS THROUGH IDENTIFICATION OF EACH RESIDENT ' S POTENTIAL. THE FACILITY ' S FALLS POLICY DID NOT ADDRESS NOT LEAVING RESIDENTS IDENTIFIED AT HIGH RISK FOR FALLS, ALONE, UNATTENDED AND UNSUPERVISED.