Every finding on record at Grayling Nursing & Rehabilitation Community

This Citation Pertains to Intake 3009239. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure timely and comprehensive assessment, treatment, and documentation, per professional standards in practice, for change in condition for two Residents (#701 & #702) of three residents reviewed. This deficient practice resulted in: Delay in diagnostic testing and treatment for a Urinary Tract Infection (UTI) causing sepsis for Resident #701, and;Lack of monitoring and follow up of laboratory testing, causing Acute Kidney Injury (AKI) and need for emergency dialysis for Resident #702. Findings include:Resident #701 (R701)Review of intake documentation dated as received on [DATE] revealed a concern that R701 was admitted to the facility on [DATE] following a hospital stay. Per the intake documentation, R701 was alert when they were discharged from the hospital and started slowly getting more and more confused and declined after getting to the facility. The intake detailed R701's family requested the facility test for a Urinary Tract Infection (UTI) multiple times including on [DATE]. R701 ended up going to the ER where they became completely unresponsive and basically catatonic and passed away from Sepsis from a UTI on [DATE]st, 2025. The intake specified R701 did a 180 from the time they came to the rehabilitation facility until they left this earth.Review of requested hospital documentation revealed R701 was transferred to the ER from the facility on [DATE] and passed away in the hospital on [DATE]. Detailed review revealed the following:- [DATE] 12:47 PM: Emergency Department Report. Chief Complaint: Decrease mental status and UTI. present from (facility) for evaluation of decreased responsiveness and abnormal labs. Patient has a history of recurrent UTIs, outpatient blood work and urinalysis were performed yesterday showing worsening renal function and UTI. nonverbal on arrival and noted to be hypotensive. systolic blood pressure (top number) in the 70s. had dry mucous membranes, not responding to verbal stimuli but withdraws to painful stimuli. Suspect sepsis secondary to UTI with dehydration. Laboratory testing with worsening renal function, baseline creatinine 1.7 and up to (over) 4 (normal level per hospital lab is 0.70 to 1.30) . Blood pressure remained low despite initial IV (intravenous) fluid. Levophed (emergency vasopressor medication used short term to treat life threatening low blood pressure often seen with sepsis) started. remains in critical condition at the time of admission.- [DATE]: History and Physical. abdominal guarding/pain. Assessment/Plan: 1 Septic Shock Secondary to UTI. Presented to emergency department with. acute metabolic encephalopathy (temporary impairment of brain function caused by organ disfunction and/or imbalances in body including septic shock), hypothermia (low body temperature) . evidence of UTI. 2. UTI. 3. AKI superimposed on CKD . Secondary to septic shock and dehydration. 4. Metabolic encephalopathy secondary to sepsis. 6. Dehydration secondary sepsis and poor oral intake. Admit ICU level care for septic shock. Prognosis poor.- [DATE]: Discharge Documents: Disposition/Condition: deceased . All Diagnoses this Visit: Septic shock. UTI, Acute Kidney Injury (AKI) superimposed on CKD (Chronic Kidney Disease) . Dehydration. AKI with possible Acute Tubular Necrosis (damage to the tubules of the kidneys often resulting from lack of blood flow) due to septic shock and dehydration. Hospital Course. present to the emergency department from (facility) with mental status changes and UTI. On arrival. was profoundly ill with septic shock and acute renal failure. initially admitted to the hospital and treated. The next day had not made much clinical progress and continued to be severely ill. (Family) made the decision to transition the focus of care to comfort. passed away. on [DATE]. 8:20 AM.An interview was conducted with Family Member Witness A on [DATE] at 7:24 AM. When asked about Resident #701's care at the facility, Witness A stated, (R701) was talking and eating by themselves when they left the hospital then they went to the facility for rehab and declined. When queried what happened, Witness A verbalized R701 had a couple falls at the facility and then started to get more tired and confused. Witness A revealed they were worried R701 had a UTI. Witness A was asked if they brought their concerns up to the facility staff and responded they had. Witness A stated they spoke to a male nurse and asked them to test R701 for a UTI. When queried what happened, Witness A stated, They (male nurse) said they make a note in the chart, but they (staff) hadn't gotten it (urine sample) yet. When queried if they recalled the name of the male nurse who they had spoke to, Witness A responded they did not but they had brown hair and were well-built. Witness A was asked when they talked to the male nurse and asked about testing for a UTI and responded, It was a few days before. With further inquiry regarding the Resident's care at the facility, Witness A stated, I came and sat with (R701) every day. They never gave (R701) fresh water and they were dehydrated. Witness A continued, When I would get there at 10:00 (AM), it (R701's water) would be warm and old. I never saw them giving out water. When asked if Resident #701 needed assistance to drink, Witness A indicated they did not when they first arrived at the facility but did by the time they were sent to the hospital because they were so confused.Record review revealed R701 was admitted to the facility on [DATE] with diagnoses which included subdural hemorrhage (bleeding between the brain and the skull), CKD, anemia, and Benign Prostatic Hyperplasia (BPH- enlarged prostrate with urinary retention). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the R701 was moderately cognitively impaired and required set up to maximum assistance to complete Activities of Daily Living (ADLs). The MDS further specified R701 was frequently incontinent of both bowel and bladder and did not have a known weight loss.An interview was completed with Registered Nurse (RN) D on [DATE] at 8:35 AM. When queried if there were any well-built male nurses with brown hair who worked at the facility, RN D responded that RN E fit that description.All Incident and Accident (I and A) reports as well as any investigations pertaining to R701 were requested from the facility Administrator on [DATE] at 11:00 AM.A review of R701's Electronic Medical Record (EMR) revealed the Resident's level of alertness and orientation declined from being Alert and Oriented (A & O) X 2 to 3 (person, place and time) to being A & O X 1 -2 with confusion and A & O to self only with confusion. EMR documentation further revealed a nurses note dated [DATE] specifying nursing staff were concerned R701 had a UTI and wanted to obtain a urinalysis (UA) but a UA was not obtained until [DATE]. Documentation review further revealed inconsistencies between nursing and Health Care Provider (HCP) documentation related to mental status/confusion, nutritional status, and continence.Review of R701's documentation revealed the following:- [DATE] at 1:58 PM- Nurse Progress Note: (R701) arrived at 1:15 PM from hospital accompanied by EMS personal. A/O (Alert/Orientated) x 2-3 (person, place, time) . here for strengthening and plans to go home.- [DATE] at 12:41 PM- Social Services Note: (R701) is alert, orientated 2-3 with some occasional confusion noted. easily re-orientated.- [DATE] at 1:18 AM- Nurse Progress Note: A/Ox2 with some confusion.- [DATE] at 2:45 AM- Nurse Progress Note: (R701) is alert/oriented x 1 (self only) with confusion.- [DATE] at 1:38 AM- Nurse Progress Note: (R701). is extremely confused this shift.- [DATE] at 1:10 AM- Nurse Progress Note: (R701) is alert/oriented x 1-2 with confusion.- [DATE] at 10:36 AM- Nurse Progress Note: (R701) is to self with confusion.- [DATE] at 1:37 AM - Nurse Progress Note: (R701) is alert to self with confusion. pleasant towards staff, ability to communicate needs. was up in w/c across from nurses' desk in a high traffic area for safety concerns, once res did go to bed was talking to an imaginary man that came into room. (R701) stated to this writer 'that a random man came into building and wanted (R701) to hide something for them. Explained that no 'random man' came into room and that (R701) would need to pee into a urinal so I could check urine for a UTI, but so far this evening resident has been incontinent of bladder. Note authored by RN F.- [DATE] at 2:05 PM - Nurse Progress Note: (R701) is A/O x1-2 (person, place) with periods of confusion . has a floor mat next to bed due to multiple attempts of crawling out of bed per day. Appetite remains poor.- [DATE]- Physician Note: Date of Service [DATE]. 30-Day Follow Up. evaluated today for 30-day regulatory visit. General: Positive: Fatigue, Low energy. Positive: Muscle Pain or Cramps. Negative: Confusion. Physical Exam. Positive: Well nourished, Alert, Awake. Negative: Confusion.- [DATE] at 10:49 AM - Nurse Progress Note: (R701) is alert to self only, can makes needs known. has a poor appetite.- [DATE] at 9:30 AM- Provider Note: Date of Service: [DATE].(Family) reported concerns with weight loss. Documented weight trends reveal 168.6 pounds on [DATE] and weight of 152.8 pounds on [DATE]. Intake trends reduced overall. plan was made with orders given to the Nursing staff to administer 100 mg (milligrams) megace (appetite stimulant medication) .- [DATE] - Provider Note: Date of Service: [DATE]. (R701) is being seen today for. follow up bloodwork results and reports of increased confusion. Nursing staff reports concerns with increased confusion and generalized weakness. sitting up in his wheelchair in the therapy room and appears confused today. General. Positive: Fatigue. Negative. Weight Loss. Negative. Loss of bladder control. Positive: Confusion. Negative. Weakness. Notes: Notes: Reports of increased confusion with no specific concerns or compliant from the Patient.- [DATE] at 4:51 PM- Nurse Progress Note: (R701). alert to self . appetite is poor has megace (appetite stimulant medication) ordered but still eats and drinks little. Sent a urine sample to the lab to r/o (rule out) UTI.- [DATE] at 1:06 PM- Nurse Progress Note: (R701) noted with positive UA, pending culture. shows s/s (signs/symptoms) of infection including change in mentation, decrease ADL function. (R701) condition was discussed with (Nurse Practitioner [NP] C) .- [DATE] at 4:02 PM- Nurse Progress Note: Alert and oriented x2 with some confusion. refused medications this morning, knocking the cup out of this RNs hand. is not eating or drinking much at this time.- [DATE] at 1:15 AM- Nurse Progress Note: Alert and oriented x2 (person and place) with some confusion. refused medications this evening, refused to open eyes when nurse approached. IV fluids have completed. IM (intramuscular) Rocephin for a UTI. is not eating or drinking much at this time.- [DATE] at 9:33 AM- Provider Note: DON (Director of Nursing) reported . (R701) is still not self, swatting at the wall, swatting at staff and not taking in anything orally. Despite IV fluids and initiation of Rocephin (antibiotic), condition remains as confused/AMS (Altered Mental Status) . send the Patient into the ER.- [DATE] at 9:53 AM: INTERACT Nursing Home to Hospital Transfer Form. Send to Hospital for evaluation. Reason for Transfer - infection. How long has (R701) had illness? 2 days.- [DATE] at 10:00 AM- Nurse Progress Note: (R701) has not responded to the normal saline IV and antibiotic medication that was given yesterday. send the resident via EMS to the hospital for evaluation. BP was low 96/50, resp. 22 (elevated- normal 16-20) . mouth breathing and reaching for things in the air. will not drink nor allow RN to swab mouth for moisture. CNA (Certified Nursing Assistant) notified RN (Registered Nurse) that (R701) has not voided in over 8 hours.An interview was completed with RN E on [DATE] at 1:40 PM. When queried, RN E indicated they vaguely recalled R701. RN E was asked what color hair they have and replied, Brown-ish black. When asked if they remembered speaking to R701's spouse, RN E revealed they recalled them being at the facility often. RN E was then asked if R701's spouse had discussed concerns related to R701 having increased confusion and wanting to get a UA and replied, I do not recall.A review of laboratory testing results in R701's EMR revealed the following:- A UA collected and resulted on [DATE]. The UA was positive for infection and showed the Resident's urine was dark yellow in color, cloudy, with mucous, protein bacteria, blood, Leukocyte Esterase (enzyme released by [NAME] Blood Cells [WBCs] indicating infection or inflammation), 130 WBCs (normal- 0-4), and WBC clumps. Culture and sensitivity (C&S) testing was completed by the laboratory. The preliminary C&S report was dated [DATE] and the final report was dated [DATE]. Both showed R701's urine was positive for Klebsiella pneumoniae (bacteria normally found in stool which can cause severe infections, including UTIs, and can be difficult to treat with antibiotics) and Enterobacter cloacae complex (bacteria found in the gut and an identified healthcare associated pathogen which can cause severe infection).- A Complete Blood Count (CBC) laboratory blood test was completed on [DATE]. The results showed low neutrophils (type of WBC) at 1.57 (normal 1.60 - 7.20) and low WBC at 3.3 (normal 3.4-10.0) which can be a sign of sepsis.A CBC was completed on [DATE] and showed R701's neutrophil count was 3.11 and their WBC was 6.2 at that time.Additionally, there was no order present in the EMR for a UA on [DATE].R701's Vital Sign monitoring and Medication Administration Record (MAR) documentation in the EMR revealed vital signs were not obtained daily nor with identified concerns related to increased confusion/change in condition.The most recent vital sign documentation, prior to the Resident's transfer to the hospital occurred on:- [DATE] at 11:21 AM: Blood Pressure- 132/60, Pulse- 77- [DATE] at 11:31 AM: Blood Pressure- 127/69, Pulse- 71- [DATE] at 11:17 AM: Blood Pressure- 140/74, Pulse- 78, Respirations- 18, O2 (oxygen) saturation- 94% Review of R701's HCP orders and MAR revealed the Resident was started on Rocephin IM daily on [DATE] and received 1500 milliliters (mL) of Normal Saline (NS) solution on [DATE] and [DATE].An interview was completed with RN F on [DATE] at 2:25 PM. When queried if they recalled Resident #701, RN F revealed they were not sure. After reading them the note RN F authored on [DATE] in R701's EMR, RN F verbalized it was helpful in recalling R701. When queried regarding the facility policy/procedure related to obtaining a UA, RN F stated, If (R701) was crawling out of bed confused, we would do it (UA). With further inquiry, RN F stated, If they have any change in condition will do a (urine) dip on them. When asked if a HCP order is required to complete a urine dip, RN F replied, Have to put in an order. With further inquiry regarding their note in R701's EMR, RN F stated, Would have spoke to Provider regarding R701.An interview was completed with RN D on [DATE] at 4:50 PM. When queried if they recalled R701, RN D reviewed the Resident's EMR and verbalized they did. RN D stated, He got Hypodermoclysis (HDC- administration of fluids into the subcutaneous tissue). RN D then stated, Couldn't get an IV so got that. I think that was a huge reason that we sent (R701) to the hospital. When queried how long R701 had gotten fluids before being transferred, RN D replied, That was started the night or day before. When asked what happened when R701 was transferred, RN D stated, It wasn't working. (R701) was grabbing at things that weren't there and hallucinating. I knew (R701) was tanking. When queried regarding R701 having hallucinations, RN D revealed they were not aware of R701 having hallucinations previously. RN D then stated, (R701) hadn't had any output either. R701's urine output was reviewed with RN D at this time. Review revealed the following documentation of urinary output in R701's EMR:- [DATE] at 3:46 AM: Urine- Large- [DATE] at 2:33 PM: Urine- Small- [DATE] at 2:37 AM: Urine- Large- [DATE] at 2:40 PM: Urine- Large- [DATE] at 9:53 PM: Urine- Large- [DATE] at 2:59 PM: Urine- Large- [DATE] at 12:06 AM: Urine- LargeNote: No definition of what constituted small, medium, or large urine output was present in the EMR.When queried if the documentation meant R701 had not had any output since 3:46 AM, RN D revealed that was the time the CNA (Certified Nursing Assistant) documented and not necessarily the last time that R701 had urinated. When queried what small, medium, and large meant in relation to urinary output, RN D replied, (R701) was incontinent so their brief. RN D continued to review the output documentation and verbalized R701 barely had any output in the 24 hours prior to leaving the facility. With further inquiry, RN D indicated it meant how much urine was in the Resident's brief. RN D was asked if that was subjective and replied, Yes. When queried regarding documentation of resident vital signs (VS) in the EMR, RN D revealed VS are documented under the VS section or in the progress note documentation. RN D further indicated VS are documented on the transfer form. A review of R701's VS documentation was completed with RN D. RN D did not provide an explanation when queried why R701's VS were not assessed and documented upon identification of R701's UTI and change in condition.An interview was completed with the facility Administrator and DON on [DATE] at 8:54 AM. Upon follow-up for a facility policy/procedure related to transfer to the hospital, the Administrator and DON both stated they did not have a policy/procedure. The Administrator and DON were asked if they were able to locate previously requested policies/procedures related to nursing assessment and nursing documentation and both verbalized they did not have policies/procedures for assessment and/or documentation. When asked how nurses know what their responsibilities are in regard to what and where to document, the DON responded, We have a facility list for specific classifications which includes daily charting guidelines and who needs to be charted on for the day. The DON was asked what they meant and revealed they were referring to what residents require skin assessments on what days and/or if a resident needs post fall documentation completed. When queried about what small, medium, and large means in relation to urine output, both the DON and Administrator responded that size is documented for bowel movements, not urine output. R701's urine output documentation was reviewed, and the Administrator and DON were asked what the sizes meant and both stated they did not know. The DON verbalized they would look. A policy/procedure related to output monitoring/assessment and change in resident condition was requested at this time.An interview was conducted with CNA G on [DATE] at 9:13 AM. When queried regarding facility policy/procedure for documentation of urinary output for incontinent residents, CNA G replied, There is an area for small, medium, and large for urine output. CNA G was asked if they receive training on what constitutes the amount of urine when they document small, medium, or large, CNA G revealed they do not. CNA G then stated, That is how it has always been. I've been here 10 years. When queried if there is a reference they can look at to know what small, medium, or large urinary output is, CNA G replied, I don't think there is a reference. When asked if there is a place they can go to find answers if they are not sure about something, like a policy/procedure book, CNA G stated, I don't know if they have anything like that. CNA G was asked if they document each time a resident is incontinent and replied, No. When asked how they document the amount of urine, CNA G stated, Large is several soaked, medium is like wet but not soaked and small is like a little.A follow up interview was completed with the DON on [DATE] at 9:44 AM. When queried regarding a policy/procedure related to output monitoring/assessment, the DON stated, We don't have a policy/procedure. With further inquiry regarding the accuracy of the documentation, the DON stated, It is subjective. When queried if staff are supposed to document each episode of urinary incontinence separately, the DON did not provide an explanation. The DON then stated that the facility goes above and beyond with documentation of urinary output.On [DATE] at 11:05 AM, an interview and review of the note dated [DATE] at 1:37 AM was completed with the DON. When queried regarding the note indicating R701 would have a UA completed due to a change in mentation, the DON stated, I don't think it was ever done. When asked if increased confusion and hallucinations would be a reason to complete a UA, the DON verbalized it was. When asked if that change in condition should have been addressed, the DON stated, Yes, it should have been passed along. The DON stated, I will look through the chart and see if I have anything. When queried regarding the EMR documentation of urine output as small, medium, and large, the DON was unable to provide an explanation and/or definition of the terms. A policy/procedure related to urinary output and documentation was requested at this time.An interview was completed with CNA H on [DATE] at 11:15 AM. When queried regarding documentation of urine output in the EMR for incontinent residents, CNA H responded they document small, medium, or large. When asked what that means, CNA H replied, When we go to change them. A little is small, flooded is large, and wet is medium. CNA H was asked what flooded means and replied, On the verge of soaking through their brief. When asked if they document each soiled brief individually in the EMR, CNA H responded they do.A follow-up interview was conducted with the DON on [DATE] at 11:27 AM. The DON confirmed a UA was not completed on [DATE]. When asked why a UA was not completed, the DON stated, (Physician B) saw (R701) on the 25th and charted negative for urinary symptoms and negative for confusion. When queried regarding nursing documentation specifying the Resident was confused and disorientated, the DON replied, At night. A review of day shift nursing documentation was completed with the DON at this time. Nursing note documentation on [DATE] during day shift specified R701 was alert to self only, a decline from admission to the facility. The DON then stated, Well, (R701) was disorientated. When asked if the date of service of [DATE] on the note authored by Physician B in the EMR dated as [DATE] meant the Physician actually saw the Resident on [DATE], the DON confirmed R701 was not seen by Physician B on [DATE].An interview was completed with Physician B on [DATE] at 1:24 PM. Physician B was asked when they would expect staff to notify them for a resident who has not urinated and stated, I would expect someone to notify if someone has not urinate in 12 to 24 hours. When queried if they would want to be notified if a resident began experiencing hallucinations, Physician B replied, Yes. Physician B was then queried regarding their documentation indicating Resident #701 was negative for confusion on [DATE] when nursing staff that day had documented the Resident was alert X 1- 2 with confusion, Physician B responded, there are Different levels of lucidity and alertness/confusion can vary throughout the day. When asked what they assess for when they document urinary symptoms, Physician B responded, I just go with what they (residents) tell me. Physician B was then queried if they reviewed R701's weights and vital signs when they documented their note and stated, I don't review because the computer system triggers if there is a weight loss/abnormality. When queried if they were aware the VS documented in their note on [DATE] were from [DATE], Physician B indicated the most recent VS are pulled from the EMR. Physician B verbalized the midlevel provider is at the facility more than they are and is more familiar with the residents as they are contacted for concerns. No further explanation was provided.An interview was attempted to be completed with CNA I on [DATE] at 1:50 PM. A voicemail with return phone number was left but a return call was not received by the conclusion of the survey.An interview with Nurse Practitioner (NP) C was completed on [DATE] at 2:00 PM. When queried if they recalled R701, NP C verbalized they did. NP C was asked when they want to be notified of decreased and/or no urine output and stated, any kind of decreased output they would need to know right away and if a resident has not had any output for 6 to 8 hours that would be a red flag. The note dated [DATE] at 1:37 AM in R701's EMR was reviewed with NP C at this time. NP C stated, I was not on call but verbalized the on-call provider should have been notified of the change in condition. When asked if they would have wanted to be notified of that, NP C stated, Yes, it's my patient so I would have wanted to be notified. NP C was asked if they were notified when they returned to the facility after the weekend and stated, No. NP C verbalized they were made aware R701 was having increased confusion on [DATE] and ordered labs and a UA at that time. When queried why a UA was not completed on [DATE] when hallucinations were documented in R701's EMR, NP C verbalized a UA should have been completed. NP C reiterated they were not notified R701 had experienced hallucinations on [DATE] and stated, The delay in care doesn't make sense. When queried regarding the lack of documentation of VS, even following identification of the infection, NP C verbalized VS should have been monitored for changes. When queried regarding assessment for hydration and R701's diagnosis of dehydration upon admission to the hospital, NP C stated, They just told me about the decreased output and I just started fluids.Review of R701's Death Certificate revealed the cause of death was list as Septic Shock due to Urinary Tract Infection. The delay in identification and treatment of R701's UTI was directly related to the lack of timely completion of the UA when symptoms were first identified on [DATE]. The facility failed did not monitor VS and R701 went into septic shock and died on [DATE]. Resident #702 (R702)Record review revealed R702 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF), weakness, permanent atrial fibrillation (irregular heart rhythm), CKD, and diabetes mellitus. Review of the MDS assessment dated [DATE] revealed R702 was moderately cognitively impaired and required supervision to total assistance to complete ADLs.Further review of the EMR revealed R702 was transferred to the hospital on [DATE] and did not return to the facility.An interview was completed with Family Member Witness J on [DATE] at 1:23 PM. When queried regarding R702's care at the facility, Witness J revealed R702 was sent to the hospital from the facility on [DATE] and died on [DATE]. Witness J stated, (R702) had potassium (important electrolyte in the body) overload. (R702's) kidneys could not filter out the potassium and they stopped working. When queried if they had any concerns with the care R702 received, Witness J replied, One of my main problems was they did not catch the potassium level. Witness J indicated that if the facility would have been monitoring the R702's potassium levels, their kidneys would not have shut down.Review of R702's EMR revealed the following documentation:- [DATE] at 12:25 PM- HCP Note: Date of Service: [DATE].Reports of increased lower extremity edema with weeping and follow up of bloodwork results . Will obtain CMP [DATE].- [DATE] at 4:20 PM- HCP Note: Date of Service: [DATE]. Patient is being seen today for reports of noncompliance with fluid restriction and increased edema/weight gain. Documented weight trends reveal recorded weight of the following. 192.8 pounds [DATE]. 195 pounds [DATE]. 197.6 pounds [DATE]. plan was made with orders given to the Nursing staff to administer 10 mg (milligrams) Lasix (medication used to treat fluid retention and increase urine output) daily. and to crush pills per Patient request [ok to change potassium to liquid or sprinkles]. Nursing staff is aware to notify provider with any changes in Patient condition or vital signs.- [DATE] at 8:42 AM: INTERACT Nursing Home to Hospital Transfer Form. Reason for Transfer - SOB (Shortness of Breath) . How long has resident had illness? 24 hrs. Vital Signs . Blood Pressure - 105/68 Temperature - 98.0 . Pulse - 105 (normal- 60-100), Oxygen Saturation - 97, Respiratory Rate - 15 . Authored by Licensed Practical Nurse (LPN) K.- [DATE] at 9:42 AM- Nurses Note: Resident transported to ER for evaluation for COPD (Chronic Obstructive Pulmonary Disease) exasperation (sic) at 8:40 AM, (NP C) . notified at 8:48 AM. Authored by Licensed Practical Nurse (LPN) K.Note: COPD was not listed as a diagnosis on the Resident's face sheet/information.- [DATE] - HCP Note: Nursing staff called to report (R702) was sent to ER for complaints of dyspnea (shortness of breath).Review of VS documentation in R702's EMR revealed inconsistent documentation of VS measurements. Documentation included:- [DATE] at 10:43 AM: Blood Pressure: 111/66- [DATE] at 9:02 AM: Blood Pressure: 126/70, Pulse: 85- [DATE] at 3:28 PM: Blood Pressure: 133/84, Pulse: 68The most recent complete set of vital signs documented was on [DATE] at 4:17 AM and included: Blood Pressure: 130/68, Pulse: 68; Respirations: 18; Temperature: 96.8; Oxygen saturation: 94%Review of R702's HCP orders and MAR for [DATE] revealed the Resident was receiving the following:- Lasix 10 mg daily upon rising (Start Date: [DATE])- Potassium chloride capsule, extended release, 30 meq (milliequivalents) twice a day (Start Date: [DATE])- Spironolactone (potassium sparing medication used to treat and manage fluid retention) 50 mg daily upon rising (Start Date: [DATE])- Torsemide (medication used to reduce fluid retention by increasing urine output) 40 mg daily upon rising (Start Date: [DATE])- Metolazone (medication used to reduce swelling and fluid retention by increased urine excretion) 5 mg daily upon rising (Start Date: [DATE])Review revealed R702 had been receiving Bumex (medication used to treat excess fluid) from [DATE] until [DATE].Review of Laboratory Testing Results in R702's EMR revealed a Basic Metabolic Panel (BMP) was completed on [DATE] with the following results:- Sodium: 129 (low - normal 136-144)- Potassium: 4.7 (normal 3.4-5.0)- Blood Urea Nitrogen (BUN- blood test used to evaluate how well kidneys are functioning): 43 (elevated - normal is 10-23)- Creatine (blood test used to evaluate how well kidneys are filtering waste and functioning): 1.23 (elevated- normal is 0.60 -1.10)Review of R702's BMP results dated [DATE] revealed the Resident's potassium level was 4.2 and their sodium was 131.Review of R702's HCP orders for laboratory testing revealed an order dated [DATE] for a BMP to be completed every two weeks on Tuesday indicating a BMP should have been completed on [DATE]. There were no results in Resident #701's EMR for a BMP on [DATE].An interview was completed with LPN K on [DATE] at 9:30 AM. When asked what occurred when R702 was transferred to the hospital on [DATE], LPN K reviewed their documen

Based on observation and record review the facility failed to properly dispose of waste and maintain dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include: On 03/10/2026 at 2:05 PM observed both dumpsters full of garbage and due to the volume of garbage in the dumpsters, the lids would not close. Fourteen bags of garbage and eight empty cardboard boxes were noted sitting on the ground behind one of the full dumpsters. Record review of facility email communications with the garbage disposal company notes that pick up wash scheduled for Friday March 6th, and the pick-up never occurred.

Based on observation and interview, the facility failed to maintain general repair of the premise. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents in the facility. Findings include:On 03/10/2026 at 12:59 PM observed the drain line from the three-compartment sink indirectly connected to the floor drain by means of a rubber adapter. Dietary Manager (DM) B was asked if raw vegetables were used in the facility and if so, where they were washed. DM B stated, Vegetables come in fresh and were washed in the third compartment of the three-bin sink. DM B said the rubber adapter was in place to prevent splashing onto the floor. On 03/11/2026 at 8:40 AM observed the drain lines coming from the ice machine extending down below the lip of the floor bowl drain. On 03/10/2026 at 2:18 PM observed water damage to the ceiling and wall just above and to the left of the entrance to the maintenance hall that leads to the kitchen, restrooms and employee back door entrance. Maintenance Director (MD) C stated that they had a service line leak recently which has been repaired and he has not had time to repair the walls and repaint yet. On 03/10/2026 at 2:20 PM observed the men's restroom wall with peeling paint on both sides of the sink and a buildup of dust and debris on the wall around the plumbing under the sink. Peeling paint was also noted in the toilet stall beside the toilet in this restroom. On 03/11/2026 at 9:33 AM observed day light coming in from under the maintenance hall rear exit door. The door sweep was observed damaged and was missing across the bottom right half of the door.

Based on interview and record review, the facility failed to ensure psychotropic medications were used to treat a specific, diagnosed, and documented condition for four residents (R8, R19, R46, and R49) of five residents reviewed for unnecessary medications. Findings include: Resident #46 (R46) Review of R46s EMR revealed physician orders for citalopram(antidepressant) 20mg (milligram) tablet, 1 tablet once a day upon rising and trazadone (atypical antidepressant) 50 mg tablet once a day upon retiring special instructions give 1/2 tab(tablet) equal to 25 mg PO (by mouth) QHS (every night at bedtime). Further review of the medical record, including physician orders, care plan, and diagnosis list, failed to identify a documented diagnosis or clinical indication to support the use of either medication. Resident #19 (R19) Review of R19's Electronic Medical Record (EMR) revealed physician orders for wellbutrin XL (antidepressant) 150 mg (milligram) tablet, 1 tablet once a day upon retiring (6:30 PM to 10:30 PM) and citalopram (antidepressant) 40 mg once a day upon rising (6:30 AM to 10:30 AM). Further review of R19's medical record failed to identify a documented diagnosis or clinical indication to support the use of either medication. Resident #8 (R8) Review of R8's EMR revealed initial admission to the facility on 8/2/19 with the following active psychotropic medication orders: Xanax (alprazolam) - Schedule IV [controlled substance] tablet; 0.25 mg; amt [amount]: 1 tab; oral, Three Times A Day, initiated 2/5/26. Zyprexa (olanzapine) tablet; 15 mg; amt: 1 tab; oral, At Bedtime, initiated 1/23/23. Further review of R8's medication orders did not indicate a specific, diagnosed condition the medications were being used to treat. The field labeled diagnosis on the medication order report was left blank. Resident #49 (R49) Review of R49's EMR revealed initial admission to the facility on [DATE] with the following active psychotropic medication orders: Quetiapine tablet; 25 mg; amt: 1 tablet; oral Once a Day, initiated 7/28/23. Venlafaxine capsule, extended release 24hr [hour]; 37.5 mg; amt: 1 cap [capsule]; oral, Special Instructions: Give with one 75mg cap Once a Day, initiated 1/10/25. Venlafaxine capsule, extended release 24hr; 75 mg; amt: 1 cap; oralSpecial Instructions: Give with one 37.5mg capsule, initiated 1/10/25. Further review of R49's medication orders did not indicate a specific, diagnosed condition the medications were being used to treat. The field labeled diagnosis on the medication order report was left blank. On 3/11/2026 at 10:05 AM, an interview was conducted with Nurse Practitioner (NP) F regarding protocol when writing a prescription for psychotropic medications. NP F stated she hand writes the script on a prescription pad, which includes an active diagnosis. NP F stated after that point, a different facility staff member enters the order into the EMR. When asked if prescribed medications were expected to treat specific, diagnosed conditions, NP F replied, Of course. On 3/11/26 at 10:58 AM, an interview was conducted with the Director of Nursing (DON) regarding the process of entering psychotropic medication orders into the EMR. The DON confirmed that an active diagnosis is not input into the EMR, but residents do have a care plan based on the psychotropic drug class. Review of the facility policy, Psychotropic Medication Use, reviewed 1/2025, read in, part: Residents are not given a psychotropic medication unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record. for psychotropic medications initiated after admission to the facility, documentation is to include the specific condition diagnosed by the physician.

Based on interview and record review, the facility failed to update or revise mobility and dietary care plan interventions in a timely manner for one Resident (#15) of fourteen residents reviewed for care plans resulting in the potential for unmet care needs.Findings include:Resident #15 (R15)Review of R15's electronic medical record (EMR) revealed initial admission to the facility on 8/12/11 with diagnoses including cerebral infarction (stroke), dysphagia (difficulty swallowing), dysarthria (difficulty speaking due to muscle weakness), traumatic brain injury, and cervicalgia (neck pain). Review of R15's most recent Minimum Data Set (MDS) assessment, dated 2/17/26, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment.On 3/9/2026 at 10:46 AM, R15 was observed sitting in a manual wheelchair inside his room. An electric wheelchair was observed in the corner of R15's room.On 3/9/2026 at 12:02 PM, a telephone interview was conducted with R15's guardian, Family Member (FM) I, regarding his mobility needs. FM I stated R15 hadn't been able to utilize his electric wheelchair for a couple years due to safety concerns which is why a manual wheelchair had been introduced as a seating alternative.Review of R15's Plan of Care revealed the following intervention initiated 8/20/20: [R15] is currently able to transport himself independently via electric wheelchair but does need help adjusting his wheelchair to get positioned correctly at the table as needed. Staff will assist transporting [R15] to/from activities as needed.On 3/11/2026 at 8:34 AM, R15 was observed receiving total assistance from Certified Nursing Assistant (CNA) E at the breakfast meal in the dining room. CNA E was observed utilizing standard cutlery and cups without lids to feed R15.Review of R15's tray card laying on the dining room table read, Beverages/Equipment: BUILT-UP UTENSILS ANGLED LEF[T]. Cups with handles and lids.On 3/11/2026 at 8:40 AM, CNA E was asked why R15 did not have the adaptive equipment as indicated on his tray card. CNA E stated R15 hadn't been able to feed himself for a while, so he no longer required the adaptive utensils as he was totally reliant on staff for feeding assistance.Review of R15's Plan of Care revealed the following interventions: Status of eating ability: independent after set up, initiated 12/12/2020. Assist with meals as needed, initiated 07/21/2020. Adaptive Equipment: Bulit-up Utensils angled left, Handled Cup w/ [with] sip thru lid for hot beverages, Divided Plate, [non-slip mat], initiated 09/07/2023.On 3/11/26 at 10:58 AM, an interview was conducted with the Director of Nursing (DON) who agreed residents' care plans should be routinely updated to reflect their most current needs and functional status.Review of the facility policy titled, Resident Comprehensive Care Plans, updated 5/24/22, read, in part: .The facility must establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. The comprehensive care plan must: . reflect changes in the residents' preferences and goals as they change throughout their stay. Updates will be made to the comprehensive care plan as needed.

Based on observation, interview, and record review, the facility failed to ensure functional positioning to carry out activities of daily living for one Resident (#15) of one resident reviewed for positioning.Findings include:Resident #15 (R15)Review of R15's electronic medical record (EMR) revealed initial admission to the facility on 8/12/11 with diagnoses including cerebral infarction (stroke), dysphagia (difficulty swallowing), dysarthria (difficulty speaking due to muscle weakness), traumatic brain injury, and cervicalgia (neck pain). Review of R15's most recent Minimum Data Set (MDS) assessment, dated 2/17/26, revealed a score of 10, indicative of moderate cognitive impairment.On 3/09/2026 at 10:46 AM, R15 was observed sitting in a wheelchair inside his room. R15 demonstrated a significant left lateral neck lean resulting in his left ear contacting his left shoulder and his chin positioned toward his left collarbone. A power wheelchair was observed in the corner of R15's room.On 3/09/2026 at 12:02 PM, a telephone interview was conducted with R15's guardian, Family Member (FM) I, regarding his positioning needs. FM I stated R15 could no longer utilize his power wheelchair due to safety concerns which is why a manual wheelchair had been introduced as a seating alternative. When asked about R15's neck positioning, FM 'I stated, They've [facility] been looking at [better] positioning for his head. They started looking last year and haven't seemed to make any progress.On 3/09/2026 at 12:47 PM, R15 was observed eating lunch in the dining room with a feeding assistant. R15 continued to demonstrate an excessive left lateral neck lean. Throughout the meal, R15 exhibited many episodes of wet coughing after taking a bite of food. On two different occasions, R15's face visibly turned a shade of red during a coughing episode.On 3/10/2026 at 12:16 PM, R15 was observed at the lunch time meal in the dining room and was assisted by Social Services Worker/Licensed Practical Nurse (LPN) J. R15 continued to be positioned with an excessive left lateral neck lean throughout the meal. R15 was observed clearing his throat, coughing, and producing a gurgled/wet vocal quality between bites of food. LPN J made no attempts to improve R15's posture or provide cues for compensatory swallowing techniques.On 3/10/26 at 1:33 PM, an interview was conducted with R15 regarding his positioning. When asked if it was difficult to eat in his current position, R15 was able to say, It's a problem. R15 was asked if his positioning in the wheelchair was painful and he replied, Sometimes. R15 demonstrated the ability to voluntarily bring his head to midline but was unable to maintain the positioning due to fatigue and muscle weakness.On 3/10/2026 at 1:45 PM, an interview was conducted with LPN J regarding R15's feeding assistance needs. LPN J stated R15 has been dependent on eating for a while and she usually helped assist him one-to-two times per week. LPN J indicated it is normal for R15 to cough and clear his throat while eating. When asked if this was a concern, LPN J stated, No. When asked about R15's positioning, LPN J stated, I don't like it. I'm not worried about the eating aspect, just worried about whether it would be uncomfortable or painful. To me, it looks uncomfortable. LPN J was asked if R15's positioning put him at increased risk of aspiration [choking] to which she replied, I don't know. Review of R15's Speech Evaluation and Plan of Treatment with a certification period of 1/7/25 - 2/25/25 read, in part: .Caregiver goals: to determine safest diet level and reduce overall aspiration risk. Position during eval [evaluation] = Posture impacts function, is modifiable with intervention. Recommendations: Compensatory Strategies/Positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: bolus size modifications and rate modification, along with the following maneuvers: upright posture during meals. Review of R15's Speech Therapy Discharge summary, dated [DATE], read, in part: .Discharge Recommendations and Status: To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: alternation of liquid/solids, bolus size modifications and rate modification, along with the following maneuvers: upright posture during meals. Prognosis to maintain CLOF [current level of function]: .good with consistent staff follow-through. Review of R15's plan of care, physician orders, and tray card revealed no speech therapy recommendations.On 3/10/26 at 3:06 PM, a telephone interview was conducted with Speech Language Pathologist (SLP) L regarding optimal positioning during meals. SLP L stated an upright position where the head is in midline is ideal for protecting the airway and mitigating the risk of aspiration. When asked for common signs of aspiration, SLP L stated, coughing, throating clearing, nose or eye running, or change in vocal quality during or after eating. SLP L stated any of these signs and symptoms would warrant a speech therapy evaluation.On 3/10/2026 at 2:43 PM, an interview was conducted with the Director of Rehabilitation (DOR) regarding therapy referrals. The DOR confirmed R15 had not been re-evaluated by speech therapy since his discharge on [DATE] as the therapy department had not received any reports of R15 choking or coughing during meals. The DOR stated, It's not really swallowing that's an issue, it's his positioning. So, we were working on things in OT [occupational therapy] like stretching or things like that.Review of an OT Discharge summary dated [DATE] read, in part: Patient was recently provided with a new wheelchair that was customized for him, however, [R15] presents with significant lateral lean to left impacting ability to perform self-feeding. Review of an OT Discharge Summary with dates of service between 11/13/25 - 1/16/26 and a PT [Physical Therapy] Discharge Summary with dates of service between 9/20/25 - 11/24/25 revealed no short or long-term goals addressing wheelchair positioning. On 3/11/2026 at 8:34 AM, R15 was observed eating breakfast with assistance from Certified Nurse Assistant (CNA) E with a continued left lateral neck lean. Several instances of throat clearing, wet cough, and gurgling sounds after taking a bite of food were heard with no intervention made by CNA E. On 3/11/26 at 10:58 AM, an interview was conducted with the Director of Nursing (DON) who understood the quality of life and aspiration concerns related to R15's positioning.Review of the facility policy titled, Dignity, reviewed 1/2022, read, in part: It is the policy of this facility to care for residents in a manner and in an environment that promotes maintenance or enhancement to each resident' [sic] quality of life, dignity, and respect in full recognition of his or her individuality. Social Service will monitor and observe for the following practices: . promoting residents' independence and dignity in dining.

Based on observation, interview and record review, the facility failed to implement fall interventions per the resident care plans for two residents (R19 and R49) of five residents reviewed for falls. Findings include: Resident #19 (R19) Review of R19's Electronic Medical Record (EMR) revealed admission to the facility on 1/29/25 with diagnoses including muscle weakness and history of falls. R19's 2/13/26 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 10/15, indicative of mild cognitive impairment. In Section J of R19's 2/13/26 MDS assessment, it was noted R19 had a fall with no injury in the look back period. On 3/9/26 at 11:05 AM, R19's room was observed to have a fall mat on the floor, with R19's bed against the wall and the bed at a hip height elevated position. R19 was not in her room at the time of the observation. On 3/10/26 at 10:51 AM, R19's room was observed to have a fall mat on the floor, with R19's bed against the wall. R19's bed was at a low-level position. R19 was not in her room at the time of the observation. On 3/11/26 at 9: 25 AM, R19's room was observed to have a fall mat on the floor, with R19's bed against the wall. R19's was not in her room at the time of the observation. On 3/11/26 at 9:30 AM, an interview was conducted with Registered Nurse (RN) D regarding R19's fall mat. RN D stated, The fall mat stays on the floor unless they are cleaning, I believe they keep it there all the time because she likes to self-transfer to her bed. On 3/11/26 at 9:45 AM, an interview was conducted with Certified Nurse Aide (CNA) E regarding R19's fall mat. CNA E stated, We keep it on the floor at all times because she tries to self-transfer. Review of R19's Care Plans, read, in part, Problem Start Date: 01/29/2025 Alteration in ADLs (Activities of Daily Living.Care Plan Approach Start Date: 01/29/2025.floor mat next to bed when in use (when resident is in their bed). Resident #49 (R49) Review of R49's EMR revealed initial admission to the facility on [DATE] with diagnoses including dementia, cerebral infarction (stroke), abnormalities of gait and mobility, muscle weakness, need for assistance for personal care, and hemiplegia of the left side (total or partial paralysis of one side of the body). Review of R49's MDS assessment, dated 10/10/25, revealed a BIMS score of 3, indicative of severe cognitive impairment. Further review of MDS Section J, Health Conditions revealed R49 experienced a fall in the look-back period (7/19/25 – 10/10/25). On 3/09/2026 at 10:56 AM, a gray fall mat was observed on the floor to the right of R49's bed. R49 was observed sitting in a wheelchair next to the fall mat. On 3/10/2026 at 10:50 AM, a gray fall mat was again observed on the floor next to R49's bed. R49 was not in the room. On 03/11/2026 at 9:06 AM, R49 was observed attempting to mobilize his wheelchair onto the fall mat which was laying on the floor. R49 experienced difficultly navigating the lip of the fall mat. On 3/11/2026 at 9:17 AM, an interview was conducted with CNA G regarding R49's fall interventions. When asked if R49's fall mat was supposed to remain on the floor throughout the day, CNA G replied, I'm still new [a new employee], but I think it stays down all day. On 3/11/2026 at 9:24 AM an interview was conducted with CNA H regarding R49's fall interventions. When asked if the R49's fall mat was supposed to remain on the floor through the day, CNA H replied, I don't work this hall, I would have to check his care plan. CNA H subsequently left the hall without checking R49's care plan and the fall mat remained on the floor. Review of R49's Plan of Care revealed a Problem initiated 1/5/21 that read, in part: At risk for falls and subsequent injury. with an approach that read, floor mat next to bed when in use, initiated 2/22/25. Further review of R49's EMR revealed the following physician's order, initiated 10/21/25: Floor mat next to bed while bed is in use. Check Q [every] shift for proper use and placement. On 3/11/26 at 10:58 AM, an interview was conducted with the Director of Nursing (DON) regarding fall interventions. The DON stated facility staff probably considered the fall mats low-profile and therefore not a fall risk or tripping hazard. The DON confirmed that all orders and care planned interventions should be followed as written including removing fall mats from the floor when R19 and R49 were not in bed. Review of the facility policy titled, Fall Prevention and Management Policy, reviewed 1/2025, read, in part: .Purpose: to assess resident risk for falls and implement interventions to reduce the incidence of falls and/to mitigate the risk of injury related to falls. When a fall event occurs, a license[d] nurse will: . implement an appropriate intervention/preventive measure.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection prevention and control practices when a nurse failed to properly don required Personal Protective Equipment(PPE), prior to providing treatment for one Resident (#32) of 5 residents reviewed for Enhanced Barrier Precautions(EBP). This deficient practice had the potential to increase the risk for spreading infection within the facility.Resident #32 (R32)Review of R32's Electronic Medical Record (EMR) indicated R32's latest admission was on 3/1/25. R32's orders indicated Enhanced Barrier Precautions (targeted gown and gloves use) during high contact resident care activities due to a PEG (Percutaneous Endoscopic Gastrostomy) tube (a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications, often called feeding tube.)During observation on 3/11/2026 at approximately 9:52 AM, Licensed Practical Nurse(LPN) A was observed entering R32's room, which had posted signage indicating EBP requiring the use of gown and gloves prior to providing care. LPN A lifted up R32's PEG tube without gloves on to place towel under it prior to flushing. LPN A trouble shot the blocked PEG tube and flushed 350ml(milliliters) of water through R32's PEG tube without donning a gown as required by posted signage. During an interview immediately post R32's treatment, LPN A stated until taking the ADON (Assistant Director of Nursing) position on 3/10/26 she was the primary day shift nurse who performed PEG tube flushes on R32. When asked if she typically wore EBP prior to flushing R32's PEG tube, LPN A stated EBP? This surveyor clarified donning gown and gloves prior to providing care, to which LPN A stated she normally forgets when it comes to R32's PEG tube. Review of the facility's policy Enhanced Barrier Precautions read in part .3. Implementation of Enhanced Barrier Precautions- .b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room .4. High-contact resident care activities include: .g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes etc.

Based on interview and record review, the facility failed to obtain consent for a psychotropic medication prior to initiation for one Resident (#31) of five residents reviewed for psychoactive medications. Findings include: Resident #31 (R31) Review of R31's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including cerebral infarction (stroke) and cognitive communication deficit. Review of R31's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicative of severe cognitive impairment. Review of R31's EMR revealed the following pharmacy order, initiated 1/10/25: Venlafaxine oral capsule [an antidepressant (psychotropic) medication], 112.5 mg (milligram), give 1 capsule, one time per day. On 1/15/25 at 8:37 AM, a phone interview was conducted with R31's legal guardian [Guardian D] who stated she had not signed a consent for psychotropic medication use nor was she educated on the risk and benefits. On 1/16/25 at 10:31 AM, an interview was conducted with Social Worker C who confirmed a psychotropic consent form for R31 had been, missed. On 1/16/25 at 1:00 PM, an interview was conducted with the Nursing Home Administrator (NHA) who confirmed residents who are prescribed a psychotropic medication should have a signed consent. Review of the facility policy titled, Psychotropic Medication Use, reviewed 1/2025, read, in part: .Residents and/or representatives will be educated on the risks and benefits of psychotropic medication use, as well as alternative treatments/non-pharmacological interventions .

Based on interview and record review, the facility failed to notify the resident and/or resident representative in writing with the reason for a transfer out of the facility for one Resident (#35) of five residents reviewed for transfer and/or discharge. Findings include: Resident #35 (R35) Review of R35's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including dementia and cognitive communication deficit. Review of R35's most recent Minimum Data Set (MDS) assessment, dated 1/5/25, revealed a Brief Interview for Mental Status (BIMS) score of 7, indicative of severe cognitive impairment. Review of the facility census report revealed R35 was hospitalized from 12/26/24 - 12/27/24 following a fall at the facility. On 1/16/25 at 10:38 AM, an interview was conducted with Business Office Manager (BOM) E who verified she was responsible for completing the necessary paperwork in the event a resident was transferred or discharged . BOM E confirmed R35 was hospitalized from 12/26/24 - 12/27/24 after a fall in the facility. BOM E stated a transfer notification had not completed for R35 as she was unaware of this requirement. On 1/16/25 at 1:00 PM, an interview was conducted with the Nursing Home Administrator (NHA) who verified the transfer notification process was not conducted in the facility as she was unfamiliar with the requirement. Review of the facility policy titled, Transfer and Discharge, reviewed 1/2025, read, in part: .when the transfer is initiated for the right reason, proper written notice will be provided to the resident. Written notice will contain the following content: Date notice is given to the Resident and Resident Representative, date of anticipated move, reason for the move, where the resident is to be moved, name, address, and telephone number of the ombudsman or other protection and advocacy agency as required or indicated by diagnosis, explanation of their right to appeal the transfer .

Based on observation, interview and record review, the facility failed to provide a physician order, care plan, and implement interventions to aide with edema (swelling due to excess fluid trapped in the body tissues) for one Resident (#12) of two residents reviewed for non-pressure related skin conditions. This deficient practice resulted in the potential for increase pain, swelling, and increase risk of skin ulcers. Findings include: Review of R12's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with readmission on 8/29/24 and diagnosis including acute respiratory failure, type 2 diabetes, kidney failure, and muscle weakness. Review of R12's 12/15/24 Minimum Data Set (MDS) assessment revealed a score of 12/15 on the Brief Interview for Mental Status (BIMS) score indicating R12 was cognitively intact. In Section M of R12's 12/15/24 MDS assessment, R12 was marked as having Moisture Associated Skin Damage (MASD). An observation on 1/14/25 at 11:34 a.m. revealed R12 sitting in his recliner chair with his feet elevated using the footrest. R12's lower legs and shins were noted to be deep purple in color and swollen. An interview with R12 was conducted to which he stated that his legs can become very swollen and painful. There was no type of wrapping noted on his lower legs. An observation on 1/15/25 at 9:32 a.m. revealed R12 sitting in his recliner chair with his feet elevated watching television. R12's lower legs were a deep purple color and swollen. There was no wrapping noted on his lower legs. An observation on 1/16/25 at 11:00 a.m. revealed R12 sitting in his recliner chair with his feet elevated. R12 had an ACE wrap on his right lower leg and his left leg had no wrap and was deep purple and swollen. An interview was conducted with R12 who stated that sometimes the nurses will wrap his legs, but it doesn't happen very often. An interview was conducted with Licensed Practical Nurse (LPN) F on 1/16/25 at 11:10 a.m. LPN F stated that she did wrap R12's right leg as it appeared swollen. When asked if there was a physician order to wrap R12's legs with ACE wraps, LPN F reviewed R12's EMR and stated that there was not. Review of R12's Care Plans read, in part, .Problem Start Date: 12/21/23 Potential for fluid imbalance, fluctuating weights and edema r/t (related to) diuretic medication . There were no interventions to wrap R12's legs using ACE wraps. An interview was conducted with the Director of Nursing (DON) on 1/16/25 at 12:59 p.m. The DON confirmed that R12's legs should be wrapped daily with ACE wraps to help with his lower leg edema.

Based on observation, interview, and record review, the facility failed to ensure appropriate assessment, interventions, and supervision were in place after a hot liquid spill for one Resident (#48) of 7 residents reviewed for accidents and hazards. This deficient practice resulted in the potential for continued spills and subsequent burns. Findings include: Resident #48 (R48) Review of R48's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including stroke, dementia, and osteoarthritis of both the left and right hands. Review of R48's most recent Minimum Data Set (MDS) assessment, dated 9/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. On 1/14/25 at 12:22 PM, R48 was observed at the lunch time meal consuming hot coffee out of a mug without a lid. Review of R48's EMR revealed the following progress note written by Registered Nurse (RN) G on 1/6/25 at 3:54 PM: Resident spilt hot coffee on his abdomen at breakfast . Abdomen slightly red . On 1/15/25 at 12:32 PM, R48 was observed at the lunch meal drinking coffee out of a mug without lid. R48 experienced difficulty grasping the mug handle as well as the fork, dropping yellow cake to the floor. On 1/16/25, at 8:40 AM, R48 was again observed drinking coffee out of a mug at the breakfast meal without a lid. On 1/16/25 at 10:48 AM, a telephone interview was conducted with RN G who verified she was working on 1/6/25 when R48 spilled hot coffee on his abdomen. When asked about typical facility procedure following a hot beverage spill, RN G stated, I should have completed an accident and incident report. RN G continued that typically, when a resident experiences a spill, a hot beverage assessment is conducted to assess if they require a lid or any other adaptive equipment to prevent future burns. When asked if this was completed after R48 experienced a spill, RN G replied, Not that I'm aware. Review of R48's EMR revealed the most recent Hot Food/Liquid Assessment was completed on 12/27/24. Review of R48's Occupational Therapy (OT) Evaluation, dated 1/8/25, revealed the following goal: Patient will exhibit improved fine motor coordination skills to facilitate patient's ability to perform functional grasp/release of daily living items .in order to facilitate follow-through with techniques and strategies and perform UB [upper body] ADLs [activities of daily living] with increased independence and safety with a baseline assistance level of, partial/moderate assistance. On 1/16/25 at 11:05 AM, an interview was conducted with the Director of Rehabilitation (DOR) H regarding R48's OT goals. DOR H stated R48 has really arthritic hands which contributed to R48 difficulty grasping and releasing daily living items including eating utensils, buttons, as well as cups and coffee mugs. On 1/16/25 at 11:26 AM, an interview with conducted with R48 who verified he experienced a coffee spill on 1/6/25. R48 stated, I have arthritis .my hands don't work! R48 confirmed he had difficulty holding on to eating utensils and coffee mugs stating, It's so painful. On 1/16/25 at 11:15 AM, an interview was conducted with the Director of Nursing (DON) who stated an accident and incident report was not completed because no injury occurred following the hot beverage spill despite the documented presence of skin redness. The DON confirmed R48 was not re-evaluated with a Hot Food/Liquid Assessment following the incident. After review of the OT assessment dated [DATE], the DON stated, He [R48] should probably have a lid. On 1/16/25 at approximately 1:00 PM, an interview was conducted with the Nursing Home Administrator (NHA) regarding R48's future safety with hot beverages. The NHA stated a Hot Food/Liquid Assessment was not completed following the coffee spill on 1/6/25 because the event was a, one-off. When asked how R48 was determined to not be at further risk of burn if a follow-up assessment was not completed, the NHA replied, It was discussed in IDT [interdisciplinary team meetings]. IDT meeting notes regarding R48's coffee spill incident was not provided to this Surveyor by survey exit. Review of the facility policy titled, Hot/Liquid Food Management, reviewed 1/2025, read, in part: It is the policy of this facility to manage resident consumption of hot liquids in order to prevent burns or resident injury . Residents will be evaluated upon admission, quarterly, and with change in condition for hot liquids and food spills . In the event of a burn event the following actions will be followed: . complete a 'Skin Incident Event' observation in the electronic medical record .

Based on observation, interview, and record review, the facility failed to follow transmission-based precautions for five (Residents #3, #5, #14, #35, and #41) of 14 residents reviewed for a gastrointestinal illness. This deficient practice resulted in the potential for transmission of infectious organisms to all 56 residents of the facility. Findings include: On 2/12/24 at approximately 9:30AM, an observation of contact and droplet isolation precaution signage was noted on the door of room numbers 18, 19, and 20. The contact precaution signage read, in part: EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . The droplet precaution signage read, in part: EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry . On 2/12/24 at 9:35AM, an interview was conducted with Certified Nursing Assistant (CNA) J. CNA J was asked why transmission-based precaution signage was posted on rooms [ROOM NUMBER] (R14). CNA J' indicated those residents had started experiencing gastrointestinal signs and symptoms including nausea, diarrhea, and vomiting which started the night before (2/11/24). On 2/12/24 at approximately 9:55AM an interview was conducted with Registered Nurse (RN) I. RN I indicated that R3, R29, R41, and R35 had just been placed on contact and droplet precautions due to new symptoms of nausea, vomiting, and diarrhea. Contact and droplet precautions signage was observed to be added to their respective doors. The following observations demonstrated breaches of the posted transmission-based precautions: On 2/12/24 at 9:58AM, RN I was observed entering R3's room for medication administration without personal protective equipment (PPE) indicated on signage including gloves, a gown, or eye protection. On 2/12/24 at 10:05AM, Nurse Practitioner (NP) L was observed entering R35's room without the indicated PPE. NP L was observed exiting R35's room several minutes later and entering R41's room without donning PPE indicated on the posted signage. On 2/12/24 at 12:55PM, RN I was observed entering R14's room without the PPE indicated on posted signage. On 2/12/24 at 1:13PM, lunch tray pass was observed on A Hall. CNA J was observed doffing PPE in R14's room, exiting the room without hand hygiene, and rolling the lunch cart down the hall. CNA J then delivered a lunch tray to an asymptomatic resident, R36, without hand hygiene upon entrance. On 2/12/24 at approximately 1:29PM, isolation and droplet precautions signs were noted on two additional doors, rooms 21 (R5) and 26. R5 was observed sitting in a recliner with a pink emesis basin in her lap. R5 was observed retching (dry heaving) into the emesis basin. On 2/12/24 at 1:30PM, the social services director (SSD) K was observed entering R5's room with only a surgical mask despite posted PPE signage. On 2/12/24 at 1:31PM, the Nursing Home Administrator (NHA) walked by R5's room. The NHA confirmed that R5's door signage indicated she was on droplet and contact precautions. The NHA indicated that SSD K should have gowned up prior to entering R5's room. The NHA stated, [SSD K], you're a department head. You should know better. SSD K acknowledged she should have donned PPE prior to entering R5's room. 34568 An interview was conducted with Infection Preventionist (IP)/Assistant Director of Nursing (ADON) M on 2/12/24 at 10:05 a.m. IP/ADON M stated that the GI issues started yesterday on 2/11/24 with 14 residents feeling symptomatic. An interview was conducted with the NHA on 2/12/24 at 10:15 a.m. The NHA stated she was made aware of residents coming down with illness the night of 2/11/24 and initiated for staff to wear PPE on 2/11/24. On 2/12/24 at 12:55 p.m. CNA N was observed passing meal trays in the hallway. CNA N entered room [ROOM NUMBER] with their meal and exited without washing or sanitizing her hands. CNA N entered room [ROOM NUMBER] with their meal and exited without washing or sanitizing her hands. CNA N then entered room [ROOM NUMBER] with their meal and exited without washing or sanitizing her hands. On 2/12/24 at 1:02 p.m. CNA N was observed walking into a Transmisison Based Precaution room without wearing the appropriate PPE. 13791 On 2/12/24 at approximately 10:10 AM, an interview with Certified Dietary Manager (CDM) F was conducted. It was learned at this time Kitchen Staff (KS) G had called in and reported experiencing symptoms of Gastrointestinal (GI) distress, including vomiting and diarrhea. KS G did not report for work on this day. CDM F stated KS G had last worked in the kitchen on the previous Friday (2/9/24) and had not reported any GI symptoms at that time. On 2/12/24 between approximately 9:15 AM and 10:00 AM, morning meal trays were observed being removed from resident rooms 18, 19, 20, 25, 27, 31, & 32. These rooms were posted with Contact Precautions signage due to residents exhibiting GI symptoms of vomiting, nausea and diarrhea. All trays were observed to have plates, glasses, cups and flatware and open to the air. At approximately 12:15 PM the same day, trays were being collected from residents' rooms following the noon meal. No isolation were being implemented to ensure the dishes and trays being removed from the posted rooms. At approximately 1:00 PM an interview with the Nursing Home Administrator (NHA) was conducted related to the collection of food delivery trays to residents' rooms posted as isolation. The NHA stated that she had just spoken with the corporate consultant and had been informed that all dietary items removed from the isolation rooms identified with contact Precautions were to be bagged before being returned to the kitchen. Staff then began using plastic bags to collect and transport dietary trays. On 2/12/24 a review of the dietary Food Usage/Temperature sheet was conducted. During this review it was learned that documentation of temperatures for food served on 2/10/24 and 2/11/24 were blank. These log sheets are used to document food met temperature requirements (greater than 135 F for hot food and below 41 F for cold food) for the control of pathogenic organisms. On 2/12/24 at approximately 11:30 AM, CDM F confirmed the log sheets are to be completed by cooks and the ones provided were missing the documentation for proper food safety. DPS B Based on observation and interview the facility failed to ensure that staff followed proper infection control per standards of practice with dressing changes for one (Resident #47) of one resident reviewed for wound care. This deficient practice resulted in the potential for the spread of infectious organisms into the wound environment. Findings include: Resident #47 (R47) Review of R47's MDS indicated resident is in facility due to recent surgery to repair fracture of pelvis and/or hip. On 2/12/24 at approximately 10:22 AM, LPN H was observed changing the wound dressing of R47. LPN H donned a pair of gloves, then removed the dirty bandage from R47's wound. LPN H proceeded to wear the same gloves to cleanse, wipe off wound, and place a clean bandage to incision site. One pair of gloves were worn from the beginning of the wound care treatment to the end. When asked about process of changing of gloves during wound care, LPN H felt the steps they followed for this dressing change were correct. This breach in infection control practices increased the risk of cross-contamination and surgical wound infection. LPN H was unaware of the requirement to change gloves and perform hand hygiene between old dressing removal and cleansing/application of a new wound dressing per standards of practice.

Based on observation, interview, and record review, the facility failed to provide proper infection control measures pertaining to indwelling catheters (a tube inserted into the bladder to accommodate emptying of the bladder) for two Residents (#2, #50) of three residents reviewed for indwelling catheters. This deficient practice resulted in the potential for infections and illness due to improper catheter care. Findings include: Resident #2 (R2) Review of R2's Electronic Medical Record (EMR) revealed an admitted [DATE] with diagnoses including cerebral palsy and overactive bladder. R2's 1/5/24 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating she was cognitively intact. R2 was also marked yes for the use of an indwelling catheter. On 2/12/24 at 9:00 a.m., 10:20 a.m., and 1:45 p.m., R2 was observed sitting in her wheelchair in her room with her door open leading to the hallway. R2's catheter tubing was observed touching the floor underneath her wheelchair and loosely attached to R2's leg. On 2/13/24 at 9:44 a.m. and 10:36 a.m., R2 was observed sitting in her wheelchair in her room. R2's catheter tubing was observed touching the floor underneath her wheelchair and loosely attached to R2's leg. Review of R2's Care Plan dated 1/19/24 read, in part, (R2) requires an indwelling catheter r/t (related to) urinary retention .approach start date: 1/19/24 Do not allow tubing or any part of the drainage system to touch the floor. An interview was conducted with Infection Preventionist (IP) /Assistant Director of Nursing (ADON) M on 2/14/23 at approximately 9:30 a.m. IP/ADON M stated that she observed R2's catheter tubing being on the floor underneath her wheelchair and this morning was able to securely clip the tubing so that it wouldn't be on the floor anymore. IP/ADON M confirmed that the catheter tubing on the floor could lead to a potential infection. Resident #50 (R50) Review of R50's EMR revealed an admitted [DATE] with diagnoses including acute kidney failure and benign prostatic hyperplasia. R50's 1/23/24 MDS assessment revealed a BIMS score of 13/15 indicating he was cognitively intact. R50 was also marked yes for the use of an indwelling catheter. On 2/12/24 at 11:03 a.m., R50 was observed laying in his bed asleep. R50's catheter tubing was observed to be on the floor and draped over the bed side table wheels. R50's catheter bag was out of its privacy bag laying on the floor. Two unidentified staff members walked past R50's room without assisting R50. This observation lasted approximately 20 minutes before a staff member went into R50's room to assist him. Review of R50's Care Plan dated 1/18/24 read, in part, .(R50) requires an indwelling catheter r/t urinary retention. (R50) will take his drainage bag out of dignity bag at times .approach start date: 2/12/24 Remind (R50) to leave drainage bag in dignity bag. If noticed out on the floor put back into dignity bag .approach start date: 1/18/24 Do not allow tubing or any part of the drainage system to touch the floor . An interview was conducted with the Nursing Home Administrator (NHA) on 2/14/24 at 9:00 a.m. The NHA stated that R50 was known to take his catheter bag and place it on the floor and that it he was care planned for this behavior. This Surveyor was not made aware that this intervention was added the day of the 20-minute observation. A request was made for the facility catheter policy on 2/13/24. The facility provided a checklist for Giving Catheter Care and Emptying a Urinary Drainage Bag. There was nothing in the policies regarding keeping catheter tubing off the floor.

Based on observation, interview, and record review, the facility failed to properly secure an oxygen tank (a metal cylinder that stores oxygen under pressure) for one Resident (#26) of two residents reviewed for oxygen services. This deficient practice resulted in the potential for an oxygen tank valve to become damaged and turn into a projectile with the potential for serious injury, harm, or death. Findings include: Resident #26 (R26): Review of R26's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a disease that causes airflow limitation to the lungs). Review of R26's orders indicated, oxygen per Nasal Cannula at 2 liters continuous . On 2/12/24 at 9:24AM, R26 was observed sitting in a wheelchair in her room with an oxygen tank in a carrier pouch that was looped over the wheelchair push handles. The loops were observed hanging on the flat part of the handles where the loops could easily slip off. R26 was observed turning her wheelchair to navigate the room when the carrier pouch loops slipped off the wheelchair push handles causing the oxygen tank to crash to the floor. R26 was startled and immediately stated, How did that happen? Why wasn't it [the oxygen tank] secured? On 2/12/24 at 9:27AM, Certified Nursing Assistant (CNA) J entered R26's room and observed the oxygen tank on the floor. CNA J stated, I don't know why that thing fell , that's dangerous. Review of facility policy titled, Oxygen Therapy reviewed 1/2024 read, in part: .Facility will ensure that oxygen will comply with State and National Fire Safety Requirements. Review of the National Fire Protection Association (NFPA) Health Facilites code read in, part: .oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve or safety device . Review of Oxygen Cylinders: Storage and Handling by [Name Brand] Medical Equipment & Supply read, in part: .cylinders should be stored with valves closed and their protective caps in place, and they must be secured to prevent tipping .if the cylinder valve is damaged when a cylinder falls, the cylinder can become a missile with a 1 ton thrust .Be sure the cylinder is secured in a pouch, use a cylinder stand, chain, rope or other device to keep the cylinder from falling over .

Based on observation, interview, and record review, the facility failed to adequately monitor a change in condition after a fall for one (Resident #1) of three residents reviewed for a fall with injury. This deficient practice resulted in a delay in the treatment of a hip fracture and a prolonged period of sustained intractable pain. Findings include: This citation pertains to intake MI00142046. Resident #1 (R1) Review of R1's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including age-related osteoporosis (a condition in which bones become weak and brittle), fracture of first lumbar vertebra (a bone in the lower spine), and ankylosing spondylitis of the thoracic region (a type of arthritis that causes stiff, painful joints in the mid-back). Record review of R1's most recent Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 14, indicative of intact cognition. On 1/16/24 at approximately 11:33 AM, R1 was observed sitting in a wheelchair with a [Name Brand] total lift sling placed underneath him. On 1/16/24 at approximately 11:35 AM, an interview was conducted with R1. R1 reported on 12/29/23, certified nursing assistant (CNA), F assisted him with a transfer using a walker to the edge of the bed. R1 stated that CNA F left him unattended at the edge of the bed when she walked around the opposite side of the bed to retrieve an item. R1 reported falling off the side of the bed and landing on his left side and immediately experienced excruciating low back pain and pain in his left leg. R1 reported he required a mechanical lift to be transferred off the floor. Review of a Fall Statement dated 12/19/23, by CNA F read in part, I witnessed his fall and was behind him. I was leaning across the bed to adjust its height and he went backwards. I tried catching him but he fell too fast. On 1/16/24 at approximately 11:45 AM, an interview was conducted with R1's Family Member (FM) A, who verified that facility staff had notified FM A of R1's fall and reported R1 was unharmed. FM A reported when she arrived to visit the next morning (12/30/23) she found R1 in extreme pain in his hip and low back. FM A subsequently located the floor nurse and requested pain medication. On 1/16/24 at approximately 12:25 PM, an interview was conducted with Physical Therapist (PT), I, who reported he attempted to treat R1 on 12/31/23 for a scheduled therapy session but elected to move his session to a different day due to R1's reports of intense pain. Review of documentation provided to this Surveyor described as a therapy communication from PT I to Director of Rehabilitation (DOR), J on 12/31/23 at 1:39 PM which read, [R1] had a fall on 12/29/23. I was supposed to see him today for a progress note but he stated that he is still in so much pain in his L (left) side this time (sic) . PT I reported on 1/2/24, he followed up with R1 and was concerned that R1 required an assist of two staff members for bed mobility and was unable to complete a sit to stand transfer at a walker due to low back and left groin pain. PT I indicated R1 was able to perform the same functional tasks with supervision prior to the fall on 12/29/23. Review of Physical Therapy Treatment Encounter Note dated 1/2/23 read, in part: Attempted sit to stand @ (at) FWW (front wheeled walker) and with therapist in front of him from bed with height of bed raised and patient was unable to complete due to 10/10 pain in low back and L groin .Nurse [Licensed Practice Nurse (LPN) H] made aware of patient's complaint of L groin pain. Recommended use of total lift for w/c<>bed (wheelchair to/from bed) transfer .Patient reported 7/10 pain in low back and L groin while he was in bed and 10/10 pain in B (both) areas with movement prior to taking pain medication. He reported 5/10 pain in low back at rest and 10/10 pain in L groin with movement after taking pain medication at least 1 hour prior. Patient declined to participate in functional activities .due to pain. Review of progress note documented by LPN H dated 1/2/24 at 6:15 PM revealed, Resident had fall on 12/29/23, he has increase pain in his lower back today. On call provider was notified, she ordered an x-ray of the sacral coccyx (area of the low back frequently referred to as tailbone) area. On 1/16/24 at 3:29 PM, a phone interview was conducted with LPN H. LPN H verified she received a report from PT I that patient was experiencing increased pain in his low back and left groin. LPN H reported she notified the on-call provider. When asked why the report of pain in R1's left groin was not documented or reported to the on-call provider, LPN H was unable to provide a reason and acknowledged it was, probably overlooked. LPN H acknowledged that groin pain could be indicative of possible hip fracture. Review of R1's orders revealed a STAT (immediate) radiology order for lumbar, sacrum, and coccyx x-rays on 1/3/24. Review of facility fax, dated 1/4/24 at 12:36 AM from [contracted radiology service], revealed an amended report which read, in part, .IMPRESSION LUMBAR SPINE .no recent fracture or dislocation .IMPRESSION: SACRUM and COCCYX: No recent fracture or dislocation . On 1/16/24 at approximately 4:15 PM, an interview was conducted with the DON. The DON was asked what her expectation would be if a resident with osteoporosis reported pain in new location after a fall. The DON replied, My expectation would be for it to be x-rayed. The DON confirmed the radiology order on 1/3/24 included lumbar, sacrum, and coccyx x-rays. The DON was asked why a hip x-ray was not ordered for R1 immediately after complaints of left groin pain and stated, I don't know. I can't answer that. Review of skilled therapy documentation read, in part: 1. Occupational Therapy Treatment Encounter Note, 1/2/24: Patient in pain w/ (with) pain med (medication) already administered .required max assist (caregiver assists with approximately 75% of task) to lift BLE (bilateral lower extremities) off of foot-rest . 2. Physical Therapy Progress Note, 12/11/23 - 1/2/24: Patient is currently needing total lif (sic) for transfers related to increased pain in his low back and L groin area related to a fall on 12/29/23. 3. Occupational Therapy Treatment Encounter Note, 1/4/24: Patient experiencing increased pain in LLE (left lower extremity) from prior fall. X-ray indicated. 4. Physical Therapy Treatment Encounter Note, 1/4/24: No transfers done today secondary to increased pain in LLE. On 1/16/24 at approximately 12:45 PM, an interview was conducted with DOR J. DOR J reported during a morning managerial meeting on 1/2/24, it was conveyed to the interdisciplinary team concerns of functional regression related to pain in his left groin. Review of R1's orders on 1/5/24 revealed a STAT (immediate) radiology for a left hip and pelvis x-ray approximately five days after R1's initial report of left sided pain to PT I and approximately three days following reports of left groin pain to LPN H. Review of facility fax, dated 1/6/24 at 12:04 PM from [contracted radiology service], revealed an amended report which read in part, .IMPRESSION LEFT HIP: Possible impacted intertrochanteric fracture (fracture of the hip) with follow-up for confirmation .IMPRESSION PELVIS: Possible impacted intertrochanteric fracture of the proximal left femur with follow-up for confirmation. Review of a Root Cause Analysis, dated 1/10/24, documented by the Director of Nursing (DON) read, in part, Once this report was received [radiology report], the on-call provider was notified .gave verbal orders to the nursing staff to send [R1] to the [facility name] Emergency Department for further evaluation . [local hospital] ER (emergency room ) did confirm a left hip fracture and [R1] was sent to [higher level of care hospital] for surgical intervention. Further review of R1's orders revealed the following: 1.Oxycodone - schedule II (a narcotic used to treat moderate to severe pain) tablet, 5 mg (milligrams), one tab (tablet) every 6 hours as needed for severe pain. 2.Tramadol - Schedule IV (an opiate used to treat moderate to severe pain), tablet, 50 mg, 1 tab, take every 6 hours as needed for moderate pain. Review of the Medication Administration Record (MAR) and controlled substance sign-out documentation from 12/1/23-12/28/23 (prior to R1's fall on 12/29/23) revealed R1 rarely requested more than two doses of oxycodone. Except for 2 out of 28 days when R1 requested three doses of oxycodone on 12/1/23 and 12/21/23. Further review of R1's MAR and controlled substance sigh-out documentation from 12/30/23 -1/5/24 (the day after R1 fell on [DATE] until R1 was sent to the emergency roiagnom on [DATE]), revealed R1 requested more than two doses of oxycodone on 4 out of 6 days as follows: A. On 1/30/23 and 1/4/24, R1 requested 3 doses of oxycodone. B. On 1/2/24 and 1/3/24, R1 requested 4 doses of oxycodone (2 of which were documented as not effective). Review of R1's MAR and controlled substance sign-out documentation dated 12/1/23-12/28/23 (prior to R1's fall on 12/29/23) revealed, R1 requested tramadol on 11 days out of 28 days. R1 also requested more than one dose on only two days (12/8/23 and 12/28/23). Further review of R1's MAR and controlled substance sigh-out documentation from 12/30/23 -1/5/24 (the day after R1 fell on [DATE] until R1 was sent to the emergency roiagnom on [DATE]), revealed R1 requested at least one dose of tramadol on 7 out of 7 days. R1 also requested two doses of tramadol on 4 of 7 days (12/30/23, 12/31/23, 1/1/24, and 1/4/24). On 1/16/24 at approximately 4:15 PM, an interview was conducted with the DON regarding R1's pain management. The DON confirmed there was in increase in R1's pain medication usage after his fall. On 1/16/24 at approximately 4:30 PM, an interview was conducted with the DON regarding R1's change in pain characteristics and subsequent delay in receiving a diagnostic x-ray. The DON acknowledged there was a breakdown in communication between the therapy department, floor nursing staff, the interdisciplinary team, and the physician. Review of facility policy titled, Pain Management Policy reviewed 1/2024, read in part, .7. The provider will be notified if comfort is not achieved following pain management interventions, for changes in pain characteristics, and/or with new onset pain or breakthrough pain.

This citation pertains to intake MI00142046 Based on observation, interview, and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for one (Resident #1) of three residents reviewed. Findings include: Resident #1 (R1) Review of R1's physician's orders revealed Tramadol 50 mg (milligrams) oral tablet give 1 tablet every 6 hours as needed for moderate pain and Oxycodone 5 mg oral tablet give 1 tab every 6 hours as needed for severe pain. Review of R1's controlled substance proof of use sheets for oxycodone dated 11/26/23, 12/3/23, 12/13/23, 12/20/23, 1/1/24, and 1/2/24 and R1's E-Mar for the months of December 2023 and January 2024, revealed that during the following dates and times nursing staff failed to sign out R1's oxycodone in both documentation areas per facility policy on: 1. 12/6/2023 at 7:20 p.m., one tab dispensed. 2. 12/9/2023 at 8:00 a.m., one tab dispensed. 3. 12/17/2023 at 8:00 a.m. and 7:00 p.m., one tab dispensed. 4. 12/22/2023 at 7:45 a.m., one tab dispensed. 5. 1/1/2024 at 10:45 a.m., one tab dispensed. 6. 1/6/2024 at 8:00 a.m., one tab dispensed. 7. 1/13/2024 at 8:30 p.m., one tab dispensed. 8. 1/14/2024 at 9:00 p.m., one tab dispensed. 9. 1/2/2024 at 10:03 p.m., one tab dispensed. 10. 1/2/2024 at 10:05 p.m., one tab dispensed. Review of R1's-controlled substance proof of use sheets for tramadol dated 11/17/23 and 12/3/23 and R1's E-Mar for the month of December 2023, revealed that during the following dates and times nursing staff failed to sign out R1's tramadol in both documentation areas per facility policy on: 1. 12/16/2023 at 8:17 p.m., one tab dispensed. 2. 12/28/23 at 3:08 a.m., one tab dispensed. These discrepancies in documentation made it difficult to evaluate if R1 had pain adequately controlled, both prior to R1's facility fall on December 29, 2023, and after. On 1/16/24 at 11:30 a.m., Rl was observed in their room visiting with their spouse. R1 was in a wheelchair with mechanical lift sling in place between R1 and the wheelchair. During an interview at the time of this observation, R1 stated they experienced increased pain compared to their typical back pain after the fall on December 29, 2023. R1 stated, the next morning when staff attempted to them up, R1 indicated they could not sit up to the edge of the bed due to the level of pain. R1's spouse stated when they arrived that morning R1 was screaming in pain. On 1/16/24 at 4:15 p.m. during an interview with the assistant director of nursing (ADON) and the director of nursing (DON), they stated the controlled substance proof of use sheet and the E-MAR were correct as far as they knew; they stated it was expected that both documents should be signed out at the time controlled medications are dispensed. The ADON and DON were presented with the documentation concern by this Surveyor and confirmed nursing staff were not signing out controlled medications correctly per facility policy including not consistently providing before and/or after pain ratings following administration. Review of (facility) policy, controlled substances standards of practice, dated 9/2022, read in part that a proof of use sheet should be received for each form of controlled substances. Nurses removing controlled substances from the narcotic storage require documentation on the proof of use sheet, amount removed using last name and signature. Once the nurse completes the administration, then the nurse is to document on the electronic medical administration record (E-Mar). If PRN (as needed) medication is administered, additional documentation regarding reason, result, time, and initials are required. If documentation is not provided on E-Mar, medication will be considered not given. E-Mar is record of administration NOT the proof of use sheet .

Based on observation and interview, the facility failed to ensure exhaust ventilation was functioning in 20 sampled resident bathrooms, serving 36 of a total 58 resident rooms. This deficient practice has the potential to result in noxious odors permeating the resident environment rendering the living conditions unpleasant and uncomfortable. Findings include: On 11/15/21 at 12:30 PM, in response to the presence of noxious odors on the A wing, an investigation was initiated into determining the functioning of the exhaust ventilation system for resident bathrooms. The bathrooms serving the following rooms were inspected for functioning exhaust by placing a paper towel over the ceiling mounted duct cover and determining if there was adequate negative pressure to hold the paper in place. The failure to hold the towel in place was deemed a failure for that bathroom's exhaust system. This failure was noted in the bathrooms serving the following resident rooms: A: 10/12; 9/11; 5/7; 8, 4 B: 21/23; 22/24; 29/31; 30/32; 25/27; 26/28 C: 38/40; 37/39; 41/43; 45/47; 42/44; 46/48 D; 55/57; 58/60 On 1/04/23 at 11:45 AM, an interview was conducted with Maintenance Director (MD) A. MD A conducted a similar test for bathroom exhaust function and confirmed there was not any negative pressure in the duct resulting in no exhaust from the bathroom. MD A stated he was unaware of the non-functioning exhaust system. When asked about the frequency of testing and observing for the functioning of the exhaust, MD A stated he observed the exhaust system motors once every three months and tested on e bathroom exhaust at the same time.

Based on observation, interview and record review, the facility failed to ensure an effective infection prevention and control program to include complete and accurate surveillance of an outbreak of respiratory illness affecting six Residents (#4, #9, #6, #2, #23 and #28) of seven residents reviewed for infections. This deficient practice resulted in the potential for transmission of respiratory illness and delay of treatment. Findings include: Resident #4 An observation on 1/3/2022 at 10:08 a.m., revealed Resident #4 resting in a recliner in her room. Resident #4 was wearing a nasal cannula with tubing leading to a portable oxygen concentrator positioned on the left side of the Resident's recliner. Further observation of the oxygen concentrator revealed the Resident was receiving supplemental oxygen at two liters per minute (2L/min). During an interview at the time of the observation, Resident #4 reported she felt terrible and suffered from a bothersome cough. Resident #4 was observed to forcefully cough intermittently throughout the interview. A review of Resident #4's electronic medical record (EMR) revealed the following progress note, dated 12/28/2022 at 5:48 p.m. and signed by Nurse Practitioner (NP): Nursing staff called to report development of a wet cough, verbal orders given to administer 400 mg (milligrams) of (guaifenesin) (medication used to loosen mucous making it easier to expel with cough) PO BID (orally, twice daily) x 5 days . Further review of Resident #4's EMR revealed the following documentation: 1/03/2023 at 3:28 a.m. - She is very lethargic this evening. 1/03/2023 at 3:43 p.m. - Resident (complains of) coughing and SOB (shortness of breath) . lungs sounds are diminished . 1/03/2023 at 4:02 p.m. - Nursing staff called to report that the patient is starting to cough again . 1/04/2023 at 5:02 a.m. - She continues to have a cough and is on (guaifenesin) for another 3 days . On 1/03/2023 at approximately 3:00 p.m., the Assistant Director of Nursing (ADON) presented a binder containing the facility infection surveillance documents to include January 2022 through January 2023. A review of the facility's December 2022 infection surveillance as provided by the ADON revealed no documentation of Resident #4's upper respiratory illness included on the infection line listing (tracking list of infections) or mapping. The ADON reported she was training in the role of Infection Preventionist and worked on the December infection surveillance with the Director of Nursing (DON), who was not present in the facility on 1/03/2023. During an interview on 1/4/2023 at 1:01 p.m., NP O reported a recent outbreak of respiratory illness in the facility in December 2022. NP O stated resident's exhibiting signs and symptoms of respiratory illness were tested for Covid -19 and found to be negative. When asked if residents with signs and symptoms of respiratory illness were tested for influenza, NP O reported residents were not tested for influenza because they did not exhibit typical signs of influenza such as fever, lethargy and body aches in addition to cough and sore throat. NP O stated she was aware of an unidentified respiratory virus circulating within the surrounding communities and believed the outbreak in the facility to be related to the same. Resident #9 12/02/2022 at 11:54 a.m. - (Resident) had c/o (complaints of) feeling weak and SOB (shortness of breath at times) . stated he felt head congestion . 12/05/2022 at 6:29 p.m. - Patient is being seen today for follow-up of cough . he does report non-productive cough is lingering and feels sinus congestion/pressure with occasional clear nasal discharge . Influenza A and B are both negative . Review of Systems: Ears/Nose/Mouth/Throat - Positive: Congestion . Respiratory - Positive: Cough . Assessment and Plans - Cough, unspecified . start 200 mg (guaifenesin) (every 4 hours) x 5 days . 12/12/2022 at 6:04 p.m. - Patient has been using his wheelchair to ambulate more as he is still feeling a little weak after his upper respiratory infection last week . Resident #6 12/06/2022 at 1:01 a.m. - (resident) is (complaining of) sore throat . (respirations) are labored . Covid test done with negative results. 12/07/2022 at 7:20 p.m. - Rhonchi (lung sounds characterized by gurgling or bubbling, indicative of fluid in airway often caused by viral upper, respiratory infections) heard bilaterally (right and left lungs) cleared with some coughing. Resident has an ongoing sickness and was given an order for (guaifenesin) today . 12/08/2022 at 6:54 p.m. - Resident remains on (guaifenesin) for congestion and cough . her lung sounds are diminished and course crackles (lung sound indicative of fluid in the small air sacs in the lungs) on inhalation and expiration . 12/10/2022 at 11:04 a.m. - Patient is being seen today for follow up of telehealth reports of a cough, congestion and sore throat . Rapid Covid-19 swab ordered and was negative . she reports coughing less than yesterday . Review of Systems - General: Positive fatigue . positive congestions . positive cough . Assessments and Plans: Cough, unspecified . Nasal congestions . Acute pharyngitis (inflammation of the throat typically caused by respiratory viruses) . Resident #2 12/12/2022 at 6:14 p.m. - notified resident's guardian that he has started with a cough and some congestion, provider ordered a chest x-ray and (mucous) relief for 7 days . Resident #23 12/29/2022 at 5:41 a.m. - (resident temperature) 101.2 (degrees Fahrenheit). Tylenol . for elevated temp . 12/29/2022 at 11:19 a.m. - Nursing staff called to report fevers, wet cough and sore throat . routine covid-19 viral testing negative . start 400 mg (guaifenesin) (orally, twice daily) x 5 days . 12/30/2022 at 3:29 a.m. - she continues to have a cough and is receiving (guaifenesin) . Resident #28 1/03/2023 at 3:53 p.m. - Resident did run a low grade temp this morning, 100.7 (degrees Fahrenheit) . resident has increased coughing and congestion . (lung sounds) are crackles . resident has been resting in bed) . 1/03/2023 at 3:50 p.m. - Nursing staff called to report cough, congestion and fever . administer (guaifenesin) 400 mg (orally, twice daily) x 5 days . Assessments and Plans - Cough, unspecified. A review of the facility infection surveillance for December 2022 and January 2023 (as of 1/03/2023 at 3:00 p.m.) revealed no documentation of respiratory illness for Residents #9, #6, #2, #23 or #28. There was no record of the Resident's symptom onset, treatment course or symptom resolution included in the December 2022 and January 2023 infection line listing or infection mapping documents. There was no record of Resident #9 being tested for Influenza A and B in December 2022, as stated in the Resident's 12/05/2022 progress note. A review of the December 2022 Resident Infection Control Monthly report revealed the following, in part: 11 residents (with) 12 infections . Process Surveillance: no concerns identified during rounds, ongoing surveillance for Covid-19 . It was noted no inclusion of respiratory illness in December 2022 was listed in the report. During an interview on 1/04/2023 at 1:01 p.m., the ADON reported the residents presenting with signs and symptoms of respiratory illness in December 2022 were not included in the December infection surveillance due to the Residents only exhibiting signs and symptoms and not having a diagnosed respiratory illness. The ADON was unsure if the DON contacted the local health department for guidance related to multiple residents in the facility presenting with signs and symptoms of respiratory illness. During a telephone interview on 1/05/2023 at 10:58 a.m., the DON reported she did not review the infection surveillance for December 2022. The DON reported she was aware several residents exhibited signs and symptoms of respiratory illness in December 2022 but did not consider the illness an outbreak. When asked if she contacted the local health department for guidance related to multiple residents exhibiting signs and symptoms of respiratory illness in December 2022, the DON stated the Nursing Home Administrator (NHA) initiated all contact with the health department. During an interview on 1/05/2023 at 11:07 a.m., the NHA reported she was unaware several residents in the facility were treated for a respiratory illness in December 2022. A review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Guidance for Influenza outbreak management in Long-Term Care and Post-Acute Care Facilities, last reviewed 11/21/2022, revealed the following, in part: Surveillance: Older adults and other long-term care residents, including those who are medically fragile and those with neurological or neurocognitive conditions, may manifest atypical signs and symptoms of influenza virus infections (e.g., behavior change) and may not have a fever . influenza testing should occur when any resident has signs and symptoms of acute respiratory illness or influenza-like illness . A review of the facility policy titled Infection Control Program, reviewed 1/2022, revealed the following, in part: Infectious outbreaks are infrequent but can be potentially devastating. The two most likely and potentially most dangerous categories of epidemics and outbreaks are respiratory infections and gastrointestinal infections . Surveillance refers to a system for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics . Prevention and treatment begin with recognizing the kinds of infections that occur and the signs and symptoms of their onset. Infections among the residents are not always obvious. A review of the facility policy titled Influenza Prevention and Control, reviewed 1/2022, revealed the following, in part: 'A resident demonstrating symptoms of influenza require the following: . request order for laboratory testing to determine specific strain and antiviral susceptibility . conduce surveillance of other residents and staff for signs/symptoms .

Based on observation, interview, and record review, the facility failed to ensure care plans were updated and revised appropriately for two Residents (#39 and #15) out of 14 Resident care plans reviewed. This deficient practice resulted in care plans which did not reflect resident needs. Findings include: Resident #39 Resident #39 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease, depression, and existing pressure ulcers. The Minimum Data Set (MDS) assessment dated [DATE] and 11/15/22 both reflected: - Section C: a Brief Interview for Mental Status (BIMS) score of 13 indicative of intact cognition, - Section M: One pressure ulcer recorded as a stage two (a wound presenting as a shallow open ulcer with a red or pink wound bed) and two pressure ulcers recorded as unstageable wounds (known but wound beds covered) - Section E: Recorded as Resident #39 did not reject evaluation or care necessary to achieve goals for health and wellbeing. On 1/03/23 at 10:52 AM, Resident #39 was observed watching TV in his room sitting in his recliner with a protective cloth covering the chair, and with his stocking feet resting on the footrest. (No additional cushion was observed in the chair and no other foot protection was noted on the resident's feet.) He stated he had sores and was in pain. Registered Nurse (RN) B acknowledged Resident #39 had pressure ulcers on his heels which had been present on admission. RN B said this resident preferred to sit in his recliner. On 1/04/23 at 9:52 AM, Resident #39 was observed in his recliner watching TV in his room. While a pillow had been placed under his calves, Resident #39's stocking feet were not floating but were resting on the footrest. No additional cushion was observed under the resident, and he declined knowing about any cushion. No additional heel protection was observed. On 1/4/22, the Electronic Medical Record (EMR) was reviewed. The Care Plan on this date included two problems regarding skin breakdown. One problem with a start date of 8/3/22, revealed Resident #39 was at risk for skin breakdown and listed a goal for the skin to remain intact even though the resident had current skin breakdown. Another problem, also with a start date of 8/3/22, read (Resident #39) has an unstageable (pressure area) to right heel with potential for infection and discomfort to area . For this care plan problem, the interventions/approaches included: - Approach Start Date: 08/03/2022 heel protectors on at all times except for showers. - Approach Start Date: 08/03/2022 Pressure reduction cushion. - Approach Start Date: 08/03/2022 .Keep (Resident #39) off affected area as much as possible. - Approach Start Date: 08/03/2022 Use pressure reduction devices PRN (As Needed) for elevation of lower extremities/heels. During an interview on 1/04/23 at 10:28 AM, Certified Nursing Assistant (CNA) N stated, I do nothing special for (Resident #39's) feet. During an interview on 1/04/23 at 10:40 AM, CNA I was asked about care provided for Resident #39. CNA I stated, We get him up out of bed each morning and dressed. He likes his recliner. CNA I indicated Resident #39 was sitting on a protective cloth but nothing special was done for his feet. During an interview on 1/04/23 at 10:43 AM, RN B said there were no heel protectors or cushions needed for Resident #39 although he had them when he first came in. During an interview on 1/04/23 at 1:16 PM, the Director of Nursing (DON) confirmed the heel protectors had been discontinued. 40029 Resident #15 Resident #15's EMR revealed an admitted [DATE] and medical diagnoses which included dementia, depression, and anxiety. Resident #15's MDS assessment dated [DATE] revealed a BIMS score of 3/15, which indicated Resident #15 was severely cognitively impaired. The functional assessment portion of Resident #15's MDS assessment indicated Resident #15 could ambulate independently in the facility. An Elopement Risk assessment dated [DATE] contained the following information, in part, Is resident physically capable of eloping out of facility by walking or using an assistive device such as a wheelchair? [response to the question was yes]. If the answer to question 1 is yes, then continue with the assessment .Does the resident verbalize the desire to leave the facility or return home? [response was no] .Has the resident stood or sat at a locked door waiting for someone to let them out' when they go through the door? [response was no]. If the answer to last question is yes, has the resident attempted to go out the door unattended, [response was no]? A nurse's note written on 12/24/22 at 1:12 p.m. contained the following information, in part, Another resident was crying out and resident stated, you better not hurt my babies, or I will kill you. RN took her down to her room and resident told her that that man killed her 2 babies, and she will get him for that. Resident came back up to the nurse's station again and asked this writer to open the [expletives] door. I told resident I would not as it is bitter cold out and you would freeze. Resident then asked the RN and CNA to open the [expletives] door, both told her it was too cold to go outside. Resident then went to the front door trying to push door open . Resident#15's EMR indicated no additional Elopement Risk Assessment had been performed after the attempted elopement. Resident #15's care plan did not identify her as an elopement risk or include any interventions to reduce the risk of elopement. On 01/04/23 at 3:51 p.m. the DON reviewed the 11/2/22 Elopement Risk Assessment and said Resident #15 would have been higher risk for elopement because she was able to ambulate and potentially leave the facility. The DON said Resident #15 should have been identified at high risk for elopement because the response to question 1 (Is resident physically capable of eloping out of facility by walking or using an assistive device such as a wheelchair?) was yes. The facility's Elopement Prevention And Management Program policy dated 11/2018 contained the following information, in part, Indications of Resident Elopement, when a resident is observed to be actively exit seeking, then the resident will be placed on one to one supervision until the Interdisciplinary team can meet with responsible party/resident representative to discuss risks and appropriate interventions to ensure resident safety. Active Exit Seeking is defined as have the below behaviors at exits and attempting to open door and leave the facility. Resident that has the ability to independently exit, voicing they are leaving without physician orders and/or discharge planning . The facility policy titled: Resident Assessment Comprehensive Care Plans and dated as updated 11/26/2017 read in part, The facility must develop and implement a comprehensive person-centered care plan for each resident . the facility must establish, document, and implement the care and services to be provided to each resident to assist in attaining and maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives . Updates will be made to this printed comprehensive care plan as needed.

Based on interview and record review, the facility failed to provide vaccinations for 3 Residents (#15, #18, and #19) of 5 residents reviewed for vaccination status. This deficient practice resulted in Resident #15's five day hospitalization for pneumonia, [MEDICAL CONDITION], and [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). Findings include: On 12/17/19 at 10:37 AM, during an interview and review of the facility infection control program with Registered Nurse (RN)/ Assistant Director of Nursing (ADON) BB and the Director of Nursing (DON), documents were requested for five Residents (#15,#18, #19, #31, and #35) to review vaccination requirements. A review of the Consent for Vaccinations form provided by the facility for Resident #15 completed on 10/2/19 showed Resident #15 had received the Pneumococcal Conjugate Vaccine (PCV) 13 (strains) on 11/17/15. The same form indicated Resident #15 met criteria and consented to receive the Pneumococcal [MEDICATION NAME] Vaccine (PPSV) 23 (strains) vaccine. There was no documentation provided by the facility to show the PPSV 23 vaccine was given to Resident #15. A review of the Consent for Vaccinations form provided by the facility for Resident #18, completed on 9/13/19 lacked information regarding whether Resident #18 had received either PCV 13 or PPSV 23 pneumococcal vaccine. A review of the Consent for Vaccinations form provided by the facility for Resident #19 revealed the form was completed on 10/2/19. Resident #19 had received the PPSV 23 vaccine on 5/17/17. The same form indicated Resident #19 met criteria and consented to receive the PCV 13 vaccine. There was no documentation to show the PCV 13 vaccine was given to Resident #19. On 12/17/19 at 2:25 PM, a follow-up interview was conducted with RN ADON BB, regarding Pneumococcal and Influenza Vaccinations, and revealed the following: When asked when the review for vaccination status for Resident #19 had been completed, ADON BB stated, On 10/2/19. When asked since Resident #19 was due for the pneumococcal vaccine PCV 13, why the vaccine had not been administered, ADON BB stated, There is no good reason why. We (facility) ordered it (vaccines), and it (vaccines) just came in to the building, so he will get it (PCV 13 vaccine). There was none (vaccines) in the facility. (as of 12/17/19) When asked why there was an indication for Resident #15 to have PPSV 23 administered and why it had not been administered yet, ADON BB again stated, We (facility) didn't have any (vaccines) in the building, and now that it (vaccines) is here, (Resident #15) will get it (vaccine). When asked if there was a reason Resident #18 had not received any vaccines as of the consent for both pneumococcal vaccines dated 9/13/19 which indicated Resident #15 desired to receive both pneumococcal vaccines, ADON BB stated (Resident #15) could not be found in (State Vaccination Database) at all, meaning Resident #15 matched no entries in the database. ADON BB stated Physician R had asked to have Resident #15 verified in the database. ADON BB stated as of the interview time, Resident # 15's had not been clarified as directed by Physician R. A review of the Electronic Medical Record (EMR) for Resident #19 revealed a recent admission to the hospital for pneumonia on 11/17/19, and Resident #19 returned to the facility on [DATE]. A review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #19 dated 11/3/19 revealed the following: Resident #19 required limited assistance of one staff for bed mobility, personal hygiene, and dressing. Resident #19 required extensive assist of one staff for transfers, toileting, and bathing. There was no physical, occupational or speech therapy being provided at the time of this assessment. A review of the EMR Progress Notes section for Resident #19 revealed the following: 11/21/2019 6:01 PM Resident returned from the hospital where resident was admitted for acute resp (respiratory) failure, Resident. Resident will use [MEDICAL CONDITION] (bi-level positive airway pressure machine)during hs (hours of sleep) as ordered . (Registered Nurse (RN) A). 11/17/2019 7:45 AM (Certified Nurse Aide (CNA)) notified nurse of abnormal vital signs and poor responsiveness, on assessment (Resident #19) was lethargic (tired, weak, fatigue, lack of energy) to obtunded (cannot be fully aroused). (Lung Sounds) coarse Rhonchi (continuous low pitched rattling lung sounds often resembling snoring) bilat. (bilaterally) (RN CC) initiated 02 (oxygen) @ 3 L(liters)/min. (minute) via n.c. (nasal cannula) and gave (Resident #19) a blow by nebulizer treatment. (Physician R) was notified and ordered rebreather mask @ 10 L/min. 02 sat (saturation) remained low. also said check with (Family Member (FM) O) to see if we needed to send resident (#19) to hospital . (FM O) confirmed we should send (Resident #19). (Ambulance) notified (sic) and report given to (Acute Care Hospital). (Ambulance) responded and (Resident #19) was transferred to E.R. (emergency room ). (Licensed Practical Nurse (LPN) DD) . O (Objective): Resident (#19) is in bed with HOB (Head of Bed) elevated. (Resident #19) is alert. Mild conversational dyspnea . Skin is pale . Lungs there is wheezing noted in all fields anteriorly and posteriorly. Becomes short of breath with physical exertion. A/P (Assessment/Plan): Acute respiratory Infection: [MEDICAL CONDITION] vs Bacterial. CBC (Complete Blood Count) and BMP (Basic Metabolic Profile) to Lab, 2 view chest X-ray. [MEDICATION NAME] DM 10 ml (milliliters) tid (three times daily) x 3 days and q4h (every 4 hours) prn (as needed) x 7 days. [MEDICATION NAME] 2.5 mg (milligrams)/3 ml nebulized tid and q4h prn cough/wheezing. Consider antibiotics if pneumonia, steroids if indicated . 11/15/2019 2:47 PM . Created By: Family Nurse Practitioner-Certified (FNP-C) EE A review of the Hospital Summary for Resident #19 dated 11/21/19 at (4:16 PM) revealed the following: The column labeled Diagnosis - This Visit revealed [DIAGNOSES REDACTED]. Hospital Course: Sepsis secondary to gram negative pneumonia: (Resident #19) is a 66 yo (year old) . with past medical history of [REDACTED]. (Resident #19 was placed of IV [MEDICATION NAME] (antibiotic) and transitioned to [MEDICATION NAME] (antibiotic) on discharge for an additional 2 days . Acute metabolic [MEDICAL CONDITION] secondary [MEDICAL CONDITION] and hypercarbia (high carbon [MEDICATION NAME] in blood): Resolved with the resolution [MEDICAL CONDITION] and improvement of (Resident #19's) ventilation. Acute on chronic hypoxic [MEDICAL CONDITION]: Acute process secondary to gram negative pneumonia . (Resident #19) did require non invasive (not requiring entry into the body) ventilator therapy on admission but was able to wean down to room air prior to discharge. (Resident #19) was discharged on two more days of [MEDICATION NAME] (steroidal anti-[MEDICAL CONDITION]) . (Resident #19) was started on [MEDICATION NAME] (Steroidal Inhaler) and [MEDICATION NAME] (Inhaler). Type II NSTEMI: Demand ischemia (lack of blood flow) from respiratory distress [MEDICAL CONDITION] . Lactic acidosis secondary [MEDICAL CONDITION]: resolved with fluid administration. [MEDICAL CONDITION] secondary [MEDICAL CONDITION]: no signs of bleeding . A review of the Therapy notes for Resident #19 on readmission to the facility revealed the following: A review of Physical Therapy (PT) Plan Of Care (P[NAME]) document dated 11/22/19 revealed Resident #19 required skilled services to focus on . Therapeutic exercise . Neuromuscular reeducation . Gait training . PT eval (evaluation) mod complex . and Therapeutic activities . 5 times a week for 8 weeks. The PT P[NAME] was signed by PT Q on 11/22/19. Physician R also signed the document in the signature area, which stated I certify the need for these services furnished under this plan of treatment and while under my care. The certification period was indicated From 11/22/2019 To 01/16/2020. A review of the Occupational Therapy (OT) Plan Of Care document dated 11/22/19 revealed Resident #19 required skilled services to focus on: . Therapeutic Exercise . Neuromuscular reeducation . OT (Occupational Therapy) eval low complex . Therapeutic Activities . Self care/home mgmt train . wheelchair assessment and management . 5 times a week for 4 weeks. The OT P[NAME] was signed by OT S on 11/22/19. Physician R also signed the document in the signature area, which stated I certify the need for these services furnished under this plan of treatment and while under my care. The certification period was indicated From 11/22/2019 To 12/19/2020. A review of the Speech Therapy (ST) Plan Of Care document dated 11/22/19 revealed Resident #19 required skilled services to focus on: . Speech Therapy . Group Speech Therapy . Evaluation of speech sound production; with evaluation of language comprehension and expression . Treat oral function, . Clinical eval swallow . Group Therapy . Cognitive skills development . 3 times a week for 4 weeks. The ST P[NAME] was signed by ST T on 11/22/19. Physician R also signed the document in the signature area, which stated I certify the need for these services furnished under this plan of treatment and while under my care. The certification period was indicated From 11/22/2019 To 12/19/2020. On 12/17/19 at 4:55 PM,a follow-up interview with ADON BB regarding vaccine availability for the facility revealed the following: When asked why vaccines were not available for the facility ADON BB stated, I don't know why we (facility) did not have any on hand in the building. I do know we (facility) needed a prior authorization as of 11/13/19 because pharmacy faxed one over for the DON to sign, and (DON) did so, and sent it back (to the pharmacy). I was told the PCV 13 vaccine was canceled because of insurance not covering it per pharmacy. When asked if the pharmacy understood the facility is responsible for providing vaccines regardless of payer source, ADON BB stated, I talked to them (pharmacy) on the phone just a little bit ago. I'm going to figure it (vaccines on hand in the building) out, and get the PCV 13 in the building to administer it (vaccine) to those who wished to have it (vaccine) and have a signed consent for it. A review of the Centers for Disease Control (CDC) website (accessed on 12/23/19 and located at https://www.cdc.gov/pneumococcal/vaccination.html) revealed the following: Pneumococcal disease is common in young children, but older adults are at greatest risk of serious illness and death. Vaccines are the best way to prevent pneumococcal disease. A review of the CDC information (accessed on 12/23/19 and located at https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv13.html) specifically regarding the PCV 13 vaccination revealed the following: . Most pneumococcal infections are mild. However, some can result in long-term problems, such as brain damage or hearing loss. Meningitis, bacteremia, and pneumonia caused by pneumococcal disease can be fatal . A dose of PCV 13 is also recommended for anyone 2 years or older with certain medical conditions if they did not already receive PCV 13 . PCV 13 also provides protection against pneumonia.

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONTINUE TO ASSESS, EVALUATE, AND TREAT APPROPRIATELY THE SKIN CONDITION OF ONE (#15) OF TWO RESIDENTS WITH A PRESSURE ULCER IN A TOTAL SAMPLE OF 15 RESIDENTS, RESULTING IN THE DETERIORATION OF INTACT SKIN OVER THE COCCYX TO A FULL THICKNESS SKIN/SUBCUTANEOUS PRESSURE ULCER AND REQUIRING THE RESIDENT TO BE hospitalized . FINDINGS INCLUDE: A RECORD REVIEW OF RESIDENT #15'S MEDICAL RECORD WAS DONE ON 9/8/10 AND 9/9/10. THIS REVIEW SHOWED RESIDENT #15 IS A [AGE] year-old MALE WHO WAS admitted to the facility on [DATE] AND RESIDED IN THE FACILITY UNTIL 8/12/10, AT WHICH TIME HE WAS discharged TO A HOSPITAL TO RECEIVE treatment of [REDACTED]. RESIDENT #15'S PHYSICIAN WAS INTERVIEWED ON 9/7/10 AT 2:00 P.M. THE PHYSICIAN STATED RESIDENT #15 WAS TRANSFERRED TO THE hospital on [DATE] FOR THE treatment of [REDACTED]. A STAGE IV PRESSURE ULCER IS THE FULL THICKNESS OF SKIN AND SUBCUTANEOUS LOSS OF TISSUE, EXPOSING MUSCLE AND BONE. ON 9/8/10, A HISTORY AND PHYSICAL REPORT REGARDING RESIDENT #15, DATED 8/12/10, WAS FAXED FROM THE HOSPITAL TO THE FACILITY. THIS REPORT READ, "LARGE DECUBITUS ULCER. CONSULT WITH DOCTOR (NAME). DO WOUND CARE CULTURE, POSSIBLY INFECTED". THE MEDICAL RECORD REVIEW SHOWED RESIDENT #15'S ADMISSION [DIAGNOSES REDACTED]. THE MOST RECENT QUARTERLY MINIMUM DATA SET ((MDS) dated [DATE] REFLECTS THAT RESIDENT #15 WAS NON-AMBULATORY AND TOTALLY DEPENDENT ON STAFF FOR BED MOBILITY, DRESSING, AND TOILET USE. RESIDENT #15 ALSO NEEDED EXTENSIVE ASSISTANCE WITH TRANSFERS, PERSONAL HYGIENE, AND BATHING. RESIDENT #15'S SKIN WAS IDENTIFIED AS BEING INTACT, WITH NO BREAK-DOWN OR PRESSURE ULCERS. THE BRADEN SCALE (A TOOL USED FOR PREDICTING A PERSON'S RISK OF DEVELOPING PRESSURE ULCERS)WAS COMPLETED FOR RESIDENT #15 ON 5/20/10. RESIDENT #15 RECEIVED A SCORE OF 18. THIS SCORE IDENTIFIED THE RESIDENT TO BE AT RISK FOR DEVELOPMENT OF A PRESSURE SORE. ON 7/23/10 AT 3:12 P.M., THE SKIN TREATMENT REGISTERED NURSE (RN) "A" WROTE THE FOLLOWING PROGRESS NOTE IN RESIDENT #15'S CHART: "UPON EVALUATION OF (RESIDENT #15)'S SKIN INTEGRITY THIS AM, WRITER NOTED RESIDENT HAS FRAGILE AREA TO THE COCCYX/SACRUM AREA. TREATMENT STARTED... NO OTHER SKIN INTEGRITY ISSUES NOTED AT THIS TIME". DURING AN INTERVIEW WITH RN "A" ON 9/8/10 AT 3:30 P.M., SHE STATED THE FRAGILE AREA SHE DESCRIBED IN HER NOTE ABOVE WAS "A REDDENED AREA". ACCORDING TO THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Q SEPTINE", WHICH WAS TO BE APPLIED TO THE COCCYX/ SACRUM AREA, EVERY SHIFT (2 SHIFTS/DAY), TO HELP PROTECT/MAINTAIN SKIN INTEGRITY. THE MAR indicated Q SEPTINE" APPLIED, AS PRESCRIBED, OVER THE NEXT 4 DAYS. HOWEVER, THE MEDICAL RECORD OF RESIDENT #15 REFLECTS NO PROGRESS NOTE OF ANY KIND FROM 7/24/10 THROUGH 7/26/10 DESCRIBING THE CONDITION OF RESIDENT #15'S SKIN OVER THE COCCYX NOR THE RESPONSE TO THE TREATMENT BEING PROVIDED. A POSTER ENTITLED "ACQUIRED PRESSURE ULCERS" WAS OBSERVED IN THE TREATMENT NURSE'S OFFICE ON 9/8/10 AT 5:00 P.M. THIS POSTER GIVES DIRECTION TO CARE PROVIDERS REGARDING ASSESSMENT AND EVALUATION OF SKIN CARE TREATMENTS. THE FIRST PREVENTION INTERVENTION LISTED ON THIS POSTER READS, "TIMELY ASSESSMENT: DAILY SKIN CHECKS. MONITOR CONSISTENT USE OF CARE PLAN INTERVENTIONS. SPEEDY ATTENTION TO SKIN CHANGES." NOWHERE IN RESIDENT #15'S MEDICAL RECORD IS THERE EVIDENCE THAT DAILY SKIN CHECKS WERE COMPLETED ON RESIDENT #15 BY ANY NURSE, INCLUDING THE NURSE APPLYING THE "Q SEPTINE". BECAUSE THESE CRUCIAL EARLY INTERVENTIONS WERE NOT BEING IMPLEMENTED, RESIDENT #15 WAS PLACED AT GREATER RISK FOR FURTHER DEVELOPMENT OF THE PRESSURE SORE. A PROGRESS NOTE DATED 7/27/10 READS, "(RESIDENT #15) NOTED TO HAVE A STAGE II/III TO COCCYX AREA WITH MEASUREMENTS OF 2.5CM (CENTIMETER) BY 2.5CM IN HORSESHOE SHAPE ESCHAR TISSUE NOTED. AREA AROUND CURRENTLY IS STAGE I." THE RESIDENT ASSESSMENT PROTOCOL (RAP) FOR RESIDENT #15, DATED 8/9/10, CONTAINED THIS ADDITIONAL INFORMATION ABOUT THE PROGRESSIVE DETERIORATION OF RESIDENT #15'S SKIN OVER THE NEXT 10 DAYS AND THE CARE PLAN INTERVENTIONS THAT WERE PUT IN PLACE AFTER THE STAGE II/III PRESSURE ULCER HAD DEVELOPED: ON 7/27/10, WHEN IT WAS DISCOVERED RESIDENT #15'S PRESSURE ULCER HAD WORSENED, THE "DOCTOR WAS IN FACILITY AND EVALUATED AREA AND ORDERED TO PLACE [MEDICATION NAME] EVERY 4 DAYS, STARTED ON NUTRITIONAL SUPPLEMENT OF HI CAL THREE TIMES A DAY". ON 7/31/10, "AREA NOTED TO BE A STAGE III. DOCTOR EVALUATED AND ORDERED A CONSULT WITH DOCTOR. APPOINTMENT WAS SCHEDULED FOR 8/3/2010 AND WOUND UNDERWENT DEBRIDEMENT." ON 8/7/10, "WOUND NOTED TO BE A STAGE IV RELATED TO DEBRIDEMENT, A FOLLOW UP APPOINTMENT IS SCHEDULED FOR 8/11/2010." OTHER DOCUMENTATION FOUND IN RESIDENT #15'S MEDICAL RECORD FOLLOWS: AN 8/7/10 PROGRESS NOTE, WRITTEN BY NURSE "A", READ, "UPON EVALUATION OF RESIDENT'S SKIN INTEGRITY THIS AM, WRITER NOTED RESIDENT HAS STAGE IV PRESSURE ULCER TO THE COCCYX/SACRUM AREA. AREA MEASURES 4.5CM BY 2.5CM BY 2.5CM.... HE HAS SOME TUNNELING NOTED 2 O'CLOCK THAT IS 1CM. AREA HAS BLACK ESCHAR AND WHITE SLOTH NOTED AT BASE OF WOUND. SLIGHT ODOR NOTED..." ON 8/9/10, A SIGNIFICANT CHANGE IN STATUS MDS WAS COMPLETED. THIS MDS INDICATED RESIDENT #15 HAD A STAGE FOUR PRESSURE ULCER, WITH THICKNESS OF SKIN AND SUBCUTANEOUS TISSUE LOSS, EXPOSING MUSCLE AND BONE. ON 8/12/10, RESIDENT #15 WAS TRANSFERRED TO THE HOSPITAL FOR TREATMENT. RN "A" WAS INTERVIEWED ON 9/8/10 AT APPROXIMATELY 3:30 P.M. RN "A" CONFIRMED SHE HAD ASSESSED RESIDENT #15 ON 7/23/10, AND WROTE THE RESIDENT PROGRESS NOTE ON RESIDENT #15'S SKIN CONDITION. SHE STATED SHE DID NOT RE-ASSESS RESIDENT #15'S SKIN CONDITION OR THE EFFECTIVENESS OF TREATMENT INTERVENTIONS UNTIL 7/31/10. FURTHERMORE, SHE CONFIRMED THAT THERE WAS NO CHANGE IN THE PLAN OF CARE FOR RESIDENT #15 FROM 7/23/10 UNTIL 7/27/10. THUS, WITHOUT AN ONGOING ASSESSMENT OF RESIDENT #15'S SKIN CONDITION, CARE PLAN INTERVENTIONS CANNOT BE EVALUATED AS BEING ADEQUATE TO PREVENT FURTHER DAMAGE TO THE SKIN, RESULTING IN A FULL THICKNESS OF SKIN AND SUBCUTANEOUS TISSUE LOSS, EXPOSING MUSCLE AND BONE. ( ) --