Every finding on record at Hampton Nursing and Rehabilitation

Based on interview and record review, the facility failed to ensure adequate nursing staff to ensure that the needs of the residents were met, resulting in insufficient and unmet resident care needs, and residents' feelings of frustration. Findings include: Record review of the facility submitted 'PBJ Staffing 2 Quarter 2025 ([DATE]-March 31) identified low weekend staffing for the first quarter 2025. Record review of the facility 'Staffing, Sufficient and Competent Nursing' Policy Statement revealed that the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Record review of 'Staffing, Sufficient and Competent Nursing' Policy Statement revealed the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation: Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: assuring resident safety; attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident; assessing, evaluating, planning, and implementing resident care plans; and responding to resident needs. In an interview on 06/24/25 at 07:28 AM, Resident #96 revealed she had at the facility 3 weeks or less and there was not enough staff to help us all. Resident #96 stated that she did wait too long and wet her pants waiting to get help. Resident #96 estimated that she did wait a while, at least 30-45 minutes to get help. Resident #96 revealed that she was not supposed to get out of bed alone and then they don't come when she would put the call light on. In an interview on 06/24/25 at 09:20 AM, Resident #18 revealed that there were not enough staff at times. in an interview on 06/24/25 at 07:41 AM, a resident, who did not want to be identified, revealed that there could be a few more staff on second shift. The weekends are short, but they try to make up for it, but still need more people. An interview on 06/24/25 at 07:20 AM with unsampled resident during the initial screening at the beginning of the survey on the 200-hallway revealed: No not enough staff, they are just not here. all shifts, we just wait and wait, too long. In an interview on 06/24/25 at 07:34 AM with unsampled resident during the initial screening at the beginning of the survey on the 200-hallway revealed: There isn't enough staff, it's hard to get people to work these days. They just can't get the staff in here. It's all about that money. An interview on 06/24/25 at 07:50 AM with unsampled resident during the initial screening at the beginning of the survey on the 200-hallway revealed: the staffing is OK, except on the weekends there is nobody here to get the work done. I don't know why. In an interview on 06/25/25 at 04:03 PM, the Nursing Home Administrator (NHA) was asked why the facility triggering PBJ low weekend staffing? The NHA stated that probably because of call offs, staff call ins. With the call-ins the facility tries to get replacement staff, and we make calls and have incentives, or switch days off with other days. Weekends are hard to staff. I have a couple of openings in the schedule. I have 2 people that we are getting ready to take positions. We do have some PRN's that pick up. PBJ is submitted by the New Jersey corporate office. The state surveyor asked about showers are not being given because the surveyor received verbal complaints of no showers. In an interview and records review on 06/25/25 at 10:56 AM, Certified Nursing Assistant C Transporter/scheduler/medical record/Central supply stated- We staff by resident census, CNA's work 8-hour shifts and nurses work 12-hour shifts. Certified Nurse Assistant shift levels were discussed: Day shift required 4 CNA's, and 2 nurses. Afternoons shift required 4 CNA's, and 2 nurses Night shift required 1 CNA, and 2 nurses. if resident census is over 45 then there are 2 CNA's on nights. Record review of schedules revealed call-ins, when a staff member calls in, I will ask all current staff in building to stay over, give them a bonus, 5 dollars more an hour. If no one stays, then I will help stay over. If I cannot, we will put out calls to staff, with a bigger bonus of 50 to 75 dollar. Usually, the staff work well. Residents do complain about not having enough aides, but then we could be fully staffed and there would still not be enough. they just say there's not enough staff. Interview and record review on 06/25/25 at 1:00 PM with Human Resource staff B revealed that the facility did not use agency staffing. Review of the number of facilities staffing levels revealed: floor RN's: 6 +3 PRN's floor LPN's: 3 + 2 PRN's CNA's: 12 +8 PRN's Call ins happen, we do not mandate staff, we have bonuses to offer to get staff to work extra. Human Resource staff B revealed that she sends in payroll every 2 weeks, I do move job descriptions depending on what staff are doing. If the Director of Nursing or Registered Nurse E Who are Management) if they work the floor as a nurse I change their job code to floor nurse for the hours worked. I don't do anything with PBJ reports. I just send in the payroll. The corporate office in New Jersey handles the PBJ reports. Human Resource staff B was asked about Low weekend staffing: I don't see who is here on the weekends. if someone misses and punch in, I have gone find that person and they fill out a form and I correct the punch. We don't have a lot of open positions, when we hire, we get them here for orientation and then they don't want to work. they will come one day and not come back. It happens so often that the new hires just don't come in. It cost money to get them hired.

Based on observation, interview and record review, the facility failed to follow care-planned interventions and prevent skin breakdown for one resident (Resident #6) out of three residents reviewed for skin problems, resulting in new skin breakdown with the likelihood of further skin breakdown and pain. Findings include: Resident #6: On 6/24/25, at 8:25 AM, Resident #6 was resting in bed on their back without positioning devices. There was a slight odor to the room. On 06/25/25, at 3:00 PM, an observation of Resident #6's abdomen wound was conducted with the Director of Nursing (DON). When the DON pulled back Resident #6's covers there was a strong odor. The DON mentioned that the wound was healing well. There were no positioning devices under Resident #6's left arm. On 6/25/25, at 3:15 PM, a record review of Resident #6's electronic medical record revealed an admission on [DATE] with diagnoses that included Stroke, Aphasia and Hemiplegia following Stroke. Resident #6 was totally dependent on Staff for all Activities of Daily Living (ADL) and had severely impaired cognition. A review of the BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK . Score: 8.0 . VERY HIGH RISK 9 or below revealed Resident #6 was at very high risk for developing pressure related skin injuries. A review of the care plan I am at increased risk for alteration in skin integrity as evidenced by Braden Scale . Goal My interventions will decrease/minimize skin breakdown risks through next review . Interventions .Encourage to reposition as needed; use assistive devices as needed, as I allow Date Initiated: 10/13/2021 Observe skin condition with ADL care daily; report abnormalities . A review of the Skin & Wound Evaluation . Date 6/25/2025 revealed no mention of the new skin breakdown to under the left breast. On 6/26/25, at 9:15 AM, an observation of Resident #6's skin along with Aide J and Aide K was conducted. Aide K assisted with observation of under Resident #6's left breast. As Aide K lifted up the breast, there was a strong odor noted. There were four open areas approximately 1 centimeter long each. The areas had a slight depth and approximately two to three millimeters width. There was intact skin tissue separating the four open areas. The entire area was linear and approximately two inches long. Aide J was asked if Resident #6's left armpit was visible and Aide J attempted to lift the arm for view. Resident #6's left arm was nearly closed over top of their left breast with no positioning device to aide with pressure reduction. Aide J offered, the resident sweats a lot. On 6/26/25, at 11:30 AM, Resident #6 was resting in their bed. The Director of Nursing was at their bedside. The Resident's left breast was assessed and The DON offered they would call the Nurse Practitioner for orders. On 6/26/25, at 12:45 PM, a further record review of Resident #6's electronic medical record revealed new orders: Wound care #6 MASD (Moisture-associated skin damage), cleanse under left breast with wound cleanser, pat area dry apply thin layer of Triad, insert interdry sheet under breast daily and PRN two times a day . Start Date 6/26/25 12:00 . A review of the WOUND EVALUATION . #6 - MASD -Other Moisture Associated Damage Body Location: Left Breast New . Acquired: In-House Acquired Dimensions . Length 4.23 cm (centimeter) Width 0.48 cm . The picture of the wound revealed an open linear wound under their left breast. A review of SKIN MANAGEMENT GUIDELINES PREVENTION OF PRESSURE ULCER/INJURIES Policy Review Dates . 11.2024 revealed The purpose of this procedure is 1) to identify residents at risk for developing alterations in skin including pressure ulcer/injury risk factors, and 2) to identify specific interventions to assist with prevention and management of skin alterations . Moisture associated skin damage (excoriation, maceration) . Risk factors . Incontinence Excessive perspiration Wound drainage .

Based on interview and record review the facility failed to provide declination documentation and education of immunization refusal for one resident (Resident #28) of 5 residents reviewed for immunizations, resulting in the lack of documentation of resident immunization education and declination of vaccines. Findings include: Influenza Vaccine Resident, dated 9/2024, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record. Pneumococcal Vaccine Policy Statement dated 11/2024, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination. Coronavirus Disease (COVID-19) - Vaccination of Residents Policy Statement dated 4/2025, Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident is fully vaccinated. If the resident did not receive the COVID-19 vaccine due to medical contraindications, prior vaccination, or refusal, appropriate documentation is made in the resident's record. In an interview and record review on 06/26/25 at 09:00 AM with the Infection Control Preventionist (ICP) G during the infection control task five residents were reviewed for immunizations. Record review of Resident #28's immunization record revealed that the resident had refused the RSV in December 2024. There was no signed refusal form or progress note found in the medical record. ICP G reviewed the electronic medical record and found no notes regarding the refusal or education of the resident. ICP G found a 'Vaccine Consent- multiple Vaccine/Screening Form' dated 4/7/2025 was blank vaccine consent form with no refusals or signature. ICP G stated that the form is part of the electronic medical record and was completed by facility staff, only that the form was not filled out. Record review of Resident #28's progress notes from 11/25/2025 through 3/31/2025 revealed that there were no progress notes for the RSV vaccine on resident education or refusal of vaccine. On 3/31/2025 Resident #28 was sent out to the hospital for shortness of breath. Record review of Resident #28's progress notes on 4/9/2025 readmission from hospital with diagnosis of RSV. Record review of Resident #28's progress notes and immunization records from 4/7/2025 through 6/26/2025 revealed that there were no RSV vaccine education or documented immunization refusal of RSV vaccine for a resident readmitted post respiratory illness.

Based on observation, interview and record review, the facility failed to 1) Follow care plans for Activities of Daily living (ADL) care for two residents (#5, #96) and 2.) follow care plan for daily dressing change for Resident #18, resulting in Resident #18 and Resident #96 to appear to be in need of showers and hair care, and Resident #18 to have a post-surgical incision dressing change timely. Findings include: Record review of the facility 'Care Planning- Interdisciplinary team' policy dated 3/2025, revealed the interdisciplinary team is responsible for the development of resident care plans. The IDT includes but is not limited to: the resident ' s attending physician; a registered nurse with responsibility for the resident; a nursing assistant with responsibility for the resident; a member of the food and nutrition services staff; to the extent practicable, the resident and/or the resident ' s representative; and other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. Activities of Daily Living Resident #5: Observation on 06/24/25 at 08:36 AM of Resident #5 was lying in bed with appearance to have greasy hair and teeth are fuzzy in appearance. Record review of Resident #5's care task Showers/bed baths Tuesday and Friday evenings. 30 days look back of bath/shower task form noted: 'No bath/shower given . on dates of; 5/27/25, 5/30/25, 6/3/25, 6/6/25, 6/10/25, 6/13/25 and 6/17/25, 6/24/25. Resident #5 only received one shower on 6/15/25. There were no bed baths given. One shower in 30 days was documented by facility staff. Record review of Resident #5's 'Care plans' for Activity of Daily Living self-care deficit related to cognition and impaired coordination diagnosis of Alzheimer's disease, anxiety and depression: Intervention of resident requires assist of one staff with bathing/showers dated 12/27/2023. There were no interventions for if resident refuses showers. Observation and interview on 06/25/25 at 09:04 AM with #5 stated, No, I didn't get a shower yesterday, they don't care about me. I just don't know why they treat me like that. Observed Resident #5 hair still greasy in appearance and lying in bed. Record review of Resident #5's progress notes dated 5/27/2025 through 6/24/2025 revealed progress notes of bath/shower refusals only for dates of 5/30/25, 6/6/25 and 6/17/25. Resident #96: Record review of the facility matrix/roster on 6/24/2025 revealed that Resident #96 was new admit on 6/11/2025. Admitting diagnosis was right dorsum second digit (toe) amputation and lack of self-care. Observation and interview on 06/24/25 at 07:30 AM with Resident #96 stated I don't get regular showers, I don't know why. Observed with facial hair on chin and upper lip of 1/4 inch estimated in length. Resident appeared messy, with greasy hair and odor noted from resident. Record review of Resident #96's care task Showers/bed baths Wednesday and Saturday second shift. 14 days look back of bath/shower task form noted: 'No bath/shower given . on dates of; 5/27/25, 5/30/25, 6/3/25, 6/6/25, 6/10/25, 6/13/25 and 6/17/25, 6/24/25. Resident #5 only received one shower on 6/15/25. There were no bed baths given. One shower in 14 days was documented by facility staff. Record review of Resident #96's progress notes from 6/11/2025 through 6/24/2025 revealed there were no documented bed bath/shower refusals noted. Observation on 06/25/25 at 12:16 PM of Resident #96 was up in wheelchair in therapy gym working with therapy for leg strengthen. Resident #96 noted to Still have chin hairs and hair is greasy in appearance. Resident #18: Observation and interview on 06/24/25 at 09:18 AM with Resident #18 revealed that the resident had a second back surgery and had a dressing /sore on his back. the state surveyor observed mid-line lower back dressing dated 6/22/2025 at 10 AM, initials staff AK. Resident was asked about the dressing changes, and he stated They are supposed to change the dressing every day. the previous day He left around 11:00 AM for a physical therapy home evaluation yesterday. Resident #18 did not leave the facility until 11:00 AM as a planned leave of absences. In an interview on 06/24/25 at 09:25 AM with Registered Nurse (RN) A stated that Resident #18 was gone before she could get to doing her treatments and that she did work yesterday at 6:00 AM to 6:00 PM. RN A stated that she gets new admissions frequently and discharges. Record review of Resident #18's 'Care plan' alter impairment to skin integrity related to surgical wound to spine. Intervention of: Wound care pre orders dated 6/2/2025. Record review of Resident #18's June 2025 Treatment Administration Record (TAR) revealed that on 6/23/2025 the night shift nurse documented that the mid-line dressing change was performed by signing the nurse's initials on the record. In an interview and record review on 06/26/25 at 11:52 AM with the Director of nursing (DON) was asked about performing dressing changes for surgical incisions. The DON stated Dressing change it needs to be completed as ordered, if the day shift nurse did not change the dressing, then the night nurse should have done it. The dressing should be changed by the next shift. Record review of Resident #18's treatment record revealed that the night nurse initials had signed out that the dressing was changed, although the observation was dated 6/22/25 with initials AK at 10:00 AM.

Based on observation, interview and record review, the facility failed to ensure that a dressing change was completed as ordered for one resident (Resident #18) of 2 residents reviewed for skin, resulting in Resident #18 having a lower back post-surgical incision with dressing that was not changed daily as ordered with the likelihood for infection and prolonged illness. Findings include: Resident #18: Observation and interview on 06/24/25 at 09:18 AM with Resident #18 revealed that the resident had a second back surgery and had a dressing /sore on his back. the state surveyor observed mid-line lower back dressing dated 6/22/2025 at 10 AM, initials staff AK. Resident was asked about the dressing changes, and he stated They are supposed to change the dressing every day. the previous day He left around 11:00 AM for a physical therapy home evaluation yesterday. Resident #18 did not leave the facility until 11:00 AM as a planned leave of absences. In an interview on 06/24/25 at 09:25 AM with Registered Nurse (RN) A stated that Resident #18 was gone before she could get to doing her treatments and that she did work yesterday at 6:00 AM to 6:00 PM. RN A stated that she gets new admissions frequently and discharges. Record review of Resident #18's June 2025 Treatment Administration Record (TAR) revealed that on 6/23/2025 the night shift nurse documented that the mid-line dressing change was performed by signing the nurse's initials on the record. In an interview and record review on 06/26/25 at 11:52 AM with the Director of nursing (DON) was asked about performing dressing changes for surgical incisions. The DON stated Dressing change it needs to be completed as ordered, if the day shift nurse did not change the dressing, then the night nurse should have done it. The dressing should be changed by the next shift. Record review of Resident #18's treatment record revealed that the night nurse initials had signed out that the dressing was changed, although the observation was dated 6/22/25 with initials AK at 10:00 AM.

Based on observation, interview and record review, the facility failed to ensure that residents were treated with dignity and had their needs met timely for a private group of residents and Resident #10, Resident #39 and Resident #41, resulting in complaints of being talked down to, feelings of sadness , diminished self-worth and not having their needs met as they wished. Findings include: Resident #39: On 6/24/25, at 11:12 AM, Resident #39 was resting in their bed. They complained their needs were met half of the time. Resident #39 used a writing board for communication. Resident #39 wrote on their communication board when Aide H answers my light she says do it on your own. On 6/25/25, at 10:15 AM, During Resident council task, the Residents were asked if they get care when they need it and unanimously all residents stated, No. The following complaints were voiced regarding getting their needs met: They don't have enough people If they're busy with someone that really needs their help, you have to wait longer There is usually not enough aides We're lucky if we get 2 aides Most of the time, it's just one CNA Any weekend usually only 1 CNA You get a couple that are supposed to be working. They don't want to do anything they don't have to do They'll not change you and push it on to someone else Aides will come in and say I have to wait for so and so to help They will answer the light and say your aide's on break you'll have to wait and then it's an hour and a half later when they come back in I waited from 6:45 PM to 8:30 PM to get changed finally Sometimes there's only 1 aide to 2 halls They don't pass waters like they should, last night we didn't get water I always miss Tuesday shower day because they are shorthanded You only get one shower a week, if you're lucky and it depends on who's working (private resident) was left on the toilet for over an hour and a half They set your tray down and run out and don't help set up They don't help me set up my tray It depends on who is working. Some CNA's work all day and then there are some that don't work at all Some CNA's sit at the nursing desk and look at the call light going off and the don't get up to answer it If a call light goes off and it's a hard room, they don't go answer it There were specific complaints regarding Aide H: She snaps at you She will say pull your pants down when I need the bathroom She will say put your bed flat She is a 3 out of 10 for rudeness; she can't even get a 5 because she is so rude If you say thank you, you get a uhuh She will say I have more people to do, and you have to wait She always seems rushed On 6/25/25, at 4:03 PM, the Administrator was alerted of resident council complaints regarding Aide H. Residents # 10 and #41: On 6/26/25, at 8:43 AM, an interview with Resident #10 and #41 in their shared room along with the administrator was conducted. Both residents complained of Aide H seemed rushed and felt it was a customer service issue. Resident #10 complained their call light was on for 45 minutes as they needed the bed pan and due to the wait, they urinated a small amount and when Aide H finally entered the room they asked what do you want and Resident #10 offered I need the bed pan to pee and Aide H said to Resident #10 well it looks like you already did. Resident #10 complained it made them feel awful. Resident #41 complained they have to wait more often than not to get incontinent care.

Based on observation, interview and record review, the facility failed to ensure safe medication storage for the 200 Hall medication cart of 2 carts reviewed, resulting in the 200 Hall medication cart to be found parked in the middle of the 200 hallway left unlocked and accessible for residents, visitors and state surveyor to access the medications. Findings include: Observation and interview on 06/24/25 at 12:13 PM of the 200 hallway medication cart left in hallway unlocked. The state surveyor was able to open drawers on the med cart. Registered Nurse (RN) A was noted in room [ROOM NUMBER] checking resident blood sugar and chatting with resident. RN A came out of the room and the surveyor was standing at the medication cart with the second drawer open. The state surveyor had to ask the nurse what's going on with the cart being left unlocked in the hallway with visitors, therapy and staff passing by. RN A stated that she didn't mean to leave the cart unlocked. Record review of Registered Nurse (RN) As employee record with human resource during the staffing task portion of the annual survey revealed that in March 2025, RN A received a one-on-one inservice for medication cart and treatment carts must be locked at all times when nurse is not at cart. In an interview on 06/26/25 at 11:55 AM with the Director of Nursing (DON) revealed that the floor nurse did come to her and state what happened with the unlocked medication cart. The DON stated that she does have a formal disciplining waiting for the nurse upon her return to work. The DON stated that the medication cart should be kept locked when the nurse is not present. Record review of the facility 'Storage of Medications' Policy Statement: The facility stores all drugs and biological's in a safe, secure, and orderly manner. (9.) Unlocked medication carts are not left unattended.

Based on observation, interview and records review, the facility failed to ensure that Activities of Daily Living (ADL) care was provided for 5 Residents (#5, #10, #38, #41 and #96) of 5 residents reviewed for personal hygiene/showers, resulting in poor hygiene and the potential for skin irritation, body odor and feelings of embarrassment, diminished self-worth, complaints of unkempt personal hygiene, feelings of sadness, overall feeling bad and a lack of dignity. Findings include: Observation and interview on 06/24/25 at 1:10 PM Observation with maintenance supervisor F of the 200 hallway shower room revealed there to be no tub or shower in the room. A toilet was noted for use. Storage items noted in the room consisted of three plastic commode chairs, a mechanical lift, a reclining shower chair and dirty linen bins. The maintenance supervisor F stated the tub was removed in March 2025 and they are waiting on quotes for a shower to be built. So only one shower is in use for all 48 residents. (If each resident (48) is to get showers 2 times a week that would be 96 showers put through one shower room per week). Activities of Daily Living: Resident #5: Observation on 06/24/25 at 08:36 AM of Resident #5 was lying in bed with appearance to have greasy hair and teeth are fuzzy in appearance. Record review of Resident #5's care task Showers/bed baths Tuesday and Friday evenings. 30 days look back of bath/shower task form noted: 'No bath/shower given . on dates of; 5/27/25, 5/30/25, 6/3/25, 6/6/25, 6/10/25, 6/13/25 and 6/17/25, 6/24/25. Resident #5 only received one shower on 6/15/25. There were no bed baths given. One shower in 30 days was documented by facility staff. Record review of Resident #5's 'Care plans' for Activity of Daily Living self-care deficit related to cognition and impaired coordination diagnosis of Alzheimer's disease, anxiety and depression: Intervention of resident requires assist of one staff with bathing/showers dated 12/27/2023. There were no interventions for if resident refuses showers. Observation and interview on 06/25/25 at 09:04 AM with #5 stated, No, I didn't get a shower yesterday, they don't care about me. I just don't know why they treat me like that. Observed Resident #5 hair still greasy in appearance and lying in bed. Record review of Resident #5's progress notes dated 5/27/2025 through 6/24/2025 revealed progress notes of bath/shower refusals only for dates of 5/30/25, 6/6/25 and 6/17/25. Resident #96: Record review of the facility matrix/roster on 6/24/2025 revealed that Resident #96 was new admit on 6/11/2025. Admitting diagnosis was right dorsum second digit (toe) amputation and lack of self-care. Observation and interview on 06/24/25 at 07:30 AM with Resident #96 stated I don't get regular showers, I don't know why. Observed with facial hair on chin and upper lip of 1/4 inch estimated in length. Resident appeared messy, with greasy hair and odor noted from resident. Record review of Resident #96's care task Showers/bed baths Wednesday and Saturday second shift. 14 days look back of bath/shower task form noted: 'No bath/shower given . on dates of; 5/27/25, 5/30/25, 6/3/25, 6/6/25, 6/10/25, 6/13/25 and 6/17/25, 6/24/25. Resident #5 only received one shower on 6/15/25. There were no bed baths given. One shower in 14 days was documented by facility staff. Record review of Resident #96's progress notes from 6/11/2025 through 6/24/2025 revealed there were no documented bed bath/shower refusals noted. Observation on 06/25/25 at 12:16 PM of Resident #96 was up in wheelchair in therapy gym working with therapy for leg strengthen. Resident #96 noted to Still have chin hairs and hair is greasy in appearance. Resident #10 On 6/25/25, at 10:35 AM, Resident #10 complained they don't always get their scheduled shower when they want it and that it made them feel sad, mad and bad as it was a personal hygiene problem. On 6/26/25, at 10:00 AM, a record review of Resident #10's electronic medical record revealed an admission on [DATE] with diagnoses that included Absence of left leg below knee, Diabetic Retinopathy and impaired vision. Resident #10 had intact cognition. A review of the care plan I have an ADL self-care performance deficit . Interventions . PERSONAL HYGIENE/ORAL CARE: I require assistance by (1) staff with personal hygiene and oral care. Date Initiated: 05/30/2025 . BATHING/SHOWERING: I require assistance by (1) staff with bathing/showering. Date Initiated: 05/30/2025. There was no care plan relating to the resident refusing showers or any cares. Resident #38 On 6/24/25, at 12:32 PM, Resident #38 was in their room. Resident #38 complained they don't always get a shower. Resident #38 was unshaven. On 6/25/25, at 3:55 PM, a record review of Resident #38's electronic medical record revealed an admission on [DATE] with diagnoses that included stroke, muscle weakness and Parkinson's disease. Resident #38 had moderately impaired cognition. A review of the care plan I have an ADL self-care performance deficit . Interventions . PERSONAL HYGIENE/ORAL CARE: I require assistance by (1) staff with personal hygiene and oral care. Date Initiated: 07/17/2024 . BATHING/SHOWERING: I require setup and supervision with cueing for safety and sequencing during bathing/showering. Date Initiated: 07/17/2024 . There was no care plan relating to the resident refusing showers or any cares. There was no care plan intervention to ensure the resident was shaven. A review of the A review of the task: Shower/Bed Bath Wednesday/Saturday evenings for the previous 30 days revealed the following days the resident received a shower 6/4/2025 . 6/18/2025 For the column No bath given attempted x 2 revealed there were multiple days check marked. On 6/26/25, at 9:36 AM, an observation of Resident #38's skin along with Aide Courtney and Aide donna was conducted. Resident #38 had bilateral groin redness. There was a noticeable odor coming from the reddened areas. Resident #38 complained of it being bothersome; more of irritated pain than it hurting. The resident remained unshaven. Resident #41 On 6/25/25, at 10:30 AM, Resident #41 complained they don't get their showers as they like, need and prefer. Resident #41 offered that they do get bed baths but prefer a shower. On 6/25/25, at 2:30 PM, a record review of Resident #41's electronic medical record revealed an admission on [DATE] with diagnoses that included Depression, Need for assistance with personal care and Obesity. Resident #41 had intact cognition. A review of the care plan I have an ADL self-care performance deficit related to obesity, pain, bilateral heel wounds . Interventions . PERSONAL HYGIENE/ORAL CARE: I require assistance by (1) staff with personal hygiene and oral care. Date Initiated: 02/05/2025 . BATHING/SHOWERING: I require assistance by (2) staff with bathing/showering. Date Initiated: 02/05/2025 . There was no care plan relating to the resident refusing showers or any cares. A review of the task: Shower/Bed Bath Wednesday and Saturday days task list for the previous 30 days revealed the following days the resident received a shower 5/31/2025 . 6/11/2025 . 6/18/2025 .6/25/2025

Based on observation, interview and record review, the facility failed to provide a homelike shower room for the 100-Hall and failed to ensure a clean functioning shower room for the 200-Hall shower room for all residents who use the shower rooms for hygiene, resulting in black residue on shower tiles, chipped off sharp tile edges and a non-functioning shower on the 200-Hall. Findings include: On 6/24/25, at 12:07 PM, an observation of the only working shower room in the building was conducted with Aide H. The wall tiles in the shower area had a black residue. The caulking in the corners had a black residue. The outside shower corner behind the curtain had an area approximately 10 inches high of chipped off tiles. The drywall underneath was also chipped away. There was a black residue on the exposed areas. The tile edges appeared sharp. On 6/24/25, at 12:13 PM, An interview with the Administrator was conducted regarding the shower room. The Administrator offered they had a quote to repair both shower rooms as the shower room on the 200 hall was not in use since they had the tub removed. On 6/24/25, at 12:20 PM, an observation of the shower room on the 100 hall was conducted with the Administrator. The black residue on the caulking and tile grout appeared to be under the caulking and grout. The Administrator was asked to provide the quote for the repairs needed. On 6/264/25, at 10:30 AM, record review of the facility provided shower repair quote for the 100-hall shower room revealed 5/26 Quote . TOTAL 350.00 . Bathroom shower moldy grout Remove old grout Replace w/moisture resistant grout Replace corner Tiles and Grout . A review of the non-working shower quote on the 200-hall revealed Construct shower and waterproof Rework drain & plumbing Supply tile and install Supply plumbing fixtures and install Relocate thermostat Labor & Materials $10,000 Demo existing shower Waterproof Supply & install tile Labor & Materials $8,000.00 On 6/26/25, at 11:12 AM, an interview with Maintenance staff C was conducted. Maintenance C offered they called the contractor the day prior, and the repairs should be completed within the next 30 days for the 100-hall shower room. Maintenance Staff C was asked if the quote for the 200-hall shower was from March/2025 why hasn't it been completed and Maintenance Staff C offered, the plan was to get the 100-hall shower done first

Based on observation, interview and record review, the facility failed to provide timely responses to call lights, ensure that call lights were within reach and ensure that privacy curtains were within reach and used for seven residents (Resident #1, Resident #4, Resident #20, Resident #36, Resident #38, Resident #39, Resident #244) and five rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]), resulting in unmet care needs, unmet privacy needs and with the likelihood of feelings of anger and hopelessness. Findings include: On 7/15/24, at 08:45 AM, During initial pool task, the following Residents' rooms had their privacy curtains tucked away out of reach: 100, 103, 107, 108 and 110. On 7/15/24, at 8:55 AM, Resident #36 was lying in bed in their gown. Their call light was out of reach sitting on a chair to the left of their bed approximately 4 feet away. Resident #36 was asked if they could reach their call light and Resident #36 stated, well, I guess someone didn't want me to bother them. 07/16/24 07:54 AM, an observation of Residents' rooms 103, 107, 108 and 110 revealed the privacy curtains remained tucked out of reach. On 7/16/24, at 9:46 AM, Resident #4 (room [ROOM NUMBER] bed 1) was on top of their bed in their clothes with the sheets pulled back. CNA F was leaning over the resident upon entering the door. On 7/16/24, at 9:50 AM, the ADON was alerted of the numerous rooms noted with the privacy curtain tucked out of reach and was asked for an observation of the 100 Hall rooms. On 7/16/24, at 9:52 AM, an observation along with ADON G of 100 room revealed the privacy curtain had been pulled to offer privacy and numerous wrinkles were noted in the curtain. CNA F had offered that they hadn't pulled the curtain because they were just clipping the resident's toe nails. A further observation of the 100 Hall privacy curtains along with ADON G revealed the privacy curtains remained out of reach.

Based on observation, interview and record review, the facility failed to wear Personal Protection Equipment (PPE) properly in Enhanced Barrier Precautions (EBP) rooms (101, 103 and 208), resulting in the likelihood of cross-contamination and further spread of the infections requiring barrier precautions. Findings include: On 7/16/24, at 8:35 AM, Nurse B was observed in an enhanced barrier precautions room [ROOM NUMBER] sitting on the edge of the resident's bed without any form of PPE. On 7/16/24, at 5:04 PM, Resident #5 (room [ROOM NUMBER]) was in their bed in an enhanced barrier isolation room. CNA H was leaning on the left side of the bed caring for Resident #5 who had an incontinent episode. CNA H had on gloves but no gown to protect their uniform. On 7/16/24, at 5:12 PM, Infection Control Nurse E was alerted of the observation of CNA H caring for Resident #5 without a gown on and IC Nurse E was asked if CNA H should have a gown on and IC Nurse E offered, yes. On 7/16/24, at 5:20 PM, a record review of Resident #5's electronic medical record revealed a Physician order . Enhanced barrier precautions: Gloves and gown prior to high-contact care activity . Active 7/28/2023 . On 7/17/24, at 1:18 PM, an observation of Housekeeper I in an enhanced barrier precautions room (room [ROOM NUMBER]) was conducted. Housekeeper I was on their hands and knees cleaning the toilet and floor in the bathroom without a gown on to protect their uniform. On 7/17/24, at 1:20 PM, IC Nurse E was alerted of Housekeeper I who was in cleaning the floor and toilet of an enhanced barrier room without a gown on and IC Nurse E entered the room and offered education to Housekeeper I of the need to have a gown on. On 7/17/24, at 1:30 PM, a record review of the Enhanced Barrier Resident list provided by the facility revealed Rooms 208, 101, 103 are on the list. A record review of the Keeping Residents Safe - Use of Enhanced Barrier Precautions provided by the facility revealed . You may have noticed new signs on some doors that say Enhanced Barrier Precautions and staff wearing gowns and gloves more often. We're doing this based on new recommendations from the Center's for Disease Control and Prevention to protect our residents and staff from germs that can cause serious infections and are hard to treat . Using gowns and gloves. Since we can't wash our clothes between caring for residents, gowns and gloves help keep these germs from getting on our clothes and spreading to others

Based on observation, interview, and record review, the facility failed to ensure that proper communication and documentation of Hospice services were provided to one resident (Resident#26) of two residents reviewed for hospice services, resulting in the lack of receipt of progress notes assessments to resident's medical record with ineffective or delayed communication and collaboration of services between the facility and hospice service, lack of residents and staff awareness of hospice schedule and potential for unmet needs, pain and suffering. Findings include: Resident #26 During the observation tour on 7/15/24 at 10:45 AM, R26 was lying in bed grimacing and looked uncomfortable. When asked how she was, she stated, I don't feel good. When asked if she had told anyone, R26 replied, The nurse has been here, but it's been a while. R26 was admitted to the facility on [DATE], with the diagnosis of rheumatoid arthritis, paroxysmal Atrial Fibrillation, and Acute Embolism and Thrombosis of the Left Iliac Vein in addition to other diagnoses. R26 was assessed with a Brief Interview of Mental Status (BIMS) score of 15/15. A score of 13 to 15 suggests the individual is cognitively intact. R26 was under Hospice care effective 2/16/2024, with the diagnosis of Paroxysmal Atrial Fibrillation, Rheumatoid Arthritis, and Hypertensive Heart Disease with Heart Failure. The unit nurse (LPN B) was interviewed on 7/15/24 at 11:30 AM and asked if she knew of R26's status. LPN B stated that R26 was in hospice and that she had yet to notify the agency about her nausea and vomiting. LPN B was asked when the hospice staff last visited. LPN B said she was unsure when, but the hospice aide and nurse provided services to R26. I am not sure what days and times. LPN B showed me the Hospice Binder for R26 and the hospice calendar of care scheduled. Upon review of the R26 Hospice Services Binder on 7/15/24 at 11:45 AM, the following were observed: There were no progress/ nursing narrative notes found in the binder. There was no Facility Communication Log An Aide Care Plan Report was found with a printed date of 4/30/24 specified: SOC date: 2/16/24 Start of Episode: 2/16/24 End of Episode: 5/15/24 *There was no follow-up documentation found for the R26 Aide Care plan after the date 5/15/24. The latest visit note report in R26 binder was dated 4/03/24 (no time). The nurse does the visit- RN Hospice A Calendar of Hospice visits for May, June, and July 2023 has minimal documentation and no details of the services provided to R26. In each calendar date boxes it was handwritten: nursing visit. It did not specify whether it was a nurse or a nurse aide visit and specific services performed on the following dates: May 1st, May 8th, May 15th, May 22nd and May 30th, June 5, July3 and July 9 Chaplain visits May 14 and May 28, June 10 and 24, 2024. Staff (by the name of [NAME] was written) May 3rd and May 2, 2024 These were all found in R26 Binder on 7/15/24 at approximately 4:00 PM. The nurse (LPN B) was asked when hospice staff visited, and she stated, they vary. The documentation is scanned in the EMR because they (hospice nurses) don't have access to electronic charting for our residents. We rely on their documents that are in each hospice resident's binder. On 7/15/24 at 1:20 PM, a review of Hospice Services in the Electronic Medical Record (EMR) revealed that the latest progress notes scanned from Hospice Agency entitled: Visit Note Report was dated 6/17/24. On 07/16/24 at 1:22 PM, According to the Director of Nursing (DON) during an interview, reported that she reached out and got clarification on Hospice Services with the Hospice Agency. Hospice Agency staff follow the scheduled calendar found in the binder. Nurses usually visit once a week, and Nurse Aide visits are twice a week. They also have the progress notes written since they can't access our EMR. The nursing progress notes are faxed over to the facility, and then scan them into the resident's EMR. The DON was shown R26's EMR. The last scanned Hospice notes were noted on 6/22/24 for 6/17/24 Hospice Progress notes. The DON admitted and stated that there is a delayed in submitting the documentation. The DON acknowledged that the last progress note in R26's EMR was dated 6/17/24. The DON stated, Nothing else was scanned from 6/17/24 visit up to today (7/16/24), which is clearly considered a problem. The DON agreed that there is a communication, collaboration, and coordination gap between the hospice and the facility. On 07/16/24 at 11:52 AM, the Hospice RN K revealed that the information in resident R26's binder was outdated. R26 started on the Hospice Services on February 16, 2024. RN K always leaves a narrative note to inform them that we provided the service. The hospice and facility are not interfaced with our electronic charting, so we have to send our progress notes via fax to the facility, and they scan them to their EMR. RN K updated the surveyor with R26's current status. She stated that R26 complained of nausea and vomiting on 7/15/24 in the morning and had active diarrhea. Zofran was ordered to rule out impaction as a diagnosis. R26 Narrative Note was presented to the surveyor on 7/16/24 at 9:34 am. The DON knew that the Narrative note page was not found in the R26 hospice binder on 7/15/24. R26 has an active order for Morphine Sulfate written on 3/7/24 at 12:00 PM. Order of Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Given 0.25 ml by mouth every 6 hours as needed for pain and discomfort. A review of the Medication Administration Record (MARS) on 7/16/24 at 3:30 PM revealed: 7/1/24 Administered Morphine Sulfate at 6:56 AM 7/1/24 Administered Morphine Sulfate at 8:56 AM (* Given 2 hours after the last dose) 7/1/24 Administered Morphine Sulfate at 13:30 (1:30 PM) (*Given less than 5 hours after the last dose) 7/1/24 Administered Morphine Sulfate at 15:57 (3:57 PM) (*Given less than3 hours from last dose) 7/2/24 Administered Morphine Sulfate at 23:15 (11:15 PM) 7/3/24 Administered Morphine Sulfate at 01:38 AM 7/3/24 Administered Morphine Sulfate at 5:15 AM (*Given less than 4 hours from the last dose) 7/3/24 Administered Morphine Sulfate at 5:44 AM (* Given less than 30 mins from the last dose) 7/8/24 Administered Morphine Sulfate at 10:50 AM (*Given less than 6 hours from the last dose) 7/8/24 Administered Morphine Sulfate at 11:42 AM (* Given less than an hour from the last dose). 7/8/24 Administered Morphine Sulfate at 23:54 (11:54 PM) 7/9/24 Administered Morphine Sulfate 00:15 (12:15 AM) There were no noted changes in the prescribed order from the facility physician, hospice physician, hospice or facility Nurse Practitioner regarding changes in dosages and frequency of administering the Morphine Sulfate. The Physician's notes were reviewed on 7/17/24 at 3:30 PM. Physician's Progress Notes, dated 7/10/24 at 15:33 (3:33 PM), wrote: Discussed with her and will continue with the treatment and will monitor and will continue with the hospice care. An attempt to call the Facility Medical Director via pager #(989) [PHONE NUMBER] at 3:32 PM on 7/17/24 but did not get a callback. No voicemail was received. The facility policy entitled Hospice Program dated revised on1/2024 specified: . 9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including: a. Determining the appropriate hospice plan of care; b. Changing the level of services provided when it is deemed appropriate; c. Providing medical direction, nursing, and clinical management of the terminal illness; d. Providing spiritual, bereavement and/or psychosocial counseling and social services as needed; and e. Providing medical supplies, durable medical equipment, and medications .

Based on observation, interview, and record review, the facility failed to ensure that the resident's food preferences were honored, food was palatable, and an adequate amount of food and choices were offered according to the care plan to one resident (Resident #39), resulting in weight loss and potential for anger and frustration, malnutrition and poor wound healing. Findings include: Resident #39 (R39): R39 was observed talking to her significant other in her room, waiting for her lunch on 7/15/24 at 1:15 PM. She was alert and oriented regarding time, place, and person. R39 was admitted to the facility on [DATE] with the following diagnosis: Pulmonary Embolism with Acute Pulmonale, Type 2 Diabetes, in addition to other diagnoses. The doctor's orders reviewed included R39's Diet orders, which were noted as CCD (Controlled Carbohydrate Diet), NAS (Cardiac or No Added Salt) diet with Regular Food consistency. A laboratory report dated 6/26/24 revealed that the blood glucose level was flagged at a high level at 439 mg/dL (normal range of 82 up to 115 mg/dL). During the interview on 7/15/24 at 11:17 AM, R39 complained about food palatability, and food served to her is rich in carbs, serving large quantities of cookies and cakes rich in sugar content when she has a diagnosis and being monitored and receiving diabetes treatment. She indicated she hardly eats what is on her tray for every meal. R39 also complained about protein shakes not being consistently provided and food/ meal preferences not being honored. R39 further stated, The food is awful. My food preferences are not honored. My tray has rice, potatoes, and pasta. I don't eat sweets, cookies, or cakes, rich in sugar content. I have to bring fresh fruits from home because they don't serve them here. An interview with R39's significant other L was conducted on 07/15/24 at 12:42 PM. He was observed bringing in fresh strawberries for R39. R39's significant other L said he received a call from R39 because the meal trays frequently do not have the food items she had explicitly indicated in the preferences, such as strawberries during lunch and cottage cheese. R39 stated, I am glad you (the surveyor) are here to see what I have on my tray. Indeed, there are no strawberries, and you served me the thickest slice of white bread, a lot of carbs, and sugar cookies. R39's significant other L stated, The meals are not planned for people with diabetes. She does not receive her protein drink consistently as she's supposed to. During meal observation on 7/15/24 at 11:17 am, R39's lunch tray came. It contained baked chicken, a thick slice of white bread (Texas Toast) that was not toasted, boiled green peas, and another side dish that looked like pasta or potatoes in white cream. R39 had a sugar cookie in her tray for dessert. After examining her lunch tray, R39 stated, Why would they bother to write down my preferences if they don't follow them? I have a thick white bread, sugar cooking, and a potato overloaded with white cream. I like chicken, but this one is hard and tough to bite. I would usually not eat and return the tray without eating the food served. R39 ate a portion of the baked chicken, ate a bite of peas, and covered her tray like she was done with it. A review of R39's meal ticket revealed CCD/NAS. CCD means Caloric Controlled Diet, and NAS means No Added Salt. R39 is in Fluid Restriction. >Baked Chicken >Fried Potatoes with Onion >Green Peas >Sugar cookie Bar >Margarine 2% Milk >Sugar substitute, pepper (1 each) R39's Preferences were written on the lunch meal ticket as specified dated July 15, 2024: DISLIKES: Scrambled eggs, egg salad sandwich, white bread, watermelon, cucumbers, lettuce Others: Lid for Hot liquids Likes: Wheat Bread, 1500 ml Fluid Restriction, Raisin Bran, Strawberries every Lunch, and cottage cheese every dinner. A review of R39's Weight record on 07/16/24 at 10:10 AM revealed the following: On 06/17/2024, R39 weighed 109.5 pounds (lbs.) On 07/8/2024, R39 weighed 99.5 lbs., a confirmed weight loss of 10 lbs. a 9.13 percent (%) weight loss in approximately 21 days (3 weeks). An interview with the Dietary Manager (CDM N) was conducted on 7/17/24 at 1:30 PM. CDM N stated she was unaware that her preferences were not followed. CDM N indicated that she did not hear any reports of R39 being received. CDM N admitted that she checks the trays to ensure that the appropriate diet is followed as prescribed and preferences are honored. CDM stated that she had spoken to her today and would follow up. CDM N was unaware that R39 was not receiving her fresh strawberries and cottage cheese. CDM N thought it was available. The Registered Dietician (RD M) was interviewed on 7/17/24 at 1:40 PM. She acknowledged that R39 had a weight loss since admission but explained that it was because she had edema (swelling) upon admission, and she is known to be a picky eater. RD M was unaware that fresh strawberries were not offered or available, the protein drink was not consistently given, and cottage cheese was not served per R39's preferences. R39's care plan, dated 6/18/24 and revised on 7/9/24, was reviewed on 7/17/2024 at 2:00 PM. The following interventions were specified: Diet as ordered: CCD/NAS/regular texture/thin liquids . Honor preferences as able. See tray card for preferences . Monitor s/sx malnutrition such as weight loss, poor appetite, muscle weakness, muscle loss/cachexia. Report to nursing/MD/RD/SLP . Supplements as ordered. SF MedPass 120 ml TID Pro Heal BID . On 7/17/24 at 1:45 PM, a review of the facility's Therapeutic Diet Policy (undated) explained: Policy Statement: Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Policy Interpretation and Implementation 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. 2. A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law. 3. Diet order should match the terminology used by the food and nutrition services department. A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: 1. Diabetic/calorie controlled diet; 2. Low sodium diet; 3. Cardiac diet; and 4. Altered consistency diet . The facility's Food Preference Policy (undated) was reviewed on 7/17/24 at 1:45 PM. Policy Statement: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Policy Interpretation and Implementation 1. Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the Dietitian or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 4. The Dietitian and nursing staff, assisted by the Physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences.

Based on observation, interview and record review, the facility failed to store narcotics properly for one resident (Resident #1) during the medication administration task, resulting in narcotics not being double locked and stored in a medication cup. Findings include: Resident #1: On 7/16/24, at 9:05 AM, During medication administration task, Nurse B prepared morning medications for Resident #1 to include 1 Norco 5/325 tablet and 1 Pregamblin 150 milligram tablet and placed them in a clear medication cup. Nurse B walked to Resident #1's room and offered the medications although Resident #1 was eating breakfast and asked to take them later. Nurse B was asked what they planned to do the medications as Nurse B walked back to the medication cart. Nurse B stated, I capped it and I'm writing her name on it. Nurse B took a black marker and wrote the room number on the medication cup. Nurse B then placed the medication cup inside the top drawer of the medication cart and prepared medications for the next resident. On 7/16/24, at 9:25 AM, during medication administration task, Nurse B opened up the top drawer and removed the clear medication cup for Resident #1 that they had prepared earlier. Nurse B counted the medications and administered them to Resident #1. Nurse B was asked why they counted the medications in the medication cup and Nurse B stated, because I put them in the drawer. On 7/16/24, at 1:30 PM, the Director of Nursing (DON) was alerted of Nurse B who placed the narcotics in the top drawer of the medication cart and the DON offered that they shouldn't have done that. A record review of the facility provided Controlled Substances Policy Statement revealed . Unless otherwise instructed by the Director of Nursing Services, when a resident refused a non-unit dose medication (or it is not given), or a resident receives partial tables or single dose ampoules (or it is not given), the medication shall be destroyed and may not be returned to the container.

Based on observation, interview and record review, the facility failed to apply bilateral palm protectors for one resident (Resident #21) of two residents reviewed for range of motion, resulting in the likelihood of decreased range of motion and discomfort. Findings include. Resident #21: On 7/15/24, at 8:49 AM, Resident #21 was lying in their bed. Their right hand was closed. They did not have any form of palm protectors on. On 7/15/24, at 11:01 AM, Resident #21 was lying in bed in the same position. There bilateral hands appeared contracted, and they were not wearing any palm protectors. On 7/16/24, at 7:54 AM, Resident #21 was lying in bed They did not have any palm protectors on. On 7/16/24, at 1:53 PM, Resident #21 was resting in bed. They did not have any palm protectors on. On 7/16/24, at 3:00 PM, a record review of Resident #21's electronic medical record revealed an admission on 8/14/2020. A review of the Kardex revealed . SPECIAL NEEDS . Bilateral hand protectors to be worn during day. Applied after hand hygiene, and taken off before sleep hours with skin checks for redness. FMP-Palm Protector (rt) hand, donned during day after hand hygiene, removed at night FMP-Palm Protector right and left hand, donned during day after hand hygiene, removed at night . On 7/17/24, at 9:02 AM, Therapy Director (TD) A was interviewed regarding Resident #21 and their range of motion needs. TD A offered that they recently had Resident #21 on therapy with a discharge recommendation for palm protectors to be warn during the day and off at night. On 7/17/24, at 9:06 AM, an observation along with TD A of Resident #21 was conducted. Resident #21 was lying in bed without their palm protectors. TD A found the palm protectors in the top drawer of the nightstand. TD A asked Resident #21 if they could clean their hands and place the palm protectors on. Resident #21 stated, I don't really care. TD A gathered linen and cleaned Resident #21's hands and asked them if they clip their nails and Resident #21 stated, I want you to. TD A completed nail care and placed the palm protectors on Resident #21. A record review along with TD A of the instruction photo that was placed inside Resident #21's closet door which revealed pictures of the placed palm protectors on their bilateral hands. TD A offered that they educated the staff on how to place the palm protectors as well.

Based on observation, interview and record review, the facility failed to prevent the development of a facility-acquired pressure injury and ensure that timely nutritional care plans are updated and implemented with the development of the pressure injury for one resident (Resident #39) of three residents reviewed for pressure ulcers resulting in deep tissue injury to R39's left heel and potential for lack of nutritional intervention to hasten the healing of pressure injury and potential for pain and discomfort. Findings include: Resident #39 (R39): A wound observation was conducted on 07/17/24 at 1:17 PM. R39's on 7/3/24 developed a Deep Tissue Pressure Injury (DTI) located at R39's left heel. The Wound Nurse O described that R39 have a blackened area on her Left Heel upon admission. Although R39 had a vascular ulcer on her right big toe before her admission at the facility, R39 developed the DTI acquired at the facility. Wound Nurse O revealed, R39 was admitted to the facility on [DATE], and developed DTI few weeks after on July 2nd when R39 complained of soreness to the left heel. The DTI on the left heel was a blackened area that measured: Length 2.55 centimeter (cm) by Width 2.57 cm. with a treatment order of skin prep every shift. It was observed to have felt tenderness and pain when surveyor observed R39 did a slight jerk movement and a grimace when treatment was applied on the left heel. R39 was observed to be alert and oriented regarding time, place, and person. According to the Electronic Medical Record EMR reviewed in 7/16/24 at 9:30 am, R39 was admitted to the facility on [DATE] with the diagnosis of Pulmonary Embolism with Acute Pulmonale, Type 2 Diabetes, in addition to other diagnoses. No wounds were indicated in her admission diagnosis. The doctor's orders reviewed included R39's Diet order dated 6/18/24, which were noted as CCD (Controlled Carbohydrate Diet), NAS (Cardiac or No Added Salt) diet with Regular Food consistency. A laboratory report dated 6/26/24 revealed that the blood glucose level was flagged at a high level at 439 mg/dL (normal range of 82 up to 115 mg/dL). A review of R39's Weight record on 07/16/24 at 10:10 AM revealed the following: On 06/17/2024, R39 weighed 109.5 pounds (lbs.) On 07/8/2024, R39 weighed 99.5 lbs., a confirmed weight loss of 10 lbs. a 9.13 percent (%) weight loss in approximately 21 days (3 weeks) since admission to the facility. A facility Wound List was reviewed on 7/16/24 at 4:30 PM. It revealed R39 developed wounds inhouse SDTI - Left Heel Acquired IH (In House) MASD- Sacrum Acquired OA Venous- Right Great Toe Acquired OA Cellulitis- Left Arm Acquired IH (In House) Care Plan was noted to have been revised on 7/15/24, on the day state survey started. The Wound Nurse O during the interview on 7/17/24 at 1:20 PM, revealed that R39 besides DTI have also developed an open area on her left forearm and later was diagnosed with vascular cellulitis of the left arm which had opened up. It was swollen, red and had an apparent wound drainage. According to Wound Nurse O, R39 was prescribed antibiotic for it with a stop date of 7/19/24. Although improving and the drainage are less, daily dressing changes continued and Wound Nurse O had indicated that she was responsible for monitoring and providing the wound care on all of R39's wound treatments. R39 in an interview on 7/17/24 at 1:20 PM, revealed that she does not consistently get the wound care when she's supposed to. R39 stated that for example today, they have not done any of her wound treatment this morning and she did not receive her protein shakes as ordered on a regular basis. An interview with R39's significant other L was conducted on 07/15/24 at 12:42 PM. He was observed bringing in fresh strawberries for R39. R39's significant other L stated they don't follow the doctor's orders especially the nutritional interventions to help with healing. He stated, The meals are not planned for people with diabetes or with wounds. She does not receive her protein drink and cottage cheese consistently as she's supposed to. I had to bring them get them from the store. An interview with the Dietary Manager (CDM N) was conducted on 7/17/24 at 1:30 PM. The CDM N indicated that she met with R39 during her care conference initial eval/assessment but not since. CDM N was unaware of the complaints and her preferences were not honored. CDM N described her responsibility of monitoring that food preferences are honored, she helps out in creating resident's meal trays and ensuring food preferences and dietary orders are followed, and to make sure trays are distributed in the units timely. CDM N admitted she was unaware that R39 had complaints with her tray received. DM N admitted that they did ran out of strawberries. Tuesday was the fruit deliveries, but CDM N was unable to follow-up up with the R39 if she got her strawberries. When DM N was queried about if they had ran out with cottage cheese, CDM N said they did not. But was unaware R39 have not been receiving the preferred nutritional needs as ordered and as specified preference. According to the Registered Dietician (RD M) on 7/17/24 at 1:40 PM. R39 was seen for the first time on 7/1/24, to address the wounds. Supplement (protein) started on 7/3/24. Ordered MedPass (sugarfree) to be given times a day and Proheal twice a day. A care plan was created specifically and was updated when the wounds developed. When RD M was queried how can they monitor if the preferences and protein supplements are given. RD M stated that they will follow-up thoroughly next time and pay more attention to the high in protein and protein supplements given to R39 and honor preferences. A review of R39's Care Plan for wound was reviewed and did not have additional nutritional interventions focusing on the prevention and promote wound healing other than supplements which were not available consistently during meals and during medication pass as observed during the survey. Wound Policy was reviewed on 7/17/24 at 2:30 PM. The purpose of this procedure is 1) to identify residents at risk for developing alterations in skin including pressure ulcer/injury risk factors, and 2) to identify specific interventions to assist with prevention and management of skin alterations.

Based on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL) care for four residents (Resident #5, Resident #21, Resident #33 and Resident #36) out of nineteen residents reviewed for ADL care, resulting in long jagged fingernails, missed showers and unkept appearance. Findings include: Resident #5: On 7/16/24, at 10:00 AM, a record review of Resident #5's electronic medical record revealed an admission on 3/22/2023 with diagnoses that included stroke, heart failure and dysphagia. A review of the I have an ADL self-care performance deficit care plan revealed . PERSONAL HYGIENE/ORAL CARE: I am totally dependent of (2) staff for personal hygiene and oral care. Date Initiated: 09/25/2023 . A review of the Task: Shower/Bed Bath - Tuesday and Friday morning and PRN (as needed) Look Back: 30 (days) . revealed the following documented showers 6/18/2024 6/21/2024 6/28/2024 7/2/2024 7/9/2024 7/12/2024 There were 2 showers missed 6/25 and 7/4. Resident #21: On 7/15/24, at 8:49 AM, Resident #21 was lying in their bed. Their right hand was closed. Their bilateral hands had long jagged nails. On 7/16/24, at 7:54 AM, Resident #21 was lying in bed. Resident #21's nails remained long and there were no hand splints or palm protectors noted. On 7/16/24, at 1:53 PM, Resident #21 was resting in bed. Their nails remained long. On 7/16/24, at 3:00 PM, a record review of Resident #21's electronic medical record revealed an admission on 8/14/2020 with diagnoses that included Hypertension, Chronic Obstructive Pulmonary disease and seizures. A review of the (the resident) has ADL Self care deficit r/t anoxic brain damage, physical limitations . I request assist of two with ADL's . A review of the Kardex revealed . SPECIAL NEEDS . Bilateral hand protectors to be worn during day. Applied after hand hygiene, and taken off before sleep hours with skin checks for redness. FMP-Palm Protector (rt) hand, donned during day after hand hygiene, removed at night FMP-Palm Protector right and left hand, donned during day after hand hygiene, removed at night . On 7/17/24, at 9:06 AM, an observation along with TD A of Resident #21 was conducted. TD A began range of motion for skin assessment which revealed long jagged nails on both hands. TD A I think they just cut his nails last week and Resident #21 quickly responded, they are not cut. Resident #21's pinky nail on their right hand was nearly a centimeter long. Their palm had dirty buildup. TD A gathered linen and cleaned Resident #21's hands and asked them if they clip their nails and Resident #21 stated, I want you to. TD A completed nail care. Resident #33: On 7/15/24, at 8:27 AM, Resident #33 complained they don't always get their showers as scheduled and are supposed to be on Wednesdays and Sundays. Resident #33 further complained that they did not get their scheduled shower the night before because the girls that normally do it weren't working. On 7/15/24, at 3:30 PM, a record review of Resident #33's electronic medical record revealed and admission on 6/30/2023 with diagnoses that included heart attack, Myeloma and compression spinal fracture. A review of the I have an ADL self-care performance deficit care plan revealed . BATHING/SHOWERING: I require limited assistance by (1) staff with bathing/showering . A review of Resident #33's Task: Shower/Bed Bath Sunday/Wednesday PM Look Back: 30 (days) revealed the following showers were given 6/16/2024 6/23/2024 6/26/2024 6/30/2024 7/3/2024 7/7/2024 7/10/2024 There were two showers missed: 6/19 and 7/14. Resident #36: On 7/15/24, at 8:55 AM, Resident #36 was lying in bed in their gown. Their call light was out of reach sitting on chair to the left of their bed approximately 4 feet away. Resident #36 was asked if they could reach their call light and Resident #36 stated, No and I guess someone didn't want me to bother them. On 7/15/24, at 11:02 AM, Resident #36 was lying in bed in their nightgown. On 7/16/24, at 9:00 AM, a review of Resident #36's electronic medical record revealed and admission on 11/06/2023 with diagnoses that included heart failure, Diabetes and Alzheimer's disease. A review of the I have an ADL self-care performance deficit care plan revealed . DRESSING: I require extensive assistance by (1) staff to dress. Date Initiated: 11/06/2023 . On 7/16/24, at 1:56 PM, Resident #36 was lying in their bed and remained in their nightgown. On 7/17/24, at 9:53 AM, Resident #36 was lying in bed in their nightgown. On 7/17/24, at 10:25 AM, the Director of Nursing (DON) was alerted that Resident #36 had not been dressed in clothing the last three days and the DON planned to follow up. On 7/17/24, at 10:35 AM, the DON offered that Resident #36 was dressed in their clothing. A review of the facility provided Activities of Daily Living (ADL's), Supporting Policy revealed Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .

Based on interview and record review, the facility failed to follow the plan of care and provide appropriate assistance (2-person transfer) during a transfer in bed for one resident (Resident #1) of three residents reviewed for transfer status, resulting in the resident rolling out of bed, sustaining a right upper arm abrasion and a left lower leg skin tear with the likelihood of further injury. Findings include: Resident #1: On 8/30/23, at 11:00 AM, a record review of Resident #1's electronic medical record revealed an admission on 6/15/2023 with diagnoses that include frequent falls, bipolar disorder and Parkinson's disease. Resident had intact cognition. A review of the Minimum data set assessment for . ARD date . 6/22/2023 . Section G . Bed Mobility . Support . 3. Two + persons physical assist . A review of the I have an ADL self-care performance deficit: I admitted to the SNF as transfer from acute had recent left TKA (total left knee replacement) and developed septic arthritis and having difficulty ambulating and weakness in his left LE and unable to take care of himself at home. Date Initiated: 06/15/2023 . BED MOBILITY: I require extensive assistance by (2) staff to turn and reposition in bed. Date Initiated: 06/15/2023 . On 8/30/23, at 1:30 PM, CNA A was asked to explain how Resident #1 fell out of bed. CNA A explained that they received report from the night shift that Resident #1 was pretty much a one person assist. CNA A was asked if they reviewed the Kardex or Plan of Care prior to assisting Resident #1 and CNA A stated, no and I will never do that again. CNA A stated Resident #1's entire bedding needed to be changed and as they switched to other side to removed the soiled linen Resident #1 was assisted to roll over and then he continued to roll out of the bed and onto the floor. CNA A was asked to clarify why they were assisting the Resident #1 with just one person when the care plan stated 2 person assistance was needed and CNA A stated I should have looked at the Kardex and I did not. CNA A further offered that after the incident they looked at the Kardex and I got a verbal warning for not having 2 people. CNA A was asked if there was anything they could have done to prevent Resident #1 from rolling out of bed and CNA A stated, yeah, I could have had another person. On 8/31/2023, at 1:45 PM, the Director of Nursing (DON) was interviewed regarding Resident #1 incident. The DON explained that CNA A was assisting the resident when they fell out of bed. The DON was asked to explain the injuries Resident #1 sustained during the fall and the DON stated, he had an abrasion and a skin tear. The DON was asked to provide a more detailed fall report as surveyor access does not allow risk management view. A record review along with the DON of the fall report was conducted and revealed Witnessed Fall Date: 6/24/2023 07:00 revealed the following: Incident location: Resident's room . CNA was assisting resident to change his bedding. While she was working on one side, resident quickly rolled himself up to other side, and continued rolling out of bed before CNA was able to move to the other side. Resident Description: Spoke with resident who stated he decided to roll over before CNA was ready to try to help her . Immediate Action Taken . Immediately assessed for injury. Fall was witnessed did not hit head. 2 cm (centimeter) abrasion to right upper arm and 2 cm skin tear to left outer calf. Scant amt (amount) of bleeding. Skin is approximated. Resident denies pain. Mattress changed out to perimeter mattress to allow resident comfort with bed boundaries . The DON was asked their conclusion as to why Resident #1 fell out of the bed and DON stated, he was impulsive and started rolling before (CNA) was ready. On 8/31/23, at 2:05 PM, a record review of the CNA A Disciplinary Action Form was conducted along the DON. The DON was asked what the CNA was disciplined for, and the DON stated, for not having the second person assist.

Based on observation, interview, and record review, the facility failed to maintain plumbing in good repair, and store nursing supplies in a manner that protects the integrity of the packaging, resulting in the potential for the contamination of domestic water supplies and the contamination of supplies, affecting all residents and staff in the building. Findings include: On 7/12/23 at 1:19 PM, the hand sink in the central bath in Hall 1 was observed to be leaking water out of the hot water handle when it was turned on. On 7/12/23 at 1:37 PM, the dietary mop sink was observed to have an atmospheric vacuum breaker (AVB) (a device commonly used in plumbing to prevent the backflow of solid, liquid, or gas contaminants) that had a downstream shutoff valve, allowing the AVB to remain under pressure for extended periods of time, compromising the integrity of the AVB. According to the 2018 Michigan Plumbing Code Section 608 Protection of Potable Water Supply, 608.16.4 Protection by a vacuum breaker. Openings and outlets shall be protected by atmospheric-type or pressure type vacuum breakers. The critical level of the vacuum breaker shall be set not less than 6 inches (152 mm) above the flood level rim of the fixture or device. Fill valves shall be set in accordance with Section 425.3.1. Vacuum breakers shall not be installed under exhaust hoods or similar locations that will contain toxic fumes or vapors. Pipe applied vacuum breakers shall be installed not less than 6 inches (152 mm) above the flood level rim of the fixture, receptor or device served. 608.16.4.1 Deck-mounted and integral vacuum breakers. Approved deck-mounted or equipment mounted vacuum breakers and faucets with integral atmospheric vacuum breakers or spill-resistant vacuum breaker assemblies shall be installed in accordance with the manufacturer's instructions and the requirements for labeling with the critical level not less than 1 inch (25 mm) above the flood level rim. On 7/12/23 at 1:48 PM, a separate storage building was observed to have two boxes of briefs, and six boxes of gloves stored on the floor in the far left storage room. In the far right storage room, four boxes of briefs were observed to be stored on the floor among countless bug carcasses.

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure medication and medical supply storage and disposal per professional standards of practice for one of one medications' room and one resident (Resident #30) of one resident reviewed, resulting in a lack of documentation of refrigerated medication temperature monitoring, medications stored at Resident #30's bedside, expired medications and medical supplies, and the potential for unauthorized medication administration and for all residents to receive medications and medical supplies with altered efficiency. Findings include: Resident #30: During the initial tour of the facility on 7/11/23 at 11:26 AM, an empty medication cup in addition to the following medications were observed on Resident #30's overbed table: - Opened Advair Diskus Inhaler (used for treatment of respiratory symptoms) - Flonase Nasal Spray (steroid medication frequently used to treat nasal congestion) - Azelastine Nasal solution (antihistamine medication frequently used to treat nasal congestion associated with allergies) When queried regarding the medications on their overbed table, Resident #30 revealed the nurse left them there so they could take them and had not come back to get them yet. When asked if the facility nurses always leave their medications for them to take, Resident #30 revealed some of the nurses leave the medications. At 11:29 AM on 7/11/23, two facility staff members were observed sitting at the nurses' station. When asked who the nurse assigned to care for Resident #30, Licensed Practical Nurse (LPN) E indicated they were. LPN E was then queried regarding the medications observed on Resident #30's overbed table and stated, I forgot to get them and put them back in the cart. When asked if Resident #30 takes the medications themselves, LPN E replied, Yeah. LPN E was asked if Resident #30 had an evaluation for safe self-medication administration but did not provide a response. When asked if the medications are supposed to be left at the Resident's bedside, per facility policy/procedure, LPN E did not answer the question but indicated they were going to get the medications and put them in the medication cart. A review of Resident #30's medical record revealed no documentation of an assessment pertaining to safe medication administration. An interview was completed with the Director of Nursing on 7/11/23 at 11:40 AM. When queried regarding observation of medications on Resident #30's overbed table and interview with LPN E, the DON revealed the medications should not be left unattended and they would address the concern. When asked if Resident #30 had been assessed for self-medication administration, the DON revealed they were not aware of the Resident being assessed to be able to self-administer their medications. Medication Room: A tour of the medication room was completed with LPN E on 7/13/23 at 09:47 AM. The following expired items were present in the medication room: - 30 Walgreen's brand Insulin syringes; Expired 2/2023, Back up was written on the box - Three Stadis Intravenous (IV) Start Kits; Expired: 3/20/22 - Two Mini Spike Vented Dispensing Pin with Luer Lock; Expired: 3/31/23 - Mini Spike Vented Dispensing Pin with Luer Lock; Expired: 1/31/21 - BD vacutainer Safety Lock blood collection set; 23-gauge (G) X 3/4 inch; Expired: 12/31/22 - BD vacutainer Safety Lock blood collection set; 23-gauge (G) X 3/4 inch; Expired: 6/30/23 - 24 G BD Insyte Auto guard IV needle; Expired: 4/30/23 - 18 G Safety Needle; Expired: 6/30/22 - BD Vacutainer; Expired: 5/31/23 - Two 22 G X 1-inch Introcan Safety 3 Closed IV catheter; Expired: 9/1/21 - Seven 16-ounce (oz) containers of Biotene Dry Mouth Oral Rinse; Expired: 7/3/23 A medication storage refrigerator was present in the medication room. A digital temperature device was present on the outside of the refrigerator but there a temperature log was not present. When asked how the temperatures in the medication refrigerator are monitored, LPN E indicated they were unsure but thought that facility maintenance staff were notified of the temperature readings. When queried how staff knew the refrigerator temperature was within acceptable parameters for medication storage, LPN E did not provide an explanation. A tour of the refrigerator at this time revealed the following expired medication: - Hepatitis B Engerix- B 20 microgram (mcg)/ milliliter (mL) vaccine; Expired: 4/29/23 Review of facility policy/procedure entitled, Storage of Medications (Reviewed: 4/2023) revealed, Policy Statement: The facility stores all drugs and biological's in a safe, secure, and orderly manner . 1. Drugs and biological's used in the facility are stored in locked compartments under proper temperature, light and humidity controls . 5. Discontinued, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed .

This Citation pertains to Intake Number MI 572. Past Non-Compliance (PNC) was accepted for this citation. Plan is identified below. Based on interview and record review, the facility failed to keep one resident safe (Resident #187) while pushing the wheel chair out of five residents reviewed resulting in pain, a broken leg bone, and hospitalization . Findings include: Resident #187: According to the care plan, printed 4/11/2022, Resident #187 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included high blood pressure, [CONDITION(S)], depression, [CONDITION(S)] with dependence on renal [CONDITION(S)], type 2 Diabetes Mellitus, and [CONDITION(S)] in [CONDITION(S)]. During an interview on 4/11/2022 at 1:46 PM with Registered Nurse (RN) R, she stated that Resident #187 had been in her wheel chair in the hallway waiting to go to [CONDITION(S)] when she came up behind her, and knowing that it was her day and scheduled time to go to [CONDITION(S)], she was going to assist her to the front lobby to wait for the transport. RN R began to push the wheel chair and Resident #187 said owww. She was alert and oriented. So, I immediately stopped pushing her and checked her leg when she indicated that it hurt. Her feet had been on the pedals , I did not notice her feet were off of the pedals. I put her feet back on the pedals and pushed her in the chair to the lobby to wait for the transport. I don't know the sequence of events after she went to [CONDITION(S)]. I was traumatized, I cried. I am still friends with her daughter. I learned to always check the foot placement of the residents before I push the chair. According to the progress notes for Resident #187, on 8/11/2021 at 11:14 AM, the entry read, Resident was sitting in wheelchair sleeping awaiting dial a ride. Nurse came up behind resident pushing her forward about two inches. Resident woke stating my leg/knee. Leg was not on foot pedal when pushed forward, bending leg back under chair. Resident went to [CONDITION(S)]. Call from [CONDITION(S)] that they had given her Tylenol for knee pain and called the daughter. Upon return to the facility, Resident #187 had an x-ray of her left knee. On 8/11/2021 at 10:02 PM, Resident #187 was sent to the emergency room to be evaluated for uncontrolled pain in her left leg. On 8/12/2021 at 1:12 AM, it was documented in the progress notes that Resident #187 had been admitted to the acute care hospital for a broken left lower femur bone, her thigh. The facility implemented the following measures which was considered PAST NON-COMPLIANCE by the State Agency: -Education was completed with staff to make sure that when we transport residents that we verify that feet are always on foot pedals. -RN causing incident was educated with one on One regarding proper procedures. -The facility will complete 3 times a week audits for four weeks of staff transporting resident to assure that feet are on foot rests during transportation with finding submitted to the Director of Nursing (DON) who will report findings to Quality Assurance Committee for review and recommendations. -Facility reviewed all resident that require assistance with transporting and were evaluated for foot pedal status. Care plans/tasks were updated. -The facility identified all residents that need to have foot pedals in place at all times. -Facility audited residents experiencing pain scores of 7,8, 9, or 10 to assure that the doctor is aware and pain is assessed. -Facility audited residents with change in conditions to make sure physician is notified timely. -Facility staff were educated on verification of feet on foot pedals prior to transport and not pushing resident in a wheel chair without foot pedals present. -Licensed nursing staff were educated on pain management and Change of Condition. -Unit manager or designee will audit random weekly audits of pain and change in conditions for four weeks. Audits will be reviewed with DON weekly and will be brought weekly to Quality Assurance Committee and review with Interdisciplinary Team. On 4/13/2022, this surveyor reviewed documentation, conducted interviews and made observations that the preceding interventions were completed prior to the recertification and abbreviated survey. A determination for Past Non-Compliance was approved by the State Agency with a Compliance Date of 08/20/2021.

Based on observation, interview and record review, the facility failed to care plan and implement interventions for a removable leg brace, assess skin under the removable leg brace, properly document the stages of two pressure ulcers, prevent the development of a new pressure ulcer and follow care planned interventions to prevent the worsening of an existing pressure ulcer for one resident (Resident #28) of one resident out of a total sample of 17 reviewed for pressure ulcers, resulting in a left foot Stage 1 pressure ulcer worsening to a Stage 3 pressure ulcer (Full-thickness skin loss. Slough and/or eschar may be visible) and the development of a right foot Stage 3 pressure ulcer, pain, the need for a wound clinic consultation and the likelihood of infection. Findings include: Resident #28: On 1/15/20, at 11:37 AM, a record review of Resident #28's electronic medical record revealed an admission on 11/15/19 with a readmission on [DATE] after a 5 day hospital stay with [DIAGNOSES REDACTED]. A review of the Minimal Data Set assessment dated [DATE] revealed Resident #28 required extensive assistance with two-person physical assist with Activities of Daily Living (ADL's) including bed mobility. Resident #28 had severely impaired cognition. The admission Braden Scale for Predicting Pressure Sore Risk Date: 11/18/2019 Category: At Risk . revealed Resident #28 was at risk for pressure sores. A review of the SKIN WORKSHEET Date/Time: 11/15/19 10:28 PM . If Abnormal circle affected area (s): . revealed a body diagram with nothing circled on the right foot. A review of Resident #28's Skin progress notes revealed the following: 11/18/2019 18:04 Skin . Admission skin assessment completed today . Right heel area is also noted to have blue/purple bruising & Pt. (patient) states that this was from her fall. Remainder of skin assessment is unremarkable . Author: Nurse C 11/19/2019 14:21 Skin . Pt. admitted with a stage 1 pressure wound to her left ankle malleolus. Area is approx. (approximately) 1.0 cm (centimeter) x (by) 0.4 cm & is reddened & non-blanchable . Author: Nurse C 12/11/2019 11:12 Skin . Second head to toe skin assessment completed . Pt. was admitted with a stage pressure wound to her left foot Malleolus. Size is approx. 3.0 cm x 1.5 cm x 0.1 cm with a red, moist, shiny wound base. Scant amt. (amount) of serosang. (serosanguinous) drainage with no odor noted with drsg. (dressing) change. No undermining or tunneling noted. Initiated daily TX (treatment) of Therahoney & comfort foam. Pt c/o (complained of) pain/discomfort to this wound area with touch . Author Nurse C. The number staging of Resident #28's left foot Malleolus pressure ulcer was left out of the documentation on this day. 1[DATE]19 12:03 Skin . Stage 2 pressure wound to Pt's left foot malleolus area is approx. 1.5 cm x 2.0 cm x 0.1 cm in size with a red, moist, shiny wound base. A scant amt. of serosang. Drainage with no odor noted with drsg. Change. Surrounding tissue is reddened, dry and blanchable. Left foot is warm, pink & dry with a weak pedal pulse. Pt. c/o moderate pain to wound area with touch & pressure . Author: Nurse C 12/24/2019 11:55 Skin . Stage 2 pressure wound to left malleolus area is approx. 3.5 cm x 3.0 cm x 0.1 cm in size with a moist, shiny reddened wound base. A scant amt. of serosang. Drainage with no odor noted with drs. change. Surrounding tissue warm, dry, intact & blanchable. Pt. c/o pain to wound area with touch & pressure . Author: Nurse C 12/31/2019 15:09 Skin . Wound rounds completed today. Stage 2 pressure wound to left foot malleolus is approx. 2.3 cm x 2.0 cm x 0.1 cm in size. Wound base is reddened, moist, shiny with a small amt. of serosang. Drainage with no odor. Surrounding tissue is reddened, dry & blanchable. Pt c/o pain to wound area with touch & pressure. Pt is up in w/c (wheelchair) daily & requires max assist with ADL's . Author: Nurse C 1/8/2020 17:16 Skin . Wound rounds completed with wound care team. (the resident) was admitted to the facility with a noted pressure area to her left malleolus. Measurements are 3.0 x 2.5 small amount of serous drainage present. No odor noted at this time surrounding tissue is reddened. Patient continues to be seen by wound clinic will ensure that they are evaluating wounds and refer to the of any changes in treatments. Patient has intermittent complaints of pain to the area and continues on prn medications which have been effective. Pressure interventions include pressure reducing mattress and continuing to encourage to turn and reposition . Author: (Director of Nursing) The stage and depth of the pressure ulcer was not documented on this day. A review of Resident #28's general progress notes revealed 1/15/2020 05:18 General Progress Note Upon removal of right leg brace open area noted to outer right foot/heel. Received order for comfort foam dressing after cleansing with wound wash. Change daily and prn. Tx done as ordered . On 1/15/20, at 11:50 AM, a record review of Resident #28's care plans revealed Focus (the resident) has noted ADL Self care deficit . Created on: 11/16/2019 . Revision on: 01/16/2020 . interventions . lower extremity immobilizer to wear at all times in relation to recent skin graft surgery remove every day and evening shift and assess skin. Date initiated: [DATE]20 . Focus . pressure wound to her left ankle malleolus related to: pressure . Created on 11/19/2019 . interventions . Blue boots to B/L (bilateral) feet when lying in bed Date initiated: 11/26/2019 . Focus (the resident) has a center acquired unstageable pressure wound to outer right heel/foot related to: immobilizer. Date initiated: [DATE]19 . interventions . Assess right leg every day for skin abnormalities . Encourage and assist as needed to turn and reposition; use assistive devices as needed Date initiated: [DATE]20 . On 1/15/20, at 1:09 PM, a record review along with the Director of Nursing (DON) of Resident #28's electronic medical record was conducted. A review of the physician orders [REDACTED]. The DON was asked when the leg brace was initiated and the DON stated, I'm not sure. I will have to look at the hard chart. The DON was asked if the leg brace was on Resident #28's care plan and the DON reviewed the record and stated, well it is now as of today when the night nurse found a wound. A review of the care plan revealed no intervention to remove the leg brace and to check the skin under the leg brace. The DON was alerted that Resident #28 was observed in their bed lying on their back without heel boots on both 1/14/20 and again in the am on 1/15/20. The DON was asked if Resident #28 had blue boots to wear and the DON along with the surveyor walked to Resident #28's room. There were two pressure reducing blue boots in their closet. The DON was asked to provide the facility policy for removable medical devices and skin care policy. There was no removable medical devices policy and the Skin Practice Guide is what the facility follows for wound care. On 1/15/20, at 1:31 PM, Resident #28 was lying in their bed on their back with no heel boots on. On 1/15/20, at 1:40 PM, an observation of wound care with Nurse Z was conducted. Resident #28 was lying in their bed on their back with no blue boots on. Nurse Z lifted Resident #28's leg slightly off the bed and Resident #28 stated, OW. OW. The brace had medal supports on each side and the distal end of the brace was resting on top of the dressing to the right outer foot. Nurse Z was asked if they felt the brace caused the pressure injury and Nurse Z stated, Oh, yeah. Nurse Z then removed the old dressing that was moderately covered in serosanguinous drainage. Nurse Z then rested Resident #28's foot on a paper towel on the bed. Nurse Z then removed the right leg brace. Resident again yelled, OW. The wound measured approximately 2 inches wide by 1.5 inches long by a half a centimeter deep. The wound base had dark grey tissue throughout with macerated edges. The DON and Nurse Consultant Y entered the room. The DON was alerted that Resident #28 did not have their blue boots on. Nurse Z cleansed and dressed the wound per physician order. Nurse Consultant Y assessed the leg brace that was dirty with old [MEDICATION NAME] stains and old bloody drainage behind the heel area placed in it a garbage bag and stated, it needs to be thrown away. The medal support was protruding down passed the white cotton holder. Resident #28 again yelled, OW while Nurse Z placed the blue boots on her feet. On 1/16/20, at 11:50 AM, an observation of Resident #28's left malleolus wound was conducted along with Nurse Z. The wound measured approximately 1 inch by 1 inch by 1 cm deep. The wound bed had yellow slough throughout with a small area of dark gray tissue. The perimeter of the wound measured approximately 2 centimeters and was bright red. There was a moderate amount of serosanguinous drainage with a yellow/green tinge to the old dressing which had been placed on the wound approximately 4 hours earlier. Resident #28 stated, OW during the treatment. Nurse Z was asked if the doctor had seen the wound and Nurse Z stated, I'm not sure if the doctor seen it. He comes in on the weekends. On 1/16/20, at 12:21 PM, Nurse Supervisor K was asked why Resident #28 goes to the wound clinic and Nurse Supervisor K stated, for the skin grafts but we are in the process of having them see her for her pressure ulcer. Nurse Supervisor K was asked why the facility was having the wound clinic assess the left malleolus pressure ulcer and Nurse Supervisor K stated, because of the increased drainage, slough and because it's worse. Nurse Supervisor K further offered that the wound clinic will assess Resident #28's pressure ulcer on her next scheduled appointment. On 1/16/20, at 12:45 PM, a record review of the facility provided Skin Practice Guide Issue Date: 01/2013 revealed the following: Alteration In Skin Integrity . Any increase in the PUSH tool score (possibly indicating wound deterioration) requires a more complete evaluation of the ulcer . Wound Team Documentation Guidelines . Describe pressure ulcers consistent with initial evaluation and compare observation over time . Document the presence of any non-removable dressing/device . cast or brace . Push tool and wound notes completed per guidelines . A review of the Resident #28's PRESSURE ULCER SCALE FOR HEALING (PUSH) TOOL for the Left foot malleolus - stage 2 revealed the following: . 1/15/19 . Tissue Type: 2 ., was written in the box. A review of the PUSH TOOL 3.0 examples of Tissue types revealed the following: Tissue Type: This refers to the types of tissue that are present in the wound (ulcer) bed. Score as a 4 if there is any necrotic tissue present. Score as a 3 if there is any amount of slough present and necrotic tissue is absent. Score as a 2 if the wound is clean and contains granulation tissue . 4 Necrotic Tissue (Eschar): black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin. 3 Slough: yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous 2 Granulation Tissue: pink or beefy red tissue with a shiny, moist, granular appearance . Date 1/15/19 . Tissue Type 2 . The PUSH tool for Resident #28's new outer right foot/heel Date 1/15/20 . revealed . Tissue Type 4 . A review of facility Interdisciplinary Care Planning policy dated 3/2018, revealed . the patient's care plan is a communication tool that guides members of the interdisciplinary healthcare team in how to meet each individual patient's needs. It also identifies the types and methods of care that the patient should receive. Planning the patient's care includes identifying problems and/or risk (potential or actual), strengths, and needs; evaluating whether the problem is acute or chronic; setting measurable goals with time frames; and determining the interventions that will enable the patient to meet their goals .

Based on observation, interview and record review, the facility failed to ensure professional standards of care were followed regarding, 1) a complete Gastrointestinal (GI) assessment upon change of condition and 2) follow-up on nursing documentation of a change in condition (black tarry bloody stools), for 1 resident (Resident #16) of 17 residents reviewed for nursing assessment and change of condition, resulting in a critically low hemoglobin (Hgb.) lab (red blood cells), delay in treatment (due to low Hgb.) with hospitalization . Findings Include: Resident #16: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated ,[DATE], nursing, physician and social worker notes dated [DATE] through [DATE], labs dated [DATE] and physician orders [REDACTED].#16 was admitted to the facility on [DATE], [AGE] years-old, alert, moderately cognitively impaired and dependent of staff for all Activities of Daily Living (ADL's). The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility after having a stroke for rehabilitation. The resident had documented black tarry stools (sign of GI bleed with documented black tarry stools), a critical lab result of Hgb. 6.7 (critically low Hgb., iron) resulted in being transferred to the hospital (on [DATE]), and deceased in the emergency room of [MEDICAL CONDITION] infraction (heart attract). Review of the facility nurse's note's dated [DATE] through [DATE], are as follows: -On [DATE] at 20:27 (8:27 p.m.), Nurse, LPN G documented had 1 black tarry stool. No documentation was found of this information being reported to the physician, NP, emergency contact nor of the resident being monitored for bloody stools by nursing. No documentation was found of a complete GI nursing assessment done. When a patient has signs/symptoms of a GI bleed (including black tarry stools), assessing for a GI bleed is the most crucial activity. Acute upper gastrointestinal (GI) bleeding is a potentially life-threatening condition requiring accurate, prompt, and appropriate patient evaluation and management. The initial assessment of patients with upper GI bleeding focuses on assessing severity and urgency of bleeding. Focus on the GI tract, relevant history, and comorbid conditions. Patients may have difficulty quantifying bleeding, so elicit symptoms of blood loss (such as orthostasis; dizziness; [MEDICAL CONDITION]; confusion; cold, clammy extremities; dyspnea; [MEDICAL CONDITION]; and palpitations). Assess the patient for GI symptoms. Abdominal pain is commonly reported in patients with upper GI bleeding. Inspect the patient's abdomen for distension, ascites, abnormal pulsations, and masses. Hyperactive bowel sounds are common as proximal blood irritates the GI tract and induces peristalsis. Severe tenderness, guarding, rigidity, and rebound tenderness suggest GI perforation. Laboratory assessment for differentials of upper GI bleeding. Journal of the American Academy of PA's: (MONTH) 2014 - Volume 27 - Issue 9 JOURNAL OF THE AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS December (YEAR) -On [DATE] at 13:13 (1:13 p.m.), Nurse G documented large black tarry stool. No documentation was found of this information being reported to the physician, NP, emergency contact, nor of the resident being monitored for bloody stools by nursing. No documentation was found of a complete GI nursing assessment done. -On [DATE] at 13:28 (1:38 p.m.), Nurse G documented 1 loose black tarry stool. No documentation was found of this information being reported to the physician, NP, emergency contact nor of the resident being monitored for bloody stools by nursing. No documentation was found of a complete GI nursing assessment done. Review of physician/NP (Nurse Practitioner) notes dated [DATE], [DATE] or [DATE], revealed no documentation of black tarry stools or discomfort/pain. -On [DATE] at 12:55 (12:55 p.m.), Nurse Supervisor, RN K documented Placed call to (Nurse Practitioner) NP to notify of black stools & low blood pressures. Awaiting return call. -On [DATE] at 15:23 (3:23 p.m.), Nurse Supervisor, K documented (Nurse Practitioner) NP in building, notified of multiple black tarry stools, orders received for CBC, BMP (labs) and occult stools in [NAME]M. -On [DATE] at 10:23 (10:23 a.m.), Nurse G documented Occult stool positive (positive stool test for GI bleed), received call from lab, critical Hgb 6.7 (normal male=13XXX,[DATE],2) NP notified. transfuse 1u PRBC (1 unit of packed red blood cells), & GI workup, labs. (Hospital) infusion clinic contacted unable to get in today. NP notified. sent to ER for evaluation and treatment. Review of the facility labs dated [DATE], revealed the resident had a Hgb. of 6.7' (a critical value), due to the GI bleed. -On [DATE] at [DATE] at 10:39 (10:39 a.m.), Nurse G documented ambulance arrived transported out VIA stretcher. Review of the Hospital emergency room records dated [DATE], stated Patient presents emergency department with dark tarry stools with rectal bleeding, bleeding has been persistent for the past couple days, this was confirmed by nursing home staff and records that were sent over. Patient was in the process of workup nursing last seen patient at 1250 (12:50 p.m.) at 1255 (12:55 p.m.) patient was found unresponsive, pulseless, CPR (Cardiopulmonary Resuscitation) was initiated. Patient was pronounced at 1309 patient without any signs of life throughout the entire code. Acute lower GI bleed with sudden cardiopulmonary arrest with sudden cardiac death. Review of the hospital lab dated [DATE], stated Hemoglobin 6.2 LL Critical value (normal male=13XXX,[DATE].2). During an interview done with on [DATE] at 7:26 a.m., the Director of Nursing/DON stated she (Nurse G) documented black tarry stools three times and did nothing at all, no physician call, no NP call, no labs ordered. The DON revealed the resident's labs did not get ordered until the DON and Nurse Supervisor K reviewed the residents Electronic Medical Record and called the NP for orders on [DATE]. There was a delay in medical treatment. During an interview done on [DATE] at 3:00 p.m., Certified Nursing Assistant/CNA W stated I know he (the resident) has been having the black tarry stools for about a week. They were black in color, like tarry and (had) a very strong smell, mostly large stools. I told them (Nursing staff) he is having loose black tarry stool every time he had one; they did not come look at the stool. We do have a problem with the nurses not listening to the CNA's we all report to the nurses and nobody does anything. During an interview done on [DATE] at 9:59 a.m., Nurse Supervisor, RN K stated I was made aware of his stools on [DATE], I read it when I came in, in the morning in the notes. I had the nurses call the doctor and get an order for [REDACTED]. On the morning of the 13th ([DATE]) I asked (Nurse G) to fill out SBAR (situation, background, assessment & recordation sheet), a change of condition sheet to call the doctor, a communication between the nurse and the doctor. They should (of) contacted the doctor or NP and emergency contact at this point (on [DATE], according to the nurse's notes, first documentation of black tarry stools). They should have filled out a condition change assessment for the system that had an abnormal at this time (GI system, on [DATE]). They should have done a complete assessment for the system that had an abnormal at this time (on [DATE]). During an interview done on [DATE] at 1:36 p.m., Nursing Supervisor, RN U stated No one told me he had black tarry stools. If the nurse has an abnormal, they start an ESBAR (condition change documentation sheet) and inform me or the other supervisor. I think that would of been pertinent information to pass forward in report. We always have a Physician or Nurse Practitioner available to contact. I think this is a problem because we had a very negative outcome and there should of been an early intervention. During an interview done on [DATE] at approximately 8:30 a.m., Nurse G stated I should of called the physician and gotten labs. Nurse G had no reason why she did not do a complete GI assessment and follow-through with calling the physician and getting labs on [DATE], when the resident had the first black tarry stool. Review of the nurse facility work violation dated [DATE], revealed the reason for the violation write-up was due to documented change of condition without proper notification to physician and assessment. Review of the handwritten nurse report sheet dated [DATE], stated next to Resident #16's name 1 loose black tarry stool. This handwritten note was written by Nurse, RN N. During an interview done on [DATE] at 2:20 p.m., Nurse, RN N stated yes that's my writing (on the nurse report sheet dated [DATE]), I worked that weekend. I remember I got that information in report on him (that the resident had black tarry stools). I just monitored him; I didn't call the doctor; I probably should have. I should have done some assessment and followed through. During an interview done on [DATE] at 12:45 p.m., Physician L stated they (nursing staff) should have called for the stools. During an interview done on [DATE] at 12:44 p.m., the Nurse Practitioner (NP) V revealed she had not been contacted regarding the residents black tarry stools until [DATE], and said the black tarry stools should of been called (on [DATE] to the NP or the physician) before [DATE]. This caused a delay in treatment regarding a critically low Hgb. Review of the facility Change in Condition policy dated ,[DATE], stated A facility must immediately inform the resident; consult with the resident's physician; and notify consistent with his or her authority, the resident representative(s) when there is: A significant change in the resident's physical, mental, or psychosocial status (that is a deterioration in health), a decision to transfer or discharge the resident from the facility. During an interview done on [DATE] at 12:00 p.m., during the Quality Assurance task, the Administrator stated to the surveyor, Resident assessments (regarding Resident #16's black tarry stools) Change of Condition through survey process, root cause analysis, nurses not utilizing nursing skills, not utilizing SBAR, not communicating, not notifying physician, no follow through from DON (Director of Nursing), UM (Unit Managers). Review of facility nursing note's dated [DATE] at 16:13 (4:13 p.m.), stated Message left for family (Family Member #2 M, Emergency Contact person) awaiting return call. Review of the facility Acute Care Transfer sheet dated [DATE], revealed a change of condition was not done on Resident #16 until [DATE] and stated, Is contact person (Family Member #2, M) aware of transfer? Yes, Is contact person aware of diagnosis (Bloody stools and critical Hgb. lab), yes. During a phone interview done on [DATE] at 3:14 p.m., Family Member #2 M stated No one called me from the facility. The hospital left me a message and I called them back; they said they were working on him (doing CPR). I told them I was two hours away, they hung up and called me in ten minutes and said he was gone (deceased ). The facility never called and told me anything, they never called and told me that (the resident had three bloody stools).

Based on observation, interview and record review, the facility failed to ensure pain assessment and pain medication was given in a timely manner for 1 resident (Resident #16) who was diagnosed with [REDACTED]. Findings Include: Resident #16: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 12/19, nursing, physician and social worker notes dated 11/20/19 through 1/14/20, labs dated 1/14/20 and physician orders [REDACTED].#16 was admitted to the facility on [DATE], [AGE] years-old, alert, moderately cognitively impaired and dependent of staff for all Activities of Daily Living (ADL's). The resident's [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the residents Pain care plan dated 11/21/19, revealed staff were to report nonverbal expressions of pain (moaning, striking out, grimacing, crying, thrashing, change in breathing), implement non-pharmacological interventions (music, art, drama therapy, exercise, therapeutic modalities, Cryotherapy, thermal therapy, biofeedback, counseling, warm/cold compress and positioning), and therapy evaluation and treatment. Observation was made of Resident #16 on 1/13/20 at 8:29 a.m., in the main dining room at breakfast accompanied by Occupational Therapist/OT F. The resident was observed to have facial grimacing, guarding of the left leg, moaning with eye's closed at times and was very distracted; would not eat breakfast. The resident only drank some of his drinks after being persuaded by OT F. The resident was unable to concentrate and eat his breakfast due to his pain. During an interview done on 1/13/20 at 8:35 a.m., Occupational Therapist (OT) F stated He is in a lot of pain, I am trying to help him. During the entire breakfast meal OT F was observed sitting next to the resident, she was not observed leaving the table and going to inform the resident's nurse of his pain. During an interview done on 1/13/20 at 8:40 a.m., this surveyor asked the resident if he was in pain, he stated yes and put his left arm on his left leg indicating his left leg was were his pain was. During an interview done on 1/13/20 at 8:45 a.m., Nurse, LPN G stated He had a stroke, is aphasic (difficulty with speech/communication), it's hard for him to communicate. He gets [MED] 500 mg TID (three times a day), last time he got it was at 11:00 p.m. (on 1/12/20), it's due at 8:30 a.m. Nobody told me he was in pain today. If he is in pain, they (staff, including OT F) are supposed to come tell me his is in pain and he is not eating because he is in pain. A second observation was made on 1/13/20 at 8:46 a.m., when OT F took the resident to his room to work on transferring from wheelchair to bed using the white slide board. Observation was made on 1/13/20 at 8:48 a.m., of OT F, Nursing Assistant (CNA) H and of Nurse G, assisting to transfer the resident from his wheelchair to his bed using the transfer board. The resident was in so much pain he was yelling out, then he just gave up and started to fall. OT F, CNA H, and Nurse G all had to grab him and put him in his bed. Then Nurse G gave him his medications including his [MED] 500 mg (the 8:30 a.m. scheduled dose). Review of the nurse's notes dated 1/13/20, stated LLL (left lower leg) dressing change 8.5 cm x 4 cm x 0.2 cm tendon exposed, edges approximated reddened, BP 125/102 (blood pressure elevation is a sign of pain). Resident #16 was in pain at breakfast due to his pressure ulcer on his Left lower leg. Review of the physician order [REDACTED]. The resident had gone approximately 9 hours and 48 minutes without any pain medication (from 1/12/20 through 1/13/20, from 11:00 p.m. to 8:48 a.m.). During an interview done on 1/13/20 at 8:56 a.m., Nurse G stated That was unsafe (the attempt to transfer using the slide board while in severe pain), he almost fell , sitting up and having pain he was weaker. That was not appropriate, she (OT F) continued to push him, but it was not appropriate to move forward. He was having pain on his left calf, he said it was aching and uncomfortable for him and his blood pressure was a little elevated. During an interview done on 1/13/20 at 9:00 a.m., OT F stated I mentioned it to (CNA H), I think I should of stopped and told the nurse first then did the transfer from there. During an interview done on 1/13/20 at 9:01 a.m., CNA H stated She (OT F) did not tell me he was in pain, I saw it for myself. I told the nurse (Nurse G) at 7:30 a.m. During an interview done on 1/13/20 at 9:02 a.m., Nurse G was asked by this surveyor if CNA H had informed her the resident was in pain on 1/13/20 at approximately 7:30 a.m., and she stated No. During an interview done on 1/13/20 at 12:37 p.m., CNA I stated When he is in pain, he kind of talks, you ask him if he is in pain. He gets very irritated when you move him if he is in pain. We have been told to tell the nurse when he is in pain. Review of the facility Pain Practice Guide dated 2011, stated Coordinate pain medication with therapy schedule to treat prior to therapy session. Review of the physician order [REDACTED]. This pain medication was ordered the day the survey began, after the resident was observed by this surveyor to be in pain in the dining room during the breakfast meal. The resident did not receive an order for [REDACTED].>Review of the residents Physician and NP progress notes dated 11/20/19 thorough 1/13/20, revealed one entry dated 12/12/19, where the NP identified the resident's pain, however there was no documentation of what the NP had done for the residents pain that was identified. Review of the Physician and NP progress notes revealed one entry (on 12/12/19) of documented complaints of the resident having pain, no other documentation of a pain assessment was found. Review of the physician/NP (Nurse Practitioner) note's dated [DATE] through 1/6/20, revealed only one assessment that included pain; on 12/12/19 stated, He has complaints of more pain in the area today (left foot). No documentation of a complete pain assessment was found after pain was identified by the NP. During an interview done on 1/15/20 at 12:45 p.m., Physician L revealed nursing staff should have called him or the Nurse Practitioner (NP) regarding the resident's pain in a timely manner. During an interview done on 1/16/20 at 12:44 p.m., the Nurse Practitioner (NP) V revealed she had not been contacted regarding the residents increased pain until 1/13/20 and said staff can always call her or the physician for increased pain. NP stated We (Physician & NP) prefer not to schedule narcotics, if they (residents) are unable to ask and we know that they are in pain, we will schedule a narcotic. It's routine for me to chart pain notes. During an interview done on 1/15/20 at 7:26 a.m., the Director of Nursing (DON) stated We should have assessed for pain immediately and given him (the resident) a pain medication. There has been education on pain for nursing, we did an education with the Therapist (OT F) and all the Therapists and Nurses yesterday (on 1/14/20, after this surveyor identified the resident was in pain) and will educate CNA's today (on 1/15/20). Review of the facility Pain Practice Guide dated 2011, stated While pain is most commonly defined as the symptom manifestation of actual or potential tissue damage, pain which is left untreated becomes a disease in and of itself. Chronic pain (the resident had a [DIAGNOSES REDACTED]. When evaluating a patient for pain: anticipate pain, listen to what the patient says and treat it, prevent pain from occurring as practicable per patient established goal. Elderly people can suffer from persistent chronic non-malignant pain. Poorly controlled acute pain can pre-dispose patients to debilitating chronic pai[DIAGNOSES REDACTED]s. Chronic pain is often a accompanied by [MEDICAL CONDITION] (the resident had a [DIAGNOSES REDACTED]. Review of the facility Change in Condition policy dated 11/2016, stated A facility must immediately inform the resident; consult with the resident's physician; and notify consistent with his or her authority, the resident representative(s) when there is: A significant change in the resident's physical, mental, or psychosocial status (that is a deterioration in health), a decision to transfer or discharge the resident from the facility.

This citation pertains to Intake . Based on interview and record review, the facility failed to assess and monitor a surgical wound for 1 (#5) of 9 sampled Residents, resulting in Resident #5 sustaining an opened surgical wound during facility stay with infection and hospitalization . Findings include: Record review of facility 'Alteration in Skin Integrity' education material 2013, page 12, revealed: If non-pressure related ulcers or other skin alterations, e.g., skin tears, surgical incision, etc. are identified, a skin alteration record is initiated. On page 18, weekly skin alterations are completed by the licensed nurse for those wounds not being evaluated by the wound team (e.g., skin tears, surgical wounds, rashes, etc.) The findings are documented in the 'Skin Alteration Record'. Record review of the facility 'Skin Alteration Record' dated 10/2010, revealed directions: Identify location of skin alteration and mark it on the body graphic, below. Use on form for each site. Complete report weekly and as needed. The metric system is used to measure skin alterations. Type of alteration (surgical, skin tear, burn) and measurement format indicators were listed on the blank form. Record review of facility 'Documentation Skills Evaluation' form dated 11/2017, revealed demonstration of nurse's skills at physician orders, skin alteration record, shin worksheet, and treatment administration record. Resident #5: Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE], fourteen-day assessment revealed a [AGE] year-old female with Brief Interview of Mental status (BIMs) score of 15 out of 15. Medical [DIAGNOSES REDACTED]. MDS section M, noted surgical wounds. Record review of resident #5's admission skin tool assessment dated [DATE] noted Groin, abdomen and left leg bruise post cardiac stent placement, right abdomen fold incision 8 centimeters and other markings. Record review of Resident #5's progress notes from 11/9/17 through 12/5/17 revealed that on 11/20/17 the resident complained of pain to the right lower abdomen at incision site, area noted as firm, tender to gentle palpation. Incision line has a thin line of open skin with yellow discoloration, scant amount of serous drainage noted, ABD pad applied. There was no note of physician notification. The nurse spoke with the vascular office and moved up the resident's appointment to Wednesday 11/22/17. Record review on 4/4/18 and 4/5/18 of Resident #5's closed electronical and paper medical record revealed that there were no notes or consult recommendations related to the wound from the vascular appointment on 11/22/17, or if the resident even went to the appointment. Record review of Resident #5's 'Skin Alteration Record' undated, found in the closed medical record paper file, revealed that there were no entry's documented on the form, no measurements, no drainage color or odors, no surrounding skin tissue assessment. Record review of resident #5's physician orders [REDACTED]. (only for 6 days) Record review of Resident #5's progress note on 11/26/17 the nurse noted: Large amount of yellow/pink drainage from RLQ (Right Lower Quad) surgical wound; covered with ABD pad. Doctor (surgeon notified), new order for culture and sensitivity of wound. Record review of Resident #5's progress note on 11/26/17 the Nurse Practioner noted: Patient seen and examined today for routine visit. Concerned about some wound dehisce of the right lower abdomen incision. Had culture taken earlier, awaiting culture and sensitivity. Incision dehiscence with some puss-like discharge present and surrounding [DIAGNOSES REDACTED] start (antibiotic) 500 mg TID (three times a day) for 7 days. There were no dressing change orders given or noted. Record review of the Medication Administration Record [REDACTED]. Antibiotic was started on 11/27/17. There were no wound notes or wound assessment notes found in the closed electronic or paper medical records from 11/27/17 through 12/2/17. Record review of Resident #5's progress note on 12/2/17 the nurse noted: During wound care an opening was noted in the abdominal incision that appeared deeper than previously observed, draining copious amounts of serosanguineous drainage, 2 ABD pads and 4 gauze pads saturated during dressing change. Depth of wound measures 6 centimeters, opening measures 1 X 0.4 yellow wound bed noted along incision line measuring 6 cm X 0.2 across lower abdomen. In an interview on 4/5/18 at 9:45 AM with the Director of Nursing B reviewed the Nurse Practioner/Physician Assistant's note of 11/27/17 of incision dehiscence and puss-like drainage and could not explain why there were no further dressing change orders or monitoring of the wound. In an interview on 4/5/18 at 12:05 PM with the Director of Nursing B and the Registered Nurse E wound care nurse, reviewed the closed medical records [REDACTED].

This citation pertains to Intake . Based on interview and record review, the facility failed to provide or ensure that dressing changes of a wound continued for 1 (#5) of 9 sampled residents, resulting in Resident #5 being being discharged from the facility to a family member and then admitted to the hospital the same day for surgical interventions of wound. Findings include: Record review of facility 'Alteration in Skin Integrity' education material 2013, page 12, revealed: If non-pressure related ulcers or other skin alterations, e.g., skin tears, surgical incision, etc. are identified, a skin alteration record is initiated. On page 18, weekly skin alterations are completed by the licensed nurse for those wounds not being evaluated by the wound team (e.g., skin tears, surgical wounds, rashes, etc.) The findings are documented in the 'Skin Alteration Record'. Record review of the facility 'Medication and treatment Administration Guidelines' dated 3/2018, revealed that licensed nurses are oriented upon hire and evaluated annually in medication and treatment administration techniques and medication and treatment documentation requirements. Orders are transcribed or electronically entered then noted by the licensed nurse. The licensed nurse noting an order is responsible for accurate transcription and initiation of orders including removal of discontinued .Medications and treatments administered are documented immediately following administration or per state specific standards. Resident #5: Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE], fourteen-day assessment revealed a [AGE] year-old female with Brief Interview of Mental status (BIMs) score of 15 out of 15. Medical [DIAGNOSES REDACTED]. MDS section M, noted surgical wounds. The MDS revealed that Resident #5 was admitted to the facility on [DATE]. Record review of resident #5's admission skin tool assessment dated [DATE] noted Groin, abdomen and left leg bruise post cardiac stent placement, right abdomen fold incision 8 centimeters and other markings. Record review of the medical record revealed that the Resident #5 discharged from the facility on 12/5/17 at 9:53 AM to the care of a family member. Record review of Resident #5's Hospital record dated 12/5/17 at 11:59 AM revealed that the resident was admitted to the hospital as surgical inpatient for debridement and surgical intervention and wound wash out with a wound vac placement. Record review of Resident #5's progress notes from 11/9/17 through 12/5/17 revealed that on 11/20/17 the resident complained of pain to the right lower abdomen at incision site, area noted as firm, tender to gentle palpation. Incision line has a thin line of open skin with yellow discoloration, scant amount of serous drainage noted, ABD (abdomen) pad applied. There was no note of physician notification. The nurse spoke with the vascular office and moved up the resident's appointment to Wednesday 11/22/17. In an interview on 4/4/18 at 2:35 PM with Registered Nurse C revealed that she remembered calling the vascular office and getting Resident #5's Appointment moved up to that week, but did not know what happened after that. Record review of Resident #5's 'Skin Alteration Record' undated, found in the closed medical record paper file, revealed that there were no entry's documented on the form, no measurements, no drainage color or odors, no surrounding skin tissue assessment. Record review of Resident #5's physician orders [REDACTED]. (only for 6 days) Record review of the Medication Administration Record [REDACTED]. The last (MONTH) dressing change was signed out on the 6:00 AM shift on 11/26/17. Record review of Resident #5's progress note on 11/26/17 the nurse noted: Large amount of yellow/pink drainage from RLQ (Right Lower Quad) surgical wound; covered with ABD pad. Doctor (surgeon notified), new order for culture and sensitivity of wound. Record review of Resident #5's progress note on 11/26/17 the Nurse Practitioner noted: Patient seen and examined today for routine visit. Concerned about some wound dehisce of the right lower abdomen incision. Had culture taken earlier, awaiting culture and sensitivity. Incision dehiscence with some puss-like discharge present and surrounding [DIAGNOSES REDACTED] start (antibiotic) 500 mg TID (three times a day) for 7 days. There were no dressing change orders given or noted. Record review of the Medication Administration Record [REDACTED]. Antibiotic was started on 11/27/17. There were no wound notes or wound assessment notes found in the closed electronic or paper medical records from 11/27/17 through 12/2/17. Record review of Resident #5's progress note on 12/2/17 the nurse noted: During wound care an opening was noted in the abdominal incision that appeared deeper than previously observed, draining copious amounts of serosanguineous drainage, 2 ABD pads and 4 gauze pads saturated during dressing change. Depth of wound measures 6 centimeters, opening measures 1 X 0.4 yellow wound bed noted along incision line measuring 6 cm X 0.2 across lower abdomen.

Based on interview and record review, the facility failed to provide adequate supervision and/or assistive devices to prevent a fall for one resident with dementia, Resident #2, from a total of 3 sampled residents, resulting in a fall with fracture. Findings include: Resident #2 no longer resided at the facility at the time of the investigation. While at the facility, Resident #2 resided in Room 109-1, the room farthest from the Nurses' station at the dead end of the hall. According to the MDS/Minimum Data Sheet, dated 7/16/15, Resident #2 was readmitted to the facility on [DATE], and scored 8 on the BIMs/Brief Interview for Mental Status (< 8 is severe cognitive impairment). Resident #2 needed 1 person physical assist with transfers and walking in his room with a walker, and 1 person physical assist with moving on and off the toilet because he was not steady and only able to stabilize with staff assist. The MDS revealed Resident #2 was continent of urine, was not on a toileting program, and his medications included a diuretic (water pill). Resident #2's [DIAGNOSES REDACTED]. According to the Intake Information, dated 8/05/15, .(Resident #2) is currently in the hospital .was deemed a fall risk and staff were aware of this. On 8/01/15, .(Resident #2) took himself to the bathroom and he was wearing only regular socks (no grippers on the bottom). (Resident #2) slipped and fell in the bathroom .The x-ray revealed a hip fracture . According to a Summary, dated 8/01/15, DON/Director of Nursing Services B documented, .(Resident #2) was found and stated 'I slipped' getting up off the toilet. After reviewing care plans and tasks it appears that we were following his care as directed by IDT/Interdisciplinary Team .This was an unfortunate accident . According to Resident #2's x-ray report, dated 8/01/15, .There is a left subcapital fracture (hip fracture) . According to Nursing Progress Notes, Resident #2 returned to the facility on [DATE] following a surgical procedure (TURP) on his prostate, and subsequently (on 5/14/15) was admitted to the hospital due to an acquired UTI/Urinary Tract Infection. In addition, Nursing Progress Notes Resident #2 needed cues and reminders: 5/13/15 - .very confused . 5/14/15 - .admitted to (hospital) to treat UTI . 6/01/15 - .alert with confusion. Requires cues and reminders . 6/25/15 - .requires cues and reminders . 6/12/15 - .frequently gets up without calling for assistance . 6/27/15 - .Alert with mild confusion, requires cues and reminders . Resident #2's Cognitive Loss Care Plan, dated 4/03/15, revealed no interventions to address Resident #2's transferring himself and walking alone to the bathroom for toileting. Review of Resident #2's Fall Care Plan, dated 4/02/15, revealed it did not address Resident #2's cognitive impairment related to dementia and inability to remember/or non-compliance (decisional capacity) to use the call light when transferring and walking to the bathroom; it read: At risk for falls due to potential medication side effects, unfamiliar surroundings. Provide assist to transfer and ambulate as needed, which did not coincide with the MDS, dated [DATE], (1 person assist with walker while ambulating in his room). Resident #2's Urinary Incontinence Care Plan, dated 4/15/15, revealed he was to have assistance with toileting, but did not specify what type of assistance: Provide assistance with toileting. In an interview, on 8/12/15 at 12:55 AM, Nurse Aide C spoke about Resident #2, his cognitive impairment, and the fall on 8/01/15: (Resident #2) was forgetful He was supposed to use the call light. I told the nurses. I know I told (LPN/Licensed Practical Nurse D) (LPN D) said, 'Tell him to use the call light'; that's what she usually says . We should have gone in there every 1-2 hours or every time we walked by. Nurse Aide C reported that because Resident #2's room was at the end of the hall, the only time staff entered the room was to answer a call light or to do cares. In an interview, on 8/12/15 at 11:52 AM, Nurse Aide E reported she was working on 8/01/15 when Resident #2 fell . Nurse Aide E reported, (Resident #2) would always take himself to the bathroom and never put the call light on. I don't know if it registered in his head. (LPN D) knew he got up by himself. I'd tell her that .We'd tell him don't get up by yourself, but he'd do it anyway. (LPN D) told us to keep a closer eye on him. He was not on 2 hour toileting .There was no walker in the bathroom when he fell ; I never saw him in the bathroom with a walker .I don't think he even had a walker in his room. Nurse Aide E reported she had left Resident #2 eating breakfast in bed, dressed and with regular socks on, prior to the fall, because she planned on putting his shoes on after he finished eating and gotten up for the day. In an interview, on 8/12/15 at 12:33 PM, with DON/Director of Nursing B, stated, (Resident #2) was very non-compliant. There should have been a Care Plan for non-compliance .saying 'check on him more frequently' is not measurable .The corporation does onto use personal alarms . In an interview, on 8/12/15 at 1:05 PM, LPN D stated, (Resident #2) is a 1 person assist. When asked if Resident #2 was supposed to use a walker for ambulating, LPN D replied, Yes. LPN D also stated, The intervention for noncompliance with a resident with dementia is educate, educated, educate . mostly educate and move closer to the front (near the nurses' station). I'm not sure why he wasn't moved. Sometimes we use 2 hour checks and 2 hour toileting. No, (Resident #2) was not on 2 hour toileting; not sure why. He got up frequently. You could get him to toilet (urinate) when you took him . In an interview, on 8/12/15 at 2:05 PM, RN/Registered Nurse F reported she was assigned to a different hall on 8/01/15, but assisted with Resident #2 at the time of the fall. RN F reported that Resident #2 should have had non gripper socks. She said, We put gripper socks on those who get up alone. When asked what interventions should be in place for a resident with dementia that gets up without assistance, but is supposed to have a 1 person assist, RN F said, put them on every 2 hour toileting; put it on the Care Plan and on the Care Guide. Nursing would initiate that. In an interview, on 8/12/15 at 2:30 PM, OT/Occupational Therapist G reported that Resident #2 was contact guard assist due to cognition, safety, and dementia. He would get up on his own, so he was a fall risk. Contact guard means a gait belt and one hand on them. OT G stated, We would educate, but he wouldn't do it because of his dementia. He would stumble sometimes and loose his balance. OT G reported that Resident #2's last fall assessment, dated 6/01/15, as 22 out of 28, which made him a moderate fall risk: You would need assistance. ( )